Improving Appointment Access at a Safety-Net Primary Care Clinic: A Case Study

By: Chloe Ciccariello + Kenny Pettersen

Quality improvement (QI) skills are becoming increasingly recognized as essential skills for the modern physician. These skills are even more critical for the primary care physician working in safety nets where technological and administrative support are lacking. While the American College of Graduate Education requires that internal medicine residents learn QI skills, there is no a consensus on how best to teach them. As graduating primary care residents, we believe there is only one way to learn QI: Dive in! It is the only way to learn the lingo and skills of QI and apply these tools to real problems.

For the past two years, we have had the opportunity to join our clinic’s practice transformation committee. The committee aims to transform our clinic into a highly functioning medical home. Practice transformation meetings are multi-disciplinary, pulling together the leaders from nursing, medical assistants, clerks, MD providers and behavior health to create multi-faceted solutions to many of the complex challenges that our clinic faces. We joined this team to provide the resident voice. This was definitely an eye opening experience!

This group has recently focused on access to care. Access is one of the 10 building blocks of primary care, as outlined by Tom Bodenheimer et al in their landmark paper on this topic. Access is a broad topic, encompassing quantitative metrics such as third next available appointment (TNAA), productivity and no-show rates. It also includes more qualitative measures like whether patients feel they can get help when they need it.

Building Blocks of Primary care; Tom Bodenheimer et al

Our clinic set out to improve access — but how does one approach this? We focused on TNAA based on financial incentives from our payers. At the outset, our clinic’s TNAA was higher than could even be measured, while the state expected us to have a TNAA of 14 or less. We definitely had room for improvement!

As residents, we set out to gather more information using Lean tools. We spoke with residents, clerks, attendings and nursing about what access meant to them and how our clinic could improve. Those interviews reflected the “supply-demand” model of clinic access. Access to clinic appointments improves only when the demand for appointments does not exceed the supply. Given that supply of appointment is fixed in our clinic based on resident and attending schedules, space, time, etc — we sought to see if we could increase supply through improved scheduling. We then “went to the Gemba” and created a process map to demonstrate how appointments are scheduled.

Process Map — Scheduling Appointment at Richard Fine People’s Clinic

We found many sources of waste and inefficiency in how appointments are scheduled. The most common route to obtaining appointments is that the provider (MD or NP) requested an appointment at the end of a patient visit. If the provider’s schedule was not open, patients were scheduled for appointments after they left clinic and mailed a letter with an appointment date and time. Making appointments without informing the patients resulted in numerous no-shows and took away slots from patients who had urgent concerns.

We trialed a few countermeasures to address these issues, including an educational campaign for providers on scheduling best practices and communication best practice between provider and clerk.

Slide from powerpoint given to resident providers on best practices for scheduling patients for follow-up

Not every QI initiative is destined for lasting success. We also trialed monthly clerk-provider huddles to increase communication around scheduling nuances. Ultimately, the clerk-provider huddles were too challenging to arrange so this initiative was abandoned. We also calculated resident productivity and fed this back to the residents to encourage them to schedule more appointments. This did not substantially increase their productivity.

Goals of chief-provider huddles from power point presentation created and shown to resident providers

Ultimately, the clinic decided to completely overhaul the way we do scheduling, and move to a patient-initiated scheduling system. Now providers decide when they would like to see the patient for follow-up. If that appointment is less than 1 month away, the patient schedules it at the front desk before leaving clinic. For appointments further in the future, the clinic sends the patient a postcard one month prior to their anticipated follow-up. The patient calls into clinic to make the appointment at a time that is convenient for them. In our first 2 months of postcards, the patients who made appointments had a no-show rate of <10%, which is remarkable when compared to our clinic average of 30%.

While the postcard system has worked swimmingly for patients who called in to make appointments, we worry about those who did not. 25% of people sent post cards did not make appointments. Patients who do not speak English, are homeless, or have cognitive impairment may have more difficulty navigating postcards.

We have several reflections that we will take away from our time improving access at our clinic.

* “Wicked problems” or complex challenges, often need multidisciplinary teams and multi-faceted approaches to solve them.

* Even things that see like great ideas sometimes flop, and it’s okay to walk away from an idea if it isn’t working.

* Projects never end, they just evolve. Our clinic team has been working on the issue of access in clinic for two full years now, but we are still far from “solving” the conundrum of access.

* Ultimately, we leave residency more prepared to face the challenges inherent to primary care thanks to this experience.

Many thanks to the Practice Transformation Working Group for including us in this important work!

Attending post-script

After years of hard work, our TNAA has gotten a whole lot better — dropping from “too high to measure” to 16. We are in spitting distance of 14, the state benchmark.

We are also embarked on a deep dive analysis of those patient who fail to make appointments when prompted by postcards, so that we can ensure they do not fall through the cracks of our new system.

This improvement would not have been possible without Kenny and Chloe’s curiosity, data driven improvement efforts and tireless energy.