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Advanced Access Basics;Demand and Supply Calculations

Catherine TantauTantau & Associates

PO Box 179Chicago Park, California, 95712

530-273-6550ct@tantauassociates.com

www.tantauassociates.com©Tantau & Associates

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Advanced AccessQuick Review….

AA is… No delays for an

appointment. CONTINUITY for

patients and providers.

Doing today’s work today

AA is Not… Holding appts in

anticipation of same day urgent demand.

A Walk in Clinic or Urgent Care Clinic.

Telling pts to call back when appts are released.

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Start with an AimThe Gold Standard

Primary Care:

Offer an appointment today

for any problem (urgent or routine)

with the PCP or teammate in the absence of the

PCP.

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Delayed systems…

Tension; medical definition, patient definition

Waste inherent in tending the delays “If you’re sick and you can prove it.” Pts get in anyway! Delays increase workload.

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The longer patients wait,The harder we work….

New PatientCalls

(1/wk/MD)

EstablishedPatient Calls

Switchboard

PCP Receptionist(4) #

(Most)

Admin.- Q & A- Page Pedi MA- Assist patient

Hold

Busy N.A.

Answer

Bounce to others whenPCP recept. fall

recept

Appt. req.

Q & ASick?

Not sure

Mesg. To MD

MD calls patient

Q & A

Advise Appt. Emerg. - ED

- Book it w/PCP- Overflow MD if walk in when avail

+

Next avail. w/PCP

-

Book it+ -

- Add on sooner- Occas. Msg to MD

Check insur. &confirm on 2systems new

patients longer

min. --hoursor lost

30" -hrs.

Note:- No triage on phone- Occas. triage walk in

Note:Always see pts.

Admin. to resolve- non PCP - 1st available

or

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RN Work Analysis in a delayed system…

ClinicalClerical

Source; CHC, Pacific Northwest, 2008

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RN Survey“In this office I have the opportunity to do what I

do best everyday.”

0

1

2

3

4

5

StronglyDisagree

Disagree Agree StronglyAgree

Source; CHC, Pacific Northwest, 2008

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What is Advanced Access ?

NO delays for an appointment. CONTINUITY for patients and

providers. Doing today’s work today…

So how many appts do weneed today?

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Demand and Supply Equilibrium

SupplyDemand DELAY

Evidence of a stable

reservoir ???

What would Starbuck’s ask???

How many customers / day? What days are busiest? How many lattes? Vs Chai tea vs…??? How many pounds of beans do we

need? How much staff do we need to meet

daily and hourly variations in demand? What else????

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Demand

Illness Burden of Population

Mood and Attitude

Continuity

Measures: True demand

Measures: Panel Size (driver for

demand)

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Demand

Look at historical data? True Demand Formula:

External Appointment requests, called in and appted regardless of day

appted. To (today or future)

+ Walk-ins for appts.

+ Other portals of entry ?(email, fax,”add-ons” etc.) + Deflections (UCC etc)Internal

+ Returns booked today for the future

© Tantau & AssociatesTotal Demand

Appointment Demand Worksheet

Date: ____________

Care Unit 3

Patients calling today, requesting appt, regardless of day appted to

(External)

Walk-Ins today

appted

(External)

Deflections,

eg UCC, if trackable

(External)

Return appts booked today as pts leave today’s appt.

(Internal)

Total Demand

Optional; Pts

turned away, not booked. Do not

add into Demand

Provider

A

Provider

B

Provider

C

Provider

D

Total

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Measured demand

Calls for visits

Other external demand

Internal demand

# appt per day

Monday 44 2 29 75Tuesday 34 5 25 64Wednesday 29 8 35 72Thursday 30 3 18 51Friday 37 1 31 69

Provider capacity

# appt per day

Monday 70.125Tuesday 61.5Wednesday 87Thursday 58.875Friday 84

VISIT RATEVisits per hour

Provider A 3Provider B 3Provider C 2.25Provider D 3Provider E 3Provider F 3

HOURS per session Mon AM Mon PM Total Tues AM Tues PM Total Wed AM Wed PM Total Thu AM Thu PM Total Fri AMProvider A 3.5 4 22.5 4 12 3.5 2 16.5 4 12 3.5Provider B 0 2.5 3 16.5 2.5 3 16.5 0 2.5Provider C 2.5 4 14.625 0 4 9 3.5 4 16.875

Appointment Capacity versus Demand

0

10

20

30

40

50

60

70

80

90

100

Monday Tuesday Wednesday Thursday Friday

Provider capacity Measured demand

Measured demand

Calls for visits

Other external demand

Internal demand

# appt per day

Monday 0Tuesday 0Wednesday 0Thursday 0Friday 0

Provider capacity

# appt per day

Monday 0Tuesday 0Wednesday 0Thursday 0Friday 0

VISIT RATEVisits per hour

Provider AProvider BProvider CProvider DProvider EProvider F

HOURS per session Mon AM Mon PM Total Tues AM Tues PM Total Wed AM Wed PM Total Thu AM Thu PM Total Fri AM Fri PM TotalProvider A 0 0 0 0 0Provider B 0 0 0 0 0Provider C 0 0 0 0 0Provider D 0 0 0 0 0Provider E 0 0 0 0 0Provider F 0 0 0 0 0

Mon Total 0 Tue Total 0 Wed Total 0 Thu Total 0 Fri Total 0

Appointment Capacity versus Demand

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Monday Tuesday Wednesday Thursday Friday

Provider capacity Measured demand

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Supply Macro Supply…dept level Deployment of Supply…bookable hours Measures

Measure when schedule is released. Appts per session for each day of week per provider. Estimate % long and shorts based on prior schedules

Hours per session ? Productivity standard? Office FTE modification

Process of Supply… What is the work? Who does the work? What can we try doing differently?

Appointment Supply Worksheet

Week of:____________

Provider

A

Mon

Tues

Wed

Thurs

Fri

Sat

Total

Supply

Provider B

Provider

C

Provider

D

Total

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Measured demand

Calls for visits

Other external demand

Internal demand

# appt per day

Monday 44 2 29 75Tuesday 34 5 25 64Wednesday 29 8 35 72Thursday 30 3 18 51Friday 37 1 31 69

Provider capacity

# appt per day

Monday 70.125Tuesday 61.5Wednesday 87Thursday 58.875Friday 84

VISIT RATEVisits per hour

Provider A 3Provider B 3Provider C 2.25Provider D 3Provider E 3Provider F 3

HOURS per session Mon AM Mon PM Total Tues AM Tues PM Total Wed AM Wed PM Total Thu AM Thu PM Total Fri AMProvider A 3.5 4 22.5 4 12 3.5 2 16.5 4 12 3.5Provider B 0 2.5 3 16.5 2.5 3 16.5 0 2.5Provider C 2.5 4 14.625 0 4 9 3.5 4 16.875

Appointment Capacity versus Demand

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10

20

30

40

50

60

70

80

90

100

Monday Tuesday Wednesday Thursday Friday

Provider capacity Measured demand

Apr-05 May-05 J un-05 J ul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 J an-06 Feb-06 Mar-06 Apr-06 Average M T W TH FDemand 197 186 174 159 161 159 156 216 211 168 146 176 Demand 261 240 235 208 184Supply 171 179 195 179 201 176 164 192 174 150 118 173 Supply 193 190 162 195 175

S&D Average Weekly Averages

Supply & Demand

0

50

100

150

200

250

300

350

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Day of the Month

Demand Supply

Average Weekly Supply and Demand

0

50

100

150

200

250

300

M T W TH F

Demand Supply

Family MedicineSupply & Demand Daily Average by Month

0

50

100

150

200

250

Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 Average

Demand Supply

Tracking Demand and Supply source: YKHC, Bethel Alaska

Activity; the 3rd Dimension

Activity is the measure of patients who were actually seen today.

At the end of the day, regardless of demand or supply, count the number of patients seen.

Accounts for No Shows.

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Three Dimensions;Demand, Supply, Activity

Average Supply & Demand December 12 - July 7

3 Appointments Per Hour

7975

60

73

82

63 62

5551 49

2732

24

33 35

0

10

20

30

40

50

60

70

80

90

Monday Tuesday Wednesday Thursday Friday

Supply Demand Patients Seen

Appointment Activity Worksheet

Week of:____________

Provider

A

Mon

Tues

Wed

Thurs

Fri

Sat

Total

Activity

Provider B

Provider

C

Provider

D

Total

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The latest…Demand, Supply, Activity

A three dimensional

look at what’s really going on in the practice.

All Physicians (Totals) - Office Visits (HG only)

0

100

200

300

400

500

600

700

800

900

1000

Sept Oct Nov Dec Jan Feb Mar Apr May

Num

ber

of Appts

Demand

Activity

Supply

Source: Huron Gastro, Ann Arbor

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Clinic Activity Availability

0

100

200

300

400

500

600

700

800

Jan-

03

Feb-0

3

Mar

-03

Apr-0

3

May

-03

Jun-

03

Jul-0

3

Aug-0

3

Sep-0

3

Oct-03

Nov-0

3

Dec-0

3

Jan-

04

Feb-0

4

Mar

-04

Apr-0

4

May

-04

Jun-

04

Jul-0

4

Aug-0

4

Sep-0

4

Oct-04

Nov-0

4

Dec-0

4

Jan-

05

Feb-0

5

Mar

-05

Apr-0

5

May

-05

Jun-

05

Vis

its Seen

Available

Scheduled

Demand… ScheduledSupply….. AvailableActivity…..Patients seen

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How to Track…How long to track…

Tic Marks vs Electronic tracking

4-6 weeks and then forever

Separating Internal from External

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What’s your situation?How do you know? D>S ? D<S ? D:S ?------------------------------------------------ “Our schedules are jammed every day.

Our Demand must outstrip our Supply”(??????)

“We’ve had the same Delay for months.” “We measure D and S, continuously and

map the trends.”

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Show and Tell

Teams share their data Ask questions Discuss next steps

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If Demand is Greater than SupplyFour Options1. Work harder ?2. Delay the work ?3. Buy more supply ?

4. Do the work differently !!! …test…. Shape Demand Eliminate duplicate visits Care Team development; leverage the work Extend visit interval Promote Continuity Max Pack Simplify Appt types and times Nurse Appts Phone Appts Improve Access to reduce No Shows and capture that

Supply Spread

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Identify source of demand and ask, “Why?”

Internal External Discontinuity Single issue visits to ramp up visit count? Bumping Delays and defensive booking Sub-optimized Care Team Growth

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Try something New!

Test, test, test…

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Critical Access Design Elements

Critical Access Design Elements

1. Continuity / familiarity

2. Appointment capacity

3. Demand and Supply

equilibrium