aA

Overview

Updated on October 22, 2015

“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 is a philosophy that focuses on meeting the demands of one’s practice population in a patient-centred and timely fashion, with the goal of giving patients the ability to book an appointment when they need it (be it today, tomorrow, or in 3 months).1 In Ontario, delays in getting appointments for family physicians, specialists, or certain tests, are common. Only 48% of Ontario adults over the age of 16 were able to see their primary care provider on the same or next day when they were sick or needed medical attention (Figure 1).2

Figure 1: Percentage of adults able to see their doctor on the same or next day the last time they were sick or needed medical attention – based on the Primary Care Access Survey FY 2009/102

 

Ontario and Canada have some of the worst access rates (same or next day appointments available) compared to other countries surveyed (Figure 2).2

Figure 2: Percentage of adults surveyed able to see their doctor on the same or next day the last time they were sick or needed medical attention – based on Commonwealth Fund International Survey of Adults 20102

 

Delays can result in increased frustration and potential health risks for patients, and can overwhelm primary care staff and health care providers. Delays cost money, create stress, waste, and can also lead to worse clinical outcomes. According to Health Quality Ontario’s 2012 Quality Monitor, “only half of sicker adults could see a doctor or nurse the same or next day when they were unwell, compared to 79% in the United Kingdom.”3 Delays are expensive:

  • There is a cost in 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;
  • More patients (almost one in two Ontarians) use the Emergency Department to access medical care that they could have received from their primary care provider had appointments been available

 

Call to Action

Faster access and a stronger link to primary health care is an important area of focus in Ontario’s Action Plan for Health Care. Timely access is a set of beliefs, principles and practices, that when implemented allow the primary care provider to “do today’s work today”.4 Patients should be part of a partnership with their care team, including having access to an appointment on their day of choice.4 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 and lower total health care system costs.5

Delays are not the fault of any provider or practice, but are systemic. As part of the transition to a new model of care that includes proactive treatment for individuals with chronic diseases and greater emphasis on health promotion, primary care providers need to find new ways to organize their office processes to make better use of their time. In an ideal medical practice, every aspect of the practice is designed around the patient’s needs based on the principle of see your own patients and don’t make them wait. The primary goal is to enhance the doctor-patient relationship. Improving access is a critical component of an effective care delivery model. It requires that practices offer an appointment when a patient needs or wants one, and make themselves readily available to patients by phone or email.

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.

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

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

While the tools and information provided in this quality improvement resource focus on the process of quality improvement, the ultimate goal is to provide patients with the best possible care. To learn more about the principles of Access, please view the Timely Access and Efficiency Workbook for Primary Care for examples of tools and resources available through the Advanced Access, Efficiency and Chronic Disease Management in Primary Care program.

  1. 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/qi-aae-interactive-workbook-en.pdf

  2. 2010 Commonwealth Fund International Health Policy Survey. Commonwealth Fund. Reported through: Quality Monitor 2011.

    Toronto: Health Quality Ontario; 2011 Sept [cited 2015 Oct 15].
    Available from: http://www.hqontario.ca/portals/0/Documents/pr/qmonitor-full-report-2011-en.pdf

  3. Health Quality Ontario. Quality Monitor 2012.

    Toronto: Health Quality Ontario; 2012 Sept [cited 2015 Oct 15].
    Available from: http://www.hqontario.ca/portals/0/Documents/pr/qmonitor-full-report-2012-en.pdf

  4. 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/qi-aae-interactive-workbook-en.pdf

  5. Glazier RH. Balancing equity issues in health systems: perspectives of primary healthcare.

    Healthc Pap. 2007;8(Sp):35-45.
    Available from: http://www.longwoods.com/content/19218

Best Practices

Updated on October 22, 2015

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

Evidence-informed best practices are based on quality evidence and should be implemented into practice to optimize outcomes.8 Listed below you will find best practices graded according to the type of evidence. To view a description of the types of evidence, click here.

To help you move from best evidence to best practice, click on the + button next to each best practice to find details on how to implement, as well as change ideas to test using a PDSA approach. 

Change ideas are specific and practical changes by experience and research that focus on improving specific aspects of a system, process or behaviour. To learn more about change ideas see the QI: Getting Started tab.

  1. 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.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/14568747

Measurement

Updated on October 22, 2015

“Some is not a number, soon is not a time.”
Don Berwick, former CEO and President of IHI, December 2004, at launch of the 100,000 Lives Campaign

How will we know if a change is an improvement? Measurement is one of the critical steps in a quality improvement (QI) initiative that assesses the impact of your tests of change. Quality indicators are used to measure how well something is performing. There are three types of quality indicators used to measure your QI efforts: outcome (indicators that capture clinical outcomes and or system performance), process (indicators that track the processes that measure whether the system is working as planned), and balancing indicators (indicators that ensure that changing one part of the system does not cause new problems in other parts of the system).

Type of Indicator Indicator of Quality Improvement How to Calculate:

numerator
__________

denominator
Targets/ Benchmarks How is This Indicator Used?
Outcome Percent of patients/clients able to see a doctor or nurse practitioner on the same day or next day, when needed Number of respondents who responded "same day" and "next day"
Number of respondents who registered an answer for this question (do not include non-respondents or respondents who answered "not applicable/ Don't know/ refused")
Targets: As high as possible (100%)

Provincial benchmarks: not available
Quality improvement

QIP indicator

The Advanced Access and Efficiency in Primary Care initiative was designed to offer different levels of learning intensity with different levels of support so that providers can find the best fit for their needs. To learn more about the principles of Access, please view the Advanced Access and Efficiency Workbook for Primary Care for examples of tools and resources available through the program. For more ideas and information on getting started on implementing the principles of Advanced Access, go to the Best Practices tab.

Run Charts

Collected measures can be presented graphically by plugging the monthly results into a run chart. The Advanced Access and Efficiency Workbook for Primary Care provides examples of data collection tools to facilitate your improvement journey.

Tools & Resources

Updated on October 22, 2015

Tools

Timely Access Tools
QI Tools

 

For a more comprehensive list of tools and resources, visit the following links on our HQO website:

 

Resources

Timely Access Resources
  • MacHealth An online interactive currciulum, created by Health Quality Ontario (HQO), in partnership with Machealth and the Ontario College of Family Physicians (OCFP). The integration of the online access and efficiency content provides an additional support mechanism to primary care practices aiming to improve access and efficiency. The existing Machealth online Quality in Family Practice project aims to improve the quality of health care through a voluntary quality assessment program. This unique delivery of quality improvement content provides an opportunity to reach additional primary care teams in Ontario.
  • Panel size: answers to physicians' frequently asked questions Murray M, Davies M, Boushon B. Fam Pract Manag. 2007 Nov-Dec;14(10):29-32.
  • Health Quality Ontario. Timely access to a primary care provider
QI Resources