Attaining Lasting Change

How to make open access scheduling work in the real world

Open access: it's the latest practice improvement buzzword. A scheduling model that leaves most slots available for same-day appointments, open access promises to cure all that ails physician practices, while erasing the patient dissatisfaction that stems from long waits for appointments. But more often than not, open access initiatives end as an exercise in frustration, with little sustainable progress toward improvement.

Why? Because waits for appointments are the result of longstanding inefficiencies, poor use of resources, and continued belief in the time-honored notion that clogged schedules are a badge of practice success. Working to eliminate backlog "symptoms" does generate short-term improvements in patient access; but without dealing with its root causes, backlog eventually creeps back into the schedule.

Sustainable practice improvement means a willingness to see our values, processes, and resources differently. In my business, we've conducted informal surveys asking client physicians, managers, and staff who they see as their primary customer. Invariably, each practice comes up with different answers. Basic customer service training during staff orientation, from establishing eye contact to individualized attention for the first 60 seconds after a patient arrives, communicates a value system not of provider-centered, but patient-centered care.

Case in point: one client we know had 1,500 different appointment types to accommodate different needs of providers. Yes, the providers were happy, but what of the long waits for patients? Another had 52 pages of appointment protocols. The minimum wage staff had no incentive to master the complicated rules, which basically guaranteed high turnover. Different appointment types create artificial barriers to access that frustrate patients and staff alike.

At another practice, which claimed to be 'redesigned' and 'customer focused,' the triage nurse routinely gave patients who called after 2 p.m. appointments for the following day, despite having openings later that afternoon. Why? So the staff could go home on time. Offering patients same-day access to their own physicians means we work for those patients, not the staff or the insurance company.

Beyond the norm

Some innovative physicians are turning these old paradigms upside down, making sustained change in work processes, in how resources are used, and in ways that staff, providers, and patients interact.

For example, Dr. Charlie Burger of Bangor, Maine, (who was profiled recently in Physicians Practice), shares profits with his staff, who have an average tenure of over 10 years. And Burger's patients are respected as active resources in the care process -- providers give each patient a printout of their medical record note after each visit. A "data wall" displays information about ongoing improvement projects, usually initiated by staff. This practice just "looks" different. Satisfaction rates for patients and staff are high and attrition rates negligible.

Similarly, Dr. Chuck Kilo and his colleagues, Dr. Steve Gordon and Jill Arena have launched GreenField Health System in Portland, Ore., reinventing office practice values to fit the needs and schedules of patients. Patients have access to all of their own medical information, and the practice offers e-mail and phone visits.

Innovative office layouts bring improved services to patients as well as to workflow. How? Clinica Campesina, which serves low-income patients near Denver, brings all visit services (except check in) to patients in the exam room. Pods of exam rooms surround two staff teamwork areas, offering staff real-time, visual access to workflow.

Today's dysfunctional healthcare system desperately needs sustainable practice improvement with physician leadership its cornerstone. Physician pioneers who are reshaping yesterday's haphazard office cultures into vibrant work environments are showing that meaningful improvement and interaction can happen.

Suzanne Houck is president of Houck & Associates in Boulder, Colo., a company that helps medical practices implement sustainable improvements. She can be reached via

This article originally appeared in the Spring 2002 issue of Physicians Practice.