A new American study has introduced some of the most potent seeds of doubt to date about the much-heralded Advanced Access scheduling method that is just beginning to achieve a measure of popularity in Canada.
In "Implementing Open-Access Scheduling of Visits in Primary Care Practices: A Cautionary Tale," published in this week's Annals of Internal Medicine, three US researchers found decidedly mixed results for medical practices that attempted to switch over to Advanced Access scheduling (also called open-access scheduling).
GAINS AND LOSSES
Of the six practices examined in the paper, five saw huge gains in access almost immediately. "The 5 practices achieved substantial improvements in access, as measured by time to third available appointment, during the first 4 months after implementation. The average time to third available appointment decreased from 21 to 8 days for short visits and from 39 to 14 days for long visits."
But those improvements didn't last. Here were some of the results:
As if the authors' failure to verify previous studies' glowingly positive results on Advanced Access scheduling weren't enough, they also question the validity of other researchers' claims: "Nearly all the [previous] studies have important methodological limitations (many of which our study shares), including no statistical testing, limited access-to-care measures, lack of concurrent control groups, small sample size, and inconsistent methods. Among the few studies that assessed outcomes beyond access to care, open access had mixed effects on patient satisfaction (2 of 5 studies reported improvement), staff satisfaction (1 of 2 reported improvement), and no-show rates (3 of 6 reported improvement). Our results add to this literature and raise the question of whether open-access scheduling truly leads to the ancillary benefits that advocates have proposed."
The researchers admit that their study may have been flawed -- "barriers" they hadn't accounted for might have caused the scheduling changes to fail, or the location of all the practices in Massachusetts might have biased the data somehow -- but the scent of failure is powerful nonetheless, and that should be disturbing to the many Canadians who have staked their practice revenues and their reputations on Advanced Access.
THE CANADIAN CONTINGENT
I wrote about several such doctors last year (one, Kishore Visvanathan, has been chronicling his urology group practice's struggles with implementing Advanced Access on a blog hosted by the Health Quality Council of Saskatchewan). And this April, I wrote about a new educational program spreading the Advanced Access gospel across Saskatchewan. "It's a tough transition -- very challenging," Catherine Tantau, a nurse who helped develop the theoretical and practical background for Advanced Access, told me. "But once people see what is possible and experience improvement in their day -- good grief, who would want to go back to practising with all the obstacles and burdens they have?"
But after the appearance of this new Annals of Internal Medicine paper, it seems that Canadian doctors may have to exercise more caution than some of the proponents of Advanced Access had initially anticipated. The new paper is far from a death knell for the same-day booking movement -- but it's a serious warning that Advanced Access is not the panacea it has sometimes been made out to be.
Check out our website: www.nationalreviewofmedicine.com
Latest headlines
Tuesday, 17 June, 2008
Still in its infancy in Canada, Advanced Access scheduling gets worrying news from US study
Subscribe to:
Post Comments (Atom)
The heart of Advanced Access ?Theory hinges on this statement:
ReplyDeletePASTE
......the theory is that your practice's capacity is actually greater than the demand and if you can manage your scheduling appropriately, it's possible to eliminate your wait times and begin seeing same-day visits......
END OF PASTE
As the thrust to get physician's to STOP:
(a)segmentation and differentiation of the "disease itself" versus the client who has the disease
(b)thinking of " span of control" as delegation only versus a " farrow to finish" event
....the physician must educate himself to understand the difference between:
(a) needs-based positions
(b) variety-based positions
(c) access-based positions
[Now get your pencil and paper and make a grid with low to high revenue on the vertical side and low to high market value on the horizontal. your job? look at where each position "fits" on the grid now.... and where it " should" fit]
Let's begin:
In Canada "the funder" pays for (a)position and you have to have a "program theory" applicable to that box on the grid (i.e. lower left which is lowest remuneration and lowest market value). This lower left corner is a magnet for professionals who believe their greatest earning asset is " skills and abilities" ( WRONG!)
Advanced Access Theory ( at present) appears to fit here.
(b)position is the " undefended hill" in terms of " coordination of services" and a doorway to making enough revenue to support manageable "clusters of care" ( millions actually ). On the grid this position is upper right and hits the " socially responsive" button for the funder as you create a circular independent activity that demonstrates " real world utility".( not just your world :).This box is empty right now.
(c) position is where " access" theories are supposed to fit.
Noone really cares about it yet because it needs to solve the dilemma of economies of " scope".... not just " economies of scale". Scope makes the best use of money/assets allotted. Scale brings more money in... you cannot successfully "perpetuate" the one without the other as aplied to clients....[not just "materials management"..or only secondary, tertiary and quaternary care levels].
Presently the focus of Advanced Access theory on " what" to do appears to need to spend more thought on the "how".
......so there it is lingering in the lower left hand box on the grid ( sigh....)
Building further on ( c) position the " how" question can be answered by the physician applying a little imagination: i.e.
....imagine the letter "z" .
the upper parallel line is the new application of Advanced Access on same-day bookings. The lower parallel line "is" advanced bookings.
The physician is the "vertical connect" line providing a "new" definition of care/case management.
IF you learn how to effect this care/case management "connect" at certain points in each line ( there is an algorithm for this) you will prosper...... and wait times will not be an issue ( been there, done that !)
However.........
if you actually want to financially prosper as well and have a stable client base that is fully served by you in every position..... you HAVE to master (b) position . It cannot be left as the domain of the private sector only.
(NOTE: monopolies don't have a "demand curve".. so they have an excuse to be in the lower left of the grid..... but you dont!
SUMMARY
In the upper left corner of the grid where ( according to the funder) the value is high.... but there is little market value here... you are seeing the "apprenticing" of their knowledge workers leaving the institutional walls of acadaemia and serving the community as mentors/coaches/preceptors equipping a "worker" complement for " cluster care".
This event could easily be moved into the upper right hand quadrant in the future IF, IF, IF, IF a " use-inspired symbiotic relationship" [Stokes} with the "funder" is established by the physician ( now there's a concept!)
KEY?
The scramble for redefining " primary care" is on......get some "workpaths matching carepaths" event in your practice and you have a good start to becoming the "vertical line in the "z".
....phew.... I need a nap ;)
When I reviewed the process Sam it became obvious that the management changes are just as important as the scheduling. If you can't control variation in need, time spend and provider availability the system won't work. Good articles. Thanks.
ReplyDeleteThanks, Sharon and Ian, for your comments.
ReplyDeleteI think both of you are correct. The take-home message seems to be that many physicians with high hopes for Advanced Access haven't figured out how to deal with some of the confounding factors -- like the "management changes" that you referred to, Ian. That includes the difficulty of improving efficiency that Sharon points to in her discussion of "economies of scale" and "scope" and her recognition that much of what is now considered "primary care" needs a rethinking. (For instance, does every vaccine booster shot really have to be given by a doctor? Probably not.)
It's important to note that none of this means Advanced Access is a bad idea -- just that it is sometimes a good idea subverted by bad follow-through. That was one of the things that Bonnie Brossart, the CEO of the Saskatchewan Health Quality Council (one of Canada's biggest Advanced Access advocates) told me a couple months back when I asked her how her organization could justify charging $3,000 to $4,500 to teach doctors about implementing Advanced Access. She told me that doctors who don't take proper precautions and do their due diligence can often end up in trouble with scheduling changes. Ms Brossart told me: "What appears to be simple is not always. When you think about supply and demand, how many people are working, scheduling — it seems to be straightforward, but with the nuances of how to change and modify them, I would suggest self-teaching would be very difficult."
"I think people are wise to get some help and support, whether it's from us or a local health authority," was how Catherine Tantau put it. "This is tough work. You can't dabble. It needs to be one of your top three strategic goals or it won't happen."
(You can read the rest of the article about the Saskatchewan HQC and self-teaching here: http://www.nationalreviewofmedicine.com/issue/special_sections/2008/practice_management/5_your_practice02_4.html)
Sorry -- the full link is here.
ReplyDeleteSam....
ReplyDeleteThank you for your remarks. There is no shortage of "true" statements that apply to this situation. The key is to get the " relevant" true statement to the physician client.
I do not see how you can bypass the development of a collaborative team and formation of a matrix model as a FIRST step to having ownership over a thriving new entity that deals with access effectively.This needs more than the " blind leading the blind" ( OUCH!)
If this can be effected for $3-5,000 dollars... classify it as a miracle!
The best you can hope for is the equivalent of hiring a closet organizer... OUCH!!!.... I did it again !)
That is not meant to be as harsh as it sounds... it is only meant to ring true " in the big magic somewhere" where project-based funding is born.
After all , what do you do when you are applying jumper cables to a group in the lower left quadrant.......... ?
Answer: you give away as much as you can and incur as few costs yourself in the process as possible..... until they learn that "as a group" they could all pay less, learn more( remember synergy?), and take advantage of " economies of scope" ;)
The recent study published in the Annals of Internal Medicine highlights that benefits from Advanced Access interventions may not be sustainable. In our experience with other quality improvement programs, we know that improvements can drop off when you stop paying attention to the processes. This really speaks to the need to continually monitor outcomes, to ensure that successes are sustained. As part of our Clinical Practice Redesign School, we specifically tell participants that Advanced Access is not a quick, one-time fix. Even after you have tested and implemented new processes, you need to monitor your outcomes, and refine processes as necessary.
ReplyDeleteThe Annals article notes that some practices faced problems when providers left. One of the key principles we teach is to do contingency planning so practices can be proactive and take necessary steps to mitigate problems when providers are away.
In terms of no-show rates and patient or staff satisfaction (which the study warns may not be improved by Advanced Access), we emphasize to our colleagues that you need to formulate some measures that will help you understand the underlying problems and then introduce changes to address them. We wouldn’t expect that simply moving to a different scheduling system will – on its own – improve complex factors like satisfaction.
In Saskatchewan, the Health Quality Council promotes a practice redesign approach to deal with access issues. Practice redesign is not only about changing your scheduling processes and offering quicker appointments; it is about looking at the way you deliver your services and examining where providers and staff spend their time. Once you gain a deeper understanding of the way your system is functioning, you can implement changes to your practice that increase efficiency and lead to sustainable improvements. Providers need to be ready to truly evaluate the current system and if they accept that the status quo is not good enough, Clinical Practice Redesign and Advanced Access offer tools which can facilitate a new way of doing business.
Just a few comments on the current posts:
ReplyDeleteFirst, I am not sure if the original article even used the term “Advanced Access” certainly not in the title.
Second, the implication here is that this work is a product but this work is not a product- this is a philosophy, informed by process (team, aim, change, map and measure) and a set of change principles to address waits and delays. The article and subsequent discussion miss the key point that needs to be addressed: delays are bad, but if we want to eliminate delays we need to understand, measure and achieve a balance of demand for service with the corresponding supply of service. The article and commentators imply that the product-the solution-lies in just offering appointments on the same day. The implication is that just the act of offering solves the problem. This behavior is the end result not the goal, that is, if we can balance the demand and the supply then we can offer the services each day without a delay (the result). Just offering the appointment services each day (the solution) in and of itself does not solve the access problem. This is the point that is missed- they imply that a solution (offering) solves the delay issue, we say that addressing the delay issue through the lens of demand and supply results in the solution of offering an appointment each day.
Mark Murray,
Mark Murray and Associates
Mark......
ReplyDeleteyou said:
The article and commentators imply that the product-the solution-lies in just offering appointments on the same day. The implication is that just the act of offering solves the problem.
I said:
....imagine the letter "z" .
the upper parallel line is the new application of Advanced Access on same-day bookings. The lower parallel line "is" advanced bookings.
The physician is the "vertical connect" line providing a "new" definition of care/case management.
IF you learn how to effect this care/case management "connect" at certain points in each line ( there is an algorithm for this) you will prosper...... and wait times will not be an issue
( been there, done that !)
this is about the physician becoming a true " knowledge worker" with relevant interprofessional connects within and outside of his physical space.....that enable his practice to expand dramatically...and permits patient care clusters to function independently of his physical presence....
This is what Web 3.0 is all about
This is what developing internet dependence in Web 2.0 is all about
This is what maturity matrix modelling is all about and you " patent" your " process
This is NOT about scheduling appointments.