4
Building from Best Practices
EXPERIENCES IN SERVICE EXCELLENCE
There are a number of emerging best practices associated with systems approaches, and the committee believes that testing, disseminating, and applying these best practices to various systems approaches to improving access and wait times is currently the most promising approach to making progress in this aspect of health care. Therefore, in this chapter the committee describes some emerging best practices in systems approaches that can be applied to the health care sector.
Identifying Emerging Best Practices
The committee identified case examples and innovative systems models that have been shown in limited settings to improve scheduling and wait times while having either neutral or positive effects on the quality of care and on the patient experience. With further research, these models have the potential to be adopted more widely and to become a foundation for standards of care. Such examples are found in all specialties, in all care delivery settings, and in different business models and geographic regions. The committee believes the changes illustrated in these examples can usually be achieved without significant additional investments in personnel or facilities, relying instead on process reengineering, resource reallocation, and behavioral change strategies within the individual settings.
Although national standards for access and wait times do not currently exist, the committee did also identify examples of organization-specific
BOX 4-1
Representative Benchmarks by Setting
- Primary care: Same- or next-day engagement for new and returning patients, contingent on their needs and preferences.
- Primary care backup for urgent services: Providers who are unable to see patients for urgent services within 48 hours refer them to others.
- Specialty care: Third next available waits of 10 days or less for specialty care new visits. For specialty care visits accompanied by greater sense of patient urgency (e.g., oncology), waits of no more than one day for new patients.
- Emergency departments: Ten-minute door-to-provider time (contact with a provider will occur within 10 minutes of patient arrival at an emergency room).
- Hospital admissions from emergency department: Holding time in the emergency department should not exceed 4 hours after a decision to admit.
- Hospital discharge assessment: Discharge planning begins immediately after admission and initial discharge assessment is completed in the first 24-48 hours of admission.
benchmarks within various health care settings. For example, some organizations set internal benchmarks of same-or next-day engagement for new and returning patients in primary care (Southcentral Foundation’s Alaska Native Medical Center) or first time appointments of newly diagnosed cancer patients (Dana-Farber/Brigham and Women’s Cancer Center in Boston);1 internal benchmarks guide door-to-provider times within emergency departments (Virginia Mason Hospital), wait times for specialty new visits (Cincinnati Children’s Hospital), and primary care backup practices for urgent services (Tufts Health Plan Network Health). The Joint Commission has also developed standards pertaining to emergency department boarding times and hospital discharge risk assessments. Organization-specific benchmarks, such as these, serve as promising reference points for future research and validation.
Box 4-1 presents these representative benchmarks and is followed by detailed information on various examples of innovative system models that have demonstrated promise in improving health care operations and performance.
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1 This information was provided in a Dana-Farber Cancer Institute news release: http://www.dana-farber.org/Newsroom/News-Releases/dana-farber-brigham-and-women%E2%80%99scancercenter-now-offers-next-day-appointments-for-new-patients.aspx (accessed June 5, 2015).
Ambulatory Care
The committee has identified best practices for an immediate responsiveness approach to new or returning primary and specialty care patients. These include scheduling strategy models, such as working toward same-day engagement and continuous monitoring and matching capacity and demand, and activities intended to achieve the optimal alignment of supply and demand, including team-based workforce improvement strategies and technology-based alternatives to in-person visits.
Scheduling Strategy Models
Open access/same-day scheduling The advanced access model of patient scheduling, also known as open access or same-day scheduling, has as a core principle that patients can obtain an appointment on the same day if desired (Murray and Berwick, 2003). Appointments are not booked weeks or months in advance, but rather each day starts with a sizable share of the day’s appointments being open, with the remainder being appointments for people who elected not to come to the office on the day they called. This workflow model involves only one primary care appointment type. In the early stages of implementation, appointments are divided into two queues or groups of patients, one dedicated to that day’s urgent demand and the other open for appointments made when patients called on previous days but did not wish to come in on that day (Murray and Berwick, 2003).
Successful use of the open access model requires accurate forecasting, an engaged team of schedulers and providers, and a carefully determined transition plan. It also requires a commitment, as demonstrated by Baylor Family Medicine (see Box 4-2), to significantly transform scheduling practices. As outlined in Appendix A, the phases of the advanced access method include the initial measurements necessary to determine demand and capacity, the steps for matching demand and capacity, and a transition strategy to scheduling for same-day access, as well as lessons learned on the maintenance of the method and contingency planning.
An effective transition to this model requires the disciplined measurement of demand and capacity, the addition of providers if there is a permanent mismatch of demand and capacity, and the elimination of appointment types. Of key importance in the transition is the elimination of the unnecessary patient backlog, that is, of those patients who have been booked for future visits as a result of an insufficient supply of same-day or next-day visits. Eliminating this backlog requires a temporary increase in patient visits each day until the backlog is eliminated. As the backlog is eliminated, which may require several months, patients are told to call the office when they are ready to be seen, and future appointments cease
BOX 4-2
Examples of the Advanced Open Access Model in Primary Care
Southcentral Foundation’s Alaska Native Medical Center
Southcentral Foundation’s Alaska Native Medical Center had some patients who waited hours for acute care or months for nonurgent appointments. To decrease wait times, the center’s managers took the following steps: matched patients with physicians, actively worked to address the appointment backlog, developed surge contingency plans, encouraged continuity of care, and adjusted the workforce by assigning tasks to non-physicians (Murray et al., 2003). Now that advanced access scheduling has been implemented, patients are guaranteed same-day appointments if they call before 4 p.m. Although it took months to eliminate the appointment backlog, once it was resolved, roughly half of all appointment slots during the next month were held open for same-day appointments. Implementation challenges included poorly functioning telephones that prevented patients from calling for same-day appointments and, because patients can call for same-day appointments until 4 p.m. daily, a high volume of patients late in the day which can strain clinicians. The keys to successful implementation included the involvement of the entire staff, implementing a data system to track patient access, and technical assistance from outside experts with experience implementing advanced access (Murray et al., 2003).
Baylor Family Medicine
At Baylor Family Medicine, an academic primary care practice, TNA (time until the third next available appointment) ranged from 10 to more than 60 days. When planning to implement advanced access, the practice’s projection was told that it would take 11 months to work down the backlog. Matching daily supply and demand in the face of the day-to-day variation in physician availability was also a challenge. To address these implementation challenges, Baylor Family Medicine opted to set a “go live” date for advanced access scheduling and, beginning 3 months prior to the “go live” date, made no appointments past that date. To give patients some flexibility in scheduling appointments, the practice also established a 5-day appointment window, which allowed patients to schedule either a same-day appointment or one in the next 5 days. Patients requiring follow-up appointments were told to call to make that appointment when they were ready to be seen, and the practice established a system to send patients reminders for necessary appointments. Patients were given access to their physicians’ clinic schedules through the phone system, in a printed handout, and on the practice’s website. The practice also established rules for provider leave, established a new process for complete physical exams, and maintained existing staffing levels. Baylor developed a daily activity report to review daily scheduling and monitor appointments over the coming 5 days. The changes reduced the length of the third next available appointment from an average of 17 days to 1 day, which the practice has sustained for more than 2.5 years (Steinbauer et al., 2006).
to exist. Using this model sustainably requires a deliberate and continuous evaluation of supply and demand and a recognition that the model is a quality improvement method that requires dedicated time and personnel within the practice. It also requires a significant change in thinking about how scheduling occurs—to a model where appointments are available in the near term rather than weeks of months into the future. Despite these implementation challenges, a systematic review found that implementing the advanced access model reduces wait times and no-show rates, although patient satisfaction outcomes are mixed (Rose et al., 2011). Box 4-3 describes case studies of how two primary care practices, Southcentral Foundation’s Alaska Native Medical Center and Baylor Family Medicine in Houston, Texas, have implemented the advanced access model to improve scheduling and reduce wait times.
The smoothing flow scheduling model A different approach to achieving same-day access uses the operations management technique of smoothing flow. This method identifies and quantifies the many types of variability in patient flow (demand) and identifies the resources available to different
BOX 4-3
Example of the Smoothing Scheduling Flow Model in Primary Care
St. Thomas Community Health Center
St. Thomas Community Health Center, a consortium of safety net practices throughout New Orleans, Louisiana, offers an example of system capacity management in the ambulatory setting. Following the passage of the Affordable Care Act, the amount of uninsured patients at the center increased from 18 percent to greater than 35 percent by early 2014. With fixed financial resources provided by Medicaid and clinic reimbursement rates averaging $30 per visit, the consortium needed ways to be more efficient and cost-effective. At the direction of the chief executive officer, techniques to smooth patient demand were used to improve practice capacity and performance. Improvement efforts based on the science of operations research targeted the widespread variability in the clinics. The methods were focused on improving efficiencies with both appointment setting and patient visits in order to increase throughput and flow. St. Thomas experienced a 35 percent increase in appointment capacity and a 25 percent increase in clinic visits. Increased efficiency has also resulted in reduced patient wait times, additional time slots for same-day and next-day appointments, and improved patient, family, and care team satisfaction. Although the improvement efforts were critical for the center’s financial stability, they also proved invaluable in optimizing the center’s function as a medical home and increasing its ability to provide high-quality care (Rickard, 2015).
patient groups (supply), with the goal of achieving improvements in wait times. Scheduling practices are tailored to minimize the number of appointment types in order to streamline patient visits (Litvak and Fineberg, 2013).
This approach, which can be applied in both primary and specialty care offices (see Boxes 4-3 and 4-4), involves the study of work flow in the office setting and uses smoothing as a form of dynamic control of the patient and work flow. Phase 1 of the approach focuses on balancing resources for the flow of patients with time-sensitive medical and elective or scheduled appointments. Phase 2 turns attention to the challenge of smoothing elective or scheduled patient flow, such as appointments for yearly physicals, immunizations, or blood pressure checks. Phase 3 addresses artificial variability in demand caused by individual priorities in order to ensure that patients are seen in the right setting, by the right provider, at the right time (IHO, 2015; Litvak and Long, 2000). Box 4-3 describes how St. Thomas Community Health Center, a primary care provider in the New Orleans, Louisiana, area, used the smoothing scheduling flow model to target variability in patient flow within a consortium of primary care safety net practices, and Box 4-4 describes how the Cincinnati Children’s Hospital and Medical Center used the smoothing scheduling flow model, focusing on improving existing capacity, to improve and continuously monitor scheduling and wait times in its specialty outpatient clinics.
BOX 4-4
Example of the Smoothing Scheduling Flow Model in Specialty Care
Cincinnati Children’s Hospital and Medical Center Outpatient Clinic
Specialty clinics at Cincinnati Children’s Hospital faced increasing demand. To balance this demand with their existing supply and thereby improve access, Cincinnati Children’s focused its efforts on improving capacity, namely, provider and resource supply (IOM, 2015). The center first analyzed the supply in its clinics. To improve flow, appointments were reduced to two types (new or return visits), supplemental appointments were temporarily added to reduce backlog, clinic operations were standardized, and the center implemented a clinic cancellation policy (Krier and Thompson, 2014). Following implementation of these changes, the medical center was able to achieve its access target of 10 days or less for the third next available appointment for new visits (Krier and Thompson, 2014). Key to implementing these changes was leadership at all levels and engaging clinical leaders of each division. Although the center has been optimized to perform at peak capacity, continuous monitoring is still required. To that end, Cincinnati Children’s Hospital has developed several tools, including a scheduling algorithm and an outpatient supply management tool. The center has also found it important to make financial and productivity data available to providers (IOM, 2015).
Reframing Supply-and-Demand Options
Team-based workforce optimization strategies The adoption of Lean and other techniques of continuous quality improvement could potentially help health care systems to become more team oriented. Team-based approaches to providing health care offer a means to provide health care more efficiently (Grumbach and Bodenheimer, 2004; IOM, 2001a; Leape et al., 2009; Wagner, 2000). These approaches all emphasize such concepts as shared goals, clear roles for team members, mutual trust, and effective communication among different parts of an organization, all in an effort to meet the goal of improving efficiency and eliminating waste (Grumbach and Bodenheimer, 2004). Team-based approaches have the potential to improve quality, productivity, efficiency, and satisfaction among both patients and employees (Montebello, 1994). In addition to increasing overall productivity and efficiency, appropriately and safely delegating certain tasks to non-clinician team members can help increase capacity and thereby improve scheduling and decrease wait times (Brandenburg et al., 2015).
Improving the health care workforce requires data for use in forecasting and managing patient demand in order to avoid an artificial provider-driven component. In practice, however, most forecasts are based on historical averages rather than on the use of newer methodologies based on predictive analytics. Workforce optimization also depends on optimally assigning care tasks to the appropriate members of the care team. For example, wait times for an appointment at the outpatient cardiology clinic at a children’s hospital were exceeding 40 days until the program was redesigned to include management by pediatric nurse practitioners. After that, not only did wait times decrease in comparison to clinics run by physicians, but patient satisfaction scores remained high (Evangelista et al., 2012). Another study demonstrated the value of using extended role practitioners, such as physical and occupational therapists, to increase capacity and decrease wait times in an arthritis clinic (Passalent et al., 2013). The increased capacity allowed the clinic to accommodate a rise in patient volumes over the 2-year study period and enabled earlier detection and intervention for patients.
Box 4-5 describes how Group Health in the Northwestern United States implemented team-based care using a patient-centered medical home model (which broadened the role of registered nurses and clinical pharmacists) to improve scheduling in primary care and in chronic care management in particular. Within specialty care, the Thunder Bay Regional Medical Center in Ontario, Canada (profiled in Box 4-6), implemented a shared care clinic that co-locates mental health and primary care services in order to increase coordination across primary and mental health care and to reduce barriers to accessing timely mental health services.
BOX 4-5
Example of a Team-Based Approach to Scheduling in Primary Care
Group Health
Group Health is an integrated delivery system serving more than 600,000 patients in Washington State and Idaho (Hsu et al., 2012). Having successfully implemented a patient-centered medical home (PCMH) pilot program at their Seattle clinic, Group Health decided to undertake a large, systemwide transformation and spread the PCMH model to all 26 of its primary care practices over 18 months (Hsu et al., 2012). Following a Lean management approach, Group Health implemented four system-level changes and four practice-level changes. Central to the practice-level changes was a team-based approach to chronic illness management. Providers were organized into physician-led teams. Key to this approach was the development of goal-driven chronic illness collaborative care plans and evaluations (Hsu et al., 2012). Physicians used a standardized, generic, disease-specific template to develop care plans with patients, and aimed to develop a care plan for each patient with a targeted chronic condition (e.g., diabetes, asthma, hypertension, chronic obstructive pulmonary disease). Physicians could also use care plans to identify patients requiring additional support. These patients received counseling and follow-up from a registered nurse or clinical pharmacist on the patient’s care team until their condition improved. An evaluation of the prototype reported that patients used more e-mail, telephone, and specialist visits, but fewer emergency department visits, and patients reported greater satisfaction with the quality of their care (Reid et al., 2010).
An analysis of the PCMH spread throughout Group Health’s integrated practice was also conducted. Among all adults impacted by the intervention, there was a 123 percent increase in the use of secure electronic message threads, a 20 percent increase in telephone encounters, no statistically significant changes for hospital admissions, and declines in emergency department visits at 1 and 2 years (13.7 percent and 18.5 percent) following the spread (Reid et al., 2013).a
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a The text in this box has been modified since the prepublication to include additional information about the analysis of the PCMH spread through Group Health’s integrated practice.
Technology-based alternatives to in-person visits In the primary care setting, the care team often works to minimize or eliminate delays for each day’s telephone appointment requests and return appointment requests. Some have suggested that many of the needs of the patients requesting appointments—both in primary and specialty care—could be addressed by non-physician providers or by phone, via telemedicine, or via mobile health units; these alternatives would not serve as a replacement for a needed visit but rather as an alternative form of health care (Charles, 2000; IOM, 2000;
BOX 4-6
Example of a Team-Based Approach to Scheduling in Mental Health Care
Thunder Bay Regional Health Sciences Center Shared Care Clinic
Because long wait times for mental health care are associated with higher rates of missed appointments and less usage of mental health services overall, Thunder Bay Regional Health Sciences Center decided to implement a shared care model in one of its clinics to reduce wait times for mental health care in the clinics. Shared care for mental health services involves co-locating mental health services within primary care offices. The mental health and primary care providers also shared a common health record, engaged in consultations, and cared for their patients collaboratively. At the Thunder Bay shared care site two full-time mental health counselors and a part-time psychiatrist were added. Primary care physicians referred patients to the mental health services, where the counselors triaged patients to either counseling or psychiatry services, including cognitive-behavioral, psycho-educational, and supportive counseling. Before the establishment of the shared care clinic, the median wait time for mental health care was 97.6 days. For the 3 years after the shared care clinic was established, the median wait time for shared care was just over 30 days, while the median wait time across nonshared care sites was more than 80 days (Haggarty et al., 2012).
Naylor and Imison, 2010). This approach could be used in particular as a way to deal with issues in rural and underserved areas.
Technology can improve patient access to health care both directly and indirectly (IOM, 2012). Telemedicine, the use of electronic information and technologies to support direct clinical services, can be used as an alternative to an in-person visit to a physician and as a way to improve access at a lower cost (Charles, 2000; IOM, 2000). The development of virtual care platforms has made possible a variety of new care models, including electronic-visits, video chat consultations, and other approaches to home-based care. One key to expanding the use of these models will be the development of new payment models to ensure that providers are properly reimbursed and incentivized to install and use these capabilities in their practices. It will also be necessary to develop a technology infrastructure that makes it possible to track, report on, and provide oversight of these patients and their care.
Patient-tracking technologies can help caregivers work more efficiently and improve patient safety by providing real-time information on a patient’s location in the hospital system and identifying obstacles to smooth and timely patient flow (Dobson et al., 2013). Interoperable and interactive health information technology systems can alert a care team of
missed appointments to a referring specialist, the presence of new results, or the need for follow-up appointments. Patients can receive reminders of upcoming appointments, manage their prescriptions, or schedule their own appointments (Pearl, 2014).
Technology can assist in the ambulatory environment by routing some office visits to telemedicine visits, with the patients being examined by a virtual clinician; such telemedicine options range from uploading a smart phone photo (e.g., of a skin rash) and sending an e-mail question to the clinician, to sending data from a personal device to the office. One important use of technology will be found in the prework portion of a health care visit. Patients could have a virtual previsit interview to determine the appropriate provider and time for a visit, the need for laboratory or testing in advance of the visit, the need for a medical record screen for outstanding specialist visits and reports, and the transportation needs of patients.
Box 4-7 provides details about how Teladoc in California, Kaiser Permanente Northern California (KPNC), and Virginia Mason Medical Center in Seattle, Washington, have all used technology-based alternatives to improve access to timely primary and specialty care, especially care outside regular business hours. Teladoc, a telemedicine provider with consultant physicians who have no regular relationships with the patients or their regular providers, provides round-the-clock consultations with licensed physicians via telephone or secure Internet video. KPNC offers patients access to providers in primary and secondary care via secure e-mail, telephone, or Web-based video in lieu of and in addition to regular office visits. Virginia Mason Medical Center uses a telephone triage tool to facilitate immediate access to urgent care and to improve scheduling for primary and secondary care appointments for patients presenting with headache symptoms.
Inpatient and Emergency Care Scheduling Strategies
The strategies for implementing an immediate responsiveness approach to inpatient and emergency care patients fall into several categories: admission strategies, care coordination strategies, and the use of predictive models.
Admission Strategies
As described below, some hospitals have redesigned operating room environments to balance resources and the flow of time-sensitive surgical cases with elective scheduled surgeries (Litvak and Fineberg, 2013; Litvak and Long, 2000). The focus of these efforts is to improve access to the operating rooms, emergency department, intensive care unit, and telemetry
BOX 4-7
Examples of Technology-Based Alternatives to In-Person Primary Care Visits
Teladoc
Teladoc is a large telehealth provider in the United States offering 24-hour access to consulting Teladoc physicians via telephone or Internet video. Teladoc physicians have no established relationship with patients, but patients are matched with physicians licensed to practice in their state. To use Teladoc, patients must create an online account and enter their medical history. Patients can then request either a phone or video consultation with a Teladoc physician whenever they need care. Physicians typically respond to requests within 20 to 25 minutes of receiving the request. In April 2012 the California Public Employee’s Retirement System began offering Teladoc consultations as a covered benefit with no copayment to members enrolled in its Blue Shield of California health insurance plan. An early evaluation of Teladoc among these users found that less than 1 percent of eligible members used Teladoc in the first 11 months of coverage; similarly, Teladoc visits made up less than 1 percent of total monthly visits to offices, to emergency departments, and via Teladoc combined. The evaluation found that more than one-third of Teladoc visits occurred on weekends or holidays, which was similar to the rate of weekend and hospital emergency department visits (36 percent) and substantially higher than the rate for office visits (8 percent). The top three diagnostic categories were for acute respiratory illness, urinary tract infections and urinary symptoms, and skin problems. This suggests that Teladoc can help increase access to after-hours primary care while also diverting non-urgent care away from emergency departments. Moreover, 21 percent of Teladoc visits were made by patients who had no previous health care use in 2011, suggesting that Teladoc could potentially increase access to care for individuals without a regular physician or who have difficulty accessing primary care. Finally, contrary to expectations, Teladoc visits were significantly less likely to result in a follow-up visit for a similar condition than visits to a physician’s office or the emergency department. Although this early evaluation is suggestive of the potential for Teladoc to increase access to primary care, Teladoc users were younger, healthier, lived in more affluent neighborhoods than average, and may have fewer access needs than individuals with the greatest challenges accessing primary care, such as those living in rural or socioeconomically disadvantaged areas (Uscher-Pines and Mehrotra, 2014).
Kaiser Permanente Northern California
Kaiser Permanente Northern California (KPNC) provides alternatives to in-person office visits via secure e-mail, telephone, or Web-based video. KPNC members can send secure e-mail messages directly to their primary care physicians or to specialist physicians treating them. In addition to asking non-urgent questions in text, patients can attach images and submit completed forms. Frequently, physicians are able to resolve patient’s concerns without scheduling inpatient visits. Physicians respond to 83 percent of cases the same day and to 98 percent of cases within 2 business days. For more than a decade, KPNC has
offered 10-to-15-minute telephone visits with a physician in lieu of office visits, and patient satisfaction with the telephone visits is high. Finally, encrypted video technology has been adopted by a number of specialty practices. For example, KPNC began offering video visits to provide after-hours care among patients with urgent needs—but not emergency needs—during hours when both regular practices and urgent care clinics are closed. While patients requiring immediate care were directed to go to emergency departments, the physician consulting via video was able to input information from the video consultation in the patient’s electronic health record and thereby facilitate the patient’s treatment in the emergency department. These alternatives to office visits have the potential to provide high-quality care at a lower cost than in-person care, although the cost savings have yet to be seen. Assessing the effect of these technologies on the quality of care has also been challenging, because they were implemented at the same time as other quality improvement measures. Barriers to implementation include ensuring compliance with the Health Insurance Portability and Accountability Act (HIPAA) standards; differing uptakes by age, race/ethnicity, and region, which makes it necessary to maintain parallel paper, phone, and in-person systems for patients not using virtual technologies; and the need to readjust physicians’ schedules to accommodate time to respond to patient e-mails (Pearl, 2014).
Virginia Mason Medical Center in Seattle
At Virginia Mason Medical Center in Seattle, Washington, a health system transformation using Lean methodology has been going on since 2002 (Nelson-Peterson and Leppa, 2007). One piece of this effort involved the redesign of care for patients with uncomplicated headaches. Analysis of internal data showed that roughly 80 percent of patients who contacted Virginia Mason with headache symptoms had uncomplicated headaches. Such headaches do not require magnetic resonance imaging (MRI) or other specialized imaging, emergency care, or a consultation with specialists; nonetheless, 14 percent of these patients underwent an MRI (Blackmore et al., 2011). To reduce avoidable visits to the emergency department and specialists as well as unnecessary imaging, Virginia Mason created and deployed a simple telephone triage tool consisting of questions that a lay telephone operator can ask to determine what initial level of care each caller needs. Patients with symptoms like fever or trauma that require immediate evaluation were directed to the emergency department, while all other patients were given the option of a scheduled appointment with either their regular doctor or a clinician in the headache clinic. Analysis of this staged triage intervention showed that a single visit with telephone follow-up was sufficient for the evaluation and initial treatment of most patients with uncomplicated headache and avoided multiple visits and referrals. Evaluation of the program between January and June 2010 found that same- or next-day appointments with the headache clinic nurse practitioner were available for 95 percent of the patients needing care, and patient satisfaction scores of patients leaving the headache clinic averaged 91 percent (Blackmore et al., 2011).
beds as well as to improve the quality of care and to determine the required hospital resources (e.g., nurses, operating rooms, beds).
Smoothing flow scheduling model The same strategy used to smooth variability in patient demand in primary care settings can also be used to improve patient flow in the admission process through providing a more structured and balanced scheduling of elective patients and surgical cases (Litvak and Fineberg, 2013). By balancing resources and the flow of time-sensitive emergency and urgent cases with elective and scheduled surgical admissions, the competition for beds and delays in surgical cases can be improved. The uneven influx of elective surgical cases—for which the standard practice is to schedule as many are requested by surgeons with admitting privileges—is a major reason why the demand for beds often exceeds capacity in inpatient units (Litvak and Fineberg, 2013). Smoothing elective admissions has been shown to be an effective mechanism for improving capacity in a busy hospital (Litvak and Fineberg, 2013). Appendix C includes an admission improvement plan detailing one way to smooth elective and scheduled patient flow, and Box 4-8 describes how Mayo Clinic, Florida, and Cincinnati Children’s Hospital Medical Center used the smoothing scheduling flow model to improve surgical capacity.
BOX 4-8
Examples of Smoothing Patient Flow in Inpatient and Emergency Care
Mayo Clinic, Florida, Operating Room Use
Faced with an increasing demand for surgical services, the Mayo Clinic, Florida, used a variability method to increase capacity without building new operating rooms by improving patient flow into hospital operating rooms. First, the surgical team, working with a design team familiar with variability methodology, defined surgical cases as urgent/emergent (cases that due to clinical need must be performed within 24 hours), work-in, or elective. Due to clinical need urgent/emergent cases had to be performed within 24 hours and were further subdivided into five classifications. Work-in cases were defined as those that needed to be performed within 5 days, but not within 24 hours, and were further classified based on clinical versus administrative needs. All other cases were defined as elective. Next, the hospital collected data for 3 months, during which time no changes were made to operating room scheduling procedures. These data were then used to model various scheduling scenarios and allocate rooms to perform urgent/emergent, work-in, or elective cases. For elective rooms, data were also used to
allocate elective operating room block time across rooms and throughout the week to ensure that elective cases were evenly distributed. All existing policies regarding operating room scheduling and functioning were reviewed and modified to align with the redesigned process. The new scheduling procedure was implemented for the entire surgical practice beginning November 1, 2010. The design team managed the implementation, using dashboards covering daily, weekly, monthly, and quarterly data to monitor the program, and they developed decision trees to facilitate real-time scheduling decision making and to manage conflicts. One year after the reengineered scheduling program had gone into effect, surgical volume had increased by 4 percent, representing nearly 500 additional cases annually. Staff overtime decreased by 27 percent, resulting in more than $100,000 in cost savings. The day-to-day variability in surgery case volume and the number of same-day changes to the elective surgery schedule both decreased substantially as well (Smith et al., 2013).
Cincinnati Children’s Hospital Medical Center
As is the case in many hospitals, surgeons at Cincinnati Children’s Hospital Medical Center scheduled elective surgeries unevenly throughout the week (Litvak and Bisognano, 2011). The hospital chief executive officer used variability methodology to spread these surgeries out over days in order to smooth the flow of patients through operating rooms (Litvak, 2009). By focusing on capacity management and patient flow through the hospital, hospital management was able to achieve a reduction of 28 percent in weekday operating room wait times for emergency and urgent surgical cases, even with an increase in case volume of 24 percent (Litvak, 2009). Furthermore, weekend operating room waiting time fell by 34 percent, despite a 37 percent increase in volume (Litvak, 2009). Using a “pit crew” approach to bed management, the hospital management used coordinated team efforts to complete critically important tasks in the minimum amount of time while avoiding errors (Reid et al., 2009; Ryckman et al., 2009). It has been estimated that, if each of the 5,700 hospitals in the United States achieved only 10 percent of the financial savings that Cincinnati Children’s did through this approach, the U.S. health care system would avoid $57 billion in capital costs associated with building new operating rooms and hospital bed occupancy would increase from 65 percent to greater than 80 percent, enough to provide hospital care for every American lacking health insurance (Litvak and Bisognano, 2011).
Implementing a Coordinated Approach to Care
Care coordination is a strategy to improve effectiveness, efficiency, and quality in health care (Bodenheimer, 2008; Hall et al., 2013; IOM, 2001a). Increased care coordination has the potential to prevent unnecessary delays by eliminating redundancies and inefficiencies (Bodenheimer, 2008). Care coordination is particularly critical at various transitions, such as between
providers. In the hospital and post-acute setting, coordinating care is particularly important at discharge. Thus care coordination interventions that have nurses or other non-physicians deliver and coordinate care after discharge, that promote patient self-management in the community, or that otherwise facilitate comprehensive discharge planning can improve patient flow through hospitals by both improving output flow (i.e., assuring timely discharge) and preventing readmissions (Coleman et al., 2004, 2006).
Box 4-9 contains two case studies of organizations that applied a coordinated approach to improving scheduling and wait times in inpatient and emergency care. Specifically, the box describes the UPMC Health System Patient and Family Centered Care Method, which established
BOX 4-9
Examples of Coordinated Approach to Improving Scheduling and Wait Times in Inpatient and Emergency Care
UPMC Health System Patient- and Family-Centered Care Method
UPMC Health System, formerly the University of Pittsburgh Medical Center, is a nonprofit, integrated delivery system containing 20 hospitals, outpatient sites, and a health insurance division (Meyer, 2011). Anthony DiGioia, an orthopedic surgeon at UPMC in Pittsburgh, and colleagues developed a care process, the Patient and Family Centered Care Method, to improve patient experiences in the hospital’s orthopedic program (DiGioia et al., 2010). The method has six steps: (1) selecting a care experience; (2) establishing a care experience guiding council; (3) evaluating the current state of the care experience using tools such as patient shadowing, care flow mapping, patient storytelling, and patient surveys; (4) developing a working group to develop an improvement strategy; (5) creating a shared vision of the ideal patient and family care experience; and (6) identifying improvement projects and assigning project teams (DiGioia et al., 2010). In 2007, UPMC Presbyterian used the method to improve its trauma service care experience. The staff at UPMC Presbyterian began by establishing a PFCC trauma care guiding council, which identified cervical spine collar clearance as an initial project area. A multidisciplinary working group composed of representatives from a variety of professions including: nursing, parking operations, admissions, pharmacy, corporate communications, and physical therapy was then established for this project (DiGioia et al., 2010). The working group shadowed patients and their families and conducted care flow mapping. Next, they mapped out an ideal care experience from the perspective of patients and families. Based on these activities, the working group created a prioritization process for patients requiring cervical spine collar clearance, upgraded the health information technology system for online X-ray reading, and implemented an alert system that uses pager
messages to notify care managers about potential avoidable delays or avoidable hospital days (for which there were an existing process and existing resources) (DiGioia et al., 2010). Within 2 weeks of appointing the working group, wait times for cervical spine collar clearance for priority patients had been cut in half, from 26.5 to 12 hours. In addition, patient satisfaction rates for the emergency department, general trauma inpatient unit, and trauma step-down unit all increased roughly 10 percent (from 77 to 87.4 percent for the emergency department, 70.3 to 79.7 percent for general trauma, and 68.3 to 72.5 percent for trauma step-down) (DiGioia et al., 2010). There are various implementation challenges, particularly as the hospital system scales up the intervention, and one of the more important is getting buy-in from leadership at all levels—specifically, getting hospital executives and departmental leadership to understand that the method is intended to make better use of existing resources and not to increase costs with new purchases (Meyer, 2011). Despite these challenges, the program has since been applied widely to other departments in eight hospitals in the UPMC Health System.
Boston Medical Center
Boston Medical Center is a large, urban, safety net hospital that wanted to reduce the rates of rehospitalizations and emergency room visits after discharge. To improve discharge services, the hospital implemented a program called reengineered discharge (RED). The RED intervention is built around nurse discharge advocates and clinical pharmacists. Nurse discharge advocates are trained using a standardized manual with scripts and practice sessions to coordinate the discharge plan within the hospital and to educate patients about and prepare them for discharge. Specific activities include making appointments for post-discharge clinician follow-up or testing, coordinating who will follow up with results from any pending tests, confirming the medication plan, reviewing processes for what to do if problems occur, and ensuring that each discharge plan is aligned with national standards. The nurses then assemble information gathered from these activities into an after-hospital care plan, an illustrated, individualized booklet designed to be accessible to individuals with low health literacy. Following scripts and using teach-back methodology, the nurses review the after-discharge care plan with patients prior to discharge. On the day of discharge, nurses send both the after-hospital care plan and the discharge summary to the patient’s primary care provider. Two to 4 days after discharge, a clinical pharmacist calls the patients, making at least three attempts to reach them, and follows a scripted interview with them to review the discharge plan. The pharmacist also reviews medications by asking the patients to bring their medications to the phone, addresses potential problems, and reports any issues to the patient’s primary care provider or nurse discharge advocate. Results from a randomized study found that patients participating in the RED intervention were significantly less likely to have a subsequent hospitalization than patients under usual care. Patients participating in RED also reported a higher follow-up rate with their primary care physician (62 percent) compared to usual care patients (44 percent). The intervention also resulted in cost savings of roughly one-third, compared to usual care (Jack et al., 2009).
multidisciplinary teams to identify priority areas, obtain patient and family input, and address wait times for cervical spine collar clearance for priority patients, as well as a program at the Boston Medical Center that used nurses and clinical pharmacists to improve discharge processes.
Use of Systems and Simulation Models
Simulation models use a set of rules, or assumptions, to forecast how different scenarios will play out and can be used as a planning tool to match hospital capacity to patient need (Everett, 2002). In the case of inpatient or emergency department planning or scheduling, these assumptions may cover such things as the number of patients, the interval between patients, the number of staff, the number of operating rooms, and the number of patient beds. Working from these assumptions, simulation models can then examine the effect of various hospital staffing configurations on patient flow (Jones and Evans, 2008). Different scenarios can then be compared in order to identify optimal scheduling scenarios (Kolker, 2008). Simulation models can also be used to model how individual patients move through a health care unit. By showing patient flow, simulation models can help identify bottlenecks and indicate ways to improve patient flow and decrease delays (Coats and Michalis, 2001; Stainsby et al., 2009).
Emergency departments have used a variety of techniques, including Lean (the Toyota Production System) to guide redesign efforts (Holden, 2011). As discussed in Chapter 3, Lean is a method to achieve continuous improvement which identifies the features of a system that create value and those that create waste. Lean processes can be used to identify and continuously monitor inefficiencies that may lead to imbalances in patient demand and hospital capacity that in turn lead to delays in patient flow and thus increased wait times, although additional research is needed about the opportunities and implementation challenges associated with modeling for the purposes of predicting and improving scheduling practices. Box 4-10 describes how Grady Memorial Hospital in Atlanta, Georgia, used systems engineering techniques to re-engineer the hospital’s emergency department and how Mayo Clinic, Rochester, used Lean and Six Sigma methods to improve surgical processes.
Scheduling Models in Post-Acute Care
Systems approaches and tools from systems engineering applied to scheduling in primary and acute care can also be applied to post-acute settings such as rehabilitation hospitals and skilled nursing facilities. Increased care coordination, the use of multidisciplinary teams, and alternative approaches to in-person visits are all strategies that can be used to improve
BOX 4-10
Examples of Employing Systems Engineering Techniques to Predict and Monitor Work and Patient Flow in Inpatient and Emergency Care
Grady Memorial Hospital
Grady Memorial Hospital in Atlanta, Georgia, is the fifth-largest safety net hospital in the United States; the hospital serves a population with diverse socioeconomic groups, and before the implementation of the Affordable Care Act only 8 percent of patients whom Grady Hospital served were covered by private insurance. Struggling to remain financially solvent, in 2008 Grady management in collaboration with operations researchers undertook a seven-step process to reengineer emergency department operations. This included process mapping of emergency department patient and work flow; analyses of patient arrival, emergency department service processes, and hospital data; the development of a predictive analytic framework to assess patient admissions demands; the application of a simulation model to improve the emergency department system performance; the identification of system improvements for implementation; and the evaluation of system improvements. The optimization model identified several areas for system improvements, of which the hospital adopted the following: combining registration and triage for certain patient groups, reducing laboratory and X-ray turnaround time, optimizing staffing, eliminating batching of patients to bring from walk-in to one of various treatment zones, and establishing a walk-in center to treat non-urgent patients. These changes resulted in a 33 percent reduction in average length of stay, a 70 percent reduction in average wait time, an increased annual throughput across the emergency department, a 32 percent reduction in the number of patients who left without being seen, a 28 percent decrease in avoidable 72-hour and 30-day readmissions among patients with emergency and urgent conditions (Emergency Severity Index acuity levels 1 through 3), and substantial cost savings. Grady Memorial Hospital has subsequently applied this methodology to other units. The emergency department model has also been implemented in 10 other emergency departments, in which performance and clinical outcomes have been similar to those seen at Grady (Lee et al., 2015).
Mayo Clinic, Rochester
Mayo Clinic, Rochester, is an academic medical center with 88 operating rooms in two acute care hospitals (Cima et al., 2011). To improve operating room efficiency, Mayo Clinic, Rochester, used Lean and Six Sigma methods to implement a surgical process improvement intervention. The hospital first developed a value-stream map of patient flow through operating rooms that detailed event location, personnel, and information technology requirements; alternative pathways; and key performance elements (Cima et al., 2011). A multidisciplinary leadership team then analyzed the map and identified five work streams to organize process improvements:
- To reduce unplanned variation in elective surgical cases, details about prescheduled cases (e.g., case time and estimated duration) and planned surgeon absences were made available to all surgeons, and each surgical specialty was required to develop a standardized case description.
- To streamline the preoperative process, the hospital developed standardized preoperative assessment criteria, staggered operating room start times (assigned to each operating room and did not change) and respective report times, and staggered patient entry through three self-triaging check-in lines based on report time.
- To reduce time in operating rooms spent on nonsurgical tasks, the hospital implemented parallel processing, in which these tasks were performed in parallel with ongoing cases in non-operating rooms. The hospital also established targets for turnover time between cases and posted weekly performance metrics outside each operating room monthly.
- To reduce redundancies in patient documentation, the hospital streamlined its electronic health record in which information collected earlier in the preoperative process was automatically put into future records.
- Finally, to ensure staff engagement, the hospital established a communication council composed of representatives from all stakeholders that developed and delivered consistent communication plans to stakeholders and resolved concerns. The hospital also conducted staff satisfaction surveys.
The surgical process improvement intervention resulted in significantly fewer wait times of longer than 10 minutes at surgical admissions, significantly higher rates of on-time arrival to the preoperative area, and significantly quicker operating room turnover times. Furthermore, these efficiency improvements resulted in better financial performance and the need for fewer nursing and other non-clinical staff for daily operations, and late shift and overtime needs among surgery and anesthesia nurses decreased despite an increased surgical volume. Despite efficiency and effectiveness gains, there was a need for enhanced staff support/liaison efforts, with three-fourths of respondents to a staff satisfaction survey reporting that the improvement program increased their efforts and staff expressing concerns about job security even though no nursing or allied health staff were either laid off or reassigned to other work (Cima et al., 2011).
scheduling and patient flow and to decrease wait times. Similarly, as is the case in both primary and acute care settings, systems engineering tools that facilitate system-wide assessments and adjustments can be used to streamline patient flow in post-acute care (Litvak and Fineberg, 2013). For example, the Veterans Affairs Polytrauma Telehealth Network (profiled in Box 4-11) supports increased access and care coordination in post-acute care by using video teleconferencing and peer-to-peer networking across rehabilitation teams and between patients and specialty care providers.
BOX 4-11
Example of Innovative and Emerging Scheduling Models in Post-Acute Care
Veterans Affairs Polytrauma Telehealth Network
Injuries sustained in combat during Operation Iraqi Freedom and Operation Enduring Freedom are of unprecedented severity and complexity, and they frequently require long-term rehabilitation; some combat-wounded veterans will require rehabilitative services for the rest of their lives (Darkins et al., 2008). The reduction in time between sustaining a battlefield injury and arrival for care in the United States further complicates the rehabilitative needs of combat-wounded veterans. To meet this need, in 2006 the Department of Veterans Affairs (VA) established a telerehabilitation system consisting of four polytrauma rehabilitation center (PRC) hub sites that support 21 regionally based polytrauma network sites (PNSs). The Polytrauma Telehealth Network (PTN) was established to make specialist expertise in PRCs available at PNSs and to coordinate rehabilitation services across sites. PTN is also intended to provide comparable or enhanced quality of care at the same or lower cost. Specifically, PTN supports videoconferencing and peer-to-peer networking of rehabilitation teams across the VA, links care across the VA sites and also to Department of Defense counterparts (e.g., Walter Reed Army Medical Center and Bethesda Naval Hospital), allows patients and their families to access distant VA sites (e.g., for specialty care), and supports multicasting for clinical and education activities (e.g., grand rounds). For severely injured patients who may require acute inpatient care in the early stages of their rehabilitation, PTN can facilitate ongoing outpatient care with the same providers in later stages while also allowing the patient to live in his or her local community. For less severely injured patients, PTN allows access to specialty care in their local communities (e.g., direct patient care) and also facilitates care coordination across treatment teams. In 2006 the VA provided 37,234 teleconsultations for patients with mental conditions and supported 25,586 telehealth devices for patients at home who would otherwise have required institutional care (Darkins et al., 2008). Since 2006, the program has been expanded to include 5 PRCs, 23 PNSs, 86 Polytrauma Support Clinic Teams, and 39 Polytrauma Points of Contact located at VA medical centers nationally (VA, 2015b).
Engaging Patients and Families in Systems Design and Implementation
As has been emphasized throughout this report, the committee recognizes that it is important for patients to be core partners in systems redesign. Studies have shown that patients’ active management of their own health care is associated with the patients’ greater satisfaction with their care and with better health outcomes, quality of life, and economic outcomes (Hibbard and Greene, 2013; IOM, 2013). However, as noted in Chapter 1, providing patient-centered care goes beyond consideration
and concern in direct care. It requires a delivery system that supports the provision of care that meets patients’ needs—and thus one that integrates patient values, experiences, and preferences into the design and governance of the health care organization. Designing such a system requires engaging patients in organizational design and governance as well as in their direct care (Carman et al., 2013).
With regard to scheduling and access, as described in Chapter 3, a patient-centered health care system understands its inherent capacity, patient demand, and variations in this supply and demand; this leads to a system that performs at its optimal capability, including with minimal delays, but that is also sufficiently flexible to handle temporary fluctuations in either its provider supply or patient demand. Engaging patients in the assessment, design, and improvement processes can lead to a better understanding of patient demand and thus how the system can be realigned to meet that demand.
Simply implementing an advanced scheduling system is not a patient-centered action unless it strengthens the patient–clinician partnership, promotes trust and collaboration, and facilitates the patient’s involvement (Davis et al., 2005). To assess patient experiences and patient satisfaction, including with access and scheduling, health care organizations can use and analyze survey data concerning patient experience and satisfaction, such as data from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys that were described in Chapter 1. These data can then be used to identify areas of waste or delays and also to inform access improvement activities such as process redesigns. The implementation of partnerships with patient advisors and the development of patient and family advisory councils have proven to be effective ways to gather this essential information; however, other methods are needed to evaluate the patient’s ability to obtain ambulatory and office-based appointments quickly.
Currently, little information exists on the effects of patient involvement in access-related improvement activities on either operational or health care outcomes. However, areas in which patients could be included in efforts to improve access and optimize scheduling may include: defining preferences, exploring alternative access strategies, contributing to the design of pilot improvement efforts, helping to shape communication strategies, and interfacing with governance and leadership. Box 4-12 describes how Seattle Children’s Hospital incorporated patient and family needs and preferences when designing its scheduling approach.
Additional opportunities to engage patients in scheduling and access include increasing transparency and communication through publishing wait times data and developing information systems to support communication about scheduling and future care needs. Currently, few data are available to patients regarding wait times, whether for scheduling appointments or
BOX 4-12
Example of Patient and Family Engagement in Design and Evaluation
Seattle Children’s Hospital
For over a decade, Seattle Children’s Hospital has used a Continuous Performance Improvement (CPI) program, a modified version of the Toyota Production System that adapted Lean methods for the health care setting, to improve the quality of the health care that it delivers (Hagan, 2011). A core principle of CPI is focusing primarily on patients. In practice, this means examining each process and determining which steps add value to the patient from the patient’s perspective and which do not (Hagan, 2011; Stapleton et al., 2009). The hospital also involves patients and their families in many, but not all, of its improvement efforts, and their direct participation early in the improvement process has reinforced the value of their input (Hagan, 2011; Toussaint and Berry, 2013). For example, when the hospital built its new Bellevue Clinic and Surgery Center, input from patients and their families early in the construction process revealed that it was important for parents to be able to stay with their children in the preoperative area. The space was designed and built accordingly, resulting in more efficient construction (Toussaint and Berry, 2013). However, patients and their families were not always included in quality improvement activities early on. When Seattle Children’s redesigned its ambulatory center, it discovered that despite having reduced appointment wait times by 50 percent, patient satisfaction measures were actually falling (Brandenburg et al., 2015). Further inquiry revealed that many families were less interested in same-day access than in the choice to make an appointment on a more convenient day, and Seattle Children’s subsequently changed the scheduling algorithm to include an assessment of family needs and preferences (Brandenburg et al., 2015). Thus, despite the use of multidisciplinary teams including members of executive and clinical leadership (e.g., the chief operating officer, the chief medical officer, and department chairs) and representatives of care teams (e.g., physicians, nurses, and residents) (Stapleton et al., 2009) to improve hospital processes driven by a focus on the patient, without direct patient participation in the process the organization was making inaccurate assumptions about patient preferences (Brandenburg et al., 2015). Leadership is now evaluating other organizational assumptions about patient needs and preferences (Brandenburg et al., 2015).
for receiving on-time care at the time of an appointment; similarly, there are few data available concerning which systems are achieving the best results with reducing wait times (Brandenburg et al., 2015). The transparency of such data could potentially help patients make better-informed decisions about their care. Patient-centered care requires communication and education, such as providing patients with details on recommended treatment
plans and on the need for and availability of future appointments. The integration of care plans, scheduling, and automatic reminders is a promising application of information technology that could improve access and scheduling throughout the care continuum (Pearl, 2014).
This chapter has explored a range of potential approaches and strategies for achieving timely care access across different populations and health care institutions. Because of the nature of the access challenge and the diversity of care settings, it is necessary to employ strategies that can be adapted to local conditions and that are flexible enough to meet changing needs. In the ambulatory care setting, best practices prioritize same-day care and rapid response to ensure that capacity is aligned with demand. Inpatient and emergency care are more variable, so that both care coordination strategies and more sophisticated analyses using predictive modeling may be required. Post-acute care presents an even higher level of variability and may benefit from strategies that prioritize multidisciplinary approaches and developing alternatives to in-person visits that meet patients’ needs. Based on a review of the cases as well as the scan of the literature presented in Chapters 2 and 3, the committee identified a number of commonalities among exemplary practices that serve, in effect, as a set of basic health care access principles for primary, specialty, and hospital and post-acute care scheduling (see Box 4-13). These basic access principles are as follows:
Supply–demand matching. A formal and ongoing quantitative assessment of supply and demand is the first principle in providing timely appointments for each request requiring a visit. As described in detail in Chapter 3, measuring and then balancing supply and demand at each step along the care continuum is essential to efficient and effective health care and is also the basic component of a systems approach to managing scheduling and
BOX 4-13
Basic Access Principles for All Settings
- Supply–demand matching through formal ongoing evaluation.
- Immediate engagement and exploration of need at time of inquiry.
- Patient preference on timing and nature of care invited at inquiry.
- Need-tailored care with reliable, acceptable alternatives to clinician visit.
- Surge contingencies in place to ensure timely accommodation of needs.
- Continuous assessment of changing circumstances in each care setting.
access to health care. Predictive analyses and simulation models are potentially helpful mathematical tools that health care organizations can use to assess patient demand and to project optimum capacity (see Box 4-8).
Immediate engagement. Every patient or family request for care should be engaged upon inquiry, with a query concerning what the problem is and what might be helpful in the moment. “Immediate engagement” may result in setting a goal of same-day appointments in primary care (see Box 4-2), in specialty care clinics meeting their internal scheduling goals of 10 days or less (see Box 4-4), or in practices that seek alternatives to in-person visits to meet immediate, non-emergent needs (see Box 4-5).
Patient preference. Patients should be invited to express their preferences on the timing of the care interaction (Berry et al., 2014). As detailed in Chapter 3, the focus on meeting patient need should drive systems strategies aimed at improving health care, and systems-based approaches to improving health care scheduling and access should be aimed to improve the patient experience and meeting patients’ needs, as defined by patients themselves. At UPMC Health System (see Box 4-9), the collection and analysis of patient preference data, assembled using such methods as patient shadowing, patient storytelling, and patient surveys, is an important component of the institutional strategy to improve access. As was the case with Seattle Children’s Hospital (see Box 4-12), patient preference data contributed to the redesign of the health system’s existing systems program.
Need-tailored care. The options for same-day response should include various proven methods for meeting patients’ needs or concerns. As described in Chapter 3 and presented in the examples above, these tailored methods for providing immediate engagement may incorporate evolving technologies in health care for the scheduling and delivery of care, including providing various options for in-person visits with physicians such as phone calls, e-mails, teleconferences, telehealth, e-prescribing, and other forms of e-consults (see Box 4-7). Other methods may use non-physician clinicians such as nurses and clinical pharmacists in new capacities (see Boxes 4-5 and 4-9).
Surge contingencies. Every practice setting should have contingency provisions for accommodating patients’ acute clinical problems or questions that cannot be addressed in a timely manner. As discussed in the examples above, technology-based alternatives to in-person visits (e.g., phone calls and videoconferences) to treat urgent but not emergency medical issues after regular office hours have been shown not only to meet patients’ immediate concerns but also to allow consultant physicians to ensure the continuity of
care by, for instance, scheduling follow-up in patient visits with the patient’s regular doctor and entering clinical notes and messages for the patient’s regular doctor through an interoperable electronic health record (see Box 4-7).
Continuous assessment. Patient access metrics—including data on patient and family experience and satisfaction, scheduling practices, patterns, and wait times, cycle times, provision and performance experience for alternative care models, and effective care continuity—should be collected, evaluated, and reported for each practice and clinic. The data collected within each health care organization can serve as tools for evaluating daily activity and monitoring appointments over a specified time period (see Box 4-2), or data can be used to design and test various scheduling models (see Box 4-8). Moreover, to facilitate the interoperability and assessment of comparative performance across care settings, standards and benchmarks on access and wait times should also be developed, tested, and implemented with the assistance of national organizations with expertise in standards development and testing.
Standards and Quality Improvement Organizations
Throughout the report, the committee has noted that few standards and measures exist to adequately reflect performance on health care access. Reviewing the current evidence and the current state of health care systems, the committee determined that it is not currently possible to develop a nationwide standard, but instead standards must be tailored to reflect the influences of the specific setting. As the evidence base grows, standards and quality improvement organizations should design more specific measures and standards to complement and even replace the current best practices. It is important that these measures and standards be evidenced-based and achievable.
Under the auspices of the Department of Health and Human Services (HHS), both the Centers for Medicare & Medicaid Services (CMS), and the Agency for Healthcare Research and Quality (AHRQ) provide federal oversight of health care quality throughout the nation and provide the leadership needed to incorporate access and methods for improvement into the national strategy for health care redesign. Together the two agencies can assist with the incorporation of access and the integration of systems strategies and operations management.
A particularly important possibility is that CMS could incorporate access and scheduling elements into its current portfolio of funded projects, including the Center for Medicare & Medicaid Innovation, the Hospital
Inpatient Quality Reporting Program, the Hospital Outpatient Quality Reporting Program, the Physician Quality Reporting System, and other long-term care and ambulatory care projects. AHRQ can further the development of access and performance-based measures and incorporate them into the National Quality Measures Clearinghouse.
Representing the private sector, the National Quality Forum (NQF), the National Committee for Quality Assurance (NCQA), and The Joint Commission offer natural complements to the efforts of the federal agencies to spur attention and needed improvements in health care access. Further improvements can be achieved through the integration of routine measures and standards of access as a starting point of a national health care redesign. As the clearinghouse of performance measurement, preferred practice, and frameworks for health care improvement, NQF is an essential stakeholder in the efforts to implement, assess, and improve the recommendations of this report. Of particular importance will be the role of NQF in the development of access measures, specifically patient experience measures that are linked to outcome. In addition, the integration of systems engineering, capacity management, and operations research into their education and outreach programs will be key to ensuring further development of the field.
As a consensus builder in the field of quality improvement and standards, NCQA can assist in the spread of the best practices described in this report. In particular, NCQA’s work with technology development and uptake and with the integration of access measures into the Healthcare Effectiveness Data and Information Set and Consumer Assessment of Healthcare Providers and Systems is essential to the redesign to a patient-centered model of health care. The Joint Commission initiative Outcomes Research Yields Excellence is well suited to integrating access-related performance measures into accreditation for hospitals and retail health care clinics. In addition, the inclusion of access measures into the National Patient Safety Goals, and partnership with patient safety organizations that advocate for transparency for patients and consumers (such as the Leapfrog Group) will be a key to introducing and enforcing national attention to this critical component of health care redesign. See Box 4-14 for additional information on these organizations.
Engaging Stakeholders in Design and Implementation
To successfully apply emerging best practices, health care delivery organizations need the expertise and vision of a range of stakeholders, including patients and families, health care organizations, professional societies, insurers and other payers, and the government. The section below describes key stakeholders that are important for implementing, regulating, and sustaining scheduling approaches.
BOX 4-14
Standards and Quality Improvement Organizations
A variety of organizations are involved in establishing and maintaining standards in health care as well as developing measures for the monitoring and assessment of these standards. Brief descriptions of key standard organizations are provided below.
- The Centers for Medicare & Medicaid Services (CMS) plays an important role in the development of standards through the administration of Medicare, Medicaid, the Children’s Health Insurance Program, and related insurance and care programs. This includes standards for providers and organizations nationwide as well as a range of programs aimed at improving quality, safety, and payment in the health system, many of which are housed in the CMS Innovation Center (CMS, 2015a).
- The Joint Commission is an independent accreditation and certification program for health care organizations. This includes the development and maintenance of standards for health care quality and performance as well as measures to enable evaluation. The Joint Commission conducts on-site surveys of all certified organizations every 2 to 3 years (JC, 2015).
- The National Committee for Quality Assurance is a care quality organization that administers a variety of programs to support measurement, improvement, transparency, payment reform, and accountability. This includes the accreditation of health plans and the development of measures, standards, and tools for tracking progress and comparing performance, including the Healthcare Effectiveness Data and Information Set (NCQA, 2015).
- The National Quality Forum is a membership-based organization that endorses health care quality measures. Activities include convening multistakeholder working groups to evaluate measures, seeking continuous feedback on measure performance, and serving as a forum for stakeholders in the health care measurement community (NQF, 2015).
Patients and Families
A key foundation of this report is that patients and their families are essential to the redesign of health care to improve access. Therefore, their preferences should be actively sought and considered when developing and implementing systems approaches to scheduling. Patients and their families can contribute expertise to help clarify patient demand challenges and help seek innovative solutions. Through a number of informal or formal channels (e.g., patient and family advisory councils, surveys, and focus groups), patients and their families can help define preferences, explore alternative access strategies, and contribute to the design of pilot improvement
efforts, shape communication strategies, and interface with governance and leadership.
Engineering and Operations Research Leaders
As health care further changes with increased financial uncertainty, a continuing need for improved efficiency, and continued vigilance for high quality and safety, the leaders of systems engineering and operations management could contribute to the redesign of scheduling practices. The role of systems engineering leaders could involve offering education to physician executives and administrative leaders as well as the development of an infrastructure of talent and expertise (Valdez et al., 2010).
Professional Societies
Developing partnerships between providers and systems engineers will require the introduction of professional societies to systems approaches and to their potential applications in health care. Professional societies have enormous potential to drive policy, determine priorities for their members, and provide an important lever of change for leaders within organizations and practices. Participating in joint workshops and education efforts will begin the process of creating an interdisciplinary partnership and developing the field of systems engineering in health care. Research has always been a high priority for professional organizations and could be focused on designing and overseeing a systems engineering portfolio of projects. Professional societies could then assist their members in the development of appropriate projects and the implementation of new methods within their practices and organizations (Valdez et al., 2010).
Insurers and Other Payers
Governmental agencies, including HHS, the Department of Veterans Affairs (VA) and the Veterans Health Administration (VHA), and the Department of Defense’s Military Health System together influence the delivery of health care to millions of people in the United States and are intimately involved in a variety of efforts that affect health care access. Together with private insurers, they can play a crucial role in the redesign of health care to improve access and decrease cost (DoD, 2014; Levinson, 2014; Murrin, 2014; Nelson et al., 2014).
Insurance company policies have a significant influence over the delivery of health care. Incentivizing providers and administrators to use the techniques of systems engineering to reduce wasteful processes and to streamline health care would lead to a beneficial partnership for all (Valdez et al.,
2010). Insurers are increasingly partnering with providers in accountable care efforts, and the associated financial support could serve to drive a large number of much-needed improvement activities. Insurers play an essential role in health care access reform because of their interest in having a strong financial performance over a longer period of time. As many of the financial effects resulting from systems engineering approaches accrue over several years with no rapid return on investment, this partnership will require a careful calibration of expectations (Gong et al., 2015).
Government
HHS has provided the impetus for the adoption of health information technology (health IT) through the Health Information Technology for Economic and Clinical Health Act (HHS, 2015). As part of the meaningful use of IT, interoperability has been singled out as an area requiring further development, and it is a factor that will have a direct impact on health care access (McGowan et al., 2012). HHS’s role in driving additional changes in IT infrastructure and governmental oversight cannot be overstated. The introduction of additional IT functionality through the Office of the National Coordinator for Health Information Technology to ensure standardized measurement and scheduling would allow successful access reform (ONC, 2015). As the national agency responsible for the training, design, and monitoring of the health care workforce, the Health Resources and Services Administration (HRSA) will play an important role in implementing the recommendations, partnering with professional organizations to educate the health care workforce and offer new roles for members of the care team (HRSA, 2015).
Also under HHS, the CMS Innovation Center is involved in funding many start-up projects investigating new payment and delivery models that align with the triple aim to achieve better care for patients, better health for our communities, and lower costs (CMS, 2015c). CMS has already provided funding for the first group of improvement efforts, including the use of e-Consult and e-Referral, and it will be a valuable partner in overseeing the implementation of the recommendations in the heterogeneous setting of health care (CMS, 2015e). The CMS Partnership for Patients was an important partner for emphasizing the need for the patient-centered focus in care redesign, and it laid an important foundation for how this principle of patient-centeredness can be applied to solving access challenges. Because access reform involves a movement toward patient-centered care, CMS wields strong influence in this movement through funding efforts, spreading success, and generally broadcasting the success of using systems engineering and operations management techniques to address the profound delays within the health care system (CMS, 2015b).
National health care providers are also important for facilitating scale and spread of best practices and expanding the evidence base. As presented in this report, the Department of Defense Military Health System is already studying variability of wait times within its own organization, seeking strategies for geographic barriers, and developing benchmarks for wait times and access (DoD, 2014). The VA/VHA efforts will require significant attention to the roles of leadership and the command and control management found within the organization. However, with some of the new efforts recently put into place and the staged introduction of techniques that were previously successful in various VA/VHA facilities, systems approaches could yield very rich results. In a system combining both financial and clinical data, the VA/VHA is set to be the national leader of integrating systems engineering into health care (VA, 2014a).
The cases presented within this chapter, as well as the literature reviewed by the committee, provide a foundation for the committee’s recommendations (presented in Chapter 5), which emphasize the needs to anchor scheduling practices within the identified access principles; to adopt systematic approaches to health care scheduling; to address variation of scheduling practices through coordinated efforts to build the evidence base, test best practices, and develop standards; and to incorporate the perspectives of patients and other stakeholder groups in planning, implementing, and evaluating new approaches to scheduling.
