Access to Care

"I am sorry, Mrs. G, but the doctor's next available appointment is two weeks from Thursday." "Doctor, Mrs. G insists on seeing you today." "Okay, double book her." "But you are already double booked all day." "Then just find a place for her."

This scenario creates stress for the patient, staff, and physician. An alternative to all scheduled appointments is "open access."² With open access, every patient is given an appointment the day he or she calls. There are no scheduled appointments. This system was piloted in one practice of a Green Bay, Wisconsin area medical group, and it was so successful that all 18 of the group's sites have implemented the open access system.³ At one site, open access improved the group's poor financial performance by creating room in the schedule for more patients, which in turn generated more income. At Malibu, last year, when all patients scheduled their appointments, the scenario of Mrs. G was a daily stress. We evaluated our patient flow and realized that one-third of our patient visits were necessarily same day visits. After reviewing the open access model, we

Phones

"I called the office, and all I got was an answering message." "I was kept on hold for fifteen minutes and then disconnected." "All I wanted to do was to ask for a refill on my medicines, and it took ten minutes." "I left a message for the office, but no one ever got back to me." "Doctor, you are hard to get a hold of."

Does any of this sound familiar? It certainly was a serious problem in our practice. We had instituted an AVA system (automated phone system with call directing capabilities) about one year ago when it became obvious that our phone system was severely limiting. The system was designed with enough mailboxes and message direction to run the Pentagon. But it just didn't work for us. We did not seem to have enough people to answer the phones; messages got lost; patients were very unhappy. In assessing the problem, a traffic study was requested from the phone company to monitor our phone activity. From this study we realized that on Monday mornings we had 500 phone contacts (incoming and outgoing). At 2PM we were deluged with calls that were transferred over to our back up system. Patients wanted to speak with a person not a message system. We realized that we were taking an inordinate amount of time handling prescription refills. Following several lengthy discussions with all parties involved, we developed a plan of action.

1. All patients were advised to call the pharmacy for refills instead of the office. We instituted a 24-hour response time for all routine refills and worked with our local pharmacies to develop standard refill request forms that the pharmacies would fax to our office. Each physician is responsible to check the prescription board at noon and by 5PM. Prescriptions that require the patients' charts are pulled and placed on the physician's desk with the prescription request. All completed refill request forms are then faxed back to the pharmacy by the end of the day and filed accordingly. Phone calls decreased.

2. The open access, urgent care scheduling plan has eliminated a significant amount of time the staff are on the phone since there is no need for the staff to check with the back office personnel or doctor before scheduling a needed appointment.

3. At high volume times, we designate an extra staff member to answer phones. Every Monday morning, our office manager spends several hours assisting the staff on the phones.

4. We no longer go "on service" during lunch, but schedule our staff so there is always someone answering the phones between 12-2PM. This has greatly alleviated the 2PM deluge of calls.

5. All office staff are trained to handle phones and schedule appointments so our medical assistants can fill in as needed.

6. Most importantly, we committed to answer all phone calls in person during office hours if possible. This required the participation of all office personnel.

Each change had a snowball effect on our phone problem. By eliminating most prescription refill calls, the staff had more time to address other phone issues. By recognizing our high volume times and keeping our phone lines open longer we found that we did not need more staff but could use our present staff more

Bateman Re-Engineering Primary Care Practice

wisely and efficiently. By involving our entire staff in solving this problem, we began developing a sense of team unity which has carried over into other areas. There are many other ways to improve phone interactions. Having a central phone number for the PCN referral system and a central intake number to preregister new patients will be helpful in economizing the phone usage at each office.

Customer Service

We are a service profession. Our major clients are our patients. In the past, physicians enjoyed great patient loyalty. But as the medical environment changes, physicians no longer command the patient loyalty once afforded to us. We have to work harder to offer a better value to our patients in order to stay viable in today's highly competitive setting. Insurance companies are looking at quality and outcomes. To survive and flourish, we must recognize that our patients are valued clients and they need to be treated as such. At Malibu, we found that we were frequently having negative patient-staff interactions. The patient who came in late or on the wrong day was chastised and told how disruptive this behavior was to the office. Over-booking and insurance changes put additional stress on the staff. This stress was transferred negatively to patient interactions.

Recognizing the problem, we decided to institute a customer service education program for our staff. The physicians and office manager chose an established course entitled "The Customer" by Integrity Systems.⁴ The office manager and an outside facilitator implemented the program. The program took ten hours, which included a four-hour introduction session and six one-hour follow-up sessions. All employees were required to attend. In order to accomplish this, the office was closed for one afternoon for the first session and the follow-up sessions were held immediately after lunch. The program covered most aspects of customer service. All sessions were highly interactive, requiring the staff to work in teams to solve problems common to a medical practice. Each team then shared the results with the group for further critique and discussion.

The program helped the staff recognize "who is the client." We have since developed better customer-service relationships with our patients/clients as well as other individuals we meet during our workday. The program provided guidance in dealing with stressful and difficult situations in a professional manner. It taught a team approach to problem solving. No longer should there be a "Who is to blame?" attitude but rather "How can I help fix it." The energy and positive attitudes that developed during this training program have carried over into the daily operations of the practice. Another benefit is that the staff felt empowered to take a proactive role in their practice. They have a sense of pride in who they are and what they do. They realize that they can call for help from any one of their teammates and that member of the team will respond in a positive and supportive way. As a result of this customer service program, we see a more professional and less stressed staff with an attitude of "How can I help" instead of "That's not my job." Our patients/clients are very impressed with the ambience and professionalism of our office. It is our goal to have all physicians complete an abbreviated course by the end of the year.

Conclusion

Re-engineering the primary care office practice is a monumental task. One might think it is too overwhelming to even attempt. This is not true. Each journey begins with the first step. This journey will take many years to complete. It will not happen by itself. No administrator will come to your office and wave a wand over your problems and make them go away. It requires the commitment and leadership to create change. Change does not occur in a vacuum, but requires examining the problem from many different points of view with an open mind to look "outside the box." This requires the input of every person who may be affected by the problem. It is extremely gratifying to identify a problem, process the problem as outlined in Table 1, and see the fruition of one's labors. It is necessary to reevaluate the problem periodically to ensure that the solution remains viable. Customer service needs to be nurtured, praised and rewarded in order for it to continue and flourish. Each time we reinforce a positive behavior, we are setting the standard for the future. A problem recognized is not an impediment, but an opportunity to improve.