Using the bathtub can help explain how practices must maintain appropriate supply and demand with patients.
Imagine a bathtub. Claw-footed or equipped with Jacuzzi jets, it doesn't matter. We're going to use this image to explain the fundamental principle of understanding demand and deploying supply to meet demand that governs access and delay for patients.
In our teaching practice at the University of North Carolina, we have about 60 part-time primary-care physicians in the UNC Family Medicine Center doing the work equivalent of 10 full-time docs in a community practice. Managing appointment access to minimize patient delay and maximize continuity of care presents many challenges - especially with part-time clinicians. Many practice and healthcare system leaders have given up on trying to have both excellent access and continuity of care and see the problem as a trade-off - either access or continuity.
But it is possible to have both excellent access and good continuity of care. If we can do it at UNC with a practice made up entirely of part-time physicians, anyone can do it.
The first step is to understand the lessons of the bathtub. Water coming into the tub represents appointment demand - new patients coming into the practice, returning patients from each primary-care physician's (PCP) patient panel when they request an appointment, and returning patients that the PCP has asked to return. Water draining from the tub symbolizes appointment supply and includes appointments that are never scheduled or canceled but not reused, appointments that are scheduled but the patient fails to keep, and appointment slots that go unfilled.
If the drain is large enough to accommodate the water coming into the tub, the tub stays relatively dry. If water entering the tub exceeds the capacity of the drain, the tub begins to fill. Following this analogy, a full bathtub represents patients whose care is delayed, measured by the time to third available appointment. As the level of water (patients) in the tub rises, patient satisfaction, no show rate, phone calls to the practice, refill requests, and chaos in the practice increase. The goal is to drain your tub and keep it as dry as possible. A dry bathtub improves provider, staff, and patient experience.
We have to keep several bathtubs in mind: We balance supply and demand at both the practice level and the level of each physician- nested bathtubs, if you will. At the practice level, we measure daily appointment demand, forecast future appointment demand, and schedule our part-time physicians in the clinic so as to meet forecast future appointment demand.
Staff and PCPs in a practice each have pivotal roles in keeping patients in the right bathtub (continuity) and in keeping the bathtub as dry as possible (access). Staff can verify or designate the patient's preferred PCP at each visit and record it in the medical record to maintain a high percentage of empaneled active patients (patients with a valid PCP from within the practice); schedulers can always offer the first available appointment with the patient's PCP. If that's not acceptable, offering the next available with another PCP on the same continuity team is the alternative. Let the patient choose.
As continuity of care improves, there is a virtuous cycle that leads to improved access. A PCP who sees a patient on someone else's panel is more likely to recommend a shorter return interval than if they are seeing one of their own patients. Improving continuity is an important demand-reduction strategy.
As described above, whenever we ask a patient to return to the clinic, we are increasing demand. Managing this internal return appointment demand (water coming through the faucet into the tub) is the most important tool an individual PCP has to reduce delay for their patients. Lengthening return visit intervals (when appropriate without sacrificing quality of care), leveraging visits with other members of the care team, and utilizing e-visits to minimize return appointment demand are all important tools to turn the faucet down.
We encourage our doctors to make the most of each visit - plan ahead and aim to do all the work needed at today's visit to help the patient stay out of the office as long as possible. The bathtub drain can also be cleaned out periodically with strategies to reduce no-show rates, recycle appointment slots from canceled appointments, and shape the remaining internal demand to "late in the week and early in the day" important practice strategies to maximize appointment use. An appointment slot is a terrible thing to waste.
The bathtub helps both physicians and staff understand how they can improve access and help a practice meet its continuity and access goals. In addition to their important clinical work day by day, this access work requires an infrastructure of technology, policies, and training to achieve results. Data systems are needed to measure continuity of care, time to third available, appointment demand, and appointment supply, and to forecast future appointment demand. Periodic calculations of expected, actual, and weighted panel sizes are needed to guide decisions about opening and closing individual PCP patient panels. These behind-the-scenes efforts create the necessary environment to improve.
Sam Weir, M.D., is Executive Medical Director of UNC Health Care's Patient Access and Service Integration department. Dr. Weir practices at and is the former medical director of the UNC Family Medicine Center at the Department of Family Medicine. He has worked with ambulatory practices across UNC Health Care to improve patient access and clinic operations and as a consultant to other health care systems in the U.S. and Canada.