In the design of the clinic template for appointments, department chiefs, provider directors, as well as the MTF staff responsible for reviewing and approving clinic schedules before they are released, should consider these factors:
TMA has had several MTFs have their head physicians look at this model. The assessment has been that by breaking appointment slots into 15-minute increments and having the time for the appointment geared to appointment type, you can create more access and efficiency in the coordination of appointments. The principle of keeping it simple seems to work better for everyone involved in the appointment process.
- Determine how many appointments of each type, by clinic specialty, are needed to be programmed into available appointments based on appointment demand, prior workload history, etc.
- A good way to ascertain demand is to review waiting times for each clinic and appointment type. Reports may be prepared locally by patient appointment management staff. Additionally you may want to review the Template Analysis Tool that has been developed by the TMA staff to help MTFs and MCS Contractors meet established TRICARE Prime access standards. Implementation of this tool has led to development and evaluation of “Best Practices” in clinic scheduling and template design. The MTF Template Analysis Tool is an automated, MS Access based program, which downloads data from CHCS hosts then graphs results in an easy-to-access, easy-to-read format. Template Analysis Tool reports are posted to the TMA WWW site at (http://www.tricare.osd.mil/tools). Please review the Performance Measure/Template Analysis Tool section of the Access Imperatives Website for more information.
- Determine each clinic's no-show rate to calculate how many appointments should be double-booked daily to compensate for the no-shows. Determine the best method to distribute the number of double booking slots through the appointment schedule.
- Determine at what point (time) during the day that unbooked, same-day appointments are released to be filled with other appointment types. What are the intervention measures (time measures) to convert or open unbooked slots to other appointment types during, as an example, a 30-day booking period?
- Determine how rescheduling of patients is to be handled, as a matter of practice, to minimize rescheduling of patient appointments. There are catastrophic or severe weather events that can close down a facility but, except for emergencies, how do you handle schedules when a provider calls in sick or has to take an unscheduled leave of absence? Many facilities in the civilian and military health care environment have decided on a clinic team concept to pick up the slack when a provider has to be absent from an already booked outpatient schedule.
- Determine the command policy on the percentage of designated prime active duty and non active duty patient slots to be available in schedules for booking appointments versus non-prime patients.
- Consider the following example of a template that was built for a (primary care) clinic at Kaiser-Permanente:
- 32 slots lasting 15 minutes each are booked in an 8-hour workday (not counting 1 hour for lunch).
- Four slots are left blank during the day for provider catch-up on his or her schedule or to see the occasional unscheduled patient from another clinic, emergency room consult, etc.
- Physicals are booked for 30 minutes.
- Patients for follow-up of an admission are given 30 minutes.
- Patients referred from the emergency room are given 30 minutes.
- Chronic headaches are 30 minutes.
- First visit for those over 65 is 30 minutes.
- Follow-up for age 65 and older is 15 minutes.
- Health assessment or physical for 65 and older is 45 minutes.
- Normal routine appointment is 15 minutes.
- Pediatrics under 12 is 20 minutes.
- Pediatrics over 12 is 30 minutes, allowing time for more counseling.
- Provider grand rounds, Continuing Medical Education (CME), meetings, etc., are scheduled during the lunch period in order not to interfere with availability of scheduled appointment slots.
- Each provider is booked for 36 hours of appointments in a 40-hour workweek.
- A four-hour period per week is marked off the schedule to allow providers to attend to their facility's administrative requirements for medical records, CME, etc. The approving authority has to approve the designated day and time.
For the Kaiser model to work in an MTF the commander needs to consider other factors such as:
The principle to evaluate here is not what Kaiser chose as their yardstick, but what they measured and how they set it up as described above. The mix for other specialties has to be determined.
- How to distribute or designate the number of prime versus non-prime appointment slots.
- How to determine the number of allowable MTF book-only slots for each specialty to build in its clinic schedule template.
- How to allocate or plan the number of slots for each appointment type in the clinic schedule template. As an example, some clinics have a need for more same-day appointments or health assessments in the distribution of appointment type slots than other clinics. As an example, in the Kaiser primary care model of 32 bookable slots for a provider in a day, the distribution need of their appointment types was determined to be as follows:
- Four open slots to be filled by the provider to meet needs for unscheduled consults, etc. that have to be seen or for allowing catch-up in his or her schedule
- Four WELL (Health Assessments, Wellness, Health Promotion) appointments
- Ten ACUT (acute) same day (24 hour) appointments
- Ten (EST) established patients (follow-ups) appointments