As much as we talk about quality in terms of the effectiveness of care, patients still tend to assess quality in terms of service and access. They expect to see their provider of choice at a convenient time. Four years ago, one of the clinics I manage was failing to meet our patients' expectations about service and access. Patient-satisfaction surveys told us that too often people couldn't get appointments when they wanted them and couldn't see their provider of choice — and that they hated our phone system. After several consecutive quarters of substandard patient-satisfaction scores, we implemented a method of scheduling developed by Marvin Smoller, MD, known as “open-office scheduling.”^1,2 Our patients, physicians and staff have been more satisfied ever since.

The guiding principle of open-office scheduling is simple: getting patients into the office when they want to be seen. The methodology recognizes that the patient's desire for an appointment may not match his or her need for care, but it aims to provide excellent customer service nonetheless. We try equally hard to accommodate the person with a hangnail and the person with pneumonia. The key is to hold open a strategic number of time slots for same-day appointments.

Because the physicians in our clinic are compensated based on productivity, leaving slots open for same-day appointments carried a certain amount of risk. But with careful planning, this system can actually increase productivity while it improves patient satisfaction.

The fundamentals

The first step is to identify the average number of same-day appointment requests your group receives for each day of the week. You'll use that number to determine how many time slots to hold open each day. We have a computerized report that tracks how many people we add to the schedule daily. If that's not an option for you, you may want to have a staff member tally how many people your practice sees per day, how many were added and how many had to accept an alternative to a same-day appointment.

In general, Smoller says, practices that have about 10,000 patients should hold open 50 percent of their total slots on Mondays and Fridays. On Tuesdays, Wednesdays and Thursdays, they should hold open 30 percent to 35 percent. In our clinics, we've noticed that Tuesdays are almost as busy as Mondays and Fridays, so we hold open 50 percent on Tuesdays, as well.

Here's how an eight-hour workday might be structured if 50 percent of appointment slots (four hours' worth for each physician) were designated as open. As you'll see, there are actually two types of “open” slots. (See “A sample schedule.”)

Half the open slots — one hour in the morning and one in the afternoon per doctor — would be held for same-day appointments (what we call “same-day adds”). The hours designated for same-day adds should be staggered so that appointments are available to patients throughout the day. We try to schedule patients to see their provider of choice, but when slots are full, we mix and match. A patient who can't make it in between 10 and 11 a.m. for one of his or her own physician's openings may be able to see another physician whose same-day appointment availability is 2 to 3 p.m.

It's best not to designate early-morning hours for same-day adds for a couple of reasons. First, we like to make early-morning appointment times available to patients who need to come in early so they can be at work by a particular time. This restriction doesn't tend to present problems for acutely ill patients. We've found that people who've been sick all night typically don't mind waiting until 9 or 10 a.m., and those who are extremely ill tend to seek care overnight in the emergency department or simply walk in the next morning. Another reason to avoid designating early-morning slots for same-day adds is that if your phone lines don't open until 8 a.m., for example, the earliest slots may go unfilled. But it's also important to be flexible. We sometimes do make early-morning appointments available to acutely ill patients who call in the mid- to late-afternoon the day before to ensure that those slots will be filled.

The remaining open slots (again, one hour in the morning and one in the afternoon for each physician) would be reserved for patients who require follow-up — for example, to make sure that an antibiotic was effective for a patient with pneumonia. We call these visits “return checks.” These slots are made available to be filled no more than two weeks from the appointment time. Our physicians usually note at the bottom of the superbill the need for follow-up within a 10-day or two-week time frame, and the appointment is made before the patient leaves the office. If on any given day we find we still have some of these slots open, they become extra slots for same-day adds.

The other four hours of the day would be devoted to appointments scheduled more than two weeks in advance (what we call “prescheduled appointments”), such as annual exams and routine checkups for patients with chronic diseases. We're careful to stagger physicals and annual well-woman exams throughout the day to prevent bottlenecks at the scales, the bathroom and the eye chart.

About 90 percent of our appointments are made by our receptionists. The remaining 10 percent are scheduled by our nursing staff as part of the triage process. Calls are forwarded for triage when the patient specifically asks to speak with a nurse or when our receptionists are uncertain about how soon a patient should be seen. Nurses also triage same-day appointment requests when we run out of open slots on a given day, double-booking when necessary. All the nurse calls are routed to the primary nurse of the caller's regular physician.

Of course, same-day appointment requests frequently aren't black-and-white issues. Although we've disciplined ourselves not to use open slots for visits that don't meet our criteria, we occasionally make exceptions to accommodate our patients when other options fail. For example, if a parent asks for a same-day physical for his or her child so the child can be admitted to preschool, we may first offer to write a note that lists the date of the patient's upcoming physical as well as his or her immunization record, and provide a copy of the previous physical. If these measures don't suffice, we may offer the patient a same-day add slot. Or, if a patient wants to come in to talk about recurring headaches but our schedule is booked solid for four weeks, we may offer the patient one of our two-week add slots. But these exceptions are few and far between — and we're much less likely to make any kind of exceptions during flu season, when the need for acute care is greater and demand is difficult to predict.

Tailoring a schedule to suit your needs

Design your open-office schedule to suit your physicians' work styles. If your physicians tend to work quickly, you might create your schedule using 10-minute slots. If you have one especially productive physician, you might set your schedule using 15-minute slots and double-book appointments for the “super doc.” If some of your physicians provide obstetric care, their inevitable absences for deliveries can complicate your scheduling.

As you create your schedule, you'll need to accommodate a variety of circumstances that require careful planning or on-the-spot adjustments, including these:

Seasonal variations in disease prevalence. The number of slots you hold open will fluctuate depending on the time of the year. A Monday during flu season may require many more slots for same-day adds than a Monday in July.

Community events. You should also set aside an increased number of same-day add slots to coincide with certain community events, such as a state fair that might bring about more cases of heat stroke, injuries and so on.

Vacations. During the week before and after a physician's vacation, hold open additional slots to accommodate the rush of patients who want to be seen by their doctor before he or she leaves and those who become ill while the physician is away but wait to be seen until he or she returns. In a small practice, while one physician is away on vacation, you may want to designate all of the other physicians' time slots for acute care to help offset the effect of the absence.

Sick doctors. If a physician calls in sick, reschedule as many of that doctor's patients as possible. If the sick doctor notifies you early enough, his or her schedule may not be completely full. At 7 a.m., 75 percent of the people on the day's schedule have appointments that were set far in advance, and they probably don't have to be seen that day. For those who must be seen, double-book slots on the other physicians' schedules.

Late arrivals. We try to work everyone in, giving priority to patients with the most immediate need, but those who are chronically late may have to wait longer. To help avoid scheduling problems caused by late arrivals, we have a list of chronically late patients to whom we assign appointment times 30 minutes later than the time we tell them to arrive.

Satisfying results

For our practice, open-office scheduling has resulted in benefits for patients, staff and physicians alike. And it's helped us increase our productivity.

Patient satisfaction. Before our clinic adopted open-office scheduling, our overall patient-satisfaction score for access was 3.6 on a 5.0 scale. (The access score is an aggregate of patients' satisfaction related to the ease of getting an appointment, the length of time between setting an appointment and the visit, the ability to see the provider of choice and the ease of using the phone system.) We started open-office scheduling in the third quarter of 1995, and in less than a year, our access score had improved to 4.0. Although we tend to experience a slight third-quarter decrease each year, our scores have held steady near 4.0 since 1996.

Patients report that their ease of getting an appointment has improved considerably since we instituted open-office scheduling, from 3.6 at the beginning to consistently above 4.0 since 1996. Improvements in patients' satisfaction with the length of time between setting an appointment and the actual visit have been slower but fairly steady, despite some seasonal fluctuation. We reached our goal of 4.0 in the first quarter of 1997, and that mark has varied from 3.8 to 4.0 since then.

We've made some changes in our scheduling system to ensure that we accommodate patients with chronic diseases and those who need physical exams as well as those with acute illnesses. The change that has made the biggest difference involves physicals. Healthy adults with no current medical problems and those who take no more than two medications for chronic illnesses receive a focused physical rather than a complete physical, which cuts the length of the visit from 30 to 15 minutes. We've also added two midlevel providers to our staff, which has improved our ability to provide preventive care and made us more accessible to patients with chronic conditions.

Staff satisfaction. In addition to quantifiable improvements in patient satisfaction, our clinical and administrative staff members have been more satisfied since switching to open-office scheduling. Our physicians love it. Their productivity has increased, and their days are more varied. At least one physician was worried that his schedule might not be consistently full, but we've learned that “if you build it, they will come”: We can always fill our open slots.

One of our major motivations for making this change was that our nurses were tired of spending time on the phone. They didn't earn nursing degrees to become telephone operators. Because the scheduling system reduces our nurses' phone-triage time, we've been able to expand their clinical roles to include suturing, casting and liquid-nitrogen freezing.

Our nonclinical staff members have also been pleased with the new system. They're glad to see that patients with acute problems are handled more quickly and efficiently. And they feel more empowered in their work because they can set same-day appointments instead of having to forward those calls to a nurse for triage. Our records clerk is the only person who didn't like the new scheduling system. We've had to get more help for her to deal with the increased number of charts that have to be pulled and prepared at the last minute.

Productivity. Our physicians who were concerned about the prospect of empty appointments slots soon found they had nothing to fear from the new system. Our total visits increased by 7.2 percent from 1995 to 1996, by 12 percent from 1996 to 1997 (this increase was due in part to our opening a convenient-care service in our office from 6 to 8 p.m. five evenings a week), and by 15.3 percent from 1997 to 1998. (See “Productivity improvements.”)

Getting started

Making the switch to open-office scheduling needn't be complicated, but it does require careful planning beyond determining how many same-day add slots to leave open. Here are some tips:

Get buy-in. The single most important step is to get the buy-in of all the physicians in the group first. If they're not happy with the change, no one in the group will be. And it's impossible to adopt open-office scheduling unless all the doctors in the group will participate. Otherwise, those who take part will spend much of their time seeing their partners' patients.

Retrain staff and patients. Any staff member who might possibly answer the phone must be trained to schedule appointments and determine whether a same-day appointment, a return check or something else is in order. Over time, many patients have learned to ask for their physicians' nurses if they want a same-day appointment, so patients must also be retrained. To that end, we've changed our phone script: “Carle Clinic, this is Sue. May I offer you an appointment, or do you need advice from a nurse?”

Decide when to start. When you're ready to convert to open-office scheduling, identify the period on your schedule where about 50 percent of your appointment slots are still open on several consecutive days (for us, this was six weeks out). From that point on in your schedule, block off the proper percentage of open slots for each day of the week, according to the schedule that your group has established (50 percent on Mondays, 35 percent on Tuesdays, etc.). Two weeks before the first day for which you've designated open slots, you can release half of the slots you have blocked out and begin filling them with return-check appointments.

Be prepared for a difficult transition. Access (and physician satisfaction) may have to suffer in the short term to improve down the road. As you wait for the day when your new system officially begins, you'll probably be frustrated by being unable to put patients into the slots you're holding open. During the transition, providers may have to work longer hours than usual to accommodate patient demand, or you may need to provide more aggressive phone triage than you ordinarily would. The optimal time to convert to this kind of scheduling would be when a new physician (with extra time) is brought on board. You can also ease the transition by implementing the system during the season of lowest demand for your services.

Building trust on schedule

By getting patients into the office when they think they need to be seen, we build their trust. If a patient has to tell the receptionist his or her problem, then repeat the explanation to the nurse, then wait for the nurse to talk with the physician and call back — only to receive advice when what the patient really wanted was an appointment — he or she eventually will go to another practice. Open-office scheduling enables us to do the job that our patients expect us to do and helps us run our offices more smoothly. As Smoller advises, “Do today's work today so tomorrow will go much better.”