Unlimited access creates a brave new world
Why wait? Appointments can be the next day
A patient thinks of his or her health care providers and says, "They give me exactly the help I want and need exactly when I want and need it."
Sound revolutionary? It’s one of the tenets of an initiative called Idealized Design of Clinical Office Practices (IDCOP) that is being promulgated by the Institute for Healthcare Improvement (IHI) in Boston.
The initiative, led by IHI president and CEO Donald M. Berwick, began in 1998 and involves about 23 health care organizations in the United States and Sweden, explains Karen McKinley, RN, CHAM, senior director of system access services, for Geisinger Health Services in Danville, PA.
"It is our belief that the health care system is broken," adds McKinley, who is past president of the National Association for Healthcare Access Management. "You can’t attack the whole system at once — it’s too complex — so the initiative was focused in a specific area, the office practice, to begin to improve health care delivery."
Geisinger Health System got involved with IHI in January 1999, when it was invited to be a prototype site for the clinical office practice initiative. The project is ongoing, she notes, and has no scheduled date of completion.
The IDCOP model focuses on the following four themes, all of which are interrelated, says Pat Rutherford, MS, RN, vice president of IHI.
• Access. Patients have unlimited access to the care and information they need, when they need it. Access to care should be available 24 hours a day, seven days a week, 365 days a year.
• Interaction. Interaction between the patient and care team is deep and personal. The care team has memory of the patient. Every patient is the only patient.
• Reliability. The system exhibits high reliability in that it provides all and only the care known to be effective.
• Vitality. The practice has vitality: a happy staff, a spirit of innovation, and financial viability.
The theme of "access" — which has a different meaning here than the one access managers typically associate with it — is getting a lot of publicity, Rutherford calls it "a delighter." Described initially as "open access" and now referred to more accurately as "advanced access," she notes, the idea is that patients have unlimited access to the care and information they need when they need it.
"This is our overarching, guiding principle," Rutherford explains. "When patients or consumers want to have interaction with providers of health care, they have access. It may be a visit, a telephone consultation, an e-mail, or a group visit. The relationship with the clinician could happen in a variety of ways."
The phrase "open access" scared off some clinicians, she says, because they thought it meant patients could walk in whenever they wished. Actually, "they call and are fit in, but within a schedule."
Under the ICDOP initiative at Geisinger, for example, the health care organization is taking actions with scheduling that are aimed at advancing access for patients in the clinic setting, McKinley explains.
The concept of advanced access is woven into the training module on scheduling, adds Lynn Schankweiler, CHAA, training specialist at Geisinger. "It is about meeting today’s needs today. It basically means the provider tries to keep a part of the schedule open to accommodate the person that needs or wants to be seen today."
It doesn’t matter, Schankweiler notes, why the person wants to be seen today — it could be because he needs a physical or because she thinks she has the flu.
Advanced access also means, she says, that wherever in the health system the patient makes contact, that employee will facilitate the meeting of that patient’s needs. When the patient is checking out, for instance, and needs a follow-up appointment, Schankweiler says, it’s not enough to say, "Here’s the number to call for radiology."
"Our employees are expected to facilitate or coordinate the request," she explains. For example, Schankweiler adds, the employee should actually make the call or schedule the appointment directly on-line for the patient.
Advanced access is best explained, Rutherford says, by consultants Mark Murray, MD, MPA, and Catherine Tantau, MPA, who developed the concept in the early ’90s, when they managed a large primary care department for Kaiser Permanente in north Sacramento Valley, CA.
Their implementation of what is alternately called "advanced access," "open access," or "same-day scheduling," included two crucial features:
• continuity, meaning the system’s ability to match patients with their own personal physician;
• capacity, meaning room on the daily schedule.
The system, described at length in the September 2000 issue of Family Practice Management, has one underlying rule: "Do today’s work today." (The article "Same-Day Appointments: Exploding the Access Paradigm" can be found on the World Wide Web at www.aafp.org/fpm/20000900/ 45same.html.)
Although not directly related to what is commonly thought of as the access department, many of the concepts used in the clinical office practice initiative "could apply to many areas," Rutherford notes, including admitting and the emergency department (ED).
"It’s about really understanding what your workload is and scheduling [with those in mind]," she says. "In the ED, for example, it’s usually quiet in the morning, so you want to staff accordingly to meet that demand. You probably have peaks of activity within the admitting office, so how do you deploy personnel so there are not long waits, but a continuous flow?"
One of the neat applications for the access department, McKinley points out, "is that we have enhanced our staff development. We can achieve levels of staff functionality and satisfaction that we haven’t seen in a long time."
Also under IDCOP, she says, health care is interactive and providers work to ensure that care is individualized. "Communication is based on patient preference," McKinley adds, noting that a patient might be asked, "Do you need a return appointment or could your needs be met through e-mail or over the telephone?"
The theme of reliability, she says, suggests a match between new science and best practice. The idea, McKinley explains, is that "all and only" effective and helpful care is given.
"Our systems should provide all past information about a patient to eliminate repetition and duplication," she says. "In addition, any new knowledge about the patient’s condition or treatment options should be right at our fingertips to be used during the patient visit."
IDCOP "talks about a clinical office that is financially viable, innovative, and a great place to work," McKinley notes. "We try to teach that clinical practice should be a living laboratory’ within a learning organization.’ Remember that you always have something new to learn."
There are measures of success that correspond to each of the four IDCOP themes. Under "vitality," for example, providers look at:
• proportion of work that is innovative;
• new patient visits;
• staff morale;
• operating margin.
For the theme of "interaction," the measures are:
• patient ratings of quality interactions (visit and nonvisit);
• use of shared decision-making models;
• patient/provider match.
IHI offers these questions for providers seeking to understand and improve their own practices:
• Who is your patient population?
• How many patients do you have?
• What are their needs?
• How do you currently meet patient and family needs?
• Who in your practice does what?
• What are your current patient and family outcomes?
• Who should your practice collaborate with in the health system/community?
[For more information on the Idealized Design of Clinical Office Practice and other IHI initiatives, visit the organization’s Web site at www.IHI.org. Karen McKinley may be reached at (717) 909-3382 or by e-mail at [email protected].]
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