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Practice is too complicated for improvements to be simple.

Fam Pract Manag. 2005;12(3):8

Open access, or “advanced access,” has long been the poster child for practice redesign. A few years ago, it held a prominent position in the Institute for Healthcare Improvement’s Idealized Design of the Clinical Office Practice initiative.1 Now it is an essential element of the new model of practice advanced in the Future of Family Medicine report.2 In part because this one innovation is claimed to afford improved patient satisfaction, improved staff satisfaction and improved physician satisfaction, it seems often to be where practices start in practice redesign.

If you’re going to worry…

It also seems to be an innovation that many physicians turn away from, scratching their heads. Plenty of concerns that leap to mind overshadow the reported advantages of open access.

First, open access seems implausible to many, as though it must involve sleight of hand. How can one make a sizeable and long-standing appointment backlog disappear like an elephant in a Las Vegas magic show? Having too many patients and too little time seems inevitable.

Second, open access is financially scary. How can you generate a reliable stream of revenue if you start every day with an empty schedule? Suppose the slots don’t all fill up? At least with a backlog, you know what you’re going to be doing tomorrow.

Third, open access seems to endanger continuity of care. How can you be sure a patient will get the three-month follow-up appointment she needs if you rely on her to remember to set it up three months from now? And there are more concerns where these come from.

Worry about the right stuff

I hope our cover story (page 59) can help allay any unfounded concerns you have – and focus your attention on the challenges that really do need addressing. In this article, Mark Murray, MD, one of the originators of the concept of advanced access, answers questions submitted by FPM readers. If you are an open-access skeptic, his answers may well help set your mind at rest. At the same time, though, you’ll see in his answers an outline of the challenges of open access:

  • You can’t make the first step without leadership from the top and the committed involvement of every physician and every staff member.

  • You can’t have open access if you haven’t measured both demand and capacity – and, if necessary, made potentially difficult adjustments in schedules, staffing or panel sizes.

  • You can’t have open access until you have worked down the backlog; that takes a good deal of hard work.

  • Open access requires that you change the way you, your staff and your appointment system work.

  • Preventing recrudescence of the backlog requires continual management and occasional extra work.

In these respects, open access truly does make a good poster child for practice redesign. It exemplifies the nature of system redesign in several respects: It promises enormous advantages but requires significant effort and more careful management than many physicians are used to. It doesn’t so much improve what you’re accustomed to as replace it. It requires measurement and at least simple statistical tools. It forces you to work in ways you’re not accustomed to. It requires the involvement of everyone in the practice and, for that matter, changes the way they all work.

If this sounds daunting, it is. The good news, though, is not only that open access can make life better for you, your staff and your patients, but that if you can pull it off, you’re in a great position to attempt any other redesign effort. You’ll already have the experience, the tools, the energized staff. There’s no holding you back then.

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