Workflow Redesign: C A L I FOR N I A H EALTH C ARE A Model for California Clinics F OU NDATION Introduction In 2007, the California Primary Care Association Patient flow, particularly initial patient access (CPCA), funded by the federal Bureau of Primary and cycle time, is crucial to community clinic Health Care and facilitated by Mark Murray and practice efficiency and capacity, which in Associates, launched the Optimizing Primary turn affects revenue and provider and patient Care Collaborative (OPCC) as a one-year learning Issue Brief satisfaction.1 As a clinic improves patient access, project. The collaborative, with 21 community it increases the timeliness of patient care, and clinic teams, was designed to reduce patient thus may improve outcomes, and in some cases flow delays in primary care settings and to the odds that a patient will receive care at all. improve clinical care. Following the first year’s Balancing appointment supply and demand, and work, in 2008 the same partners organized a establishing and managing provider panels, can second OPCC, with additional funding from increase access and improve practice efficiency the California HealthCare Foundation (CHCF). and patient satisfaction. Moreover, effective A total of 24 community health clinics from panels and resulting continuity can strengthen California and Arizona participated in the prevention efforts, improve outcomes for patients 2008 OPCC. The collaborative used a learning with diseases that can be detected early, and community framework to help clinic teams set help manage chronic conditions through regular goals, collect data, and measure effects. monitoring. Upon completion of OPCC in 2009, CHCF Improved access and practice efficiency, and supported an evaluation of its methods and resulting clinical improvement, depend on outcomes by White Mountain Research Associates factors specific to each clinic — such as goals (White Mountain). The evaluation found that the and priorities, physician preferences, and level of improvement varied among clinic sites, but patient population — which together constitute that there was marked overall success: Virtually all a particular practice system. While there participants saw improvements, with 88 percent are many approaches a clinic might take to of teams reporting positive changes in at least address individual aspects of practice efficiency, two access and patient satisfaction measures, meaningful practice redesign requires a thorough and 63 percent reporting positive changes in understanding of the practice’s patient care three or more of these measures. The greatest processes and identification of practice-specific improvements were in access and cycle time. strategies for improving efficiency. Such practice Most clinics also undertook the calculating of redesign requires a multi-component approach, practitioner panels, to help manage both provider which can be enabled and enhanced by the efficiency and patient care. Notably, virtually application of a comprehensive, field-tested all teams reported that the OPCC framework framework for change. introduced them to new approaches to system J une 2010 improvement or helped them to use known redesign ◾◾ Managing bottlenecks; approaches in a more strategic way. ◾◾ Maximizing visit activity to reduce future demand; The evaluation provided clear evidence that the OPCC ◾◾ Supplementing face-to-face visits through other learning community framework is a viable vehicle for media (e.g., telephone advice and triage, email, and introducing not just particular patient flow improvements group visits); but true system redesign. The value of adopting strategies ◾◾ Expanding the role of nurses and non-clinician used by peers, and of troubleshooting issues in a learning staff, thus reducing non-clinical tasks performed by community environment, was broadly reported by the physicians; participating teams. The findings suggest that the OPCC framework has strong potential as a model for other ◾◾ Balancing capacity and demand on a daily, weekly, community clinics throughout California. This issue and long-term basis; and brief summarizes the OPCC project, and is intended to ◾◾ Synchronizing patients, information, and resources complement the evaluation report prepared by White within the office.6 Mountain and published simultaneously with this brief.2 Collaboratives to Facilitate System Redesign Project Background In 2007, CPCA launched the first OPCC initiative, supported by the federal Bureau of Primary Health Care Strategies for Patient Flow Improvement and facilitated by Mark Murray and Associates. This was It is well-understood among researchers that improving a one-year learning collaborative designed to reduce delays patient flow is key to increasing medical practice in access to care and at appointments, to improve clinical efficiency and capacity, which can both generate more care with a special focus on cancer, and to improve revenue and improve patient and provider satisfaction.3 provider and staff satisfaction. A total of 21 teams from Better patient flow depends on practice-specific factors, the Health Disparities Collaborative’s Pacific West Cluster including goals and priorities, provider practice style, region completed the 2007 OPCC.7 and patient characteristics.4 Collaborative improvement strategies, using “whole system” approaches to optimize OPCC was offered again, beginning in April 2008, patient flow, have been implemented across a range of with goals similar to the 2007 collaborative. Each 2008 health care settings.5 OPCC team was charged with creating three project aims within three categories of primary care optimization: Practice-specific strategies that can optimize patient flow access, office efficiency, and clinical care. OPCC Phase I might involve shaping demand, matching supply and activities, with 16 community health clinic teams (15 demand, and increasing capacity, and could include: from California, one from Arizona), included a pre-work teleconference cycle, five “learning sessions” (the first and ◾◾ Reducing the number of appointment types; last of which were in-person meetings), five one-hour ◾◾ Reducing backlog; monthly team teleconferences, and team reports. Phase II activities, with eight teams, also included quarterly team ◾◾ Extending return visit intervals (within a calls and reports. During the course of the collaborative, clinically appropriate range); team improvements were documented regarding access, ◾◾ Predicting and anticipating patient needs; office efficiency, and clinical care, as well as team efforts 2  |  California HealthCare Foundation regarding program sustainability and internal spread of Another aspect of improving access addressed in the the redesign processes. collaborative was balancing supply (the number of appointment slots each provider could offer per time In 2009, CHCF funded White Mountain to conduct an period) and demand (the number of patient visits evaluation of OPCC to document program successes, requested per time period). A practice with more supply challenges faced, and evidence of sustainability and than demand wastes resources and loses revenue by spread. Both quantitative and qualitative methods were failing to make use of available provider time. On the used to evaluate the learning community, including other hand, a practice with greater demand than supply success in improving access, office efficiency, and clinical experiences access delays, which affect patient satisfaction care outcomes. A combination of surveys and interviews and, ultimately, health. with community clinic staff was used to document OPCC’s longer-term impact on system-level sustainability Many teams also sought to identify and/or determine and on the spread of change strategies, tools, and the proper size of provider panels. This was seen as resources to other clinic sites. contributing to overall efficiency and also as a way for the practice to better assess and track clinical care, Project Findings especially for periodic screenings and chronic disease The framework for OPCC, after the establishment of care. Establishing provider panels can improve patient teams, included setting goals, systematically collecting satisfaction, help define workloads, predict patient data, implementing and testing changes, and measuring demand, reveal differences in provider productivity, impact, including the potential for sustainability. These improve clinical outcomes, and reduce costs. Some teams components were applied to three areas of practice also sought to improve appointment continuity (patients concern: access to care, office efficiency, and clinical care. being seen by their regular PCP), which was considerably easier to achieve once provider panels were determined. Goal Setting At the beginning of the collaborative, each team The other most prominent OPCC office efficiency goal developed a set of goals regarding access, efficiency, and was reduction in cycle time—the time between a patient’s clinical care. Each team determined for itself those goals arrival at and departure from an office appointment. it believed were both important and attainable for its About half of the teams aimed to reduce overall cycle practice. times to an hour or less, while other teams aimed for 45 minutes. Some teams targeted specific aspects of their Access to Care and Office Efficiency Goals practice for this goal (e.g., pediatric appointments). Improving access to care, in the context of OPCC, meant reducing the time between a patient’s request for Clinical Care Goals an appointment and the availability of one. For “short” Clinical care goals varied considerably, in both focus and appointments with a primary care provider (PCP), many target populations, across the various OPCC teams. They teams sought to achieve same- or next-day access for their included increases in the overall rate of patients who patients, while a few teams set their access goal at between received: two and five days. Some teams extended the time-frame ◾◾ Screenings for various cancers (mammograms; pap for “long” appointments, and a few teams concentrated tests; prostate examinations; colon examinations); their access aims on increasing after-hours appointments. Some teams also worked on reducing patient no-shows. ◾◾ Vaccinations; Workflow Redesign: A Model for California Clinics  |  3 ◾◾ LDL screening; and access measures, and ten teams (63 percent) reported positive changes in three or more of these measures. ◾◾ Diabetes management (inclusion in a registry; Positive changes in either short or long next available follow-up; retinal screening; A1c reduction; and appointments were reported by 75 percent of teams. self-management). Over half of reporting teams from 2008 documented Data Collection and Reporting reductions in cycle time. Also notably, 81 percent of Because OPCC teams varied in organizational structure, teams were able to calculate their panel sizes, and some staff and management support, available resources, patient of these were able to determine the most appropriate population, and other organizational and team-specific panel size for their individual providers. The results, by factors, data collection and reporting differed considerably category, can be summarized as follows: across teams and measures. As shown in Figure 1, the number of teams reporting on specific measures ranged Access. Three-fourths of all teams reporting access data from only 19 percent for continuity to 94 percent substantially reduced access time, as measured by the days for access, with only 25 percent reporting on clinical to the third next available appointment, for either short measures. However, at least half of all teams reported on or long appointment types, and across multiple provider five tracking measures, and 80 percent of teams reported panels. on four. Cycle Time. Of 11 teams reporting on average cycle time, six demonstrated overall decreases and/or decreases Performance Measures for at least one of their clinics. Additionally, six teams Within the data collection limitations noted above, reported cycle times of 60 minutes or less. significant improvements were documented for access to care and cycle time. Almost every OPCC team was Supply/Demand. Few teams managed to provide data on able to document positive changes in at least one access changes in supply and demand ratio, but of the ten teams measure. Of the 16 teams that reported data across that initially documented greater supply than demand both Phase I and Phase II of the 2008 OPCC, 14 teams (out of 13 teams reporting on the issue), five teams were (88 percent) reported positive changes in at least two able to achieve a better balance. Figure 1. PCC Teams Overall Performance, by Measurement Category, 2008 – 09 O A cc e ss t o C ar e S u pp l y / No-Show C l i n ica l A v e rag e D e l a y * C y c l e Tim e D e ma n d R at e Continuity M e as u r e s Pa n e l S i z e † Teams Reporting Phase I: 92% Phase I: 75% Phase I: 83% Phase I: 83% Phase I: 17% Phase I: 25% Phase I: 83% on Measure Phase II: 100% Phase II: 50% Phase II: 75% Phase II: 100% Phase II: 25% Phase II: 25% Phase II: 75% Overall: 94% Overall: 69% Overall: 81% Overall: 88% Overall: 19% Overall: 25% Overall: 81% Teams Reporting Phase I: 75% Phase I: 56% Insufficient Phase I: 50% Phase I: > 90% No overall Phase I: 83% Positive Phase II: 75% Phase II: 50% data Phase II: 50% (1 of 2 teams) pattern, but each Phase II: 75% Changes in Phase II: > 90% of four teams Overall: 75% Overall: 55% Overall: 50% Overall: 81% Measure (1 of 1 team) reporting had (as % of all teams improvement reporting data) in at least one measure or from one provider. *Third next available appointment — short or long. †Team documentation of its panel sizes. 4  |  California HealthCare Foundation No-Show Rate. Of 14 teams tracking no-show rates, Specific Change Strategies 50 percent reported an improvement. Team leaders were asked about specific system-level change strategies introduced at their sites through the Clinical Measures. Only four teams reported on clinical collaboratives. In particular, they were asked which measures but each of those showed improvement in strategies were most and least successful, and which ones at least one measure. The improvements included one they continue to use. The following change strategies were overall team increase and one provider increase in the rate reported to be the most successful and continue to be of mammogram screenings, one provider increase in pap used. test rates, one clinic increase in colon cancer screenings, and one clinic increase in provider-patient discussions Regularizing Broad Collaboration about cancer screenings. All teams sought, in various ways, to institute broadly Panel Size. Most teams had not calculated individual collaborative elements into their regular practice provider panels before the beginning of OPCC, let alone processes. Some teams had group “huddles” each morning determined what “ideal” provider panel sizes would be to sort out the day’s priorities, while others held regular, for their individual providers. So, the fact that 13 of 16 brief (half-hour) cross-disciplinary meetings to generate teams (81 percent) were able to calculate individual panel ideas about what works and what does not, as a way to sizes during the course of the collaborative indicated engage staff in providing routine feedback and developing significant progress. Four of those teams also managed creative solutions. A number of groups also focused on to determine appropriate, practice-specific panel sizes for using a team-based approach to care, which included their individual providers. pairing medical assistants (MA) with providers, and sometimes creating “teamlets” pairing a physician, nurse OPCC Impact: practitioner, or MA with a health coach. Responses from Team Leaders Post-project interviews were conducted with clinic team Establishing and Managing Panels leaders from both the 2007 and 2008 collaboratives. The Defining panels is a crucial practice redesign strategy, interviews sought information on how specific strategies since panel size ultimately can affect patient satisfaction, for change affected operational processes and efficiencies. help define workload, predict patient demand, reveal The interviews also sought responses on the participating differences in provider productivity, improve clinical clinics’ plans for sustaining positive changes. Finally, the outcomes, and reduce costs (by improving continuity interviews sought feedback regarding the collaborative and outcomes, and by appropriately reducing return visit methods used by the project staff. intervals).8 During the course of OPCC, participating groups began to measure and manage panels — both A Web-based survey also was conducted with team a practice panel (the group’s patients) and individual leaders and other core team members from OPCC. provider panels, making certain that all patients were The survey focused primarily on the extent to which assigned to a particular provider. Some groups instituted participants used the various strategies for redesigning the “four-cut” method both to establish individual access, office efficiency, and clinical care as taught through provider panels and to make a patient assignment for the collaborative. The survey also documented perceived each specific visit.9 Making every clinician responsible for benefits gained and barriers encountered in implementing his/her own patients can enable clinics to measure both the various redesign strategies. how those patients are doing and how the clinician is performing. Workflow Redesign: A Model for California Clinics  |  5 Reducing Backlog likely to seek an additional appointment to see “their” Almost all OPCC groups introduced backlog reduction provider, even if that is medically unnecessary. Thus, strategies. Some added more appointments each day, lack of continuity increases demand-per-patient, which by starting earlier or ending later, or by adding more ultimately limits the total number of patients who can be provider “sessions” (scheduled work periods, usually served by that clinic. half-days) per week. Each of these strategies, it should be noted, requires increased staff support. Some teams implemented an “open access” system, leaving Pay-Per-Visit Can Work Against Making Changes appointment slots available so that patients could have Most OPCC-participating clinics are reimbursed on a a same-day visit with their assigned provider. And some pay-per-visit basis. As a result, there can appear to be teams implemented a reminder system for managing a conflict between some changes in office processes “fail-to-keep” appointments. (e.g., reducing visits-per-patient and shifting tasks from clinicians whose time is billable to non-clinicians) and the financial interests of the clinic. Thus some clinic Balancing Supply and Demand leaders among OPCC participants initially resisted certain Groups instituted a variety of methods to reduce changes that in the short-run reduced the number of imbalances in supply and demand. Some teams reduced billable patient visits. This resistance can be overcome, however, when leadership understands that if the the number of appointment types, since each added number of visits-per-patient and the amount of provider appointment type creates a channel of appointments, non-clinical time are both reduced, the clinic can use the some of which can become clogged while others remain provider time it gains to expand its patient population. By unfilled. Other teams learned to balance daily supply and so doing, it can again reach just as many or more billable visits while even better meeting its mission by serving demand through contingency scheduling plans. These more patients overall. plans included building in scheduling flexibility (not trying to schedule the same number of appointments for each day) and modifying supply based on recognition of and response to patient population demand patterns Changing Phone Triage (day-of-the-week and seasonal). Other contingency A number of teams changed their phone triage process so planning involved post-vacation scheduling — leaving that every patient who requests a same-day appointment blocks of open time for a provider returning from gets one without first having to go through a nurse. vacation to see those patients who deferred appointments Patients were still offered the option of first speaking during the provider’s absence. with a triage nurse, and a large proportion of patients chose to do so, in many cases obviating the need for an Some teams addressed supply and demand variations by appointment. Some teams also set up a patient call-back seeking to reduce demand. One method for doing so process that triaged urgent and non-urgent phone was to lengthen the time between return visits (within messages, thereby eliminating many phone interruptions medically appropriate time-frames), thus allowing for staff and resulting in more timely return calls. for shorter access times for other panel patients and permitting more patients overall to be served. Another Developing Cycle Efficiencies demand-reduction method used by some teams was that Teams developed various ways to increase office efficiency, of improving continuity (which, in turn, depended on which not only moved patients through the visit establishment of provider panels). If patients are seen by cycle more quickly but also freed up time to provide someone other than their regular provider, they are more faster initial patient access and, ultimately, allowed 6  |  California HealthCare Foundation clinicians — physicians and nurse practitioners — to serve time with patients was dramatically reduced. A number more patients. These efficiency methods included: of teams reported that their MAs expressed greater work satisfaction due to their pairing exclusively with ◾◾ Performing care team workload analysis, which one provider; these teams reported that providers, too, examines the work clinicians have been doing and were pleased with the effects of pairing. Finally, during should be doing, then ensuring that each staff the course of the collaboration, one team rediscovered member handles tasks that reach the full level of their the value of a chronic disease management system and competency, freeing others from tasks that they are regained its focus on making it operational. no longer needed to perform; ◾◾ Shifting non-clinical work away from clinicians, such Only one team reported continuing negative as by training MAs to do most patient education; consequences, which included resistance to provider panels and difficulty establishing a stable support team ◾◾ Conducting interruption studies, which analyze the around one provider. This team is trying different nature and frequency of interruptions to clinical strategies to overcome these barriers and to create a more visits, in order to reduce those interruptions; functional team. ◾◾ Flow-mapping office processes (e.g., intake, laboratory and specialty referral, prescription refills) Sustainability and Spread in order to spot and rectify inefficiencies; Teams from the 2007 collaborative were asked whether they had developed specific plans for sustaining the ◾◾ Standardizing patient examination rooms, so that any gains they had made through implementation of their clinician can see any patient in any available room, practice redesign strategies. Most teams reported having and feel comfortable doing so; and struggled with developing sustainability plans, due ◾◾ Improving visit preparation by making sure that to some or all of the following: competing program examination rooms are stocked with necessary priorities; lack of commitment from management; staff supplies, including those particular to the specific shortage or turnover; limited infrastructure; difficulty in visit, and by checking the patient chart to ensure that creating stable and/or cross-disciplinary teams; lack of an all necessary patient information (e.g., lab results, automated data collection system; lack of staff buy-in; and notes from previous visits) is included. resistance to change in role definitions. Also, most Phase I teams from the 2008 OPCC reported that it was simply Unexpected Consequences too early in the process (at the time the interviews were Teams were asked about unintended or unexpected conducted) for them to think about sustainability. consequences — positive or negative — that resulted from their redesign processes. Several teams reported that they Some teams did manage to make efforts toward had anticipated resistance from providers but instead sustainability. These included embedding the redesign found little such resistance, and provider satisfaction strategies, from the beginning of the collaborative, into improved. A number of teams also noted a positive their daily, routine care operations and expanding them impact at the staff level, including a reduction in staff beyond the OPCC project. Other efforts regarding turnover. One team reported less nonproductive work sustainability involved obtaining solid institutional as a result of increased continuity of care (for example, support, including from the medical director and chief less responding to calls from upset patients); similarly, operating officer. Another consisted of maintaining another team noted that its receptionist’s overall phone vigilance around measurement (particularly with panel Workflow Redesign: A Model for California Clinics  |  7 size), permitting ongoing course corrections based on the overall quality improvement processes as a vehicle for data collected, with an eye toward framing the redesign as spread to other sites. part of the routine quality improvement process. Feedback from Program “Dropouts” Teams were also asked whether they had spread their The evaluators interviewed team leaders from clinics practice redesign within their health care delivery that began but did not complete the 2007 or 2008 system — deeper within the improvement team, to the OPCC (Phase I) collaborative. When asked about their practice team from the improvement team, or from the primary reasons for not continuing in the collaborative, practice or improvement team to an entirely new entity. all cited the non-readiness of their clinic to participate All teams reported that they were interested in spreading and/or organizational factors; that is, none pointed to the lessons learned, but few were in a position to spread the perceived value of the collaborative itself. In fact, full-scale to other sites. This may be due, in part, to the most of these dropout teams were enthusiastic about relatively short follow-up period between the time when the collaborative’s potential; one of these teams reported 2007 OPCC teams completed the collaborative and that it had adopted several strategies suggested by the the time when the follow-up interviews were completed collaborative and hoped to participate in the future. (about eight months) and the even shorter follow-up for 2008 Phase I OPCC teams (about four months). One team cited, as its reason for dropping out, However, almost all the teams reported “testing the its simultaneous participation in another, similar waters” with other clinics to seek provider and senior collaborative and an inability to sustain both. Another management buy-in, and a few teams reported drafting clinic dropped out because its practice management plans for spread to some of their larger clinics and/or system was not equipped to accomplish the required data making presentations to other clinics about their practice collection, and adding the necessary resources to do so redesign efforts. A couple of teams reported success in would have severely strained its already critical financial spreading particular redesign elements (such as calculating situation. Other team leaders similarly noted that the provider panels and improving cycle time) to other sites timing was wrong for their clinic given its financial within their own health care system. Teams also have been instability and/or lack of resources needed to fully strategically integrating some redesign elements into their participate. What Would You Do Differently? Regarding the collaborative’s impact on access and office efficiency, the teams were asked what they would do differently if they had the chance to begin the collaborative again. The following are selected responses from team leaders: • “ ook a long time to adopt the teamlet approach and would have liked to do this sooner.” T • “ nless there is buy-in from leadership, it isn’t worth investing in this.” U • “Need to make sure the infrastructure is there first.” • “nvolve more MAs on the team to get their investment.” I • “Would streamline data collection.” • “ ould have gone to an easier/smaller site first to get a ‘win’.” W • “Try to get panel size right off the bat.” • “ ould have involved a few more people — key support staff (receptionist, MA) — other than just the management staff to W immerse clinic in OPCC culture.” 8  |  California HealthCare Foundation Leaders from teams that dropped out were also asked Conclusion what they would have done differently. One team OPCC is one of only a handful of comprehensive leader reported that, before committing to the project, programs designed to help health care delivery systems she would have more carefully reviewed her clinic’s provide timely and efficient patient care by way of system finances because of the collaborative’s “resource-intensive redesign. Through OPCC, CPCA project staff and its approach.” consultants were able to offer a unique set of skills to community health clinics for transforming and leveraging the way they deliver care to their patients. OPCC helped Follow-Up Web Survey Confirmed Results clinics offer patients same-day appointments, standardize 2008 OPCC teams participated in a Web-based survey appointment lengths, complete work in a timely fashion, following completion of the collaborative, to supplement the direct interviews conducted. The survey focused on and develop appropriate panel sizes so providers could adoption of practice redesign strategies, the benefits effectively manage their patients. Together, these redesign and barriers to continued use of these strategies, and elements helped increase patient and provider satisfaction the overall impact on target outcomes. All 2008 Phase I and improve patient health. teams participated in the survey, as did all but one team from Phase II. Respondents included both those who were involved in direct patient care and those in other Although the success of OPCC was variable across sites, roles (e.g., administration, management, data support, IT, virtually all participating clinics documented positive and quality improvement). changes in at least one patient flow measure for some or New Design Strategies. Most teams reported that the all of their provider teams. These findings are particularly design strategies they used were either entirely new noteworthy given the organizational instability and to them or an expansion of existing strategies in new economic uncertainty faced by a number of these directions. This supports the results from the interviews, which indicated that many teams were introduced community clinics. to new approaches to improving clinical care at the systems level and/or used redesign approaches that they The results of post-project interviews and surveys suggest had previously adopted but in a more strategic way. that the learning community framework is a particularly Implementation Effort. Most teams reported that it appropriate vehicle for introducing practice teams to was moderately difficult to implement the redesign improvement models. The value of adopting strategies strategies and time-consuming for providers and staff to learn how to use them. Nonetheless, two-thirds of team used by peers, and of troubleshooting issues in a true leaders reported that it was “extremely likely” their learning community environment, was a consistent theme teams would continue to track measures to monitor in reports from the participating teams. There were varied improvements in access and office efficiency, with only opinions about the most effective program strategies, 4 percent of respondents unsure whether their site but teams consistently gave high ratings to the measures would continue with measures monitoring. tracking, to the interactive and in-person learning The Business Case. About one-fourth of team leaders sessions, and generally to the assistance received from reported moderate to strong financial improvements as a result of OPCC. As for specific analyses related to the consultants. Ideally (budgets allowing), teams would financial benefits from redesign, 58 percent of teams have liked more one-on-one tailored and on-site technical reported working on the business case during their assistance, a comprehensive strategy for including senior OPCC time, with another 12 percent reporting that they leaders in the redesign process, and more assistance had begun to work on it following OPCC. achieving “buy-in” from other providers and staff. Workflow Redesign: A Model for California Clinics  |  9 On the whole, the positive response by participants Patients Smoothly through Acute Care Settings. Innovation in the OPCC projects suggests that this collaborative Series, 2003. framework has strong potential for a larger rollout to 4.Backer, L.A., 2002; Institute for Healthcare Improvement, other community clinics. Such a large-scale effort, with 2003. appropriate funding levels and organizational support, 5.Walley, P., K. Silvester, and R. Steyn. Sept/Oct 2006. could serve as a catalyst for a more general shift in the “Managing Variation in Demand: Lessons from the way health care is provided in community health centers UK National Health Service.” Journal of Healthcare and clinics throughout California. Management 51 (5); 309–22. 6.Institute for Healthcare Improvement. Improving Access and Efficiency in Specialty Practices. Breakthrough Series. A c k n ow l e d g m e n t s October 2004; Boushon, B., L. Provost, J. Gagnon, and For their assistance with the preparation of this issue brief, P. Carver. 2006. “Using a Virtual Breakthrough Series the California HealthCare Foundation would like to thank: Collaborative to Improve Access in Primary Care.” Journal Vanesscia Bates of the California Primary Care Association; on Quality and Patient Safety 32 (10); 573–84. Mark Murray, M.D., M.P.A. of Mark Murray and Associates; 7.The 2007 OPCC included clinic teams from Alaska, Barbara Boushon, R.N., B.S.N.; and Seth Emont, Ph.D., Arizona, California, Hawaii, Idaho, Nevada, Oregon, and and Nancy Emont, Ph.D., of White Mountain Research Washington. Associates, L.L.C. 8.Murray, M., M. Davies, and B. Boushon. April 2007. About the F o u n d at i o n “Panel Size: How Many Patients Can One Doctor The California HealthCare Foundation is an independent Manage?” Family Practice Management, American Academy philanthropy committed to improving the way health care of Family Physicians, 44–51. is delivered and financed in California. By promoting 9.Under the four-cut method, a patient who has seen only innovations in care and broader access to information, our one provider for all previous visits is assigned to that goal is to ensure that all Californians can get the care they provider for his or her current visit. A patient who has need, when they need it, at a price they can afford. For more seen more than one provider is assigned to the provider information, visit www.chcf.org. he or she has seen most often. A patient who has seen multiple providers equally is assigned to the provider who Endnotes performed the patient’s most recent physical or health 1.Access to care is used in this brief to refer to the time check. Remaining patients, who have not had a sentinel between a patient’s request for an appointment and the exam, are assigned to the provider they saw most recently. appointment offered. Cycle time means the time from patient check-in to completion of the medical visit. 2.White Mountain Research Associates, L.L.C. (S. Emont and N. Emont). Evaluation of the Optimizing Primary Care Collaborative. California HealthCare Foundation. 2010. 3.See, e.g., Nolan, T.W., M.W. Schall, D.W. Berwick, and J. Roessner. Guide to Reducing Delays and Waiting Times. Institute for Healthcare Improvement, 1996; Backer, L.A. “Strategies for Better Patient Flow and Cycle Time.” Family Practice Management, June 2002; Institute for Healthcare Improvement. Optimizing Patient Flow: Moving 10  |  California HealthCare Foundation