In this evaluation of a case-series of six practices, we found mixed results on the impact of open access scheduling. Substantial improvements in appointment access were achieved in some practices, but none of the practices was able to sustain same-day access and no clear improvements in patient or staff satisfaction and no-show rates were demonstrated.
Our findings contrast with a number of prior articles that discuss potential benefits of open access scheduling including improved patient experience, provider work satisfaction, provider continuity, and decreased no-show rates (2
) In a systematic search for studies of open access scheduling from 1998-2008 on PubMed using the search terms (“open access” AND (schedule or schedules or scheduling or appointment or appointments)) OR “advanced access” OR “access time”), we identified 124 articles, of which 29 studied the impact of open access scheduling. (5
) Nearly all of these 29 articles have important methodological limitations (many of which our study shares), including no statistical testing, being limited to access to care measures, lack of concurrent control groups, small sample size, and inconsistent methods. Among the few studies that assessed outcomes beyond access to care, there were mixed effects of open access on patient satisfaction (2 of 5 studies report improvement) (6
), staff satisfaction (1 of 2 report improvement) (14
), and no-show rates (3 of 6 report improvement) (10
). Our results add to this literature and raise the question of whether open access scheduling truly leads to these ancillary benefits that advocates have proposed.
Quality improvement projects that have face validity or preliminary evidence of effectiveness sometimes fail to demonstrate clear benefits when evaluated more rigorously (40
). Thus, a large-scale cluster randomized trial of open access scheduling using both intervention and control sites would provide a more definitive assessment of this promising approach. Such a study should assess other secondary outcomes such as patient and staff satisfaction, quality of care, and continuity. Furthermore, it should assess costs of implementation. Although open access makes intuitive sense, practice leaders, physicians, health plans, and policymakers need to understand its potential benefits more thoroughly.
Our own belief is that the open access model may have the positive impacts described by proponents and that the mixed results we and others report stem from unexpected barriers that prevented the practices from fully implementing the model. We describe these barriers to inform other groups that are considering open access scheduling.
Unexpected fluctuations of appointment supply arose from extended provider leaves at each of the six practices. Some of these leaves, such as for maternity leave, were anticipated well in advance and attempts were made to arrange adequate coverage. However, these interventions could not fully offset the loss of physician supply. When unexpected barriers led to a worsening of patient appointment availability, it was difficult to convince busy providers to re-do the hard work of improving access. It is possible that sustaining the model might be more feasible in an environment where there are external incentives to improve access to appointments through, for example, pay-for-performance initiatives.
Another barrier to implementation was the difficulty in assessing appointment demand. Ideally each practice would have a roster of patients assigned to each physician, but in reality none had these data available. We were forced to estimate appointment physician panel size and patient demand, using measures of the number of unique patients seen in the last 3 years and the number of appointments requested over a sample period. Because these were estimates, practice leaders remained concerned about whether supply and demand were truly matched for their practices. As a result, planning periods were prolonged and there was less enthusiasm and fewer resources devoted to the implementation. Our experience highlights the need for more sophisticated means of measuring accurate panel sizes (42
Though staff and providers at the practices agreed that improvements in access were important, there was sometimes disagreement on whether same day access was an appropriate goal. For example, many physicians believed a busy parent would prefer to schedule an appointment for themselves or their child far in advance, rather than on the same or next day. The implementation team emphasized the flexibility of the model and that patients were able to make an appointment in advance if they desired. Nonetheless, this disagreement made it difficult for the implementation team to convince the practices to devote more resources to improving access beyond the improvements seen initially.
Interestingly, despite the limited benefits seen in our outcome measures, most practice leaders felt the open access initiative was beneficial. In their view the process of implementing open access forced a re-evaluation of the practice systems and a change of the mindset of the physicians and staff towards access to care. The implementation exposed longstanding issues such as problems in handling patients’ phone calls, scheduling, job descriptions, and patient flow. These issues had to be addressed, which led to improvements in practice processes but may not have been captured in the outcome variables we measured. For example, one practice noted there was more nursing time available for direct patient care as the nurses now spent less time on triage.
Our study had several important limitations including a small sample size, a lack of control practices, variable follow-up time, infrequent measurement of data, and being limited to Eastern Massachusetts. We also did not assess the impact of open access on other important outcomes such as continuity of care or quality of chronic disease management. Finally, as noted above, greater improvement in the outcome measures might have been observed if all physicians had fully embraced the model. Our study should therefore be considered exploratory in nature. Nonetheless, our findings may assist other practices and health care systems considering implementation of open access scheduling. As pay-for-performance incentives and other health plan initiatives focus on improving access to care, more practices will be considering this model. Our findings also underscore the need for rigorous large-scale evaluations of open access scheduling to assess more fully its impact (30