Access Management:
Appointment Scheduling and Beyond (Part 2)

By Sue Altman

October/November 2009

Now that the business case is made for appointment scheduling (see “Access Management: Appointment Scheduling and Beyond, Part 1”), your call center needs to determine the best entry point.  We're covering the three most common scenarios:

• From physician referrals to new patient appointments

• From physician appointments to outpatient services

• Merging the referral center with central scheduling or patient access.

From Referrals to Scheduling New Patient Appointments: From the survey results, the most common starting point would be organic growth.  This is growth from existing business versus growth through a merger with another call center or business unit.  You may have considered converting referrals to appointments in the past, and for a variety of reasons, encountered barriers.  Luckily, there are methods for accomplishing this: from a three-way call with the practice, facilitating online appointment requests, or gaining direct access to the practice schedules.  You may need to accommodate several different scheduling processes at first.  But over time, your outcomes data can be leveraged to establish best practices and drive convergence.

• Is there a group of physicians on a single scheduling system?  This is often the case with employed physicians or large group practices.

• Physicians who are eager to grow their practices may be open to offering standing appointments for your call center to fill.  It's low tech, but it is very efficient.  Any unused appointments can be returned to the practice by 10AM each day. 

• Three-way calling is still a common practice.  Establishing a back-line into the physician office for use by the call center may help shorten wait times. 

Restructuring staff roles may be necessary, and even preferred, over time.  Currently call center employees are expected to know how to process 8-9 services and functions.  You may consider designating certain staff to focus only on scheduling physician appointments in order to understand the intricacies in greater depth. 

From Triage to Appointments: Telephone triage results in a disposition of "See Your Doctor" approximately 40% of the time.  This presents an opportunity for call centers to make appointments while the caller is still on the line.  During regular office hours, this scenario has the same options as mentioned above: direct access to schedules, use of standing appointments, or a three-way call.  After hours (weekday evenings and weekends), the three-way call drops out, but the other two methods remain.  This is a great customer service to the caller, who would otherwise have to wait to call their physician's office until 8AM or 9AM the next morning.  It can also be a benefit for the practice.  They are bombarded with start-of-the-day calls.  Each pre-scheduled appointment takes one more call from their frantic morning queue.

We interviewed Rita Svatos, RN, BSN, PN, director of NurseDirect for Affinity Health System.  During daytime hours, her staff facilitates appointments through a warm transfer process, connecting callers to the office or clinic.  But if an after-hours triage call results in a disposition of “See Your Doctor,” they can now arrange the appointment while the patient or caller is still on the phone.  Once the triage process is complete, the call is transferred to a referral associate who accesses the appropriate physician’s schedule in Meditech and finds an open appointment.

Their venture into this service built upon their previous success in managing appointment cancellations.  The referral associates had already proven their ability to navigate the Meditech scheduling system.  The idea that they could also locate available appointments and schedule triage callers was a logical next step.  Plus, it enhanced customer service and removed some burden from the practice or clinic’s call load the following morning.  Other initiatives have helped make this transition easier.  The number of different appointment types within Meditech has been consolidated, and the post-triage appointments have their own code, AH (After Hours), to identify which were made because of the NurseDirect service.

A Single Scheduling Center for Appointments and Outpatient Services: Kay Vogel, director of telecommunications and central scheduling, described her service at St.  Alexius Medical Center as a central scheduling center that started when the Physician Hospital Organization (PHO) pursued a strategy of improving access.  Prior to the formation of her centralized center, it was not uncommon for patients to try for 20 minutes or more to reach a receptionist at their physicians’ offices.  At that time, there were multiple switchboards and scheduling desks; all were, in effect, small call centers.  The prospect of centralizing resulted in more collective resources, and more staff meant better flexibility and call coverage potential. 

The St. Alexius Call Center manages calls for the medical center and four primary care and specialty clinics.  The staff now schedules for more than 100 providers, which equates to 340,000 appointments per year and encompasses scheduling for more than 1300 different procedures.  Did patients benefit?  Absolutely!  The gain in coverage from centralizing staff has meant greatly improved service levels.  Plus, patients can schedule multiple appointments and/or procedures at the same time.  For instance, a woman can schedule her check-up and mammography by placing just one call. 

The call center still works very closely with the clinics.  If a specific request falls outside of their guidelines, the call is transferred back to the practice.  Similarly, if an urgent appointment is needed but none appear available for that particular specialty, the call is transferred to the practice, which has the final decision whether or not to “work a patient in.”  The collaboration is very patient-focused.

Enterprise Growth, an Evolving Process: In our previous issue, we touched on the evolution of central scheduling at Detroit Medical Center (DMC).  Kathy Ingalls Hefni, RN, BA, had managed DMC's triage, marketing, and referral center for several years.  Detroit Medical Center had been growing rapidly through acquisition, and in 2004, the new System COO had a vision to enable scheduling across the multi-hospital enterprise.  This project started with the combining of one hospital’s scheduling center to the triage and referral call center location.  Five years later, the Health Access Center and Central Region Operator Services schedules for six of the seven DMC hospitals. 

The growth has occurred in phases; each with adjustments in staffing and process, coupled with service analysis.  Corporate Director Ingalls Hefni has gone nearly full circle in her thoughts regarding the optimal staffing model.  When the first scheduling group was brought over, it was combined with her referral center and all staff was cross-trained.  This functioned well to a point, but eventually the generalist role impacted service efficiency.

Now she has created specialty pods, each with expertise in either referrals and appointments or scheduling and pre-registration.  Still, to maximize flexibility, all staff is knowledgeable on both processes.  For example, if a patient appointment is made (by referral and appointment staff) less than 24 hours in advance, the same staff will verify insurance and pre-register the patient at the time of the call. 

Ingalls Hefni believes staffing adjustments will be ongoing with continued growth and evolving technologies.  At the time of our interview, she and her team were studying what to do about the growing number of electronic requests.  Does ‘online’ become its own pod?  Or, does it become a mini-specialty within each pod?  They are currently completing due diligence on the electronic fulfillment process to develop a best practice.

Call Center Manager as Internal Consultant: Kathy Ingalls Hefni shared that with each consolidation, they gain new expertise in what to do and how to do it.  Her team is often tapped to help other scheduling services on their operations.  Acting as consultants, they evaluate service levels, wait times, and abandonment rates.  They also look for symptoms, such as multi-step manual processes and instances of duplicate data entry, as indicators of areas for improvement in efficiency. 

Like any project, the movement to scheduling is a sequence of steps: analyze, design, implement, analyze, fine-tune, and demonstrate value; then repeat these all again for the next phase.  To be a successful change-agent, be prepared to use process improvement methods and gather adequate pre- and post-data to show the benefits to all stakeholders: 1) patients, 2) clinics, practices, and departments, and 3) the sponsoring organization. 

Both Vogel and Ingalls Hefni described how data collection and analysis have been at the core of their growth strategies and successes.  Improvements continue to be process focused and data driven, which means analysis is a key component of their roles as managers.  At Primecare, Ms. Vogel is often asked by leadership, “How can we manage access better?”  Administrative reports become critical in demonstrating the facts of access management and reducing misinterpretation and incidental hearsay.

Beyond experience and analysis, all three managers touted the benefits of a good telecom system: one that provides data on how calls arrive, how they're distributed to staff, and where calls are transferred.  Call recordings and post-call data have been invaluable in resolving problems and supporting their actions if quality issues have been raised. 

The three also strongly recommend managing variation.  Rita Svatos mentioned that at one time, there were nearly 6,000 appointment types to choose from within Meditech.  Navigating through that many options would have greatly increased the risk of error for her staff.  Since that time, Affinity has worked as a system to consolidate appointment types and make scheduling more manageable.  This consolidation is in preparation for open access scheduling.  They now have the total down to approximately 100 visit types.

Similarly, Kay Vogel lists her biggest challenge as managing changes to their “protocols,” that is, the various rules and processes that must be followed for scheduling patient visits and procedures.  The practices have been allowed to designate individual preferences on visit types, how they are scheduled, and when the practice takes time off for meetings or closures.  Her software manages 75-90% of these, but staff still have to be on their toes when it comes to knowing the specifics of the protocols.  Moving forward, new physicians will be given a template to use for setting up schedules and optimizing patient access."

It's All Good: All three leaders agree that scheduling has raised the profile of their call centers and put them in a stronger, more stable position within their organizations.  They serve as key components of access management and, therefore, affect their organizations' revenue cycles.  Through their growth, their centers have realized benefits from increased budgets and staff, as well as upgraded infrastructure.  Their organizations have gained from enhanced and standardized customer service, which has contributed to a service brand that is a competitive advantage in the marketplace. 

Sue Altman is the president of 3CN, Call Center Consulting Network (CCCN).  She can be reached at Sue.altman@3cn.org or 480-706-2226.