Open-Access Scheduling: 5 Surprising MisconceptionsFebruary 11, 2014 by Marshall Jones
Medical practices looking to stay competitive need ways to operate more efficiently and increase their capacity to care for patients. One way to do this is through open-access scheduling—also called easy access or advanced access. It’s a model that lets patients schedule non-emergency appointments on the same day, as opposed to days, weeks or even months in advance.
In an office using traditional scheduling, there may be some same-day slots for emergencies, but they’re often handled by double-booking appointments or the doctor simply working overtime. This system also fosters high no-show rates and diverts frustrated patients to urgent care facilities, where they receive less personalized care at a much higher cost.
With open access, patients are usually assigned appointment slots on a first-call, first-serve basis. Problems needing immediate attention are given priority. If patients don’t want or need to be seen on the day they call, they can schedule an appointment on a low-traffic day in the future reserved specifically for advanced bookings.
Proponents of this model say it’s a more effective way to treat patients. But because it isn’t widely implemented, open-access scheduling is often misunderstood. Here, we take a closer look at the most common misconceptions to find out if they’re valid arguments, or simply much ado about nothing.
Misconception #1: Open-Access Results in More No-Shows
The popular Web-based restaurant reservation system OpenTable found success by making reservations easier for diners to book. Software vendors now offer a similar approach to help patients schedule same-day appointments online.
Mike Hoaglin is the clinical scholar-in-residence for Practice Fusion, which operates the online patient scheduling platform Patient Fusion, and is a big fan of open-access scheduling. “Human behavior is so unpredictable, but if a solution like OpenTable takes this into account with a system that works so well for restaurants, why wouldn’t it work in a medical environment?” he asks.
For some doctors, however, the prospect of going into each day with open appointment slots is nerve-wracking. “I have friends who won’t go to a restaurant unless there are a lot of cars out front,” says Dr. Jean Antonucci, a family practice physician in Maine who has used open-access scheduling for eight years. “If it’s popular, it must be good, right? But is that approach really good for the patient and the doctor?”
Antonucci says doctors who worry about not being fully booked don’t understand the way supply and demand works. Indeed, practices offering same-day appointments frequently see a drop in their no-show rate. Antonucci says it’s “extremely rare” to get a no-show, and when it happens it’s almost always a new patient. A Kaiser Permanente study confirms this, reporting that no-shows can drop from 20 percent to nearly zero with open-access scheduling.
Misconception #2: All Appointments Are Same-Day
The fundamental idea of open-access is to leave slots open for same-day appointments. When Dr. Mark Murray and Catherine Tantau proposed open-access scheduling in an article for Family Practice Management magazine in 2000, they called it “doing today’s work, today.”
Tantau, who runs a California healthcare consulting group that helps practices make the switch to open-access scheduling (she prefers the term “advanced access”), believes that “there’s rarely any value in delay” when it comes to addressing medical issues.
“The gold standard of care is to offer an appointment today with the PCP (primary care provider) or with a teammate in the absence of the PCP,” Tantau says. “The key word here is ‘offer.’ The patient can take it or not.”
Despite many doctors’ concerns that they must “force” their patients to schedule day-of appointments and risk irritating them, not all appointments are same-day in an open-access model. Patients can continue to make traditional (long-range) appointments and schedule follow-up visits for low-demand times.
The key is finding the right balance of same-day and long-range appointments for each day’s schedule. For example, on Mondays and Tuesdays (when appointments are typically in high demand), your practice might devote most of the day to same-day appointments. On days that are typically less busy, devote a larger portion of the schedule to long-range visits.
Misconception #3: Your Patients Won’t Like the Change
While your long-term patients may take time to adjust to open-access scheduling, you can be confident they’ll be pleased with shorter wait times. Nationally, it takes about 20 days to get an appointment with a family physician, according to a survey by physician recruiters Merritt Hawkins & Associates.
Once in the door, patients typically wait 21 minutes or more, according to patient advocate website Vitals. And recent Software Advice research found that 97 percent of patients are frustrated by wait times, which means reducing this can greatly increase patient satisfaction.
Allowing patients to schedule same-day appointments significantly reduces wait times and is likely to result in much happier patients. Meanwhile, continuing to allow patients who prefer to book advance appointments to do so will ensure they’re also satisfied with the new model.
Murray and Tantau suggest a model that features 65 percent open slots per day and 35 percent booked in advance. Finding the right mix for your practice depends on factors unique to your situation.
Misconception #4: Your Staff Will Be Overworked
Murray and Tantau admit that a successful shift to open-access scheduling takes time and work. It often means seeing more patients every day for six to eight weeks to work down the backlog before starting same-day appointments. But once on the new model, Tantau says doctors may actually work less.
“Physicians [using traditional scheduling] spend too much time making room in their schedule for what someone else calls an urgent problem,” she says. And of course it may or may not be urgent; patients will sometimes say anything to get in.
“The line I frequently hear from doctors is, ‘I’m already working too hard,’” Tantau continues. “And they are—they and their staff are constantly battling delays, and everybody’s working harder than they need to.”
With open access, however, “[my staff] actually spend less time on the phone than they used to,” Antonucci says. “Typically staff get tied up on the phone with people begging for an appointment. With open access, you can cut the conversation short by saying, ‘Do you want to be seen today?’”
To minimize time spent on the phone, keep appointment types to a minimum—having to select one of many reasons for coming is confusing for the patient and can prolong the time it takes to book an appointment. To streamline the scheduling process, Murray and Tantau suggest using only three appointment types:
- Personal (P): When a patient is seeing their preferred personal physician;
- Team (T): When the patient is seeing another physician in your absence; and
- Unestablished (U): The appointment is not tied to a specific doctor.
To ensure staff aren’t overworked upon switching to the new system, Tantau recommends first conducting an analysis to determine the average number of hours doctors are currently working and how many patients they typically see each week. This analysis will help determine how long it will take to tackle your backlog and how many patients your staff will comfortably be able to see per day once you switch to the new model.
Ensuring that your supply and demand are in equilibrium can be a challenge, but getting it right the first time will save your staff time in the long run. “A lot of doctors invest a lot of time sending postcards and calling patients to remind them of appointments, for example,” Antonucci says. “Since so many of our appointments are now day-of, we don’t have to do that.”
Misconception #5: Operating Costs Will Rise
“When CFOs first hear about advanced-access, they get nervous,” Tantau says. For them, a fully-booked schedule means a profitable practice. “But overbooking and missed appointments lead to chaos. After CFOs see the results [of open-access], they’re all smiling because they see how the numbers have shifted in a favorable way.”
Financial data isn’t easy to come by—most practices don’t want to divulge their operating costs and profits. But Tantau says she has seen consistent outcomes that include a drop in the volume of office visits, an increase in the quality of those visits, fewer urgent visits, and “the income of the individual providers and the organization as a whole goes up.”
If implemented the right way, Hoaglin says there’s no reason that open-access scheduling should cost you more time and money. “The misconception is that you’re going to have to stay open later and spend more money on more resources, but it could be just the opposite,” he says. “The time you’ve been spending on administrative tasks is decreasing, and you’re now able to reallocate that time for something like an extra appointment.”
Tantau also says administrative staff typically spend too much time on the phone trying to evaluate the purpose of the visit, when an appointment date is available, and so forth. Meanwhile, nurses spend most of their time in triage mode, determining which patients really need to be seen today and which don’t. As a result, Hoaglin says, “The real benefit to having patients make their own appointments is you can ultimately reduce the cost of staffing.”
Creating an Implementation Plan Is Key
As with any major change in your practice, our experts say you have to first make sure everyone on your team is on board with open access in order to ease the transition. Whether you’re adventurous and looking to try something new to improve patient satisfaction or motivated by desperation because your current system is a failure, everyone has to understand the plan and be in agreement.
This means having a contingency plan. Know how your practice will react during periods of both high and low demand, as well as when a physician on staff is out of the office. If a patient can’t see their primary doctor on the same day, offer an appointment with another physician or midlevel practitioner. You can also offer to have them come in the next day his or her primary doctor is on duty.
“The common pitfall is when we stop measuring and we stop being nimble in our response to the demand and supply,” Tantau says. For example, a group practice has to decide together how to handle the holidays. Half the providers may get the week of Christmas off; the other half may get the week of New Year’s off. Each group will usually have to work harder during “their” week to compensate for the absence of their colleagues. If someone isn’t on board with that plan, the model will likely fail.
“It’s not that nobody can take a vacation,” Tantau says. “But how does the group agree to act when we are in short supply?” Communication is key, and when a practice fails to discuss its contingency plan, “of course it results in a mess.”
While there are many benefits of switching to an open-access model, the greatest may be the control it gives patients over their health. “It’s a way for practices to provide more of a concierge medicine feel,” Hoaglin explains. “Patients want to have more ownership on issues that affect their health—they want to be listened to.”
Tantau shares a similar opinion. “Open access is the only thing I’ve ever seen that makes patients happy, makes staff happy and makes doctors happy,” she says. “I think every primary care doctor should be doing this.”