 Do
you feel buried under a mounting backlog of appointments
booked months in advance? Maybe you should consider
seeing your patients today.
Same-day booking is an increasingly
popular solution in the US for physicians who want to
simplify their scheduling and put the kibosh on no-shows.
More and more Canadian docs, such as Halifax GP Dr Vicky
Mitchell, are successfully switching over to a same-day
booking system, proving that the concept can work in
Canada's healthcare context.
Same-day booking was brought into
the mainstream in 1994 by Dr Anthony Cantelmi, chief
of medicine for HMO giant Kaiser Permanente in California's
Sacramento Valley. Dr Cantelmi first implemented a system
for himself, but soon, with the help of some colleagues,
made same-day booking the standard for his whole facility.
Two of his staffers, FP Mark F Murray and nurse Catherine
Tantau, went on to popularize the system by teaching
the method to other practices.
Other people call the system "open
access scheduling" but Dr Cantelmi prefers the simpler
"easy access." "We don't force people to take an appointment
that day, we just ask them, 'What do you want'? Do you
want to be seen today, tomorrow, next Tuesday? What's
your pleasure?"' he explains in an interview with NRM.
EASY
DOES IT
Dr Cantelmi recalls the origins of his easy access scheduling.
"It was a system that I put into place after an extended
leave and when I got back I had to work down my backlog,"
he says. "In October I decided to start seeing all my
patients who called that day plus all my existing appointments
— by December I'd cleared the backlog."
Once word got out that he was seeing
his patients the same day they called they were incredulous.
"I had a guy call in and make an appointment and he
didn't even want it," recalls Dr Cantelmi. "He just
wanted to see if he could really see me on that day!"
Was there any backlash? "No," he
says. "My patients just love this system." Do you ever
run into cases when patients have to call for days on
end trying to see you? "No, it just doesn't happen."
PATIENT
INSPIRATION
He's been with Kaiser Permanente for 22 years; at the
time he decided to try same-day booking he'd been with
them for 10 years. Something about the way things were
going just didn't sit well with him. "The mismatch was
that same-day care — really urgent care —
was being relegated to per diem physicians who didn't
really have a big stake in the success of the organization,"
says Dr Cantelmi. "Patients don't like that — they
want to see a familiar face. People who are bonded to
me want to see me when their nose is running as well
as when they're having chest pains. They don't say 'I'll
see you when I'm fine' and they certainly don't say
'I'll just come in for a physical or preventive stuff
but whenever I'm sick I'll see somebody else.'"
The logic behind the status quo
puzzled Dr Cantelmi. "When you have the proper doctor
to patient ratios and you're booking three months out
— that never made sense to me," he says. "Supply
and demand management says you need to do today's work
today — why put it off until tomorrow?
"It doesn't matter who, it could
be chest pain, shortness of breath, bleeding or whether
you just need an update to go on a cruise," he explains.
"In other words we don't triage the day's appointments,
we don't put off things like physicals. We just lump
everything together and say 'If you have a need to be
seen, come on in.'"
THE
SWITCH
Dr Vicky Mitchell told the Chronicle Herald that
she put herself through 'boot camp' to get rid of the
backlog before she could starting seeing patients on
a same-day basis. Dr Cantelmi says that's something
you can't avoid. "Whatever it takes to bring that backlog
down you have to do — work evenings, weekends or
bring in people to help," he says. "But once the backlog
is cleared, and you have a pretty good match of the
number of patients to the number of physicians then
you're in pretty good shape to hit the ground running
— it's easy."
"We definitely had our hard times
in a switch-over," he recalls. "But I oversee 188 physicians
and if I asked them, 'Would you like to go back to seeing
pre-booked appointments and have urgent care go to someone
else', there wouldn't be a single person in that group
who'd say 'yes' — all of them like this system."
Dr Mitchell's experience confirms
the set-up can work in Canada. She said she "felt as
light as air" after her system was up and running.
FORGET
NO-SHOWS
The effect on no-shows has been staggering. "We went
from an almost 20% no-show rate to virtually zero,"
says Dr Cantelmi. "When appointments are booked months
ahead people just forget about them."
He said empty slots are not a problem
either since his facility, like most in Canada, has
an abundance of patients. "For us it's very rare that
supply exceeds demand," he says. "Yet, here in the North
Valley of California 85% of calls will be booked for
an appointment the same day — that number has been
as high as 94% at points."
"Certain days are a little bit
busier and certain days are a bit light but you can
calculate the ebb and flow. It works great for a population
of 10,000-20,000 patients. It doesn't do as well for
a single doctor," says Dr Cantelmi. "If I were in solo
practice, it could be four or five patients one day
and 40 another — that supply and demand is a little
harder to calculate."
"I think to run a seven-day-a-week
operation you need eight to nine with an 18,000-19,000
patient population," he adds. "With that it gets really
easy to predict demand."
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