Opening doors: a path to improving access for your patients

Even if you’re a brilliant, up-to-date physician, your patients won’t benefit unless you can get them in the door to your practice. Patients who are at the end of your appointment queue are faced with three options: wait for their time with you and risk their condition worsening, seek care elsewhere in emergency departments and urgent care centers, or leave your practice in search of a more available physician.

Beyond seeing a full schedule on your appointment calendar every day, do you have a good understanding of the potential office visit demand from your patient populations, and your capacity to meet this demand? If the answer is “no,” there is a four-step process which can help you get there.

Step One is to understand how large your patient panel might be, and the visit demand expected from a panel of that size. One easy method to estimate your panel size is to track how many requests for a future appointment (by phone or in person) you receive on a particular day. In studies on daily visit requirements in the 1990’s, on average 0.75% of a patient panel would require an office visit on any particular day. So divide the number of unique appointment requests for a particular day and divide it by 0.0075. For instance, if you have 20 requests for appointments on Monday, your panel is approximately 2,600.

Step Two is to understand your capacity for providing visits. There are several ways to do this. One is count all the visits you performed last year, and presuming this year is like the last year, you have your total visit capacity. A second way is to multiple total visits on your calendar this week by the total number of weeks you will be working this year.

Step Three is to understand the visit demand of your estimated panel size. Again, there are several ways to estimate this. One is to count the number of your patients by age and gender, and using national visit patterns by age and gender (can be found in the National Ambulatory Medical Care Survey (, estimate the specific age-gender visit demand and sum these subtotals to give you a total visit demand. A second way is to use the chart below which was developed using the National Ambulatory Medical Care Survey data. Reading the estimated panel size from Step One on the ‘y’ axis, follow to the right till you meet the nomogram line then follow straight down. For instance, a panel size of 1,200 will require 4,200 age/gender adjusted visits each year.

Panel Size

                                         Practice Capacity (Total Annual Visits)


Subtracting the value in Step Two (Visit Capacity) from the value in Step Three (Panel Visit Demand) will give you the visit gap you will need to close in Step Four. For example, if your visit capacity is 3,800 and your panel visit demand is 4,200, the gap to be filled is 400 visits/ year or 1.5 additional visits per day.

Step Four is to design and test strategies for improving access to your practice, and rebalancing your demand and capacity. Below are specific types of strategies for managing demand for services and expanding capacity of your practice. Key concepts in the access improvement work include combining services, eliminating un-necessary services, relocating services closer to patients, using technology to communicate and assist patients, and smoothing the flow of patients through your practice. We will be highlighting several of these in future blogs. In the meantime, take a look at the resources below to get started.

Dartmouth Access Improvement Guide

VHA Advanced Access Toolkit

Fig. 1: Demand Improvement Strategies
Innovation Comment
Eliminate things not used Cease to supply something not wanted or rarely used, e.g. simple formularies, procedures used
Insert informative delays Postpone immediate service for specific purpose of obrtaining information from waiting period. e.g. patient education during waiting times, triage of child with fever to waiting period
Combine services Reframe original demand for individualized service into a larger cluster of services, e.g. group appointments for hypertension
Automate Meet recurrent need with standardized process, e.g. answer clinical questions with audiotapes, pamphlets etc.
Triage Establish multiple channels for satisfying different needs, e.g. direct referrals to ophthalmology for routine care
Extinguish demand for ineffective care Do not provide care for which there is no evidence of efficacy, e.g. chemistry panels as part of general medical exams
Relocate demand Meet the demand for a service in an out of office location, e.g. sports physicals in schools
Anticipate demand Meet a need before it arises, e.g. give breast feeding instructions before hospital discharge
Promote self care Create or reveal capacity of patients to treat themselves, e.g. provide nebulizer therapy at  home, use home diagnostic testing


Fig 2: Capacity Improvement Strategies
Innovation Comment
Improve predictions Predict demand based upon past experience and plan capacity to meet predictions, e.g. predict number of annual patient visits and schedule capacity accordingly
Smooth work flows Take steps to reduce fluctuations in demand. E.g. schedule routine care at low demand times
Adjust to peak demand If fluctuations in demand cannot be reduced further, make plans to meet periods of high demand, e.g. schedule physicians on days or time of year of peak demand such as Mondays or piro to start of school
Identify and manage constraints Find and remove the bottlenecks in the system, e.g. maxpack visits, freeing capacity for non-routine care. Use wheelchairs for disabled patients, allow computerized registration
Work down backlog If a system has accumulated a backlog, add some capacity in the short term to reduce the backlog, e.g. add an extra general exam or extra visit slot per session, schedule after hours or weekend clinics
Balanced centralized vs. decentralized capacity Used centralized staff to meet fluctuations in demand at the local level, e.g. cross train nurses to be able to do triage or scheduling when demand in high
Use contingency plans Prepare backup plans to deal with unexpected delays, e.g. plan for when the clinic physician is called to hospital for delivery

Scott Endsley, MD

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