Mark Murray & Associates 916-441-3070

murraytant@msn.com

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