Opening up your schedule

Tags: practice management, patient-centered medical home, open-access scheduling

Opening up your schedule

How to switch your practice to open-access scheduling

By Gail Jones

As the push for the medical home and the ability for patients to see the provider that they want become more commonplace, the need to determine how to provide open access comes to the forefront. Open-access scheduling has been popular in many work places and outpatient clinics for years and in many cases has been successful. If done correctly it has been said that it can decrease patient wait and improve patient satisfaction and employee morale. This may be possible, but if done incorrectly it can create more problems.

There are many types of open access and ways to handle it. One of the most common is to include a portion of the day that is open and available for work-ins. This ensures that the scheduled patients will still be seen and, if the time is not booked, will allow flexibility for staff in finishing bookkeeping and other duties.

Others have a regular schedule during the day and then provide a stat-care clinic for the work-ins. Many are staffed into the evening and weekends and in some cases are 24 hours a day. By doing this it allows the physicals and long appointments to be scheduled in advance, but allows what would have been scheduled further out or “worked-in” to have a normal schedule.

A more radical approach has been to no longer offer scheduled appointments and instead have everything as a first-come, first-served basis for the practice. Patients start calling that morning and are told when they can come in. The problem is, of course, that everyone wants to come in that same day and other days remain open. This also can lead to patient frustration due to planning issues. Many patients schedule doctor appointments around work, child care and other family issues. Not being able to plan in advance for many is not an option. Others love this type of setting and use clinics staffed by nurse practitioners for this reason.

A Family Practice Management article from 2006 titled “Scheduling in an Academic Practice” described the adaptation of a practice establishing a “five-day appointment window.” The practice featured described how many practices were offering 50 percent of appointments as same-day while the remaining patients were seen over the next few days. This practice established a five-day policy. When patients called, instead of setting up the appointment the same day, the patient was offered an appointment within the next five-day period. This allowed greater flexibility for patients and staff and ensured the schedule was balanced. The article reported that the practice had maintained success in this arrangement for two and a half years at the time of the article’s release.

This takes some planning in advance to switch to this type of scheduling. It is important that the scheduling staff understands the concept and is willing to follow the new guidelines. Plan ahead and schedule the new appointments several months out. When changing the schedule, I found it necessary to look four to six months in advance. It depends upon the existing schedule and the physician’s ability to change to the new schedule. Some start-up dates will be further out than others. Take time to examine what types of appointment you typically have and how long they really take.

A problem occurs when a physician cancels office hours due to “emergencies;” in some cases these can be personal or professional. If a practitioner regularly cancels or shortens hours, it pays to have extra open-access slots for this provider to keep from moving the patients. Another problem can occur when the physician is scheduled to be away from the office. Some offices handle this by having all appointments open access for one to two weeks after the physician returns. Usually two to three days before the scheduled leave, at least half of the appointments are left open. This can reduce the overbooking that commonly occurs when a physician is on leave.

During the process, reschedules should be kept to a minimum and the staff should make an effort to track them. This may be as easy as documenting in the chart or managed electronically. However, a record should be maintained as well as why the appointment was rescheduled. This can help show if there is a trend developing and what changes might need to be implemented to counteract the trend. Develop a policy on how many times reschedules are allowed and alert the patients if you charge for missed appointments and if there is a time frame in which they must reschedule in order to avoid a fee.

By establishing a system to verify that patients follow up with appropriate care, you ensure that you are providing a better standard of care. Patients should be expected to be responsible for their care, but even the best of us can miss an appointment. This is why it is good to take steps to remind patients of any upcoming appointments. While you are reminding them of upcoming appointments it is a good time to give instructions, verify insurance and referral status, as well as check their balance. If needed, the patient can then be referred to the medical staff or collections department for additional information.

If the patient does reschedule or no-shows, this should be documented in the chart. A list of the rescheduled and no-show appointments should be given daily to the manager and physician for review to ensure proper care. The physician or staff should follow up with the patient to ensure compliance.

Some suggestions for monitoring include:

  1. A tracking sheet to determine if a patient followed through with a consultation or a log of canceled/no shows,
  2. A system of a physician reviewing canceled or missed appointments,
  3. A method to follow up with missed appointments or rescheduled appointments,
  4. A method of notifying a referring entity that the patient was no show or rescheduled,
  5. A method to contact the patient at least two times for missed appointments or to reschedule, and
  6. A method to ensure that a follow-up was done.

When deciding to analyze the current time required for various appointment types, you should ask a few questions. Has this been a productive use of the practice’s time or would it be better as open access? Would a modified version be best? Maybe only a very limited section of the appointments should be open access with limits to the number of visits that are time-consuming. Possibly have one provider with open access and a different one with scheduled appointments. Often the physician will have scheduled appointments and the nurse or physician assistant will have open access. You will need to adapt to your setting.

Steps to changing to open access:

  1. Find out what types of appointments are being made and how long they really take; for example, a physical compared to a blood-pressure check.
  2. Develop a timeline of when you want to go to open access and what you want to provide to help with scheduling; for example, an interactive Web site that allows patients to schedule their appointments. Many practices have reported success in doing this. Be sure to develop a policy to ensure that it is monitored.
  3. Start eliminating the backlog. This may mean adding additional hours for a short time or pushing back the date of the implementation of open access.
  4. Consider sending out patient forms before appointments or having them available on your Web site. This can reduce the wait time. If patient cannot fill out the forms before an appointment, ask them to come in 10-15 minutes early.
  5. Develop backup plans for emergencies such as staff calling in sick.
  6. Before starting, conduct patient and staff satisfaction surveys. Provide the same individuals with the survey after open access is implemented to gauge reactions and success.

One of the biggest keys to make this work is your scheduler. Train the staff to think in the terms of seeing patients who call in that day. Having to wait for an appointment is often one of the main reasons that patients give for going to a StatCare Clinic or RediClinic. Patients are busy and want their needs met; by working a schedule correctly you can allow the patients to achieve their goals while achieving yours.


Resources

  1. Steinbauer J, Korell K, Erdin J, Spann J. “Implementing Open-Access Scheduling in an Academic Practice” Family Practice Management. March 2006.

Gail Jones is the manager of practice management in the Professional Support Division of the American Academy of Family Physicians. She assists physicians and managers with privileging and credentialing, as well as other issues. She can be reached at (800) 274-2237 or gjones@aafp.org.