A Radical Redesign of Patient Scheduling

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Mark Masselli: This is conversations on healthcare, I am Mark Masselli.

Margaret Flinter: I am Margaret Flinter.

Mark Masselli: Margaret, like many I have been watching the debate on
healthcare in Washington. This week work on reform legislation took a
major step forward when the Senate Finance Committee voted out a final
bill yesterday, 14-9 with Senator Snowe voting with the democrats. Now
attention shifts to Senate Majority Leader Harry Reid who emerged the
Finance Bill with the Senate’s Health Education and Labor Committee Bill.

Margaret Flinter: You are right Mark. And it remains to be seen how the
public action will be debated before the full Senate. Other major issues
of disagreement that have been kicked down the road include some
pretty significant ones, large subsidies for insurance companies, the high
cost of coverage for low income people and that’s among the supporters
of the bill.

Mark Masselli: In the next two weeks, you will see di ! erent pacing than
we have experienced over the past month and Senator Reid will have lots
of negotiating to do, mostly with democrats as the republicans have
taken themselves out of the debate.

Margaret Flinter: And those will be interesting negotiations because the
senate democrats have some very passionate and very well informed
views.

Mark Masselli: Yes, and we have some interesting conversations coming
up on the show with key members and both the House and Senate and
the next few weeks is the bill of the health.

Margaret Flinter: And we have been hearing from many of you. We got
one e-mail about a program enhancement. Our listener was in Ireland
during our first three shows and he suggested that we supplement our
audio podcast with photographs and a slideshow during the podcast.

Mark Masselli: Would I have to wear a tie/

Margaret Flinter: You might, we will see about that, but please keep
those e-mails coming to conversations at www.chc1.com , we love
hearing from you.

Mark Masselli: Each week we highlight innovations that are making their
profound impact in the way healthcare is delivered in America.

Margaret Flinter: We have heard about the successful public option called
Healthy San Francisco and we have discussed the growing convenient
care industry and last week we focused in on group healthcare and the
benefits of centering pregnancy for mothers and for babies.

Mark Masselli: In this week, we are discussing a topic that has touched
all of us, the waiting game to get in to see your doctor, and that’s sure to
get everyone’s attention.

Margaret Flinter: So stay tune to learn more about a model that’s been
embraced by private practices, specialists, generalists, public health
clinics even the veterans administration. It’s based on a few simple rule,
supply, demand and doing today’s work today.

Mark Masselli: It’s an idea that’s borrowed from the assembly line just in
time delivery.

Margaret Flinter: It’s called Open or Advanced Access and we will be
talking with Dr. Mark Murray. Dr. Murray helped create this system that
really eliminates delays in care and it improves both patient and provides
a satisfaction. But first here is a look at healthcare – alliance from our
producer Lucy Nalpathanchil.

I am Lucy Nalpathanchil with this week’s headline news. The waiting is
over as Mark and Margaret mentioned the Senate Finance Committee has
approved a bill after weeks of delays – liberations and hundreds of
amendments. In a 14 to 9 vote, the committee passed a 10-year $829
billion reform bill. Senator Olympia Snowe of Maine, the lone Republican
to vote yes, told the committee that she may not agree with the entire
bill, but she called it an important starting point as the full senate looks
to debate final reform legislation in the coming weeks.

Senator Olympia Snowe: There are many, many miles to go in this
legislative journey. People do have concerns about what we will do with
reform, but at the same time, they want us to continue working and that
is what my vote represents it to continue working the process.

Senator Snowe also said she is concerned with any changes the full
Senate will make that will a ! ect the finance committee’s provisions and
the bill relating to costs. Finance Chair Senator Max Baucus applauded
the work of his committee praising members on both sides of the aisle.
He says there have been many hearings on healthcare reform in the last
two years and his intent from the beginning was to report out a bill that
would pass on the senate floor and be a part of final Healthcare Reform
Legislation.

Senator Max Baucus: We all understand we cannot a ! ord the status quo,
we all understand Americans are looking for commonsense solutions and
I think that’s exactly we have achieved in this committee. Ours is a
balanced bill that does bend the cost curve, it does lay the foundation for
continued progress, it lowers the federal deficit, ends insurance industry
discrimination, expands coverage and improves quality.

Margaret Flinter: The Finance Committee’s Bill does not include a public
option, it remains to be seen how Senate Majority Leader Harry Reid will
merge the bill with the Senate Health Education and Labor Bill approved
earlier this summer which included a public option. Once the full senate
approves the bill, it will have to conference with the house before both
chambers to send a final bill to President Obama.

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Margaret Flinter: This week we are exploring Open or Advanced Access,
it’s a system that helps doctors and other healthcare providers schedule
today’s work today. How does that relate to you? Well the concept can
eliminate a lot on the frustration anyone has ever felt when they have
called their doctor for an appointment and – but told that well it was one
to several weeks out. Dr. Douglas Ili ! has a private solo practice in
Topeka, Kansas. His sta ! includes three full-time registered nurses, a
receptionist and some part-time employees. He has been using a version
of Open or Advanced Access since the late 1980s.

Dr. Douglas Ili ! : It's all I have done from the first day, I have opened my
doors. The only important thing is that the patient needs to be seen
today, they get seen today.

Margaret Flinter: The idea behind the Advanced Access is balancing
supply and demand. A principal that may sound better suited to the
manufacturing sectors than say healthcare. In fact that’s where the idea

stems from. Manufacturers have learned to reduce inventory and avoid
delays to improve the bottom line. Dr. Mark Murray and colleague
registered nurse, Catherine Tantau created Advanced Access to help
healthcare providers – see their patients when patients want to be seen.
Well at the same time, improving e " ciency – by eliminating no shows or
cancellations. Pete Gutierrez is a Service Line Administrator at Denver
Community Health Services, the nations largest Community Health Center
Program. Gutierrez implemented Advanced Access to its primary care
division in 2003. He says Denver CHS handles 350,000 visits a year and
backlogs were common before Advanced Access. Gutierrez says this
happened because the farther out an appointment was booked, the less
likely a patient would keep the appointment.

Pete Gutierrez: We were experiencing across our department a 35% no-
show rate and so we were trying to overbook to try and get an e ! ective
productivity out of the resources that we had and we had been doing that
for many years and when we discovered Open Access Scheduling as it
was called then, we really felt as though we had an opportunity to impact
that no-show rate.

Margaret Flinter: Gutierrez says, it’s a lot of work transitioning to
Advanced Access from the old way of handling appointments. First he
says a provider or individual o " ce has to figure out how many patients
the practice has, not as simple as it sounds. It has to look backward to
see how many visits per year on average those patients make, how many
calls for appointments there are and then most importantly, determine
just how many appointments the practice can make available. That’s
basically a function of resources how many providers, how many hours
they are available to see patients and even other resources like how many
exam rooms are available. Once Denver Community Health Services
balance its supply and demand the e ! ects of Advanced Access were
instantaneous.

Pete Gutierrez: We went from that 35% average across our department
down to under 10% with each one of our sites immediately, it happens
within the first month after you go live with Open Access.

Margaret Flinter: Since 2003, he says the no-show rate has crept from
10% to 15%, but he says the system has still shown a 50% improvement.
Open or Advanced Access has also helped the countries largest
healthcare system. The Federal Veterans Administration has more than 7
million patients. At one time veterans who needed care were waiting and
they were waiting at least 60 days from the time they scheduled an

appointment to actually being seen by a provider. The VA recognized
this as a problem and started working with Institute for Healthcare
Improvement or IHI in 1999. To learn ways of eliminating wait times, Dr.
Mike Davies, Director of Systems Redesign for the VA describes the
hardest part in making the change.

Dr. Mike Davies: Changing people’s minds you know developing this
vision that it was possible to o ! er appointments on the same day a
patient requested the appointments. No one has thought that way
before, everyone assumed that waiting times were inevitable.

Margaret Flinter: Because of the VA’s shear size the Federal Agency
developed computer software that connected every one of its patients
with a provider. This system allowed the VA to keep track of demand and
then feed it to individual providers who could measure its patient panels
and balance its resources or supply with demand. Dr. Davies adds
Advanced Access has helped the VA in other ways.

Dr. Mike Davies: Everything gets better, not only your operational
e " ciency and the patients notice this with the patient satisfaction scores
getting better, but also the clinical care gets better, we found we
delivered better clinical care when patients didn’t wait.

Margaret Flinter: Dr. Davies calls Advanced Access a journey of change
for the VA. In 2002, the agency decreased wait times to 28 days. In
2006, 65% of patients were able to see a provider in two weeks after
making the appointment. Today 85% of patients are seeing a provider
within 14 days. It’s a marked improvement for the VA since 1999 when
the average wait time was 2 months. Open or Advanced Access isn't just
suited for a large health systems, Dr. Ili ! from Kansas says any provider
can use the scheduling process, in fact, he says small practices have been
operating like this for years.

Dr. Douglas Ili ! : My great grandfather was a family doctor in Southeast
Kansas. He saw every patient needed to be seen everyday, they just
showed up at door, there was no appointment system. Large practices
on the other hand get to be pretty impersonal, pretty quickly. There is a
lot of sharing of personnel, you don’t necessarily know the patient you
are talking to because they are somebody else’s patient, so I think that
Open Access is usually caught on as a concept because large practices
had a real big problem but they realized it needed to be solved.

Margaret Flinter: To learn more about how healthcare providers from
many backgrounds have adapted to Open or Advanced Access, Mark and
Margaret spoke with Dr. Mark Murray, Principal of Mark Murray &
Associates, a healthcare consulting firm.

Mark Masselli: Dr. Murray, thanks for speaking with us today.

Dr. Mark Murray: Oh thank you.

Margaret Flinter: Welcome Dr. Murray. You have modeled this Advanced
Access, has really had a profound e ! ect on how long patients have to
wait to get an appointment, but your first success was your own o " ce at
Kaiser Permanente where you reduced wait times from 55 days to 1 day,
how did you do it and how does it work?

Dr. Mark Murray: Well I think that one of the key things here is to
recognize that the term Advanced Access implies a product you know
instead of required unpleasant behaviors. It’s really not that, this is really
a philosophy and I think the philosophy starts at the endpoint. You know
if we want to get patients an appointment you know what they want,
when they want it and we want people, our clinicians to see their own
patients and not make them wait. If that’s the endpoint then we have to
think about how do we get the capacity, the space on the schedule to do
that and there is a number of di ! erent ways to do it that don’t work well
that I am not going to walkthrough but the best way to do that is to make
sure that the doctors panel size, the number of patients or clients that
that provider is responsible for is right, there is not too many and not to
few, so make sure that the basic overall supply and demand is going to
work well. Then work down the backlog, get rid of the current warehouse
or inventory of work and then just start changing the way that we think
can change in the way that we work by o ! ering an appointment today for
any problem, basically doing today’s work today.

Mark Masselli: In your writings you have said that the issue is not just
about having a di ! erent scheduling system, it’s about delay reduction,
tell us about that?

Dr. Mark Murray: Yeah the basic issue here, it really grows out of the
premise that the most e " cient, e ! ective, and satisfying way to work is
the balance supply and demand. If we live in an environment where
demand exceeds capacity then we will fail, I mean there is no way around
that, we will fail, we can play on the edges but we will fail. So we have to
get an overall balance of the capacity to the demand. Then again, the

most e ! ective, e " cient, and satisfying way of work is to take our capacity
and put it as close to the demand as possible. So this whole philosophy
is around how do we understand what our capacity is and match that
demand as soon as possible, so it's really about delay reduction.

Margaret Flinter: So supply and demand is not probably worth that we so
often hear from our clinical colleagues and that’s really where your
system starts. But in your experience is that data easy to gather at most
practices, do people know what their supply and demand is, is it
something they are already aware of?

Dr. Mark Murray: It’s not easy to gather initially because we don’t look at
that. You know but to me this is like grabby, it’s the basic fundamental
underlying dynamic that runs our business. That’s what we do, everyday
all day long, one patient at a time, what we are doing is we are matching
our, using our capacity to meet the customer demand. The choice is not
whether we are going to do that but the choice is whether we are going
to do it well or do it poorly, so we have to measure. And there are three
lenses through which we need to measure, number one is what’s the
waiting time what’s the current waiting time, is it stable which implies
that supply and demand are balanced but we maybe late. What’s the
daily demand, supply, and activity, what is it that we do, what could we
do and what it is the demand and then the third lens which is a broader
overview as how many patients do I have, how many visits are they going
to generate and does that reconcile with how many days I work and how
many appointments I can deliver per day the basic supply and demand
equation.

Mark Masselli: You know customer demand and customer satisfaction
seem to go hand in hand and we know patients are happy seeing their
own provider, in healthcare we called that Continuity of Care. Does using
Advanced Access actually a ! ect the Continuity of Care for patients?

Dr. Mark Murray: Oh absolutely, I mean the fundamental basic dynamic
here is, is that we have to balance supply and demand at the individual
doctor level. So the focus here is basically, see your own and don’t make
him wait. So we recognize that we have two real problems to solve, one
is the delay problem and one is the continuity problem, you cannot solve
one without the other, they are not independent, really, we have to solve
both of them together.

Mark Masselli: This is conversations on healthcare. We are speaking with
Dr. Mark Murray, Principal of Mark Murray & Associates, a healthcare

consulting firm. Dr. Murray helped create Advanced Access the
revolutionary redesign of appointment scheduling at doctors’ o " ces and
other healthcare providers.

Margaret Flinter: So Dr. Murray, it would be interesting in hearing a little
bit about di ! erent types of practices and your thoughts on whether there
are certain kinds of practices or specialties where you think Advanced
Access just doesn’t work or is particularly challenging, is it really more
suited to primary care or is it relevant in other practices as well?

Dr. Mark Murray: Well you know that’s a very good question. And the
gravity exists for all of us, so matching supply and demand exists for all
of us. Are there is going to be some environments where there is a
greater challenge around matching supply and demand, yeah of course
there is. If we are working with the specialty care practice, it’s highly
diluted where the clinician is not in the o " ce but infrequently, then the
demand will come in, in a regular normal predictable kind of way, but the
supply is sporadic. So what that means is that it’s more di " cult to match
the supply to that demand, immediately there will be a time lapse simply
because of the dilution e ! ect, but does that change the basic dynamic,
no it doesn’t. So the issues around the payment scheme, the specialty,
and other particular kind of nuances of environments that doesn’t really
matter. What really matters is, is how do we e ! ectively understand what
our capacity is, measure it, see how often it's present, its frequency of
presence and then compare it to the demand which is very predictable.
So the fundamental dynamic is the same. There are some challenges in
particular practices but it’s still the same.

Mark Masselli: You know I think that for most practices the boogieman in
the room is that there will days and maybe a lot of those days where
there will be no way to see all the patients who call in other days where
income and productivity will su ! er because of low demand, but this
program now has had a long track record, what would you say to those
concerns?

Dr. Mark Murray: I think that lot of that is, I understand the concerns, but
a lot of the realities are myths. Let’s take a look at what we do now. If
we take a look at our current schedules at the end of the day, the activity
and let’s say the doctor has a schedule of 25 appointments scheduled,
what is the likelihood of the doctors seeing exactly 25, about a third of
the time. Most of the time, two-thirds of the time, it's either above that
or below that, so what we are dealing here with is variation. Demand will
vary, supply actually varies more than demand, but demand varies. We

are already dealing with variation. When we eliminate the waiting time or
minimize the waiting time and learn strategies around how to predict and
understand demand variation and supply variation and matching them,
what we find in our experience is that that range of variations and those
range of fears, I have too much work, I don’t have enough work that
range is actually reduced, so the day becomes far more predictable using
these strategies than it does currently, so that those fears about too
much work, too little work that’s actually a myth.

Margaret Flinter: Now Dr. Murray, you have done work with some pretty
large systems, I know both here in the United States and abroad. One of
those I would like to talk about is the Veterans Administration, the VA
system, a large network certainly no stranger to complaints about
delivering e " cient care to veterans and maybe one of the reasons is just
the sheer size of the agency, but tell us how Advanced Access helped the
VA system and really that’s how it’s helped veterans.

Dr. Mark Murray: Well the VA system is very complex and very old but in
the recent past has made tremendous e ! orts to transform itself and to
change itself. So there has been a focused on the VA systems over the
last number of years around addressing the issues of waiting time. And
they have done a tremendous job in a very big system in incorporating
multiple set of new ideas and new tools to make those ideas work. So
they have really made tremendous stride both in primary care and in
specialty care particularly around tools and measurements and around a
new philosophy around minimizing their waiting time.

Mark Masselli: Dr. Murray conversations on healthcare focuses on
innovations and healthcare delivery. What other innovations are you
working on and whose work should we be keeping an eye on?

Dr. Mark Murray: Well I think some of the innovations really again arise
in IT stu ! , where we are really moving towards an electronic health
record. An electronic health record is more than just typewritten clinic
notes. An electronic health record really allows us to gather and keep
information for a whole practice. And it allows actually us to be able to
use our resources far more e ! ectively, not so much the doctor resources,
but the health resources, so some of the innovations I see are how do we
get the team to work more e ! ectively together given the freedom that the
electronic health record has given us. The electronic health record also
allows us to measure things in ways that we haven’t measured before, to
look at you know continuous measurement of things like “minutes
behind”, how many minutes is the doctor behind in the day. To be able

to look at things like demand, supply and activity, to be able to use
statistical process control to look at variation in demand. So it allows us
a lot of opportunity and information in that area. So I see most of the
innovations coming in that arena.

Margaret Flinter: Great and very intriguing to think about. We have been
speaking with Dr. Mark Murray Principal of Mark Murray & Associates, a
healthcare consulting firm. Dr. Murray helped create Advanced Access.
Thank you for speaking with us Dr. Murray.

Dr. Mark Murray: Alright thank you.

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Each week conversations on healthcare highlights a bright idea about
how to make wellness a part of communities in everyday lives.

This week, we focused on a program that helps get kids reading, babies
looking at books and parents reading to their children, Lucy.

Lucy: Reach out and Read was developed by doctors and early childhood
educators. The program was founded in 1989 at Boston City Hospital,
now Boston Medical Center. After pediatricians and nurse practitioners
realized that regular interaction with young children and parents at
routine pediatric checkups could help communicate the importance of
parents reading to their kids. Healthcare providers who participate in the
program give the parent age and even language appropriate books at
each checkup starting at six months and continuing till age 5. The goal
of Reach Out and Read is to encourage parents to read aloud to their
child. Well also helping the young boy or girl have at least 10 books in
their home library by the time they start kindergarten. Why is this
important? Research has shown that reading aloud gives children a rich
exposure to language, much better than the words they hear during the
television or radio program and children who are read to regularly also
are more prepared for school, an important outcome noting that one-
third of children enter school unprepared to learn.

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