Bob Carlson
Contributing Editor

"Advanced access means that if somebody wants an appointment, you offer the appointment for today." It's not that difficult to implement.

Bob Carlson

Contributing Editor

The longer the wait for an appointment, the better the doctor, right? Not any more. Not when happy patients start telling friends and neighbors about the excellent doctors who can see them the same day they call for an appointment.

It's not smoke and mirrors. The clue that backlogs are unnecessary is that they remain relatively constant through time. If your patients now have to wait three months to see you, chances are you had the same backlog last year, and next year they'll still be waiting three months to see you.

Now suppose you got rid of that three-month backlog by coming in a little earlier, working a little later, maybe hiring a nurse or medical assistant. You'd be able to offer your patients same-day appointments, too. That's advanced access, in a nutshell.

"Advanced access means that if somebody wants an appointment, you offer the appointment for today," says the consultant Mark Murray, MD. "The patient decides whether to come in today, tomorrow, or next week."

In the decade since Murray originated the advanced access approach to scheduling, office practices, clinics, and integrated delivery systems throughout the United States are demonstrating that it works, that patients who call for an appointment today can see their doctor today. That makes for satisfied patients, happy physicians and staff, fewer no-shows, higher quality care, and increased revenue.

"We've had incredible success with advanced access in primary care pediatrics, and now I'm one of the leaders in spreading these improvement concepts across all of our specialty and primary care areas," says Jill Swanson, MD, chairwoman of the division of community pediatric and adolescent medicine at the Mayo Clinic in Rochester, Minn.

Trial and error

A January 2001 New York Times article reported on the success of advanced access — also referred to as open access — and other practice improvement strategies, as did the cover story of the April 2002 U.S. News & World Report. But it hasn't always been smooth sailing, according to Murray, a principal in Murray, Tantau & Associates in Chicago Park, Calif., who now consults internationally on health care practice improvement.

"It took years of trial and error to develop advanced access," he says. "I made every mistake you can make, but I only made them once."

In 1991, Murray practiced family medicine and was assistant chief of medicine and director of operations at the Department of Adult Primary Care at Kaiser Permanente in Roseville, Calif. Like most practices, the clinic scheduled same-day appointments only for patients who were very sick. Everyone else had to wait weeks.

Determined to find a better way, Murray formed a partnership with Catherine Tantau, RN, MPA, the nurse manager at the Roseville clinic.

They studied how restaurants, Toyota manufacturing plants, UPS, trucking companies, trains, and airlines matched supply with demand as soon as possible after the demand was made. The eureka moment in the development of advanced access came when Murray realized that the way to eliminate delay was to eliminate the distinction between routine and urgent appointments and simply "do all of today's work today."

Protecting tomorrow

The old paradigm was, "To protect today, push work to tomorrow." The advanced-access paradigm is, "To protect tomorrow, pull work into today."

By "all of today's work," Murray means not only office visits, but also the two other broad categories of work in an office practice, the process work (documentation, prescription refills, laboratory review, claims, and telephone calls), and the referrals to other providers. In other words, advanced access is not a panacea for an inefficient practice. Its long-term success depends on effective clinical teamwork and efficient work flow.

"I implemented advanced access, and I immediately realized I could not do everything in a day's time," says Gregg Omura, MD, a family physician at Primary Care Partners, a 25-physician group with three offices in Grand Junction, Colo. To do every day's work on that day, he hired a medical assistant and a medical office assistant to join him and his RN. Now he is spending more. Will he recoup that?

In 2000, Omura saw an average of 20 patients per day. Today, he sees about 30, takes home substantially more pay, has more satisfied patients and a happier staff. "I also feel that I'm working less hard," adds Omura, whose family practice is part of Primary Care Partners, a 25-physician group with three locations in Grand Junction, Colo.)

Omura learned about advanced access at an Institute for Healthcare Improvement program on depression management in February 2000. Murray has served as chairman and planning group member for IHI's Breakthrough Series Collaboratives on Reducing Delays and Waiting Times.

No time to waste

By referring to Murray's articles in medical journals or to his materials on the IHI web site «», it is possible for practices to implement advanced access on their own. But Murray cautions that practices don't have the luxury of experimenting for five years, as he did.

"You get one shot with the docs, and if you blow it, you blow it," says Murray. "I've been in contact with a few groups recently that made significant mistakes and lost all credibility with their docs."

With that caveat, Murray outlines the steps in implementing advanced access.

  • Compare demand and supply daily. This requires daily measurement of the demand for appointments, the supply of appointments, and the elapsed time between when demand is initiated and supply is applied, all in units of time. The gap between demand and supply is the access problem.
  • Eliminate the backlog. It took Gregory Long, MD, three months to eliminate the six-month backlog in his family practice. He added a part-time NP to his team, came in early, worked on his call days, and worked for a half-day on his "day off" and on Saturdays. Long is medical director of Physician Services at ThedaCare, a large integrated delivery system headquartered in Appleton, Wis., and is spreading advanced access to 90 more physicians in the system.
  • Decrease appointment types. By definition, different appointment types (including but not limited to routine, urgent, male, female, and new patient) introduce queues and delays because they involve inclusion and exclusion criteria that make them noninterchangeable, even if they're all 20 minutes. Maximum flexibility in a provider's schedule is achieved when all appointments are interchangeable, even if they are billed differently.
  • Develop contingency plans. To maintain the backlog at one day or less, determine in advance how to divide the work of providers who are on vacation or have the day off, how to accommodate a surge in demand, how to anticipate and accommodate needs such as school physicals, and how to predict demand by clinical condition, time of day, day of the week, month, and time of year. "It was contingency plans that finally got us into a steady state of advanced access," says Long.
  • Reduce demand for unnecessary visits. "The best demand reduction strategy is continuity. Try to have doctors see their own patients," says Murray. "Just doing that will reduce demand by about 10 percent. The second-best demand reduction strategy is to do as much as possible with every visit." Often referred to as "max-packing," this strategy minimizes inconvenience to patients and increases RVUs per visit.

Leadership, Murray says, is essential.

"The CEO has to say 'We believe that we can reduce waiting times.' The other crucial element is physician leadership, engagement, and involvement. Just because you have some of the doctors engaged in the process doesn't mean you'll be successful. But if you don't have the doctors, you won't be."

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