Stanford Health Care enhanced patient access at newly acquired physician practices by identifying key metrics, improving the efficiency of workflows, and leveraging technology.
As Stanford Health Care added more than 70 physician practices to its community network over the last eight years, the organization’s leaders knew they had to address inefficiencies and create common goals to ensure patients would have consistent and reliable access to providers. The health system wanted to exceed patient expectations while also creating a standardized and efficient workflow that supported clinicians and staff, said Hilary Garrigan, administrative director.
The following strategies can help organizations enhance access and meet patients’ needs more effectively, Garrigan and colleagues said during a presentation at the MGMA’s 2018 annual conference.
Set a Goal and Identify Metrics
Stanford Health Care defines access as “exceptional care when, where, with whom, and how a patient wants it.” Meeting this definition entails offering seven-day access to primary care physicians, extended hours in specialty clinics, video visits, home visits, and more.
“Access is more than just making sure you have enough availability,” Garrigan says. “You need to think more broadly about helping patients stay healthy.”
The organization created specific metrics to measure performance, including:
- Answer at least 95 percent of calls rather than letting them go to voicemail (and 80 percent within three seconds)
- Handle and resolve calls within three minutes
- Resolve 80 percent of calls during the first call
- Consistently fill 80 percent of appointment slots (with 20 percent remaining for urgent and same-day requests)
- Provide same-day appointments for 90 percent of patients who call before noon
- Schedule 80 percent of new and returning patients within seven days
- Maintain a 5 percent (or lower) rate for cancellation and no-shows
Improve the Efficiency of Workflows
Stanford conducted six Kaizen rapid-process improvement events over the course of 18 months to create more predictable and efficient workflows that ultimately improved patient access.
Among the many changes the health system made to reduce inefficiencies:
A centralized concierge line. This resource was available to staff when they couldn’t accommodate a same-day appointment with the patient’s preferred provider or another provider in the same practice. Staff working the concierge line were tasked with identifying an available appointment slot elsewhere within the health system so patients didn’t need to go to the ED or urgent care, says Michael O’Connell, senior vice president of operations. Most sites now can schedule appointments in other clinics.
New scopes of practice. “As we developed the workflows, it became obvious that we needed everyone working at the top of their scope—having the right person doing the right job at the right time,” says Garrigan. “We wanted to minimize interruptions and redundancies and maximize the patient’s time with the provider.”
To meet that goal, medical assistants became flow managers responsible for reviewing care gaps, working clinician inboxes, and following up with referrals. Clerical staff follow standardized workflows and can double-book and schedule procedures themselves.
Extended appointment availability. Office hours were expanded to include early-morning, later-evening, and Saturday. Under a new policy, appointments were offered to waitlisted patients via texting as slots became available.
Morning huddles each day. “The whole office gets together very briefly—three to five minutes—to discuss things that are pertinent to the day, so everyone is on the same page,” Garrigan says. For example, if staff anticipate a shortage of appointment slots, they proactively identify times that can be double-booked, if necessary. They mark these appointments with a special symbol in the electronic health record (EHR), allowing schedulers and clinicians to easily identify them.
A revamped physical space. The office was reorganized to ensure providers had supplies when and where they needed them.
Standardized scheduling guidelines. Before the Kaizen events, says Jyotika Rattia, administrator, Stanford struggled with several challenges.
First, providers had only 15 minutes for established patients and 30 minutes for new patients, which wasn’t enough time to conduct the visit and finish all documentation. Second, medical assistants could block schedules for a provider without formal approval (e.g., when clinicians wanted to leave early), which decreased patient access. Third, staff had to choose from more than 60 visit types and had different scheduling protocols depending on the provider, which led to scheduling errors and appointment-scheduling delays. Finally, providers were not working their contracted hours (e.g., providers were contracted for 36 hours but only scheduled for 32 hours in-clinic).
After the process improvement events, health system leaders created standardized scheduling guidelines for each specialty. They restricted schedule-blocking access to managers, meaning medical assistants and clinicians had to place formal requests to block time. They also allowed patients to schedule appointments online and decreased the number of visit types to 15. Most importantly, they increased providers’ patient-facing hours to match their contracted hours.
The efficiencies gained by taking these steps allowed the health system to increase appointment durations to 40 minutes for new patients and 20 minutes for established patients, giving clinicians time to perform real-time charting, answer messages between patient appointments, and receive a hand-off to the next patient from the medical assistant. “We really wanted to make sure that when providers left at the end of the day, charts and messages were done,” O’Connell says. “We didn’t want them going home and working until midnight to finish their work.” As a result of the process improvement work, practices increased access to care and the availability of appointments.
Triaging of phone calls. Patients were prompted to identify whether their call was administrative or clinical in nature to ensure the appropriate individual could resolve the call during the initial conversation. For example, clerical staff scheduled appointments while clinical staff refilled medications, provided medical advice, and helped with referrals to specialists. Effective call triage created access by preventing unnecessary appointments and decreasing downstream messages, freeing up clinicians to focus on patient care, Garrigan says.
“Ultimately, we ended up with a very strong culture of problem solving and continuous improvement, and our patients do have better access to providers and staff,” Garrigan says.
Rattia notes several ways in which the health system used technology to maximize efficiency and improve access:
- Allowing new and returning patients to schedule appointments online
- Offering video visits
- Permitting patients to message clinicians for nonurgent reasons via the patient portal
- Providing after-visit summaries via the patient portal so patients can reference any instructions provided
- Pulling patient e-records before each visit via interoperable EHRs to ensure patient information is reviewed and reconciled
- Releasing labs within seven days via the patient portal
- Sending automated appointment reminders via text, email, or phone
- Using a phone service for on-demand and scheduled interpreter services
- Using dictation tools to support providers in entering notes directly into the EHR
To continue to meet patient demands, O’Connell says, the health system plans to refine its metrics, continually improve workflows, and pilot new models of service, including by expanding telemedicine capabilities and providing additional express-care options.
Lisa A. Eramo, MA, is a freelance writer based in Rhode Island.
Quoted in this article: Hilary Garrigan, administrative director, Stanford Health Care, Newark, Calif; Michael O’Connell, senior vice president of operations, Stanford Health Care; Jyotika Rattia, administrator, Tri-Valley Region, Stanford Health Care.
This article is based on a presentation at the Medical Group Management Association’s 2018 annual conference, which took place Sept. 30-Oct. 3 in Boston.