Exploring Open Access Scheduling in Patient Access to Care

What is open access scheduling?

Open access scheduling allows clinicians to create same-day appointments for patients by keeping most of their workdays free, according to AHRQ:

Open access\u2014also known as advanced access and same-day scheduling\u2014is a method of scheduling in which all patients can receive an appointment slot on the day they call, almost always with their personal physician\u2026 Rather than booking each physician's time weeks or even months in advance, this model leaves about half of the day open; the other third is booked only with clinically necessary follow-up visits and appointments for patients who chose not to come on the day they called (typically no more than 25% percent of patients).

The concept of open access scheduling became popular from the 2000 article “Same-Day Appointments: Exploding the Access Paradigm,” published in Family Practice Management.

“The access model we created is often called ‘open access,’ ‘advanced access’ or ‘same-day scheduling,’” wrote aricle authors Mark Murray, MD, MPA, Catherine Tantau, BSN, MPA from Kaiser Permanente. “It has one very simple yet challenging rule: Do today's work today. Doing so enables patients to see their own personal physician on the day they call for any problem, whether urgent, routine or preventive.”

Open access helped Murray and Tantau reduce their organization’s 55-day wait period down to one day, increased the likelihood of a patient seeing her personal physician, and raised patient and physician satisfaction scores.

The idea turned the traditional scheduling method on its head, the pair wrote. Usually, clinicians go into their offices to see their schedules completely full or even “saturated,” as Murray and Tantau called it. These patients made their appointments months ago, and to accommodate urgent needs, doctors overbooked and worked through lunch.

“In other words, the way practices gain capacity in these systems is to pile visits on top of an already-full schedule; they gain capacity on their backs,” the pair explained.

Healthcare professionals realized that patient demand can be somewhat predictable, sparking new and innovative strategies to create same-day appointment time slots. Blocking a chunk of time dedicated to urgent needs was a valiant effort, but still asked patients with less urgent needs to wait to receive care.

Open or advanced access scheduling asks providers to keep nearly all of their days – between 65 and 75 percent – completely open for same-day appointments.

“To succeed, physicians must suspend what they have thought forever,” the pair noted. “In health care, it is genetically encoded that ‘if you are really sick, we will see you today; if you are not really sick, you can wait.’ Advanced access eliminates the distinction between urgent and routine and requires that practices ‘do all of today's work today.’ That's the motto.”

The 25 to 35 percent of already booked appointments – called “good backlog” – are patients who could not make it in on a certain day or who the clinician deliberately scheduled for specific or follow-up care. Ideally, the practice will do Monday’s work on Monday so that all of Tuesday and subsequent days are open.

According to Murray and Tantau, there are numerous benefits to this model, including:

• First, the wait time for a routine appointment is\u00a0today. No one can beat that.
• Second, practices no longer have to hold appointments in anticipation of same-day needs, so they've maximized their schedules and gained capacity (or appointment availability) they didn't have before.
• Third, the likelihood that patients will see their own personal physician has increased, which means greater efficiency, a greater sense of control for the physicians and improved satisfaction for everyone.

Challenges to advanced access scheduling

Although the open access scheduling model has many proponents, it also poses considerable challenges that bar its widespread adoption. Open access scheduling is completely counterintuitive to what clinicians are used to doing, according to AHRQ.

“For both clinicians and their staff, this approach seems unintuitive; it defies both their beliefs and their experiences with scheduling systems,” the agency says. “Because routine and urgent requests are treated similarly, the model also forces them to abandon the solidly ingrained notion that routine care can wait. Finally, clinical and administrative staff are typically skeptical that existing resources can meet demand.”

The strategy also requires a considerable amount of preparation and poses a lengthy transition time, Murray and Tantau explained.

“For most groups, it's not something that can be fully implemented tomorrow, but it is doable with a few months of hard work,” the pair stated. “The best strategy is to identify a test team made up of people who have tried other improvements, have a sense of adventure, have perhaps succeeded at other quality improvement projects or are so desperate they're willing to try anything.”

Adequate data collection and predictive capabilities are other barriers, AHRQ said. Addressing both these cultural and logistical challenges will require organization-wide teamwork and strong leadership.

The hardest part of the transition, aside perhaps from the cultural adjustment, is getting rid of the backlog. This can even prevent a facility from fully starting open access scheduling.

Reducing the appointment backlog can take between six and eight weeks, Murray and Tantau said. Organizations will need to overbook for a period of time before they reduce the backlog completely, posing a challenge that can threaten the full implementation of open access scheduling.

Doctors can make this process easier by reducing redundant appointments (is there something they can do today to get rid of another appointment?) and by questioning the clinical necessity of some in-person follow-up appointments.

Strategies for advanced access scheduling

Most experts have agreed upon a series of standard steps that will help organizations create an advanced access scheduling system, AHRQ reports. Organizations must measure facility demand, create a pilot team of providers, reduce the appointment backlog, simplify appointment types, develop a contingency plan, reduce demand for visits, and continuously measure appointment availability.

After the organization has established its leadership team and reduced its existing appointment backlog, it must streamline the appointment scheduling process. This means that appointment times should be standard (Murray and Tantau suggest between 15 and 20 minutes). Appointments should be categorized as personal, seeing a care team member, or with an unestablished patient.

Practices must also make contingency plans for when demand has not been predictable. This means defining office hours timelines, understanding how demand typically works, and addressing who on a care team can see a patient when the personal doctor is not available.

Clinicians must reduce unnecessary appointments by making the most of a singular appointment and scheduling follow-up appointments judiciously. Providers can also utilize phone calls, email, and secure messaging to reduce unnecessary visits.

Organization leadership must aid their clinicians by requiring a reasonable panel size. Doctors with a large panel size will not be able to accomplish open access scheduling. Additionally, organizations must ensure that clinicians who are successful in open access scheduling do not bear the load of a colleague’s overflow.

“When physicians see their own patients and do today's work today, a sense of order and control is restored to their practices,” Murray and Tantau concluded. “We have found, almost universally, that when practices clean up their access systems and make them more coherent, the visit ceases to be a scarce commodity, patient anxiety goes down, demand goes down, visits become richer and physicians discover there is more capacity in their systems than they ever imagined.”