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This is no way to run a medical office

Taking control of your appointment schedule can result in better care and happier physicians.

By William F. Pfeiffer Jr., MD
Pediatrician, Honolulu

The pediatric department in our Kaiser Permanente clinic used to be a chaotic place to work. My three partners and I frequently had to see patients through lunch and after hours. On a normal day, there was only a 50/50 chance of seeing my own patients. If my schedule was full—and it frequently was—they'd be shunted off to the next available physician or one of our two midlevel providers.

Scheduling anomalies also reduced the quality of care. For instance, a nurse practitioner might have been asked to see a child who had a cough with fever for five days because I was already "booked." So while I was seeing a routine ear recheck, the NP was seeing a patient with a potentially serious illness.

As 5 pm approached each day, I'd look at the next patient's chart and notice that I was just getting into the room with a 4 pm appointment for a sore throat. Much later, I'd see the last scheduled patient of the day, a child with obesity and enuresis who'd been booked three weeks earlier.

Patients were naturally unhappy with this system. They were lucky to get an appointment with a doctor. Then they had to wait for up to two hours to be seen. For most visits, I found myself apologizing for the long delay. This was no way to run a medical office.

A large part of the problem was our scheduling system, which tried to match patient needs to very rigid appointment templates. These were often based on guesswork, because the rules were too lengthy and complex for the receptionists to remember. Many patients with nonurgent needs were deferred until the next month's schedule came out, or placed on the interminable "waiting list."

Receptionists spent a large part of their time on the phone responding to frustrated patients and making excuses for why we couldn't meet their needs.

About two years ago, tired of the way things were, my colleagues and I studied the problem, and found that we could make reasonable predictions of the demand for urgent appointments on any given day. This also held true for the average monthly demand for routine physical exams.

We decided to try "demand-based scheduling." The goal was to see ill patients the day they called, while booking routine physical exams, rechecks, and consults for times we knew we'd be slow. That way, we'd reduce wait times for appointments and relieve the pressure on us at peak times.

Kaiser's strategic planning department helped us design a computer model that predicted future demand and matched it to the supply of clinicians, taking into account vacations, time off, part-time physicians, etc. By predicting how many urgent appointments we'll have on a given day, we can figure out how many slots we'll have open for rechecks, physicals, and other nonurgent patient needs.

For instance, on a Monday in January, our pediatricians expect to have 87 urgent visits. We know that the four of us can handle 96 urgent appointments. So if the receptionists reserve 87 slots for ill patients, they have nine openings that day for nonurgent visits. On days when fewer urgent visits are forecast, the front desk can book more rechecks and physicals. In most months, the model is accurate 80 percent of the time.

Knowing how many urgent slots we'll need helps us plan for them so that we're not overloaded, regardless of whether any physicians are on vacation. I still get five extra visits on a bad day, but that used to be the norm on the best day. Our receptionists now have only two types of appointments: urgent and nonurgent. They can see at a glance which days have ample availability, and which are running a bit tight.

When patients call with a nonurgent request, the receptionists offer them options instead of excuses. As a result, they can maintain a fairly smooth flow during each day, avoiding the peaks and valleys we used to have. They can also handle many more phone calls, and answer them faster. And they can usually ensure that patients will see their own physicians.

My colleagues and I now see our own patients between 89 and 96 percent of the time. We rarely work though lunch anymore, and we nearly always get out on time. Best of all, we're no longer on a treadmill, trying to keep up with extra patients inserted into full schedules. That means we can spend more time with each patient.

By taking control of our schedule, we've regained control over our professional and personal lives. It takes time and effort to develop a more efficient scheduling system. But that investment promises extraordinary returns. By providing sick patients with access to physicians, by booking appointments when patients need or want them, and by ensuring that physicians are not backlogged or rushed, our practice has shown that demand-based scheduling can improve service and quality.