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Mark Murray & Associates 916-441-3070
ACCESS IMPROVEMENTACCESS IMPROVEMENT How to see Differently How to see DifferentlyACCESS IMPROVEMENTACCESS IMPROVEMENT How to see Differently How to see Differently
Mark Murray, MD, MPA
AccessAccessAccessAccess
• An access problem is a delay problem
•An access problem is a system problem
Every system is Every system is perfectly designed perfectly designed to get the results it to get the results it gets.gets.
ResultsResults
TermsTermsTermsTerms
Demand: what the customer wants/what we should be doing
Activity: what we are doing Supply: what we could be doing Backlog: what we should be doing but
haven’t Wait list/queue/work in
progress/inventory/warehouse=backlog Constraint/bottleneck: the rate limiting step
Why focus on delay?Why focus on delay?Why focus on delay?Why focus on delay? Delays lead to patient dissatisfaction Delays lead to staff dissatisfaction Delays lead to provider dissatisfaction Delays cost money Delays sub-optimize revenue Delays adversely effect clinical outcomes We can only go as fast as the slowest step Perception that delay=lack of resource
Why do queues form?Why do queues form?Why do queues form?Why do queues form?
Demand > Supply Variation Paradigm Buffer for revenue, for predictability and
for assurance of 100% utlilization ( false productivity)
Demand > capacityDemand > capacity Demand > capacityDemand > capacity
Time
waiting numbersIf Demand
> Activity or Capacity
Sources of demand Sources of demand variationvariationSources of demand Sources of demand variationvariation
Randomness of presenting patients Randomness of clinical
condition/acuity/time Randomness of internally generated
demand System factors ( includes discontinuity,
future open schedule etc)
Sources of supply Sources of supply variationvariationSources of supply Sources of supply variationvariation
Lack of time in/out policies Number of providers Pattern of providers Carve outs that restrict flexibility Other system constraints ( rooms, staff,
equipment etc)
Moment of truthMoment of truthMoment of truthMoment of truth
Even if the average demand = average supply
The variation of demand + the variation of supply
Will result in a queue
Demand & capacity for breast Demand & capacity for breast clinicclinicDemand & capacity for breast Demand & capacity for breast clinicclinic
0
20
40
60
Week
Number
3 January 2000 22nd January 2001
Total number of patients referred
Number of clinic slots available
Computer model Computer model demonstrationdemonstrationComputer model Computer model demonstrationdemonstration
0
10
20
30
40
50
60
70
80
90
100
1 21 41 61 81 101
121
141
161
181
201
week
wai
ting
0
5
10
15
20
25
30
35
40
45
50
dem
and/
was
te
demand waiting list waste
ConstraintsConstraintsConstraintsConstraints
Demand in the population
Request for service
constraint
Access to that service
Delivery of that service
Access to secondary
service
constraint
constraint
Access ImprovementAccess ImprovementAccess ImprovementAccess Improvement
Team Aim Changes Measures
Model for Model for ReconstructionReconstructionModel for Model for ReconstructionReconstruction
D:S D = S D reduction S enhancement
Demand
Supply
2 MONTHS
FTKA Triage Rework
Critical Access Critical Access Design ElementsDesign Elements
Critical Access Critical Access Design ElementsDesign Elements
Continuity
Appointment capacity
ModelsModelsModelsModels
Traditional Model
Carve Out Model
Advanced Access Model
R
H
R
OPEN
R
H
R
H
R
H
R
H
R
H
R
H
R
H
R
H
R
H
R
H
R
H
R
H
R
H
OPEN
H
R
H
R
H
R
H
OPEN
H
M T W TH F
Carve Out One Month ViewCarve Out One Month View
R=Routine
H=Held
Demand
©Murray / Tantau
Return
OPENOPEN
DemandDemand
M T W TH F
Patient Choice
OPENOPEN
Return
OPENOPEN
Patient Choice
OPENOPEN
Return
OPENOPEN
Patient Choice
OPENOPEN
Return
OPENOPEN
Patient Choice
OPENOPEN
Return
OPENOPEN
Patient Choice
OPENOPEN
Advanced Access -Advanced Access -One Week ViewOne Week View
Advanced Access -Advanced Access -One Week ViewOne Week View
No specific time for this “good
backlog”
Advanced AccessAdvanced AccessAdvanced AccessAdvanced Access
Fears:– Saturated schedules– Demand is insatiable– Panel size
Pitfalls: – Panel size– Supply side variation
Do all today’s work today
OldOld OldOld
In order to protect today, we push work to tomorrow.
NewNewIn order to protect tomorrow, we In order to protect tomorrow, we
pull pull work into today.work into today.
ResultsResultsResultsResults
Patient satisfaction improved Staff satisfaction improved Provider satisfaction improved Delays reduced Continuity improved Quality improved Unnecessary visits reduced Financial improvement
Staff Turnover 2002-2003
0.00%5.00%
10.00%15.00%20.00%25.00%30.00%35.00%40.00%
J -02 F-02 M-02 A-02 M-02 J -02 J -02 A-02 S-02 O-02 N-02 D-02 J -03 F-03 M-03 A-03 M-03 J -03 J -03 A-03 S-03 O-03 N-03 D-03
13 M
onth
Rol
ling
Aver
age
Voluntary Involuntary
Physical ExamsPhysical ExamsPhysical ExamsPhysical Exams
3rd Next Avail. Appt. for PE Appt. with PCP
0.0
5.0
10.0
15.0
20.0
25.0
30.0
10/4
/99
10/1
8/99
11/1
/99
11/1
5/99
11/2
9/99
12/1
3/99
12/2
7/99
1/10
/00
1/24
/00
2/7/
00
2/21
/00
3/6/
00
3/20
/00
4/3/
00
4/17
/00
5/1/
00
Day
s
Provider 1
010203040506070
Dates of Observation
# O
f Wor
king
Day
s O
ut
Provider 2
010203040506070
Dates of Observation
# O
f W
ork
ing
Day
s O
ut
Provider 3
010203040506070
Dates of Observation
# Of
Wor
king
Day
s Ou
t
Provider 4
010203040506070
Dates of Observation
# O
f Wor
king
Day
s O
ut
Number of Days for 3rd Number of Days for 3rd Available Routine AppointmentAvailable Routine Appointment
0
10
20
30
40
50
60
70
80
MD AVG NP
1
2
34
5 67
Alaska Native AmericanAlaska Native American
Health Care PediatricsHealth Care Pediatrics
Match with PCPMatch with PCP 2 Year Comparison 2 Year Comparison
Sacramento
0
25
50
75
100
Apr-95
Jun-9
5
Aug-95
Oct-9
5
Dec-9
5
Feb-9
6
May
-96
Jul-9
6
Sep-9
6
Nov-96
Jan-9
7
Mar
-97
Months
Avg. 59%
Avg. 72%
% o
f M
atch
Improved Clinical Improved Clinical OutcomesOutcomesImproved Clinical Improved Clinical OutcomesOutcomes
Interventions: Health prompt
Continuity
Advanced Access
98%99%86%93%
95%97%90%87%
65%
70%93%
69%76%
Tobacco UseTobacco users advice% of serv. Complete
1998 Q 459%50%88%50%
60%
52%InfluenzaPneumovaxBreast CaCervical Ca
1999 Q492%74%
88%97%
2000 Q1LipidsColorectalBP - diag.Tetanus
100%80%
94%
100%92%70%
97%96%88%86%
88%
97% 94% 97% 96%88% 86%
98% 99%
86%93%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
110%
120%
Lipi
ds
Col
orec
tal
BP
- di
ag.
Tet
anus
Influ
enza
Pne
umov
ax
Bre
ast C
a
Cer
vica
l Ca
Tob
acco
Use
Tob
acco
use
rs
advi
ce
% o
f ser
v.
Com
plet
e
88%97% 94% 97% 96%
88% 86%
98% 99%
86%93%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
110%
120%L
ipid
s
Co
lore
cta
l
BP
- d
iag
.
Teta
nu
s
Infl
uen
za
Pn
eu
mo
vax
Bre
ast
Ca
Cerv
ical
Ca
To
bacco
Use
To
bacco
users
ad
vic
e
% o
f serv
.
Co
mp
lete
1998 Q4
1999 Q4
2000 1Q
Change in Visit UtilizationChange in Visit UtilizationApril 1995 - March 1997April 1995 - March 1997SacramentoSacramento
-
50,000
100,000
150,000
200,000
250,000
4/95 to 3/96 4/96 to 3/97
Year
Vis
its
1.950
2.000
2.050
2.100
2.150
2.200
2.250
Primary Care Visits Avg. # Impaneled Visits / Impaneled Member
Visits 194,305
170,746
Impaneled Members
86,896
83,867
Visit Rate
(-8.3 %)
Initiated Second Generation
End Year 1 End Year 2
"Over and Under" Appointments - Provider 1 # of Appt slots Filled / # of Appt Slots Available
0%25%50%75%
100%125%150%175%
%
"Over and Under" Appointments - Provider 2 # of Appt Slots Filled / # of Appt Slots Available
0%
25%
50%
75%
100%
125%
150%
%
"Over and Under" Appointments - Provider 3 # of Appt Slots Filled / # of Appt Slots Available
0%
25%
50%
75%
100%
125%
150%
175%
%
"Over and Under" Appointments - Provider 4 # of Appt Slots Filled / # of Appt Slots Available
0%
25%
50%
75%
100%
125%
150%
%
““Over and Under” Over and Under” AppointmentsAppointments
Improved Finances Improved Finances Average per month over 1 yearAverage per month over 1 yearImproved Finances Improved Finances Average per month over 1 yearAverage per month over 1 year
429
378
340
360
380
400
420
440
April 98-March 99 April 99-March 00
Office Visits per Physician
Decrease of 11.9%
355
379
340345350355360365370375380385
April 98-March 99 April 99-March 00
Work RVU per Physician
Increase of 6.8%
Improved FinancesImproved FinancesAverage per month over 1 yearAverage per month over 1 yearImproved FinancesImproved FinancesAverage per month over 1 yearAverage per month over 1 year
$167,560
$196,521
$150,000
$160,000
$170,000
$180,000
$190,000
$200,000
April 98-March99
April 99-March00
Net Revenue
per Month
Increase of 17.3%
$14,654
$16,054
$13,500
$14,000
$14,500
$15,000
$15,500
$16,000
$16,500
April 98-March 99 April 99-March 00
Net Income per Month
Increase of 9.6%
High Leverage Changes High Leverage Changes for Access Improvementfor Access ImprovementHigh Leverage Changes High Leverage Changes for Access Improvementfor Access Improvement
Balance demand and supply daily
Reduce backlog
Decrease appointment types
Develop contingency plans
Reduce demand for visits
Increase the supply
High Leverage Changes for High Leverage Changes for OEOEHigh Leverage Changes for High Leverage Changes for OEOE
Balance the demand and capacity for non appointment work
Synchronize patients, providers and information
Predict and anticipate needs Optimize rooms, equipment and staff Manage the constraints
