Jag S. Gill, FACHE, vice president and executive director, Hillcrest Healthcare System, Tulsa, Oklahoma

PREFACE
Until the mid- to late-1980s, medical group practices seemed to enjoy relatively few restrictions in improving revenue and making an overall positive financial performance. Relatively few insurance companies focused on decreasing costs. Price increases were simply passed on to the employer, and physician practices were able to raise prices with relative ease. Around that time the concept of managed care began to surface in the healthcare industry, causing practices to rethink the way they did business. The concerns related to managed care caused physician groups to reconsider their business approach, primarily from a financial perspective. The physicians had to adapt to controls by nonphysicians, insurance company guidelines, and actuaries creating the rules under which patients were allowed to receive care. The focus changed to utilization management, the gatekeeper concept, and risk shifting to physicians. During this time, staff-model health maintenance organizations (HMO) were developed, independent practice associations (IPA) were formed, the move toward hospital-owned practices and physician health organizations (PHO) occurred, and the physician practice management (PPM) industry was spawned. The reasons these shifts occurred were as follows:

• Consolidation to leverage contracting
• Reduction in supply costs
• Better staffing pools
• Decreased liability insurance
• Defined networks to manage costs

Because of an emphasis on the above reasons, the focal point of the healthcare industry shifted away from the physician and patient as the center of the system and toward insurance companies. Insurance companies changed their roles from collecting premiums, actuarial science, and paying claims to the role of managing care. Essentially, physicians became a product sold and controlled by outside entities. The concepts discussed in this article indicate that it is possible to refocus all efforts back to the physician and patient. These concepts are effective in providing excellent service and quality healthcare, resulting in high physician and patient satisfaction as well as appropriate utilization of medical services.
Advanced Access, also known as "Advanced Open Access" or "Open Access," is a system based on a patient-centered philosophy that dictates the following:

• Patients will be seen when they want to be seen or when their referring physicians want them to be seen.
• Patients will see their provider of choice (Murray and Tantau 1999).

Another definition of Advanced Access is the use of "available capacity to serve patients at the time, in the location, and in the fashion most convenient to them, with the most appropriate provider for their needs" (Health Care System Excellence in Management 2001).
The entire basis of Advanced Access is that patient demand and medical service capacity can be brought into equilibrium and that the continuity between physician and patient will occur. Advanced Access is patient centered, whereas the traditional method for creating physician availability is physician centered. These concepts represent a significant paradigm shift in physician appointment-scheduling philosophy. Advanced Access relies on a system that allows the next available appointment time to be used for any type of appointment. This reduces the queues and backlog usually created by more traditional, or carve-out, appointment scheduling systems and enables providers to do today's work today (Murray and Tantau 1999).
Successful implementation of Advanced Access has proven to be one of the best foundations for creating and identifying opportunities for improvement within the physician practice. Before a practice can move to an operations enhancement initiative it needs to completely understand the exact status of its organization at the present time. Medical group practices that desire to adopt an overall strategy for changing their approach and culture should understand that the entire process can take up to two years. A detailed timeline needs to be created. Implementation needs to occur in steps. Measurement needs to occur simultaneously. Progress needs to be communicated. The entire practice, including physicians and support staff, must be involved in the education, development, measurement, and implementation process.
Advanced Access is designed to work with the physician group as a critical component for operational and financial improvement. This is a core concept of clinical office redesign. Improving patient access to medical care may be the most important step a medical group practice can embark on to improve patient satisfaction, enhance practice growth, increase revenue opportunities, and create an environment that results in both personal and professional balance for physicians and staff. Ultimately, a practice can only be successful if it can see patients in an effective and efficient manner. Under Advanced Access, "Patients get exactly the help they want (and need) exactly when they want (and need) it" (Institute for Healthcare Improvement). The essential elements of the Advanced Access process are as follows:

• Engage physicians to drive positive change.
• Focus on increasing patient satisfaction.
• Simplify clinical and support operations.
• Create the appropriate capacity to meet 100 percent of market demand and still allow the practice to continue to grow.
• Increase staff morale and decrease staff turnover.
• Identify variation between physician practice styles and use this information to implement physician-driven operational and clinical improvement plans.
• Create a standard set of reports to identify variation in current practice operations and maintain measurement and reporting on an ongoing basis.
• Minimize appointment backlog and increase patient access to the practice.
• Gain a competitive customer service advantage in the marketplace.
• Know when to appropriately add physicians to the practice.

Before the advent of the Advanced Access concept two models of access were available-the traditional model and the carve-out model. In a traditional model the provider goes to the office each morning and the schedule is full. Furthermore, the schedule is full of patients who made an appointment two weeks ago, a month ago, two months ago, and so on. Routine appointments fill the schedule, and urgent cases are squeezed in by double booking, skipping lunch, working late, or running behind. With this model, practices gain capacity by allowing visits to pile on top of an already full schedule. In a vain attempt to control demand, medical group practices create a variety of restrictive and complex appointment types (e.g., male physical, female physical, return diabetes). These systems typically have high no-show rates. In addition, because schedules are full, these systems lead to an abundance of patients visiting urgent-care clinics, which are costly and disrupt the physician-patient relationship. The motto for these systems is, "Do last month's work today" (Murray and Tantau 2000).
The carve-out model is a first-generation Open Access or Advanced Access model. In the mid-1990s, researchers began looking at the problem of patient access scientifically and discovered that demand was actually fairly predictable. Researchers identified that if a practice had 10,000 patients, the demand for urgent visits would normally be 55 on Monday, 50 on Tuesday, and 45 on Wednesday through Friday. With this information in hand, practices started to carve out, or hold, a certain number of urgent-care slots. The rest of the slots were booked in advance, just like the traditional model. The motto for these systems is, "Do some of today's work today" (Murray and Tantau 2000). Although the carve-out model is an improvement over the traditional model, it still has several shortcomings. First, this model has very little capacity because appointments are either booked in advance or held for same-day urgent needs. Patients calling today with nonurgent needs for care continue to be pushed into the future, thus delaying work. Second, these systems tend to create a third appointment type for patients who cannot be seen today but cannot wait until the end of the queue. This makes the system more complicated and eventually extends the practice's waiting time. Third, tension between the routine and urgent appointments always exists. How many of a particular type should the practice carve out? Precision is important because if the practice carves out too many slots for urgent care that go unused, it has wasted valuable resources. Fourth, there is pressure to steal from future "held" appointment slots to accommodate patients who do not easily fit into the currently complex scheduling systems. When practices consistently "steal" appointment slots, the waiting list begins to grow and the practice eventually returns to the traditional model (Murray and Tantau 2000).
Although the Advanced Access system is far simpler, it does require a paradigm shift. To succeed, the practice must do today's work today. Through literature review and personal experiences, this article will discuss the history, components, essentials, and benefits of an Advanced Access system. An emphasis is placed on the various reports that should be generated and analyzed to implement the necessary steps to improve patient, physician, and staff satisfaction and increase market share and financial results.

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History of Medical Groups
Medical group practices are an affiliation of providers (usually physicians) who share incomes, expenses, facilities, equipment, medical records, and support personnel in the provision of services through a normal, legally constituted organization (Ross, Williams, and Pavlock 1998).
Some of the earliest medical group practices were started by businesses to provide care to employees at rural sites where medical care was unavailable. In 1833, Northern Pacific Railroad organized a practice to provide care for its employees who were building the transcontinental railroad. Another example is the establishment of the Mayo Clinic in Rochester, Minnesota; in fact, the Mayo Clinic was the first successful nonindustrial group practice. The Mayo Clinic was originally organized as a single-specialty practice in 1887 and was later expanded into a multispecialty practice. The Mayo Clinic thus demonstrated that group practice was feasible in the private sector. After World War II a number of groups were established. They included the Health Insurance Plan of New York, which was organized to provide prepaid medical care to the employees of the city, and the Kaiser Foundation Health Plans, which provided healthcare to employees of the Kaiser industries (Ross, Williams, and Pavlock 1998).
In the late 1940s, the Group Health Cooperative of Puget Sound-a consumer-owned, cooperative, prepaid group practice-was established (Ross, Williams, and Pavlock 1998). As the years progressed, more and more medical group practices were formed. By 1969, there were 6,371 groups in the United States; this number increased to 8,483 in 1975 and more than doubled by 1995 to 19,478 (Havlicek 1996). With the proliferation of group practices came the advent of managed care philosophy and processes. These processes spawned a large number of acronyms to describe distinctive organizations operating under the managed care philosophy (e.g., HMOs, IPAs, PHOs, PPM, hospital-owned practices).
HMOs are organized healthcare systems that are responsible for both the financing and delivery of a broad range of comprehensive health services to a pre-enrolled population (Kongstvedt 1993). The IPA is actually the original form of an open-panel plan. In this situation the IPA is actually a legal entity that contracts with physicians, and the IPA in turn contracts with the health plan. The advantage to the plan is that a large number of providers become available with the contract. Furthermore, if relations between the IPA and health plan are close, a confluence of goals may benefit all parties (Kongstvedt 1993). The PHO is a method of developing organizations that will legally and structurally bond physicians to the hospital. The advantages to this type of an organization are identical to the IPA's (Kongstvedt 1993). PPMs are a perpetuation of an independent business entity to facilitate the practice of medicine. These organizations are for-profit in nature; examples include Phycor and Med Partners. Also in the 1990s, hospitals started to acquire physician practices of their own, and this practice continues in integrated delivery systems throughout the United States.

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HISTORY OF ADVANCED ACCESS
Advanced Access was pioneered by Dr. Mark Murray and his partner Catherine Tantau in the early 1990s in their efforts to reduce wait times and increase patient satisfaction for Kaiser's Sacramento enrollees. The Institute for Healthcare Improvement learned of this process and collaborated with Murray and Tantau to make it an integral component of its Idealized Design for Clinical Office Practices. Advanced Access is predicated on five basic principles (Boelke, Boushon, and Isensee 2000):

• Balance supply and demand.
• Do today's work today.
• Change the current steady state of appointment availability to a new and better steady state.
• Empower all providers and staff to function at their highest level of skill, education, experience, and credentials.
• Maximize efficiency.

Advanced Access is a radical departure from how most physicians are used to practicing medicine and scheduling patients. Most medical groups are not prepared to launch this initiative tomorrow. However, implementation is very possible within a few months of hard work. The most crucial step in implementing Advanced Access is data gathering. The best strategy for a practice is to identify a team of individuals who have been successful at other improvements, have a sense of adventure, and include at least one physician champion. If the organization is large, the initial team may be made up of all the clinical and office staff at one site. If the practice is smaller, it can start with one provider.
When medical group practices adopt Advanced Access they achieve many positive benefits. First, the wait time for a routine appointment becomes nonexistent; patients love such a system. Second, practices no longer have to hold appointment slots for same-day urgent needs, thus maximizing their schedules and gaining capacity they did not have before. Third, the likelihood that patients will see their own personal provider increases, which means greater efficiency and a greater sense of control for physicians.

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Components of Advanced Access
For a medical group practice to be successful in implementing Advanced Access it must gather data (manually and from a practice management system), produce reports on the various components of Advanced Access, and come up with defined action plans to enhance the operations of the practice. These components include the following:

• Appointment types
  
• Panel size
• Patient demand and current capacity
• Backlog identification and reduction strategies
• Physician-patient contact hours
• Analysis of visit frequency and intervals by disease type
• Patient demographics
• Physician coding profiles
• Cancellations and no shows

The practice may also discover other measures during the study that contribute to improving the overall efficiency of the practice while working toward improving access as the ultimate goal.
Advanced Access is not a walk-in clinic. Patients still must make appointments, but the medical group practice now has the methodology in place to match appointment demand and available capacity. In some instances this can require a shift in thinking on the part of the patient and may result in the group devoting some time to patient education.

Appointment Types
This report is a listing of types of appointments and the time allotted for each (see Appendix 1*). Each provider has developed a preferred set of rules and procedures for making appointments. Variations between each provider's specific criteria and the quantity of different appointment types for similar patient complaints are a valuable starting point for improving patient access and decreasing the burden on the practice's staff. The group also needs to minimize the variety of appointment types when possible. Groups commonly have dozens of different types of appointments with no valid rationale for the variety of appointment types, rules, and procedures. The whole concept of Advanced Access is patient centered, whereas the traditional method for creating physician schedules is physician centered. In Advanced Access, appointment types are reduced to three: (1) personal (the patient seeing his or her own physician), (2) team (the patient seeing someone else on the clinical team in the absence of his or her own physician), and (3) unestablished (for patients who are not linked to a particular provider). The length of appointments also needs to be standardized at about 15 to 20 minutes, with doubled amounts used only when necessary (e.g., physicals, lengthy procedures). Although actual appointment lengths will vary, the physician-patient face-to-face time is actually quite short and in most cases can be handled in the standard 15 to 20 minutes (Murray and Tantau 1999).

Panel Size
The next report the medical group practice needs to compile is the panel size report (see Appendix 2). This is the most critical report for developing the Advanced Access concept because it is a good indicator of the actual number of patients the practice is caring for. The entire basis of Advanced Access is that patient demand and medical service capacity can be brought into equilibrium. Each physician, based on a variety of factors, has the capability to care for a defined population of patients at the appropriate clinical and satisfaction levels. The panel size report identifies the following for each physician:

• The physician's unique patients
• Average visits per patient per year
• Total average number of visits per year
• Estimated capacity (or lack of)

This report, in conjunction with all of the other reports, especially the patient-to-provider continuity report, provides an excellent overview of the practice's current status.
The report also identifies unique patients for the group as a whole. In most instances, the report will show that if all of the physicians took care of only their own patients, the group would have sufficient internal capacity to grow without additional providers or support staff. Practices commonly find 20 percent to 40 percent hidden capacity because of inherent inefficiencies within current operational methodologies.

Multiple Visit or Continuity
Another critical report to review alongside the panel size report is the multiple visit report (or continuity report; see Appendix 3), as it demonstrates how frequently patients see more than one physician within the practice. The specifics of the report include the following:

• Visits per patient
• Visits per month
• Visits per year
• Visits and percentage of visits seeing just one provider

Patient-to-provider continuity is a critical element of success for a practice. A basic tenet of Advanced Access is continuity between the physician and patient. A lack of continuity leads to patient dissatisfaction, inefficient practice styles, ineffective nonclinical practices, and unnecessary return visits. Some studies have indicated that up to 50 percent of a visit is wasted if a patient does not see his or her own provider. If a chronic patient comes in for an acute visit and does not see his or her own physician, the physician often will not take the time to review the patient's history and take advantage of creating a comprehensive visit. Additionally, many patients schedule return visits with their own providers within two weeks of seeing another provider because they are not satisfied that all of their healthcare needs were met. This creates unnecessary visits and reduces appointment slots available for other patients.
Recent industry data are also beginning to document a direct link between continuity and quality. Murray and Tantau (1999) have documented that continuity between patient and provider leads to higher quality in patient care. Examples of areas of improvement in patient care include screenings for lipid levels, colorectal problems, high blood pressure, and breast and cervical cancers; tobacco user advice; and influenza and pneumonia vaccinations. Patients who consistently see the same physician have a significantly higher level of these types of services being appropriately addressed in a timely manner (Murray and Tantau 1999).
In some practices, the hospital component is a significant portion of a provider's activity. In this case a report should be developed to identify the effect of the hospital practice on patients and patient visits on the provider's panel. This report can also lead to productive discussions regarding various options for taking care of hospitalized patients, such as utilization of a hospitalist service.

Demand Analysis
The demand analysis report (see Appendix 4) shows when the patients within the practice actually accessed the medical group for healthcare services. The distribution of patient visits is shown by day of the week, week of the month, and month of the year. These data show the true demand on the provider or practice. True demand can be determined, and each physician's schedule, hours of operation, and scheduling parameters can be changed to more closely match that demand. As one might expect, significant variation of appointment demand exists by day of the week, month, and year. However, there seems to be ample capacity to ensure that patients do not have to wait a long time to get an appointment with their physician of choice.
The demand analysis report can be compared against the physician-patient contact hours (see Appendix 5) and current backlog reports to develop action plans to further match patient demand with practice capacity. Another benefit of this report is that it can help determine support staffing levels and identify services that can be potentially shifted to less-busy times of the year. Additionally, creative methods for matching physician capacity to true demand can be developed.
The demand analysis report also gives the practice an indication of where changes can be made to decrease and finally eliminate any existing backlog. One element that this report does not measure is the number of patients turned away from the practice. This information can be gathered as a further measure of demand by performing telephone volume studies and categorizing the reasons for the calls. However, demand patterns compared to current provider schedules are effective tools for matching capacity to demand.

Backlog Identification and Reduction Strategies
The practice needs to identify and track each provider's backlog by appointment type (see Appendix 6). Backlog equals the total number of appointments on the books divided by the number of patients, on average, seen each day. Thus, a practice with 1,000 patients scheduled and 80 seen each day has a backlog of 12.5 days (Lippman 2000). This information is used to determine the length of time between the request for an appointment and when an appointment is actually scheduled by appointment type. The practice should pick three common appointment types that are difficult for patients to make with a particular physician and implement plans to reduce the backlog in these appointment types first. The time to the third available appointment is a good indicator of a true backlog. Appendix 7 shows two reports: the third available appointment per provider report shows the variation among providers, and the third available per appointment type report shows the types of appointments being requested. These reports are compiled by gathering data on the third available appointment when a patient requests a certain type of appointment. The comparisons between providers by appointment types are useful in developing backlog reduction strategies including the following:

• Identifying good versus bad backlog
• Looking ahead into the schedule to combine visits
• Increasing intervals between visits
• Optimizing visit efficiency by doing more with each visit
• Adding daily capacity by implementing evening hours
• Adding weekly capacity by implementing weekend hours

Each of these techniques can free up appointments to increase access and would need to be individually tracked.

Physician-Patient Contact Hours
The physician-patient contact hours report (see Appendix 5) summarizes the patient contact hours per physician. The report further breaks down the data by day of the week and time of day. The data presented in this report show the variation between physicians. In this particular example Physician A has 27.75 patient contact hours compared to 32.50 for Physician E. Physician A may have a large inpatient practice or a large nursing home practice, thus reducing his patient-contact hours in the office. Each practice should do the math to ensure that each physician has the appropriate number of patient-contact hours to meet access requirements and operate a financially viable practice.

Analysis of Visit Frequency and Intervals by Disease Type
A critical opportunity to identify potential capacity is to analyze the intervals between patient visits (top diagnosis-individual physician), number of patient visits by disease category (top diagnosis by disease category), and visit frequency. The top diagnosis-individual report (see Appendix 8) looks at the most frequently used diagnoses within the practice and compares the individual physician's frequencies against his or her peers within the practice. The variation between practice patterns is used to develop a physician-driven effort to increase standardization. The practice should limit the number of disease categories for change to two or three. Attempting to improve the visit rate and intervals between visits of more than three categories during the first year is too onerous. Once the group reaches a consensus on two or three categories the positive effect of this change will have an immediate effect on decreasing backlog and creating access. A starting point for managing a specific disease category is often diabetes. In this particular example (see Appendix 8), if the diabetic visits can be reduced by 0.58 visits (from 3.58 to 3.00) through group visits or other interventions, 33 visits would be freed up for the practice. Multiplied across all physicians in a group, minor adjustments in visit activity accumulate in a positive manner for the practice. Nearly every practice that moves in this direction finds that diabetes offers the most opportunity for improvement. Additional categories could include coronary heart disease and asthma.
The top diagnosis by disease category report (see Appendix 9) shows physician activity against his or her peers within each disease category. By ranking visit activity from most frequent to less frequent, physicians can discuss the variation and develop physician-driven interventions to minimize the variation. For example, if the range of visits per patient year for diabetes is between two and six visits, a significant opportunity exists to come up with a figure somewhere in between. The two-visit situation may mean a lack of necessary care, whereas the six-visit situation may demonstrate excessive care with little or no clinical benefit. If a physician has 300 diabetic patients and can reduce annual visits by two, this frees up 600 appointments. This additional capacity will work down the backlog and allow new patients to enter the practice.

Patient Demographics
The patient demographics report (see Appendix 10) allows each physician to review his or her patient distribution based on age and sex as well as compare that information to his or her specialty within the practice. The demographics of a physician's panel help determine the appropriate capacity for that physician. Unless the physician prefers to care for patients with a particular diagnosis, practices that do this analysis have found in most cases insignificant variations in patient demographics among physicians in the same specialty. This helps diminish the excuse, "My patients are different or sicker."

Physician Coding Profiles
The physician coding profiles report (see Appendix 11) compares a particular physician's actual evaluation and management (E & M) coding (99211, 99212, 99213, 99214, and 99215) activity against that of his or her peers within the practice and against industry averages. This report also quantifies the financial effect of each provider's coding. In this particular example, the report shows that if the provider had coded according to the target or industry average, an additional 765 relative value units (RVU) could have been billed. A practice can quantify this into dollars by multiplying the average reimbursement value by the number of RVUs. Some groups have a correlation between low-coding physicians and poor access to those physicians. This is usually a result of physicians seeing few patients, because of low panels, but with lots of visits. Frequent visits with a low panel size do not contribute to comprehensive visits but do lead to lower levels of coding. Frequent visits with a low panel size also create a barrier for new patients to enter the practice.

Cancellations and No-shows
The cancellation and no-show report (see Appendix 12) is another integral report in matching demand with practice availability. If a patient does not have to wait, he or she is more likely to come in for a visit. If a patient is a no-show, the practice does not have a mechanism to sell the slot to someone else, thus introducing inefficiencies, wasting resources, and missing revenue opportunities. This report is an effective way to measure system rework and unused capacity. A practice should use this report to do the following:

• Determine what percentage of cancellations are practice driven and what percentage are patient driven.
• Review current scheduling protocols to make sure that staff is not scheduling follow-up visits on busier days of the week.
• Review physician follow-up protocols. A practice can determine how many physicians require an actual follow-up visit for acute patient visits that are then never used by the patient because their health status does not warrant another visit.

These components of Advanced Access usually require six to 24 months to start showing positive improvements, and they require continued discipline, constant reporting of progress, total staff involvement, and physician support. This may not come easy and requires extra work in the short term.

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IMPLEMENTATION OF ADVANCED ACCESS
At present, Advanced Access is a fairly new process, and it is somewhat difficult to find guidance on actual implementation. However, a number of resources do exist. The Medical Group Management Association, American Academy of Family Practitioners, Institute of Healthcare Improvement's Idealized Design of Clinical Office Practices, and Veterans Health Administration have implementation resources available. However, for this initiative to work, physicians and staff must be prepared to embrace this concept. The change to Advanced Access can be made by doing the following:

• Forgetting the status quo (i.e., "We always have done it this way") and expecting innovation.
• Finding a physician leader who will champion the process and help obtain the needed resources.
• Planning for change but moving out of the planning mode as soon as possible.
• Testing ideas rapidly using a prototype or pilot group, which could range from one individual patient to one physician or site within a group.
• Taking what has been learned from experiments and expanding work to the next level.
• Not expecting the process to be smooth or easy. Innovation requires trial and error.

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ESSENTIALS OF ADVANCED ACCESS
Advanced Access in a physician practice is an operational methodology that designs all of its processes around the needs of its patients (customers) in a manner preferred by its patients (customers). It builds trust. Patients know that their physician will be there when they need him or her. Moreover, getting the patient in sooner may allow the physician to intervene earlier in an illness, which can reduce the need for follow-up visits (Grandinetti 2000). At first, physicians can be reluctant to embrace the Advanced Access concept because they have become used to the notion of having long backlogs and because of their fear of becoming overwhelmed with patient demand. For some physicians a large backlog is a sign of success: "If a lot of patients are waiting to see me, I must be needed." Eliminating that backlog sometimes creates fear for the physician and the insecurity of wondering whether the slots will actually fill up. This is why measurement and identification of true demand are so critical. Without this knowledge the practice cannot create the optimal capacity to meet demand. Once the backlogs are eliminated and patients are able to get access when they want it, however, the physicians and staff will be better satisfied. Once the system is implemented experience shows that about 0.8 percent of the average patient panel will visit on any given day (Grandinetti 2000).
The essentials of Advanced Access are as follows:

• Demand is predictable
• Operational simplification
• Provider continuity
• Do today's work today
• Performance measurement

Demand Is Predictable
One of the integral, and possibly the most important, principles of Advanced Access is to be able to know, understand, measure, and predict the demand that will be placed on each of the providers in the practice. Using the reports, we can identify the quantity and time of demand, leading to the determination of the appropriate capacity for each provider. We can not only predict the amount of demand but also the times at which this demand will occur. Demand for all types of services is predictable and can be used prospectively to guide the management of a practice's resources (Kilo, Triffletti, and Murray 2000).
This type of analysis is common in the airline, hotel, and retail industries. Using statistical analysis, inventory management, and queuing theory, these industries are able to measure demand and ensure that adequate capacity is available to meet demand. The same approach can be used in healthcare. As an example, why does the typical medical group practice operate set hours each day of the week when we know intuitively that certain days or times of the year are busier than others? We do this in healthcare because we design our systems around us, not the customers. Appendix 4 makes abundantly clear that physicians should have different hours of operation in the summer months. The typical pediatrician works 138 hours per month, or 1,656 hours per year. Appendix 13 shows a possible deviation from that schedule, including working longer on Mondays for nine months; working on every day of the week, including Saturdays, for nine months; and having three-day workweeks during June, July, and August. In this example, the total number of hours worked is almost exactly the same. Implement this exact schedule may be difficult because of the number of days worked for the busier nine months. Nevertheless, this example points out the potential for restructuring the schedule based on the demand placed on the practice.

Operational Simplification
Most medical group practices have created strict rules and sometimes-inflexible processes in an attempt to manage access to their services. The traditional mindset at the physician's office has been to schedule the hours of operation using scheduling templates and appointment types around the practice's needs or the practice's perception of patient wants. Patients are often told that they will have to wait days, or even weeks, to be seen for a specific complaint. However, groups that have implemented same-day access programs have found that they can still meet patient demand and get the rest of the work done as well. Fairview Red Wing Clinic in Red Wing, Minnesota, reduced patients' cycle time through the office from 75 to 40 minutes while increasing face-to-face time with the physician (Murray and Tantau 1999). An additional benefit has been that the staff usually gets finished with their work on time, thus increasing their morale.

Provider Continuity
Patients are much more satisfied if they get to see their own physicians. A physician who knows a patient and his or her particular disease process will be able to better care for that patient. As much as half of the visit can be wasted if no history or prior relationship exists between the patient and physician. Furthermore, when the patient is not seen by the physician of his or her choice and at the time of his of her choice, the physician providing the service can spend invaluable time apologizing for the inefficiencies of the system. In many cases, the patient ends up scheduling an additional appointment with his or her regular provider because the patient's needs were not met by the substitute physician. This introduces another inefficiency placed on the provider and practice. When patient continuity is absent, the physician often wastes an inordinate amount of time reviewing the patient's chart. In one practice, when continuity reached more than 90 percent, physicians were able to see 80 percent of their own patients without pulling the chart. A copy of the last visit's dictation attached to the encounter form was sufficient for the physician to care for the patient. When physicians see their own patients and do today's work today, a sense of order is restored to their practices.

Do Today's Work Today
In an Advanced Access system, once demand is determined capacity needs to be created to meet that demand. The practice will need to determine hours of operation and provider availability. This might mean that if demand dictates it the practice will need to be open from 7:00 AM until late at night on Mondays during the busy winter flu season. Demand could further require that physician schedules be adjusted as well. This requires some flexibility and contingency plans for times out of the norm. The beauty of Advanced Access is that the practice is constantly measuring. Armed with data, the practice can look into the future and plan more appropriately. It is easier and more productive to ask the staff to change their schedules with advance notice than it is to manage by crisis on a daily basis.
As in any other business, with Advanced Access one must continue to work until all the customer needs are met. In effect anything that gets taken care of today will result in less work tomorrow. Although demand becomes highly predictable, there will be times that will be more or less busy than anticipated. This requires some flexibility and contingency plans for times outside the norm.

Performance Measurement
Successful implementation and adoption of Advanced Access as an operational basis for a physician practice requires discipline in gathering, measuring, evaluating, and interpreting key points on a regular basis. Each practice must set achievable quarterly goals. Backlog, panel sizes, telephone volume, coding profiles, patient cycle times, payer mix, patient demographics, and productivity standards need to be continually monitored. An example of a medical group's full-time productivity standards for the department of family practice is shown in Appendix 14. These standards include the following:

• Minimum in-clinic patient-contact hours per week
• Minimum days in clinic per week
• Evening and weekend patient-contact hours
• Appointment availability for new patients
• Appointment availability for referral patients
• Annual productivity target

Every medical group practice is different based on payer mix, geography, demographics, and so on. However, each practice should determine its minimum levels of capacity to ensure success.

TELEPHONE VOLUME
Most of the components of Advanced Access have been discussed, with the exception of the telephone volume and patient cycle time reports. The telephone volume reports (see Appendix 15) are useful in determining and predicting daily patient demand. The information gathered in these reports can help the practice understand how well it is serving the needs of its patients. If the report indicates that a significant number of telephone calls are about how to take the medication prescribed at the last visit, the practice needs to put an emphasis on patient education regarding medication administration. The reports can measure the following:

• Average telephone calls per day. In this example the highest number of calls is on Mondays with calls tapering off during the week. This can be a useful tool in planning staffing levels.
• Average telephone calls per individual. In this example Lyndee and Jackie receive the bulk of the calls for the practice.
• Average message calls per day. In this example Friday is the day that most message calls are received. This is particularly true in a pediatric clinic, when patients call before trips or events scheduled for the weekend.
• Triage calls per day. This report shows that the practice spent nine hours triaging phone calls on a Monday and that the calls tapered off to a little more than three hours on Friday. If the practice adopts Advanced Access and accommodates those patients' needs, additional personnel capacity can become available to the practice.

The patient cycle times report (see Appendix 16) is a useful tool in determining and predicting the amount of time it takes for a patient to complete the entire appointment cycle, the total difference in the time between check-in and check-out. When cycle times appear to be excessive or a wide variation exists between physicians, further data points can be collected and analyzed in more detail as the patient moves through the clinic appointment. Review of these results is helpful in evaluating the variances in practice methods between providers and helps determine whether the appropriate amounts of time are being allocated to each patient based on the patient's initial complaint or reason for appointment. This exercise should be repeated for a one-week period every six months or so. In this particular example the variation between days is significant and warrants further study. Why does it take so much longer to process a patient on a particular day of the week?

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BENEFITS OF ADVANCED ACCESS
Successful implementation of Advanced Access can take anywhere from six months to two years and is dependent on physician commitment, staff education, willingness to gather and analyze data, and willingness to work down and maintain appropriate backlog. Medical group practices-such as Kaiser Permanente, HealthPartners Medical Group and Clinics, the Mayo Clinic's Primary Care Pediatric/Adolescent Medicine Team, Fairview Red Wing Clinic, Strong Health System, and Dean Health System-have embraced the Advanced Access concept and experienced some or all of following benefits:

• Increased patient satisfaction
• Process simplification
• Standardization of procedures
• Increased staff morale
• Competitive market advantage
• Decreased stress
• Increased revenues

Increased Patient Satisfaction
Patient satisfaction is much higher when the patient is able to see his or her own physician at a time that is most convenient for the patient. At Kaiser Permanente, patient satisfaction scores were among the highest in the organization after implementation of Advanced Access. HealthPartners Medical Group and Clinics also improved patient satisfaction; the percentage of patients who said they "strongly agree"-that they are able to schedule an appointment within a reasonable time-went from 32 percent to 58 percent, and the percentage of patients highly satisfied went from 40 percent to 60 percent (Murray and Tantau 1999). Higher patient satisfaction will lead to greater patient retention and growth for the practice.

Process Simplification
Moving to Advanced Access greatly simplifies the processes in the medical group practice. As the practice understands where improvement needs to occur, it naturally improves the process along the way. When activities are less cumbersome, everything flows better. An added benefit is that staff can actually do the jobs that they were hired to do, which leads to higher staff satisfaction, less turnover, and better retention. In many instances simplification decreases the amount of time spent on training and rework because of errors.

Standardization of Procedures
Standardization of the medical group practice through a decrease in appointment types, agreement between physicians on appropriate treatment for certain diagnoses, and consistent availability of physicians increases office and staff efficiency. Processes that are well understood, consistent across the practice, and simple in nature reduce the chances for errors and increase the level of satisfaction for both staff and patients. By embracing Advanced Access, the Mayo Clinic's Primary Care Pediatric/Adolescent Medicine Team was able to reduce the wait time for routine appointments from 45 days to within 2 days (Murray and Tantau 1999).

Increased Staff Morale
After the successful adoption of Advanced Access, the effect on the staff is universally positive and an increase in staff morale and decrease in turnover will be seen. When a physician lets the staff perform with a defined degree of freedom and constructive communication is constant, the effect on the staff is universally positive. Direct savings are also realized in terms of recruitment, training, and retention costs.

Competitive Market Advantage
The medical group practice that has the ability to offer a patient an appointment with his or her preferred physician and time enjoys a significant market advantage. In this age of increased choice, medical group practices that have the capacity to offer immediate choices to patients have a competitive advantage. Furthermore, the groups' higher satisfaction rating with patients can result in more favorable contractual arrangements with payers.

Decreased Stress
All the changes that occur as the group moves to Advanced Access will usually also lead to improved physician income and less stress in their personal lives. Employees also report having less stress in their day-to-day activities under an Advanced Access model.

Increased Revenues
Practices that have implemented Advanced Access have enjoyed a significant increase in revenues. Through same-day scheduling, improved coding, growth in patient volume, and patient-to-physician continuity, the opportunity to capture additional revenues in a variety of ways exists for the practice. Murray and Tantau (1999) claim that same-day scheduling in itself will boost practice benefits and cite Strong Health System and Dean Health Systems as examples. In the case of Strong Health System, each of the two physicians in one internal medicine clinic is attracting an average of 10 to 15 new patients a month and the ophthalmology clinic has registered a 17 percent increase in revenue. Dean Health Systems found that Advanced Access scheduling and greater capacity enabled its three-physician clinic to increase income by 20 percent in one year. These new patients are the ones who tend to generate the most robust RVUs. Many of these new patients are in need of procedures, surgeries, and hospital consults (Grandinetti 2000).
Another source of increased revenues exists for those practices that have capitation contracts. By using Advanced Access, these practices gain the ability to handle a bigger panel of patients and command more dollars from the plans they contract with. Because patients will be making fewer (but more productive) office visits, physicians can enlarge panel size without working longer hours (Grandinetti 2000).
The increased efficiency also means that these practices can grow without the expense of hiring additional physicians. Some capitated practices have discovered that their patients no longer need to visit urgent-care clinics or emergency departments, thus eliminating the cost of caring for that patient twice (Grandinetti 2000).

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CONCLUSION
The move to Advanced Access as a method of operational and financial improvement requires a lot of work and typically results in a significant cultural shift within the medical group practice. To progress from the decision point of using Advanced Access to the beginning of implementation can take between six and eight weeks. This initial period will require several manual data-collection activities by the practice's staff with submission of data from the practice management system, analysis, and reporting of the data. Full implementation of Advanced Access can take from six months to two years depending on acceptance by physicians and staff, availability of data, and size of the organization. The medical group practice will need to do the following:

• Commit to how the practice is going to gain capacity.
• Reduce the backlog of appointments.
• Use fewer appointment types.
• Develop contingency plans.
• Reduce demand for unnecessary visits.

Each practice must be willing to commit to the processes outlined in this article. Each element of this process will contribute to developing appropriate plans and methods for improved patient satisfaction, staff morale, financial and operational status, and balance between the professional and personal goals of the physicians. This approach reduces no-shows, boosts provider productivity, promotes practice growth, and increases revenues.
The most important aspects of a physician practice are the physician and the patient. Financial success will result with the appropriate structure in place to allow the physician to provide services to patients in a timely manner. It is better to work from the physician forward than from results backward. Moving to Advanced Access requires education, vision, physician support, and willingness to have the healthcare delivery system revolve around the needs of its patients. Today's healthcare market is highly competitive and offers freedom of choice. With strong pricing pressure and quality as givens, Advanced Access offers the healthcare delivery system the opportunity to truly differentiate itself within the market and realize improved patient satisfaction, operational, and financial results. Practices that embrace this concept are truly able to combine clinical, operational, and financial elements that lead to continued success.

References

Health Care System Excellence in Management. 2001. "Management: Eye on Improvement." [Online article; retrieved 8/02.] http://www.ihi.org/resources/eyeoi/2001/8-16abs.asp.

Boelke, C., B. Boushon, and S. Isensee. 2000. "Achieving Open Access: The Road to Improved Service and Satisfaction." Medical Group Management Journal 47 (5): 58-62, 64-66, 68.

Grandinetti, D. A. 2000. "You Mean I Can See the Doctor Today?" Medical Economics 77 (6): 102-04, 109, 13-14.

Havlicek, P. L. 1996. Medical Groups in the U.S.: A Survey of Practice Characteristics. Chicago: American Medical Association.

Institute for Healthcare Improvement. 1999. "Idealized Design of Clinical Office Practice." [Online article; retrieved 8/02.] http://www.ihi.org/idealized/idcorp/access.asp.

Kilo, C., P. Triffletti, and M. Murray. 2000. "Improving Access to Clinical Offices." Journal of Medical Practice Management 16 (3): 126-32.

Kongstvedt, P. R. 1993. The Managed Healthcare Handbook, 2nd Ed., p. 13. Gaithersburg, MD: Aspen.

Lippman, H. 2000. "Same-day Scheduling." Hippocrates 14 (2): 49-53.

Murray, M., and C. Tantau. 1999. "Redefining Open Access to Primary Care." Managed Care Quarterly 7 (3):45-55.

---. 2000. "Same-day Appointments: Exploding the Access Paradigm." Family Practice Management 7 (8):45-50.

Ross, A., S. J. Williams, and E. J. Pavlock. 1998. Ambulatory Care Management, 3rd Ed., p. 10. Albany, NY: Delmar.

Additional References
Appleby, C. 1997. "Open Access Plans: Will Family Physicians Be Left Behind?" Family Practice Management 4 (3): 58-60, 63-64, 67.

Bodenheimer, T., B. Lo, and L. Casalino. 1999. "Primary Care Physicians Should Be Coordinators, Not Gatekeepers." Journal of the American Medical Association 281 (21): 2045-49.

Chesanow, N. 2000. "Easy Ways to Track Your Progress." Medical Economics 77 (10): 131-34, 136, 141.

Crane, M. 2000. "Get the Most out of Every Patient Visit." Medical Economics 77 (16): 96-98, 101-04.

Droste, T. 1999. "Same-day Appointments Create Capacity, Increase Access." Executive Solutions in Healthcare Management 2 (2): 7-10.

Edsall, R. L., L. A. Backer, J. Bush, B. White, O. Maresh, and K. A. Hocker. "The Family Practice Management Practice Self-test." [Online article; retrieved 8/02.] http://www.aafp.org/fpm/20010200/4thef.pdf.

Forjuoh, S. N., W. M. Averitt, D. B. Cauthen, G. R. Couchman, B. Symm, and M. Mitchell. 2001. "Open-access Appointment Scheduling in Family Practice: Comparison of a Demand Prediction Grid with Actual Appointments." Journal of the American Board of Family Practice 14 (4): 259-65.

Gallagher, M., P. Pearson, C. Drinkwater, and J. Guy. 2001. "Managing Patient Demand: A Qualitative Study of Appointment Making in General Practice." British Journal of General Practice 51 (465): 280-85.

Goldberg, S. E. 1998. "Demand Management: Implementing Your Own Program." Family Practice Management 5 (8): 49-50, 55-56, 59-62.

---. 2000. "Make the Most of Your Staff." Medical Economics 77 (8): 56, 63-66.

Herriott, S. 1999. "Reducing Delays and Waiting Times with Open-office Scheduling." Family Practice Management 6 (4): 38.

Kilo, C., and S. Endsby. 2000. "As Good As It Could Get: Remaking the Medical Practice." Family Practice Management [Online article; retrieved 8/02.] http://wwwaafp.com/fpm/20000500/48asgo.html.

Lippman, H. 2000. "Do Patients Love You, but Hate Your Phones?" Medical Economics 77 (18): 77--78, 81-84.

Murray, M. 2000. "Modernizing the NHS-Patient Care: Access." British Medical Journal 320 (7249): 1594-96.

Murray, M., and C. Tantau. 1998. "Must Patients Wait?" Joint Commission Journal of Quality Improvement 24 (8): 423-25.

Raddish, M., S. D. Horn, and P. D. Sharkey. 1999. "Continuity of Care: Is It Cost Effective?" American Journal of Managed Care 5 (6): 727-34.

Saunders, A. B. 2002. "Open Access and the Tools You Will Need to Implement It." Partners' Practicum [Online article; retrieved 7/02.] http://www.partnershc.com/pdf/2002/apr_2002.pdf.

Schneck, L. 2001. "Open Access Scheduling Can open the Door to Better Performance-Nine Steps to Help Boost Patient, Physician and Payor Satisfaction." MGMA Connexion [Online article; retrieved 7/02.] http://wwwcmgma.org/newsletr/fall2001/open_access.htm.

Schwartz, L., S. Woloshin, J. H. Wasson, R. A. Renfrew, and H. G. Welch. 1999. "Setting the Revisit Interval in Primary Care." Journal of General Internal Medicine 14 (4): 230-35.

Simmons, J. C. 2000. "Striving to Provide More Efficient Care in the Outpatient Setting." The Quality Letter for Healthcare Leaders 12 (1): 2-12.

Sipkoff, M. 2001. "Advanced Access Improves Quality and Patient Satisfaction." The QI Physician. [Online article; retrieved 8/02.] http://www.qiphysician.com/cgi-bin/article.cgi?article_id=1024.

Terry, K. 2000. "Re-engineer Your Practice-Starting Today." Medical Economics 77 (2): 174-76.

Tuso, P. J., K. Murtishaw, and W. Tadros. 1999. "The Easy Access Program: A Way to Reduce Patient No-show Rate, Decrease Add-ons to Primary Care Schedules, and Improve Patient Satisfaction." The Permanente Journal [Online article; retrieved 7/02.]
http://www.kp.org/medicine/permjournal/fall99pj/frea.html.

White, B. 1999. "Measuring Patient Satisfaction: How to Do It and Why to Bother." Family Practice Management 6 (1): 40-44.

---. 2001. "Starting a Revolution in Office-based Care." Family Practice Management 8 (9): 29-35.

Woodcock, E. 2001. "How to Implement 'Second-generation' Access in Your Practice." Shands Healthcare [Online article; retrieved 7/02.] http://www.shands.org/professional/ppd/practice/office/implement.asp.

Zablocki, E. 2000. "A Change in Practice." Healthplan 41 (6): 52-54.

Open Access/Healthcare Delivery Web Resources

American Academy of Family Physicians Practice 2010, Office Efficiency and Patient Care Enhancements-Same Day Appointment Scheduling: http://www.aafp.ort/x3847.xml-office.

Center for Healthcare Strategies Open Access in Clinical Office Practice Settings: Benefits and Challenges: http://www.chcs.org/ManagedCare/Openaccess.html.

Institute for Healthcare Improvement's Idealized Design of Clinical Office Practice: http://www.ihi.org/idealized/idcop/background.asp.

Discussion/Listserv Groups
American Academy of Family Physicians: http://www.aafp.org/fpm/990100fm/40.html.
American Medical Group Association Patient Satisfaction Survey Information: http://www.amgo.org/AMGA2000/QMR/PSAT/survey_psat.htm.

Institute for Healthcare Improvement Idealized Design of Clinical Office Practice Listserv: http://www.ihi.org/communities/.

Consulting Firms

First Consulting Group (http://www.fcg.com/def_flsh.asp).

Houck & Associates, Inc. (e-mail: shouck@houckhealthcare.com).

Murray, Tantau and Associates (e-mail: mailto:murraytant&msn.com).
Veterans Health Administration, Inc. (http://www.vha.com/public/pagebuilder.asp?url=public/prodserv_clinenhance.asp).

For a faxed copy of the appendices, please call (312) 424-9473, or send an e-mail to Jane Williams at jwilliams@ache.org. Please include your fax number, as the appendices will be faxed to you.