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Friday, June 14, 2013

What is Advanced Access?

Jo-Anne Lutz is the Director, Primary Care Clinics, Northern Health Region at the Burntwood Community Health Resource Centre, Thompson, Manitoba

Advanced Access is a frequently misunderstood term.  It is a comprehensive approach to effective patient care delivery built on the principles of access improvement and office efficiency.  There are many benefits that come with same-day access in primary care.  The goal is to start your day on time and end your day on time. Patients receive timely care and benefits associated with seeing their family physician or nurse practitioner.

Advanced Access is not a scheduling system.  The goal is same day access; however, patients can book anytime into the future at their convenience.  There are several mantras with Advanced Access.  “See your own and don’t make them wait” is an integral part of this concept where “continuity is king.”
Advanced Access is not about working longer, harder or faster.  It is not about adding more patients into already full schedules.  It is about doing work differently.  Think of it as resetting the system.  Consider a paradigm shift in how health care is provided.  Advanced Access is built on the premise of pulling work into today to save tomorrow.  This is different than the traditional model of pushing work into the future.  Various articles have been written on advanced access however not all have been written from this perspective, a true Advanced Access viewpoint.

There are six principles to access improvement and five principles of office efficiency.  Access improvement includes: understanding and balancing supply and demand; reducing backlog, decreasing demand, developing contingency plans; reducing appointment times and types; and optimizing the care team.  Office efficiency incorporates the principles of: understanding and balancing supply and demand for non-appointment work; synchronizing patient, provider and equipment; optimizing the environment; managing constraints; and predicting and anticipating needs.
The improvement journey takes time and will use existing resources.  Improvement activities are intended to become part of our work, not a distraction from our work.

Advanced Access : Drain the Bathtub and Track Demand


The first step to same-day access is to understand and balance supply and demand.  Consider your clinic’s panel of patients as a bathtub spout. The bathtub is filled with virtual patients waiting for their appointments.  How long your patients wait for an appointment will correspond with how full your bathtub is.  As patients attend their appointment they “drain” out of the bathtub.  If you would like to see them again though, they return to the virtual bathtub.  This is an important concept.  The goal is to “drain your bathtub.”  

The people waiting in the bathtub often generate additional work for the clinical setting. They may call multiple times looking for an earlier appointment.  Clinics then create cancellation lists and other means, spending time and effort in maintaining these, in an attempt to provide more timely care.  The longer a patient waits for an appointment, the greater the chance they will not show for their appointment.  This is due to several reasons: they may forget about their appointment, their problem may resolve, or they may have sought care elsewhere.  Advanced Access considers wait time from the patient perspective and, as a result, all waits are bad.

Have a piece of paper for each receptionist with each physician’s name.  Start by having the receptionist or booking staff, each time an appointment is booked, place a hash mark on a piece of paper that corresponds with the requested provider’s name.  Do this for each appointment that is booked.  A hash mark should be placed by the primary care provider’s name regardless of whether the patient walks into the clinic, calls in, a fax referral is received or other.  The important concept here is that the requested provider gets the hash mark.  If an appointment is booked with another provider, in the case where the family physician is unavailable, the family physician still gets the hash mark for demand.  This will provide information regarding the demand for each provider in your setting.  Remember, the goal is to balance supply and demand.


Today, the Health Council of Canada  launches the first two videos in our feature series, “Innovations in Reducing Wait Times,” on the Health Innovation Portal and website. Pan-Canadian in scope, the series highlights the innovative practices and solutions working to reduce wait times in specific health care settings. 
Ari Grief is the Project Lead on the series.
Video #1 took the production team to Thompson, MB to visit the Burntwood Community Health Resource Centre (BCHRC) to learn more about their success story in Advanced Access for the primary health setting. 

An old mining town originally built “not to last,” Thompson is now a city of 15,000 residents. As a “Hub of the North,” its location poses specific challenges to residents needing timely access to primary health care. 

Since opening in 2000, the BCHRC was plagued with long waits for appointments and received many complaints from community members trying to make appointments. In 2008, with the help of Manitoba Health, the BCHRC implemented the Advanced Access project with the aim of decreasing appointment waits and providing same-day access while ensuring quality improvement. In order to realize this goal, office efficiency needed to be increased while decreasing the time for arriving patients waiting for their appointments. 

So far, the program has been a great success: complaints are reported as down to zero; delays for appointments have dropped so that most providers have either same day or next day availability; and the continuity of care (in this case, seeing the same primary care provider) has improved. “There was a paradigm shift in how we manage our patient flow,” says Dr. Harold Nyhof, Medical Director, Primary Care Clinics for Manitoba’s Northern Health Region. “We used to push work to tomorrow in order to protect today. Now we look to do more work today, in order to protect tomorrow. It’s a completely different attitude.”

Other jurisdictions across Manitoba and throughout the country are taking notice from what the BCHRC itself has learned. However, Jo-Anne Lutz,  Director and Project Lead of the Advanced Access Program, is quick to point out that Advanced Access is much more than a scheduling system: “It’s a comprehensive approach. By respecting the patient’s time and matching them with the right provider, we are more able to handle today’s work today so we can optimize the care team to provide the best care in the best possible way.”

Dr. Harold Nyhof (right) collaborates with the BCHRC team. Clinic Director Jo-Anne Lutz is to his right.

Video #2 in the series shines a light on Eastern Health’s Orthopedic Central Intake (OCI) based in St. John’s, Newfoundland. OCI was instituted in 2011 with the purpose of reducing wait times by creating a system change to redesign the orthopedic service along the entire continuum of care. 

The Bone and Joint Canada “Hip and Knee Replacement Toolkit” suggests that a central intake model is ideal, but Eastern Health’s OCI took it one step further: OCI is the first in Canada to expand central intake for all orthopedic referrals, and not just hip and knee joint replacement. 

Elaine Warren, the former Director of Regional Surgical Services who was part of the team that helped secure start-up funding from Health Canada and the Province of Newfoundland and Labrador to get OCI underway, believes that the model “… helps streamline care. We had a very broad vision and to see this through, it’s been great.” 

The previous model of referral and assessment was individual physician-based, with no formal process for tracking wait times from family physician to initial surgeon visit, also known as Wait 1. Prior to OCI’s implementation, the median time of Wait 1 exceeded 300 days. “[Now,] it’s the way the system should work,” adds Warren. 

Today, the average for Wait 1 is 92 days for high priority referrals.
“Our wait times have gone down. We’ve seen a fairly significant improvement, about a 71% improvement,” says Michelle Alexander, Project Lead. 

Michelle Alexander with patients in a pre-surgery information session.
Ms. Alexander acknowledges that the early engagement of stakeholders was key to achieving goals and implementing change. System change can be difficult but with all levels on board, the Regional Health Authority (RHA) is now able to better evaluate referral practices and measure referral services. Access has improved, including better clinic capacity through the redesign of templates to reflect referral volumes and surgeon practice. 

Make sure to bookmark to view these as well as new videos in the series, set for launch in the summer and fall of 2013.
For more information about the video series please contact Ari Grief, Project Lead at .