Practice Management

Same-day service comes to dog-eared patient appointment books

"Are you sure this is the doctor's office, not the hair dresser's?"

On a grey Friday afternoon in February 2002, a Sudbury, Ont family physician came to the end of her tether. She'd come out of her office and was rifling through the supply cupboard when she heard her practice nurse on the phone saying, "No there hasn't been some mistake. I can't give you an appointment before May 17. Take it or leave it."

The doctor went over and put her arm around her only employee and said, "We can't go on like this, can we?" The epiphany wasn't about the nurse's apparent rudeness to the patient, it was about a practice with an appointment schedule and patient load so out of whack, it was about to sink them both.

Your patients love the Canadian healthcare system -- except when they hate it. And what they dislike -- indeed almost the only thing they dislike -- is the waiting times. Much of the frustration about long waits is focused on hospitals -- over-crowded emergency rooms, months-long waits for surgery. Why don't you do something about it, doctor?

Surprise, there is something you can do to offset at least some small part of the frustration: You can see your own patients on the same day they call for an appointment. Sound utopian? In the past five years hundreds of groups around the world have implemented same-day scheduling with gratifying results and now even solo practices are cleaning up their appointment books and taking it one day at a time.

Putting same-day scheduling into practice is, as we like to say these days, a challenge -- but the benefits can be remarkable. Patients, of course, love it. What's not to like? Happy patients mean a less stressful practice life, say doctors who've converted. There are benefits too in the continuity of care. When same-day service is up and running, patients generally see their own doctor instead of another in the group and have little need to go to emergency rooms. Care is also improved by seeing the patient at the onset of an illness, not to mention the increase in patient trust. Even better, it can actually reduce the number or hours you spend in the office, which means more time for family and friends.

HOW DO YOU DO IT?
The first thing to do is to determine whether you can actually fit your present-day patient load into a same-day schedule. If the patient panel is too large and the waiting list is continuing to grow, the system will be hard to implement. But don't be too hasty. Track how many calls for appointments you receive over a three- or four-week period. Also look at how many are calling for return appointments, how many are being put at the end of the waiting line, and how many are being redirected to emergency rooms or community clinics. See if demand could be reduced by cutting the number of multiple appointments. Suggest, for example, a complete physical when a patient comes in for a flu shot instead of scheduling a second visit. Some of your colleagues may equate big backlogs with prestige. "I have a three-month waiting list -- how big is yours?" Not a good attitude. Assuage them of it, they'll thank you later.

Once you've decided to take the bull by the horns and cut the backlog, set a target date for when it's to be completed. You may find that at the beginning 10 or 20% of your patients are seen the day they call. Target when it will be increased to 30%, 50% and so on, then get busy on the backlog. This is going to mean extra hours at first. One way to do this is to add weeknight visiting hours. The satisfaction in the heavier workload is seeing waiting times decrease. Make sure your nurse/receptionist keeps you up to date on the progress you're making. Consider extra pay for non fee-for-service physicians. If you find yourself eating dinner at the office, see that you order in good take-out food you enjoy and not pizza from the same joint night after night.

It's not going to happen overnight. Allow three of four months to chip away at waiting times. To fully implement same-day scheduling typically takes a year. Consider 70-80% same-day service a great success. Clearly there are always going to be some patients who need to book appointments down the road to review tests, evaluate progress and so on.

WHAT TO HOPE FOR
Once up and running, your colleagues will report shorter hours. A Halifax GP in solo practice who's been using the system for almost two years after attending a seminar about it in the US says she's cut her workweek by almost 10 hours. "I now open at 7:00 a.m. and am walking out the door by 5:15 p.m. -- and I don't work most Friday afternoons."

Says a St Boniface IM in a medium sized group, "The biggest benefit for us was that utilization rates went down maybe 10% or more with no drop in group income. We learned to pack more into a visit. Sure, some of us are better at it than others but being in group practice is a compromise by definition. The only people that like this more than we do is our patients." The practice manager reports that the number of patients seen has risen "about 7%."

"The biggest kick I get out of it is overhearing my receptionist on the phone saying, 'Yes, that's right, today. Not tomorrow, not next week, today. The doctor will see you at 3:30 today,'" says the FP mentioned at the beginning of the article, who's now coming up to the second anniversary of her same-day appointment schedule. " They can't believe it," the practice nurse purrs and adds, "One new patient brought me flowers for 'fitting her in!' Can you believe that?"