Opening the door: Increasing access and revenue with templates, flips and a portal

By Matthew J. Davis, BS, clinical research fellow, Division of Plastic Surgery, Texas Children’s Hospital, davis.matthew@bcm.edu; Amjed Abu-Ghname, MD, clinical research fellow, Division of Plastic Surgery, Texas Children’s Hospital, amjed.abu-ghname@bcm.edu; Carrie T. Rys, MBA, assistant vice president of pediatric ambulatory operations, Texas Children’s Hospital, ctrys@texaschildrens.org; Ramzey M. Ibrahim, MEng, LSSMBB, manager, business process transformation, Texas Children’s Hospital, rmibrahi@texaschildrens.org; Larry H. Hollier Jr., MD, surgeon-in-chief, Texas Children’s Hospital, lhhollie@texaschildrens.org; and S. Richelle Fleischer, MPH, CPA, president, Texas Children’s Physician Group, Texas Children’s Hospital, rxfleisc@texaschildrens.org.

When thinking about seeing their doctor, very few patients envision navigating the convoluted network of schedulers, waiting lists, appointment restrictions and cancellations that have come to serve as gatekeepers to many large hospital systems. As healthcare in the United States tends increasingly toward a model of super-specialization, resulting increases in patient demand for specialized services have manifested as sharp increases in the number of annual ambulatory care visits, especially among pediatric patients.1,2 Hospital systems must adapt their models of patient access to accommodate this increased demand for specialty clinic appointments.

The primary incentive for hospital systems to optimize patient access platforms is simple: to ensure patients are receiving the best care possible. Decreases in patient access have been tied to decreases in quality of care delivered, diminished hospital productivity and increased healthcare costs.3 When barriers to access are removed, hospital systems improve the health of their patients and create an opportunity to generate substantial increases in revenue.

Identifying the problem

Providing care to more than 3.4 million patients annually, Texas Children’s Hospital (TCH) in Houston is home to more than 40 specialty services and serves a patient population representing all 50 states and more than 60 countries. By 2017, massive demand for hospital services resulted in long wait times for specialty appointments and associated increases in patient dissatisfaction. Paradoxically, however, almost 20% of total available TCH clinic appointments were going unfilled, and an additional 300,000 appointments were being cancelled annually. In August 2017, TCH addressed the barriers to access that many patients were experiencing.

Hospital administration tackled these patient access issues head-on. A leadership task force was assembled and given a single goal: improve access to ambulatory specialty clinics. There were three primary areas of focus: capacity management, appointment utilization and patient scheduling experience.

Access initiatives

Capacity management

In the setting of unprecedented demand for clinic appointments, the fact that 20% of hospital-wide available appointment slots went unfilled was unacceptable. Truncated clinic schedules were identified as the main source of this underutilized clinic capacity. The leadership task force found that clinic sessions were scheduled for less than the expected four hours. To address this issue, all clinic sessions were rebuilt to a standardized four-hour template to which providers were required to adhere. A mix of new and return patient visits were added to these newly opened time slots.

In the year following implementation of the four-hour templates, TCH experienced an increase of 23,488 new appointments scheduled and 29,636 return appointments scheduled, resulting in a total increase of 53,120 appointments. Table 1 shows the breakdown of appointments added annually by each pediatric specialty following the hospital-wide adoption of four-hour clinic templates.

Although increased numbers of scheduled appointments are a strong sign of improved patient access, an even better metric is increased numbers of completed appointments. Following the implementation of four-hour templates, there was an increase of 17,996 total scheduled annual appointments for surgical subspecialties (Table 1).

Across this same intervention time frame, the number of completed appointments across all surgical subspecialties increased from 41,450 to 56,206 (Figure 1) — a total increase of 14,756 completed annual appointments. Taken together, these findings suggest that 82% of the increases in scheduled appointments ultimately translated into increases in completed appointments. Extending this estimate across the hospital, there were an additional 43,556 annual visits completed at TCH following the implementation of four-hour templates (Table 2).

Appointment utilization

As a large specialty hospital, TCH often cares for patients with complex medical needs who require more than a standard appointment time to receive proper care. Prior to the implementation of these access initiatives, across all surgical services, special appointment slots were held for these patients. Appointments could also be held for a variety of other reasons. Realizing that these reserved appointment slots often went unfilled, another access initiative required that these unutilized slots be opened, or “flipped,” within 72 hours of the appointment so that any patient, regardless of complexity, could claim that slot.

Following the introduction of 72-hour flips, TCH saw a 93% decline in held appointment slots. The combined effect of all access initiatives on surgical specialty appointment designations is shown in Table 3.

Patient scheduling experience

Prior to 2017, a large portion of schedulers’ days was spent answering patient phone calls and transferring patients to other schedulers around the hospital. This process resulted in high levels of patient and staff frustration, suggesting the need to implement a streamlined scheduling process. The result was the development of a patient-centered, online scheduling portal. The goal was for patients to self-schedule appointments using a computer, tablet or smartphone.

In the first six months after introducing the patient scheduling portal, more than 2,000 appointments were self-scheduled online. Additionally, Press Ganey top box “ease of scheduling” scores increased from 57% to 72%, indicating that patients are more satisfied with this new process of scheduling appointments. A summary of resultant changes due to the patient scheduling portal are depicted in Table 4.

Increased revenue

How did these access initiatives ultimately impact the bottom line at TCH? The average gross patient revenue (GPR) opportunity at TCH has been estimated at $190 for a new appointment and $130 for a return appointment. Thus, the additional 23,488 new appointments and 29,636 return appointments attributable to the access initiatives resulted in approximate annual revenue increases of $4,462,720 and $3,852,680, respectively, which add to a total estimated annual revenue increase of $8,315,400 across TCH specialty care (Table 5).

Lessons learned

During this journey to increase hospital-wide patient access to specialty care, TCH has learned many valuable lessons, including:

• Match interventions to clinic dynamics: Many potential interventions have been put forth to increase patient access. Some have involved standardizing appointment times4 or instituting shared clinic visits5,6 while others have attempted to predict no-show rates7,8 or implement open-access scheduling.9,10 There is no single panacea to cure hospital access issues. Initiatives must be selected only after careful study of your hospital system’s barriers to patient access.
• Secure physician buy-in: While altering the format of clinic appointment slots may seem intuitive from an administrative point of view, these changes might be viewed as an imposition by physicians and staff. Make clear the goals of each intervention, announce any planned changes in advance of implementation and actively solicit provider feedback.
• Measure impact: The true impact of these access initiatives can only be demonstrated if outcomes are clearly defined long before the interventions are enacted. From the outset, take the time to learn how others have studied the effects of access initiatives, and define clear outcomes for your own initiatives.

Notes:

1. DuCoin C, Hahn A, Baimas-George M, Slakey DP, Korndorffer JR. “The change in surgical case diversity over the past 15 years and the influence on the pursuit of surgical fellowship. Am Surg. 2018 Sep 1;84(9):1476-1479.
2. “Characteristics of office-based physician visits, 2016.” National Center for Health Statistics. 2019. Available from: bit.ly/2nNPnpS.
3. Huang Y, Verduzco S. “Appointment template redesign in a women’s health clinic using clinical constraints to improve service quality and efficiency.” Appl Clin Inform. 2015 Apr 22;6(2):271-287.
4. Huang, YL. “Appointment standardization evaluation in a primary care facility.” International Journal of Health Care Quality Assurance. 2016 1 Jul;29(6):675-686.
5. Jhagroo RA, Nakada SY, Penniston KL. “Patients attending shared medical appointments for metabolic stone prevention have decreased stone risk factors.” Journal of Endourology. 2016;30(11):1262-1268
6. Edelman D, Gierisch JM, McDuffie JR, Oddone E, Williams JW. “Shared medical appointments for patients with diabetes mellitus: a systematic review.” J Gen Intern Med. 2015;30(1):99-106.
7. Huang YL, Hanauer DA. “Time dependent patient no-show predictive modeling development.” International Journal of Health Care Quality Assurance. 2016;29(4):475-488.
8. Creps J, Lotfi V. “A dynamic approach for outpatient scheduling.” J Med Econ. 2017;20(8):786-798.
9. Cruz HE, Gawrys J, Thompson D, Mejia J, Rosul L, Lazar D. “A multipronged initiative to improve productivity and patient access in a federally qualified health center network.” The Journal of Ambulatory Care Management. 2018;41(3):225-237.
10. Ansell D, Crispo JAG, Simard B, Bjerre LM. “Interventions to reduce wait times for primary care appointments: a systematic review.” BMC Health Services Research. 2017;17(1):295.