Medical Insurance Exchange of California - Managing Your Practice/title>

Patients in several states including, Florida, Nevada, and California have sued their physicians in small claims court for wage losses the patients claimed they suffered because they were kept waiting too long in their doctors’ office. Both patients won their cases and the doctors paid the judgment. Not every patient who is upset by being kept waiting to see a doctor considers suing, but patient satisfaction surveys find that few things anger patients more than a long, unexplained wait to see their physician. Such waiting periods are perceived by patients as disrespectful of their time constraints, cause patient dissatisfaction, and have a negative impact on the physician-patient relationship.

Although physicians acknowledge that excessive time delays upset patients, health care providers must address their own pressing concerns, including the pressure to see more patients in less time, in response to lower reimbursement rates. This practice increases the potential for medical error and further complicates already full schedules.

A SOLUTION: MIEC recommends that physicians, with the help of their staff, revisit scheduling policies in their offices. Consider these suggestions about time studies, scheduling models, and other practical recommendations.

Where to start: Analyze the problem

Most of the numerous articles published on the topic of long waits and inefficient scheduling begin with the recommendation that physicians first time analyze the problem:

Cathy Treadway, office administrator for The Woman’s Clinic in Boise, Idaho, has found in her years of experience that for a physician to adhere to a schedule, one must first “identify how the physician works best.” According to this practice manager, “Flexibility is key . . . Each physician works with his/her own nurse and together they manage patient flow. A scheduling template was developed for each of our doctors so that certain types of exams for obstetric and gynecologic patients are scheduled at specific times of each day based on physician preference.”

Occasionally, when time delays occur, Ms. Treadway and each specific physician/nurse team conduct a two to three week time study to assess the problem. Documentation for each patient includes: when the patient checked-in; when the patient’s chart was placed in the doctor’s box; when the nurse saw the chart; and when the physician entered and exited the examination room. The study provides insight for each practitioner, and allows the doctor and nurse to adjust the schedule to address problems. “This ongoing, ever-changing process heightens not only patient satisfaction, but also physician satisfaction,” says Ms. Treadway.

Other practical advice from Ms. Treadway: “Make the last appointments in the morning and in the afternoon new referrals from other physicians and in-office procedures. If these appointments run longer than anticipated it does not effect the entire schedule. Avoid double booking. If the schedule is formatted to meet the physician’s normal working pattern, double booking will just create additional wait times for patients. Have some walk-in slots for post-operative, post-partum, or other urgent patients.”

Appointment scheduling: What model fits your practice?

After completing a time study to determine where and why delays occur in your practice, review various scheduling models that may prove effective in your office. The paradigms presented in this advisory may not suit every practice; however, they are offered as possible solutions to the often inefficient standard model: scheduling a patient every fifteen minutes months in advance.

Advance Access: In the 1990's, Kaiser Permanente instituted the “Advance Access” system developed by Mark Murray, MD, former head of the Kaiser Permanente Sacramento Medical Center’s Department of Family Practice. After months of analyzing Kaiser’s operating procedures, Dr. Murray concluded that advanced scheduling was the problem. His solution, “Drop advance scheduling, erase the distinction between urgent and non-urgent visits and simply ‘do today’s work today.’. . . It’s a system built around who the patient’s doctor is, not on how sick the patient is. . . .”

“The system works like this: Patients who call for an appointment are offered one that day. If they cannot make an appointment that day, they are scheduled for the next day. All appointments are scheduled in universal 15- or 20-minute blocks on the assumption that the longer and shorter appointments will balance out.

“If the patient’s doctor is on vacation that day, the patient is told to call back when the physician returns. If the patient needs to see a doctor urgently, he or she is scheduled with another doctor on that day. Patients who need routine follow-up are told to call the day that they are due for the follow-up appointment . . . Scheduling staff must carefully monitor how many patients call each day to make sure ‘that supply and demand balance out.’ ”¹

To make the switch to Advance Access, a medical group must first assess each physician’s established patients, how many patients the doctors see each day, and the number of patient phone calls received daily. This will help determine patient volume per physician per day. For a four- to six-month transitional period, each doctor in the group should work an extra hour or two per day to clear out the backlog of scheduled appointments while also treating same-day urgent patients. Patients who call to schedule appointments in advance should be told to call back on the day they want to come in for their follow-up visit.

For more information about Advance Access, read Dr. Murray’s article, “Same-Day Appointments: Exploding the Access Paradigm,” Family Practice Management, September 2000: 45-50. The article is available at www.aafp.org.

Open-Office Scheduling: A second time management model is “Open-Office Scheduling,” developed in the 1990's by Marvin Smoller, MD. The guiding principle for this paradigm is simply, “Get patients into the office when they want to be seen.”² Unlike Advance Access, where most of the appointment slots are kept open and filled on a daily basis, Open-Office Scheduling holds only a certain percentage of the time slots open for same-day appointments and/or follow-up visits. This system separates appointments into three categories: same-day appointments (“same-day adds”); follow-up appointments made no more than two weeks in advance (“return checks”); and visits scheduled more than two weeks in advance, such as annual exams and checkups for patients with chronic conditions (“prescheduled appointments”).

To begin the transition to Open-Office Scheduling, determine the average number of same-day appointment requests for each day of the week. Also tally: how many people are seen in the office daily; how many are added; and how many accept an appointment on a different day. These numbers will help you decide how many slots should be left open for “same-day adds.”

Then “. . . identify the period on your schedule where about 50 percent of your appointment slots are still open on several consecutive days . . . From that point on in your schedule, block off the proper percentage of open slots for each day of the week, according to the schedule that your group has established (50 percent on Mondays, 35 percent on Tuesdays, etc.). Two weeks before the first day you’ve designated for open slots, you can release half the slots you have blocked out and begin filling them with ‘return check’ appointments. . .”³

Modified-wave scheduling: “Modified-wave scheduling” is a third scheduling model. M. Kyu Chung, MD, chief of the Department of Family Medicine in the Cooper Health System in Camden, New Jersey, and associate professor at the Robert Wood Johnson Medical School in Camden adapted this model from “wave” scheduling. This is “a simple technique where patients are purposely double-booked at the front . . . of each hour and the end of the hour is left open for catch-up.” ⁴

It has been Dr. Chung’s experience that patients do not complain if they are required to wait for 15 to 25 minutes to see their physician; however, after 25 minutes they begin to become upset. With this time management model, patients are never required to wait for more than 25 minutes; wait time is usually 15 minutes or less. Advantages of “modified-wave scheduling” include:

To ensure success with modified-wave scheduling, Dr. Chung advises physicians to: identify where the scheduling “peaks and valleys” occur; together with a nurse or medical assistant, review the schedule several days prior to the appointment days to anticipate and correct any problems with the schedule; call patients to confirm appointments; avoid filling the last slot of each hour with acute need visits; and avoid double-booking new patients, difficult patients, or patients with multiple problems at the beginning of the hour.

Scheduling staff must carefully monitor how many patients call each day to make sure “that supply and demand balance out.” ⁶

MIEC recommends

These three scheduling models each possess features that may help you address problems with scheduling delays in your practice, improve patient satisfaction, and assist you to increase your practice income. MIEC’s Loss Prevention experts and other time management consultants offer a few more suggestions:

In a 1997 study published by Wendy Levinson, MD, (currently Professor of Medicine and Vice-Chair of Internal Medicine at the University of Toronto) and her colleagues, Dr. Levinson compared “communication behaviors of ‘claims’ vs. ‘no-claims’ physicians using audiotapes of 10 routine visits per physician.” Her research revealed, in part, that ‘no-claims’ primary care physicians spent approximately 3.3 more minutes with patients for routine visits than ‘claims’ physicians, and that “the length of the visit had an independent effect in predicting claims status.”⁷

An effective way to reduce the number of no-shows is to call patients at least one day before their appointment as a reminder. If calling all patients is impractical, consider phoning first-visit patients, those whose appointments were scheduled months in advance, or patients who have missed previous appointments. Use the call to remind these patients to bring in insurance forms, medications, or other needed information, or to remind them about dietary or other preparations for the visit.

Loss Prevention Department

Oakland, CA
510/428-9411 (Bay Area)
Outside 510: 800/227-4527
Fax: 510/420-7066
E-mail: lossprevention@miec.com

Hawaii Claims Office

Honolulu, HI
Phone: 808/545-7231
Fax: 808/531-5224

Idaho Claims Office

Boise, ID
Phone: 208/344-6378
Fax: 208/344-7192

APPOINTMENT TIPS FOR OUR PATIENTS

We know your time is valuable. Unfortunately, scheduling delays do occur and sometimes cannot be anticipated. It may be necessary on occasion for you to wait beyond your appointment time. We apologize in advance for delays, and assure you that we and our staff will do our best to keep waiting time to a minimum. These suggestions will help us reduce appointment delays:

Keep your scheduled appointment. If you cannot, please call the office as early as you can so that we can free your time for another patient. If you are going to be late, call us and we'll try to re-schedule you in the same day.
Our staff is trained to interview patients on the phone on our behalf so that we can set enough time for your needs. When you call for an appointment, you may tell the person scheduling your appointment the reasons for your visit; the information will be kept confidential.
Each patient must have his or her own appointment. Please do not bring more than yourself (or your child) for examination or treatment unless you have asked us to schedule time for the other patient. We will be happy to schedule additional appointments if we are alerted in advance.
Please call the office an hour or two before your appointment. Our staff can tell you if we are on schedule or are experiencing delays.
If you need to speak with one of us in between appointments, because we want to give all our patients the time and attention they deserve, our staff will take your message, and we will return your phone calls between the hours of aa and bb.
Please call our office to make an urgent same-day appointment. If you come to the office without an appointment, you may have to wait until patients who have scheduled appointments have been seen before we can take you to an exam room.
If you experience problems or unusual delays, or have suggestions on how can improve service to our patients, please let us know. We welcome your comments.

Thank you for your cooperation and understanding.

John B. Good, MD and Jane S. Nice, MD
123 Main Street ♦ Yourtown, USA
555-5555

1. Julie A. Jacobs, “Same-day appointments catching on with doctors,” AMNews, January 29, 2001.
2. Herriott S. April, “Reducing delays and waiting times with Open-Office Scheduling,” Family Practice Management, April 1999:38-43.
3. Ibid.
4. M. Kyu Chung, MD, “Tuning up your patient schedule,” Family Practice Management, January 2002:41-45.
5. Ibid.
6. Ibid.
7. Wendy Levinson, MD, et al., “Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons,” JAMA, February 1997; 277:553-557.