Transforming Health Care Scheduling and Access Getting to Now (2015) / Chapter Skim
Currently Skimming:
4 Building from Best Practices
4 Building from Best Practices
Pages 49-78
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From page 49... ...
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.
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;1 internal benchmarks guide door-to-provider times within emergency departments (Virginia Mason Hospital) , wait times for specialty new visits (Cincinnati Children's Hospital)
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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)
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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.
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. Box 4-3 p d escribes 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.
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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.
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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.
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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)
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Patient-tracking technologies can help caregivers work more efficiently and improve patient safety by providing real-time information on a atient's location in the hospital system and identifying obstacles to p smooth and timely patient flow (Dobson et al., 2013)
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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)
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This suggests that Teladoc can help increase ac cess 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.
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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 prac tices 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.
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. 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)
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. 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)
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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)
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In addition, patient satisfaction rates for the emergency depart ment, 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)
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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.
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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)
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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)
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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.
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. 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)
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. However, patients and their families were not always included in quality improvement activities early on.
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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)
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. 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.
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Patient access metrics -- including data on p atient 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)
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In particular, NCQA's work with technology development and uptake and with the integration of access measures into the Healthcare Effective ess Data and Information Set and Consumer Assessment of n Healthcare Providers and Systems is essential to the redesign to a patientcentered 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.
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. • he National Quality Forum is a membership-based organization that en T dorses health care quality measures.
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and the Veterans Health Administration (VHA) , and the Depart ment 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.
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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)
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From page 78... ...
, 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.
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