What’s the single most effective practice innovation you can make?

• add an examination room
• hire a nurse practitioner
• move to an EMR system
• switch to same-day appointments
• none of the above

Four years ago access to family doctors was a big problem in Cape Breton. Fully a third of patients had to wait days for an appointment and many took even the most minor complaint to hospital emergency rooms — levels 4 and 5 on the triage scale. Today patients in some practices make far fewer visits to the ER, receptionists are happier and there’s better continuity of care. One GP/FP has seen his
no-shows drop while patient satisfaction is way up. What’s more, his revenue has increased by 7%.

The innovation that had such beneficial effects cost next to nothing. All that was done was to switch to same-day scheduling or, as it’s also called, open access. The Nova Scotia example is contained in a report from the Canadian Health Services Research Foundation (CHSRF) described in the following article. You can find out more about it at their website, www.chsrf.ca.

Same-day appointments have been around since the mid-90s. Despite the benefits for both patients and practitioners, most practices have yet to try it.

Some are reluctant to make the move out of fear that demand will surge and overwhelm their practices. It’s true that when patients can simply call and come in the same day, the nature of the practice can change. For one thing, peaks and troughs are likely to develop. A Sarnia family physician who made the switch found that she was run off her feet on Mondays and Tuesdays and had very few patients on Friday afternoons. Her solution was to close the office at noon on Friday and instead see patients on two evenings a week.

Fewer visits per patient

These days she actually sees fewer patients yet her billings are up. In fact, most practices that have switched do see a decline in the number of visits a given patient makes in a year. Part of the reason is that the same-day bookings encourage practioners to pack in more when the patient does comes in. For example, should a diabetic patient present with a possible throat infection, tests that might normally have been done at a future appointment will be performed then. As the Sarnia MD experienced, this has the effect of both reducing visits and increasing the number of procedures that can be billed. Before she moved to same-day billing, this doctor’s patients had an average wait time of 44 days for routine physical exams and 27 days for a PAP test. Today the waits have been virtually eliminated.

Working your way through your backlog is a gradual process. If you’re seeing 25 patients a day on average, the first question to ask how is many walk-ins do you get and what’s your no-show rate. You may well find that they more or less cancel themselves out, which is a good indication that once in place, open access will work for your practice.

Start by moving patients who come in on a regular basis for routine tests to less busy days. Keep the remaining scheduled appointments as booked, while fitting in the same-day appointments around them. It will mean bigger loads and longer hours for the first couple of months but things will taper off as scheduled patients become same-dayers.

The benefits will depend on how complicated – and perhaps chaotic – your present system is. Under his old system, a Delta, BC GP/FP had his receptionist simply note down every request for an appointment, telling patients that she would call them back with a date. At the end of the day, the doctor would go through the list and do the triage himself. “I felt strongly that it was my responsibility to do this,” he explains, “I was the only one who could properly judge which cases were the most urgent.” The task took him between 45 minutes to an hour each day. He sometimes didn’t leave the office until after 7:00 pm. “Now I’m gone by 5:30, notes completed and all.”

Tough transition

Expect to work harder during the transition period. A 12-member group practice in Edmonton found it took each practitioner about three extra days a month for the first two months to clear the backload. It took one member 12 extra days over three months before same-day appointments were fully operational. It’s meant other changes. In most cases patients are given lab and other test results over the phone. The idea is to keep the schedule as open as possible.

The first summer after the change was completed was a shock. Patient loads dropped off significantly in July and August and some members considered abandoning the system. The receptionists would have none of it. The argued that same day bookings were an instant hit with patients and had substantially reduced waiting room stress making their own lives easier. The practice decided to reassess in the new year. Patient traffic returned to usual levels in the fall. When the books were closed, group billings were up almost 4% for the year, after adjusting for fee-increases. The system stayed.

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