The call to improve patient “access” is often focused on improving a specific metric, whether that is increasing the number of patient appointments or decreasing lag days. While these are important metrics, access isn’t just appointments or lag days or clinic session length. Improving access requires a holistic approach to the clinic’s operations — examining multiple metrics and their relationships — and a strong partnership between a physician champion and operations administration.
Access isn’t just a single metric. Getting the right patients into the right appointment with the right provider requires a holistic approach to clinical operations.
A deep dive is necessary to determine current state and often results in a number of unexpected findings.
A physician leader present in clinic is critical to achieving physician buy-in.
In the summer of 2016, the Saint Louis University General Internal Medicine primary care clinic (SLUCare GIM) had reached a crisis — incoming phone abandonment rates were rising weekly, from 30% to 40%, eventually reaching almost 50%, with wait times of 40 minutes or longer. While improving telephony access and service levels had been a goal for some time, it was thrust into the spotlight as an immediate imperative.
Improve overall patient access by streamlining clinical operations with an initial focus on telephony access and service levels.
The two-part execution comprised assessing the current situation and developing corrective actions.
Determining Current State: The first step was a deep dive to determine current state of clinic operations (including staff and provider interviews, clinical observation, and data review). Incoming calls were answered by three medical assistants (MAs) functioning as switchboard operators; they routed most calls to nurse triage. The MAs were inconsistently able to handle routine tasks such as medication refills and appointment scheduling due to variable training and lack of policies and protocols. As a result, the clinic was unable to deliver one-call resolution, leading to increased work and volume of calls. For example, when a medication refill was not completed or was completed incorrectly, additional calls came into clinic (both from patients and pharmacies) for further resolution.
It was difficult to fully understand the current state of the clinic’s telephony performance due to limitations in data. The MAs answered the primary clinic line. In an effort to create a workaround, triage nurses gave patients their “back line” numbers, resulting in frequent calls directly to nurse triage (to avoid long wait times of the main clinic number). Because of these backline calls, as well as the configuration of phone systems, we were unable to determine the number of unique calls coming into clinic, the total number of calls coming into clinic, average hold times, average handling times, and average lag time between calls. Our limited data set made it difficult to determine the workforce necessary to handle calls moving forward.
As we discovered the chaos of the clinic phone systems, it was evident that the current system was negatively affecting our clinic staff’s morale and performance. We had high MA turnover and absenteeism. There were no defined staff roles and responsibilities, resulting in the overall feeling that “everyone was responsible” and no one was held accountable.
Creating the Future State: Using the call abandonment rate and overall number of phone calls coming to the clinic main number, we set out to improve our telephone access and service levels. We first instituted an interactive voice response (IVR) or “phone tree” as each call’s first clinic contact. The IVR replaced our MA switchboard; we retained and redistributed our MAs into more clinical roles that aligned with their license. The IVR routed calls to improve first-call resolution and minimize wait and handle times. Significant discussion occurred around an IVR option to speak to a physician/nurse. Ultimately, we did not include this as an initial option. Because we lacked specific data on caller type and because our patients were used to speaking directly to a nurse regardless of their concern/need, we were concerned that patients would bypass the IVR, choosing only to speak to the physician/nurse. We do plan to reevaluate this as an addition to the IVR after analyzing use and routing data.
We contracted with RelateCare, a health care communications consultancy company that specializes in patient access and engagement solutions, to move our scheduling calls off-site and out of the clinic. This required the creation of uniform scheduling protocols. A review of the 30+ possible appointment types for SLUCare GIM revealed that only 7 appointment types were utilized by providers. A scheduling protocol was created, defining each appointment type, duration, and appropriate utilization. The team also created an up-to-date provider directory, including associated advanced practice provider and resident teams, clinic session schedule, and provider-specific considerations.
Considerable redesign occurred in master schedules; for example, each provider’s master schedule was realigned to a 4-hour session duration, allowing for improved capacity within clinic. Radio buttons were added to the Follow-Up tab in the Epic electronic health record to ensure consistent, clear documentation of follow-up appointment type. Using these tools, off-site schedulers were able to uniformly schedule patients, ensuring the right patient with the right provider at the right time. Each call interaction was scripted and recorded to encourage early arrival to appointments, MyChart sign-up, preregistration and overall enhanced service levels. Each call agent with RelateCare was evaluated on a sample of the recorded calls through the use of an agent KPI scorecard. Call abandonment rates declined and hold and handling times improved. We also saw a statistically significant change in the number of scheduled appointments (increase) and new patient lag days (decrease).
To address clinic staff disorder, we interviewed multiple staff members and created a list of all clinical tasks as well as each clinic staff member’s skills/credentials. After several sessions with clinic leadership and representative MAs, we created standardized roles and responsibilities for our clinical care teams. New standardized roles were implemented in January 2017; over the subsequent months, our staffing stabilized (between April 2016–January 2017, we saw nine employees leave; between January–August 2017, one employee left). Our absenteeism also declined. Quality metrics completed by MAs improved — specifically, depression screening (completed during patient rooming) increased from 51% to 95% over 6 months. The MAs now have a sense of clinic ownership, which is anecdotally evident through their participation in clinic huddles, creating daily room assignments, and self-reported happiness. From the patient experience perspective, both clinic staff and providers are now able to focus on delivering high-quality care, rather than apologizing for the poor phone access and difficulties in scheduling appointments.
Our interventions occurred concurrently — RelateCare began scheduling appointments at the same time we implemented the IVR and our staff’s roles and responsibilities were redefined. This makes it difficult to attribute change to any one specific intervention; however, as a holistic approach, it made a significant impact.
Four key roles were involved in this effort:
- Physician Champion: In both the clinical aspects of health care and in this process improvement initiative, the physician serves as the nucleus of the high-performing team. The physician champion must be someone who “lives” in clinic — someone who is regularly present, experiencing changes as they occur. This position provides clinical vision and critical peer leadership. She/he must be willing to dedicate the time and effort to problem resolution, soliciting and then incorporating feedback from all members of the clinical team. She/he must truly champion the project, creating a sense of urgency, celebrating successes, and pushing forward through setbacks. Culture change was and is one of the largest hurdles of this project. The physician champion must take the anger and frustration that significant change brings and harness those disruptions into constructive information to make real-time adjustments to new processes.
- Operations Administration: This role requires experience in process improvement and operations redesign. In our project, our operations administrator took the lead in negotiating contract terms with RelateCare, and assisted in protocol creation and master schedule redesign, as well as data compilation. The operations administrator must work collaboratively with the physician champion to ensure a holistic approach is taken to improve clinical operations.
- Leadership: Individuals from both the practice C-suite and department chair were critical in this project’s success. Leadership buy-in ensured the resources — financial and personnel — necessary to the project’s success.
- Clinic Management: In our case, this role was filled by our clinic nurse supervisor. The person filling this role should be consistently available in clinic, and must have rapport with the clinic staff and the authority to hold them accountable. They bring invaluable input to developing policies and protocols and refining roles and responsibility assignments. They must be able to troubleshoot problems as they arise. This role is critical in evaluating efficacy of change and offering ideas and solutions for continual improvement.
The key metrics included call data, appointment data, and return on investment.
Call Data. We studied the Saint Louis University General Internal Medicine calls offered (i.e., calls presented to the queue), abandonment rates, hold time, wrap time, and average speed to answer. NB: A notable difference in the number of incoming calls (more than 300% reduction) is attributed to answering on the first call (i.e., patients did not need to call back repeatedly) and to an increased first-call resolution; however, as limited pre-project data is available, we are unable to know definitively.
Appointment Run Charts. We analyzed the real-time impact of go-live on January 27, 2017. Go-live of multiple interventions included: RelateCare scheduling support, IVR implementation, and redefinition of staff roles and responsibilities. Data included new patient lag day, new patient scheduled appointments, and all scheduled appointments.
- New Patient Lag Day Run Chart (statistically significant p<0.05). This shows a statistically significant decrease in the new patient (patients who have never been seen in General Internal Medicine or who have not been seen in the last 3 years) lag days (days between the date an appointment is scheduled and the actual appointment). Concurrent interventions were implemented Jan. 27, 2017 (indicated by green line). Median new patient lag days decreased from 37 (blue line) to 31 days (gray line).
- New Patient Scheduled Appointments Run Chart. This shows a statistically significant increase in the number of new patient (patients who have never been seen in General Internal Medicine or have not been seen in the last 3 years) appointments scheduled per week. Concurrent interventions were implemented Jan. 27, 2017 (indicated by green line). Median number of appointments scheduled increased from 69 appointments/week (blue line) to 79 appointments per week (gray line).
- All Scheduled Appointments Run Chart. This shows a statistically significant (p<0.05) increase in the number of all (including new and return/established) appointments scheduled per week. Concurrent interventions were implemented Jan. 27, 2017 (indicated by green line). Median number of appointments scheduled per week increased from 600 (blue line) to 638 (gray line) appointments.
Return on Investment. We analyzed cost and reimbursement data based on the number of scheduled appointments.
Where to Start:
- Quantify your burning platform: Why is it important? How will this project improve overall clinic or practice value?
- Identify project team: Ensure you have a strong physician leader, operational knowledge, and buy-in from leadership.