Strategies for Improving
Access and Efficiency
Michael Rothman
Senior Program Officer
Robert Wood Johnson Foundation
© 2002 Institute for Healthcare Improvement
Access & Efficiency Aims
Advanced Access
 “same day” access to eligibility staff
 “planned” visits at desired intervals if
necessary for follow-up work
Office Efficiency
 average time client spends in office
(cycle time) = 1.5 times length of
scheduled time with eligibility worker
© 2002 Institute for Healthcare Improvement
Access & Efficiency Aims
Client satisfaction with Access

90% rate the timeliness of getting an
appointment to be excellent
 90% rate timeliness to see the eligibility
worker during an appointment to be
excellent
 90% satisfaction with match to the
eligibility worker
© 2002 Institute for Healthcare Improvement
Core Measures
•
Time to 3rd next available appointment
•
Appointment cycle times (time client
spends in the office)
•
Client satisfaction
•
Staff satisfaction
•
Daily capacity (available worker hours)
•
Daily demand for appointments
© 2002 Institute for Healthcare Improvement
Three Strategies for
System Optimization
System
Demand
Strategies



Shape the demand
Match capacity to demand
Redesign the system
© 2002 Institute for Healthcare Improvement
1. Match Capacity & Demand
• Design and implement a barrier free
access system that is client-focused
• Understand demand and schedule
supply
 If
demand is less than capacity then do outreach
to find more clients
 If demand exceeds capacity then add staff &/or
redesign team roles
© 2002 Institute for Healthcare Improvement
Measure True Demand
External = calls for appointments (regardless when
scheduled)
+ Walk-ins
+ Referrals (e.g. from other offices)
+ Deflections (e.g. clients sent to other offices)
+ Other
Internal = return visits generated by staff
External + Internal = True Demand
© 2002 Institute for Healthcare Improvement
Know your Capacity/Supply
What is your staff capacity?


Number of people
Hours of availability
Understand fluctuations in capacity

Increase supply for seasonal
demand (e.g. outreach campaign)
© 2002 Institute for Healthcare Improvement
Matching Demand and
Supply
8
7
6
5
4
3
2
1
0
7
6
5
5
5
Demand
M
Tu
W
Th
F
8
7
6
5.6
5.6
5.6
5.6
5.6
5
4
Supply
3
2
1
0
M
Tu
W
Th
F
© 2002 Institute for Healthcare Improvement
Matching Demand and
Supply
8
7
6
5
4
3
Demand
2
1
0
M
8
7
6
5
4
3
2
1
0
Tu
W
Th
5
5
F
7
6
5
Supply
M
Tu
W
Th
F
© 2002 Institute for Healthcare Improvement
2. Reduce or Shape
Demand
• Improve continuity with worker, reduce confusion
• Maximize appointment efficiency (do more in
appointment using generic workers)
• Reduce return appointment rates
• Extend eligibility through alternative mechanisms
(e.g. reenroll at provider offices)
• Leverage the workers’ time through triage &
protocols that other workers can use
• Use telephone advice as an alternative
• Use group appointments as an alternative
© 2002 Institute for Healthcare Improvement
3. Reduce Appointment
Types
• More types decreases flexibility in
schedule
• Different durations = types
• Building blocks of 15 or 20 minutes
• Suggested types
 New
client
 Follow-up visit
 Renewal
© 2002 Institute for Healthcare Improvement
Truth in Scheduling
•
Measure from start of appointment
to start of appointment
• Average over 50-100 consecutive
appointments
• Use this average to build your true
schedule
• Accounts for activity in and
outside of 1-1 appointments
© 2002 Institute for Healthcare Improvement
4. Work Down Backlog
•
Measure the delay for appointments
(backlog)

•
Make a plan for reducing backlog



•
Distinguish between planned (necessary
revisits) and backlog
No substitute for hard work
Add temporary capacity
Extend re-visit intervals & look ahead
Start and end date for working down
backlog
© 2002 Institute for Healthcare Improvement
5. Contingency plans
•
•
•
•
Tools to close the gap between
capacity and demand
Proactively manage demand variation
Used when the backlog has been
reduced, and the office is functioning
has achieved Advanced Access
Used to maintain the new and better
status quo
© 2002 Institute for Healthcare Improvement
Triggers for
Contingency Plans
Seasonal variations

outreach efforts; new programs
Staff vacations/illness/leave
The “predictably unpredictable”

staff late
 client late
 emergency
 post vacation schedules
© 2002 Institute for Healthcare Improvement
Contingency Plans
•
Increase staffing based on
demand predictions
•
Develop flexible, multi-skilled staff
•
Anticipate unusual but expected
events
© 2002 Institute for Healthcare Improvement
6. Manage the Constraint
•
•
•
•
•
•
•
Constraint resource is never idle
Phone follow-up rather than in-person
Utilize triage & work protocols
Shift work within the team
Simplify what the worker needs to do
Choreograph hand-offs
Alternatives to traditional 1:1 visits
© 2002 Institute for Healthcare Improvement
7. Optimize Staff Teams
•
•
•
•
•
Co-location of people and resources
Cross-functioning and cross-training of
staff
Self-organization & sharing of work
All-team huddles to plan appointments
Weekly team meetings to fine-tune and
innovate
© 2002 Institute for Healthcare Improvement
What Should the
Team be Doing?
Explore the Mismatch:
Things to look for:
Between role and activity
State guidelines and current
role
Between activity and client
needs
Between staffing and demand
by hour of day, days of week,
month of year
Where do you see variation?
Are the right people doing the
right things?
Are roles commensurate with
education, training?
Are staff trained to the highest
level of capability?
Are there systems to support and
monitor performance?
© 2002 Institute for Healthcare Improvement
Cross-functioning
Train as many team members as possible
to perform as many team functions as
possible, within limits of regulations
Separate the work flows and create flow

In-office flow
 Non-appointment flow
Rotate duties, level the work, work the
constraint
© 2002 Institute for Healthcare Improvement
8. Synchronize Client, Staff
& Information
• First AM and PM appointments start
on time
• Client registration done on the phone
if confirming appt.
• File-check to make sure file is
complete, accurate, and present
• Use prompts to anticipate full
potential of today’s needs
© 2002 Institute for Healthcare Improvement
9. Predict & Anticipate Needs
•
•
•
•
Production planning – developing
a list of contingency plans to
accommodate variations in the
work
Short term - Huddles
Medium range – next 30 days
Long range next three months
© 2002 Institute for Healthcare Improvement
Appointment Planning
Team huddles
Gather all pertinent information prior
to visit

Prep at huddle
 Ensure all necessary personnel,
supplies, forms, etc. are available at
the time of the appointment
 Discover special needs when
scheduling the appointment
Max-packing
© 2002 Institute for Healthcare Improvement
Visit Planning: Huddles
Five minutes max
Don’t sit down
Entire microsystem/care team: workers,
and clerical support
Typical short term contingency plans for
unexpected appointment demand

Deflect some demand to other sites
 Team stays late
© 2002 Institute for Healthcare Improvement
10. Optimize space &
materials
• Use architecture to structure flow
and promote outstanding service
• Create generic spaces with
customized items accessible
• Eliminate steps and hand-offs
• Build teams and define roles
© 2002 Institute for Healthcare Improvement
June 19-23
May 15-18
Apr 17-21
1
Mar 13-17
Feb 14-18
Jan 17-21
Dec 20-24***
8
Nov 22-26
9
Oct 25-29
Sept 27-Oct 1
Aug 30-Sept 3
Aug 2-6
June 28 - Jul 2
May 31-June 4
April 26-Apr 30
Before Open Access
Mar 29-Apr 2
Mar 1-5
Feb 1 - 5
Jan 4-8
10
Dec 7-11
Nov 9-13
Days to 3rd Next Available Appt.
After Open Access
ThedaCare/AMC
7
6
5
4
3
2
Target Level
0
© 2002 Institute for Healthcare Improvement