aA

Overview

Updated on August 14, 2017

“If it currently takes 2 weeks to get a non-urgent appointment –but it always takes 2 weeks – then the practice is meeting its demands…just 2 weeks late. The challenge is getting that demand met today.”
Vineet Nair, MD CCFP, Lead Physician London Centre Family Health Organization

Issue

Timely access to primary care is about getting supply and demand in equilibrium; meeting the demands of one’s practice population by supplying timely patient-centred care (IHI, 2017). In Ontario 94% of people aged 16 and older have a primary care provider, however delays in getting appointments for family physicians, specialists, or certain tests, are common. Figure 1 shows that only 43.6% of Ontario adults over the age of 16 are able to see their primary care provider on the same or next day when they are sick or need medical attention (HQO, 2016; IHI, 2017).

FIGURE: 1 Percentage of people aged 16 and older who were able to see their primary care provider, o another primary care provider in their office, on the same day or next day when they are sick, in Ontario, by LHIN region, 2015

As shown in Figure 2 Ontario and Canada have some of the worst access rates (same or next day appointments available) compared to the other countries in the Commonwealth (CIHI, 2017).

FIGURE: 2 Percentage of people who were able to see their primary care provider, or another primary care provider on the same day or next day when they are sick. Commonwealth Country Results, 2016

A gap in the supply and demand of primary care creates delays which create stress, waste, and can lead to worse clinical outcomes (IHI, 2017). Furthermore, delays are expensive:

  • There is a cost to maintaining the wait list and triaging patient requests for appointments;
  • The no-show or fail-to-show rate increases the time patients must wait for their appointment;
  • Many patients (almost one in two Ontarians) use the Emergency Department to access medical care that they could have received from their primary care provider if a same day or next day appointment was available.

Action Plan for Health Care

Faster access to the right care is an important area of focus in Ontario’s Patients First: Action Plan for Health Care. Better access to a primary care provider can reduce use of the emergency department, reduce use of walk-in-clinics, and improve continuity of care. In addition, increased access to primary care can lead to better health outcomes and lower total health care system costs (HQO, 2016; IHI, 2017).


Delays are systemic, and not the fault of any one provider or practice, however there are ways to organize office processes to make better use of time and resources. The primary goal is to enhance the doctor-patient relationship, and improving access is a critical component of this relationship. It requires that practices offer appointment options to suit the patient’s current needs.


Quality Improvement in Timely Access and Efficiency

Quality improvement initiatives strive to improve access (providing timely patient access to a scheduled appointment with the patient’s primary care provider) and efficiency (being more efficient in the office processes leading up to, during and after a patient’s appointment).

Efficiency goes hand in hand with improving access, the table below outlines the principles of Timely/Advanced Access and Efficiency. These principles come from the Advanced Access and Efficiency Workbook for Primary Care.


Quality improvement timely access change ideas in primary care can help address the root causes of the problem.

Principles of Timely Access Principles of Efficiency
  1. Understand and balance supply and demand
  2. Increase supply of visits
  3. Reduce demand for visits
  4. Reduce appointment times and types
  5. Reduce backlog
  6. Develop contingency plans
  1. Balance supply and demand of non-appointment work
  2. Synchronize patient, provider, information, room and equipment
  3. Anticipate and predict patient needs
  4. Optimize rooms, staff and equipment
  5. Manage constraints
  6. Eliminate waste
  1. Canadian Institutes for Health Information (CIHI).
    How Canada Compares: Results from the Commonwealth Fund’s 2016 International Health Policy Survey of Adults in 11 Countries – Accessible Report.
    Ottawa, ON: CIHI; 2017.
    Retrieved from: https://www.cihi.ca/sites/default/files/document/text-alternative-version-2016-cmwf-en-web.pdf

  2. Glazier RH.
    Balancing equity issues in health systems: perspectives of primary healthcare.
    Healthcare Papers. 2007;8(Sp):35-45.
    Available from: http://www.longwoods.com/content/19218

  3. Health Quality Ontario.
    Advanced Access Workbook for Primary Care.
    Toronto: Health Quality Ontario 2012 Sept [cited 2015 Oct 15].
    Available from: http://www.hqontario.ca/Portals/0/documents/qi/primary-care/qi-aae-interactive-workbook-en.pdf

  4. Health Quality Ontario (HQO).
    Primary Care: Impressions and Observations 2016/17 Quality Improvement Plans.
    Toronto: Queen’s Printer for Ontario; 2017.
    Retrieved from: http://www.hqontario.ca/Portals/0/documents/qi/qip/analysis-pc-2016-17-en.pdf

  5. Health Quality Ontario (HQO).
    Measuring Up 2016: A yearly report on how Ontario’s health system is performing.
    Toronto: Queen’s Printer for Ontario; 2016.
    Retrieved from:  http://www.hqontario.ca/System-Performance/Yearly-Reports/Measuring-Up-2016

  6. Health Quality Ontario (HQO).
    Quality in Primary Care Setting a Foundation for Monitoring and Reporting in Ontario.
    Toronto: Queen’s Printer for Ontario; 2015.
    Retrieved from: http://www.hqontario.ca/System-Performance/Specialized-Reports/Primary-Care-Report

  7. Institute for Healthcare Improvement (IHI).
    Primary Care Access.
    Retrieved from: http://www.ihi.org/Topics/PrimaryCareAccess/Pages/default.aspx

  8. Vogel, L. (2017).
    Canadians still waiting for timely access to care.

    CMAJ; 189 (9): E375 – E376.

Best Practices

Updated on August 14, 2017

“Insanity is doing things the way we’ve always done them and expecting different results”
Albert Einstein

Timely access to a primary care is a priority indicator for the QIP. This indicator refers to the percentage of patients and clients able to see a doctor or nurse practitioner on the same day or next day, when needed. In Ontario only 43.6% of adults are able to access care in a timely fashion when they need it (CIHI, 2016; HQO, 2016).

Below are the best practices for timely access to primary care. They are graded according to their Type of Evidence. Evidence-informed best practices are based on quality evidence, they can optimize outcomes and should be implemented into practice where possible.

To help you move from best evidence to best practice refer to the Advanced Access and Efficiency Workbook for Primary Care (AAEWPC) or browse the interactive table below for a quick summary.

  1. Ford JA, Jones AP, Wong G, Steel N. (2015).
    Weekend opening in primary care: analysis of the General Practice Patient Survey.
    British Journal of General Practice; 65(641):e7928, pg. 1-7.

  2. Health Quality Ontario.
    Advanced Access Workbook for Primary Care Toronto: Health Quality Ontario; 2012 Sept.
    Retrieved from: http://www.hqontario.ca/Portals/0/documents/qi/primary-care/qi-aae-interactive-workbook-en.pdf

  3. Health Quality Ontario.
    Practice Assessment Tool: A Guide to Advanced Access and Efficiency for Primary Care Providers: Time for Change. 2013 July.
    Retrieved from: http://www.hqontario.ca/portals/0/Documents/qi/learningcommunity/practice-assessment-tool-july-2013.pdf

  4. Health Quality Ontario.
    Impressions and Observations 2016/17 Quality Improvement Plans. April 2017.
    Retrieved from: http://www.hqontario.ca/Portals/0/documents/qi/qip/analysis-pc-2016-17-en.pdf

  5. Houck, S. What Works to Improve Primary Care.
    Boulder, Colorado, USA: HealthPress Publishing; 2017. IHI Resource
    Retrieved from:http://www.ihi.org/resources/Pages/Publications/WhatWorkseffectivetoolsandcasestudiestoimproveclinicalofficepractice.aspx

  6. Hudec JC, MacDougall S, Rankin E.
    Advanced access appointments: Effects on family physician satisfaction, physicians' office income, and emergency department use.
    Canadian Family Physician. 2010 Oct;56(10):e361-7.

  7. Institute for Healthcare Improvement.
    Improve Primary Care Access [Internet]. Cambridge (MA): Institute for Healthcare Improvement; 2012.
    Retrieved from: http://www.ihi.org/explore/PrimaryCareAccess/Pages/default.aspx

  8. IOM (Institute of Medicine). 2015.
    Transforming health care scheduling and access: Getting to now. Washington, DC: The National Academies Press.
    Retrieved from: http://iom.nationalacademies.org/Reports/2015/Transforming-Health-Care-Scheduling-and-Access.aspx

  9. Grol R, Grimshaw J.
    From best evidence to best practice: effective implementation of change in patients' care.
    Lancet. 2003 Oct 11;362(9391):1225-30.

  10. Kiran, T., O’Brien, P. (2015).
    Challenge of same-day access in primary care.
    Canadian Family Physician. 2015 May; 61(5): 399–400.

  11. Mehrotra, A., Keehl-Markowitz, L., Ayanian,J.Z. (2008) .
    Implementation of Ope Access Scheduling in Primary Care: A Cautionary Tale.
    Annals of Internal Medicine. Jun 17; 148(12): 915–922.

  12. Rose KD, Ross JS, Horwitz LI.
    Advanced access scheduling outcomes: a systematic review.
    Archives of Internal Medicine. 2011 Jul 11;171(13):1150-9.

Measurement

Updated on August 14, 2017

“While all changes do not lead to improvement, all improvement requires change”
Institute for Healthcare Improvement

How will we know if a change is an improvement? Measurement is a critical step in QI to assess the impact of a change. Quality indicators are used in the QIPs to measure how well something is performing. There are three types of quality indicators used to measure QI efforts:

  • Outcome Indicators: capture clinical outcomes and or system performance,
  • Process Indicators: track the processes that measure whether the system is working as planned, and
  • Balancing Indicators: ensure that changing one part of the system does not cause new problems in another.

Indicator Timely access to primary care
Topic Access
Quality Dimension Timely
Type of Indicator Outcome
Measure Percentage (%)
Data Source In-house data collection
Data Collection Instrument The Primary Care Experience Survey (available in 12 languages)
How to Calculate

(Numerator/Denominator) x 100

Numerator: Number of positive respondents to "same day" and "next day"

Denominator: Total number of respondents

Target Higher is better (provincial benchmark not available)
Range 0 – 100%
HQO Reporting Tool Quality Improvement Plans (QIPs)

This data can be presented using Run Charts to track improvement over time. To read more about general measurement in QI refer to Measurement for Quality Improvement.

To learn more about advanced access measures refer to Section 4: Measures, of the: Advanced Access and Efficiency Workbook for Primary Care.