Same day access in healthcare: be quick, but don’t hurry

Introduction

The rhetorical phrase—“be quick, but don’t hurry”—is attributed to legendary basketball coach John Wooden and was meant to motivate his players to strive for speed and agility on the court while simultaneously maintaining discipline, self-control, and focus on team effort (1). Although seemingly paradoxical, this maxim is worthy of special consideration in health care given the paramount importance of seeing and treating patients as expeditiously as possible while maintaining the highest quality care. However, for many patients, excessive delays in appointment scheduling are a major source of frustration, contributing to anxiety and decreased patient satisfaction. While the level of acuity should still be prioritized in access paradigms across all health conditions, there is no question that the issue of expediency is widely relevant for patients.

Indeed, access to care—defined by the National Academy of Medicine as “the timely use of personal health services to achieve the best health outcome”— represents one of the fundamental public health issues facing society across all populations (2). Tellingly, multiple studies have shown that delays in care are associated with inferior health outcomes across a variety of clinical conditions (3-5). While obstacles to access have generally included those related to insurance coverage, financial resources, and/or social determinants, the role of provider availability cannot be overlooked. According to one survey from 2022, the average wait time for a new physician appointment in large metropolitan markets was a staggering 26 days across all specialties (6).

Healthcare delivery paradigm

Given the desire to promote a more patient-centric delivery paradigm with respect to the ease of obtaining appointments, same day visits have been proposed as a means of improving patient access to care. On the surface, this proposition is an appealing one, as it provides patients an unprecedented opportunity to be seen seemingly within hours—a not unreasonable expectation given that many services in modern times from laundry cleaning, food delivery, automobile repairs, hair appointments, and television programs, among others—can be scheduled at a moment’s convenience. For health systems, the implications on cost-effectiveness are also significant as a backlog of appointments lead to waiting patents seeking care elsewhere resulting in decreased throughput, lost revenue, a higher rate of “no-shows”, and wasteful spending given that the resources allocated and unused could have been more efficiently spent elsewhere. While these costs may be lessened in countries with a national health system, the importance of addressing patients in a timely fashion cannot be understated.

Yet the potential pitfalls of hurrying to implement same day access in health care are plentiful. Since this paradigm is counterintuitive to traditional practice in which visits are scheduled based on a “first-come, first serve” model or in some cases, based on acuity, skeptics of same day access have historically abounded (7-9). And for good reason. Health care is notoriously sluggish to adapt to change, and questions regarding the feasibility of such an ambitious delivery model, particularly with regard to infrastructure demands have long been entrenched in the minds of critics. Specifically, concerns related to logistical coordination, space capacity, resource allocation, and provider availability, among others, have rendered this paradigm overly idealistic at best and unrealistic at worst. To many, the rush to offer same day appointments poses the real possibility of introducing new inefficiencies and burdens to an already clunky health care system rather than ameliorate the ones that It so loftily aims to address. Similarly, the utility of expediency would be moot if the quality of care delivery was compromised in any way.

Since data on the feasibility of same day access in health care had largely been limited to anecdotal experiences, we recently published a longitudinal 2-year experience with same day access in outpatient oncology (10). While same day appointments significantly reduced the time to consultation and treatment for patients with newly diagnosed cancer—and were widely embraced across all disease sites—the initiative presented new challenges—both expected and unexpected—which required thoughtful reflection to navigate. In this sense, arguably no other principle conveyed the spirit of same day access as the phrase “be quick, but don’t hurry”. Notably, this initiative was not a “walk in” clinic but one based on methodical scheduling prior to the patient appointment.

But what does the mantra “be quick, but don’t hurry” really mean? While Coach Wooden intuitively saw the difference between quickness and hurrying, the distinction, in actuality, is much more elusive to define. In simplest terms, what he implied is that the more one hurries, the more likely that focus is lost, leading to blunders and errors. However, at the same time, if one is not quick, the sense of purpose can be diluted, resulting in the squandering of any competitive edge needed to achieve greatness. While these lessons were initially meant for basketball, they are equally applicable to the “game” of health care. As in basketball, a clinical team’s ability to achieve speed while maintaining focused control and effort is essential—particularly when it comes to patient access. The purpose of this review is to thus summarize the basic lessons learned from our experience with same day access in health care using the Plan-Do-Study-Act (PDSA) method as a way to evaluate this novel initiative.

Set realistic expectations

Being quick involved creating an understanding among providers and staff that as with any new strategic initiative, the introduction of same day access in the clinic would inevitably be associated with “growing pains”. With the recognition that perfection would not be attainable, any undue pressure placed on the team to execute with flawlessness was alleviated. Instead, a “can do” attitude was promoted, emphasizing the need to be resourceful to achieve success within the natural constraints of the workplace. For example, to pre-emptively assess the feasibility of same day access, initial consideration was given to the pace at which this strategy could be implemented with a 3-month time study of physician schedules to gauge capacity and availability. During this time, all established patients returning for visits were prospectively audited to identify appointments that may have been redundant, frivolous, and/or even unnecessary. Since the same day access initiative was deliberately designed to be integrated into everyday physician workflow without the creation of new patient slots, the optimization of existing space in schedules through the elimination of inefficiencies and/or idle time were critical. This required frequent and detailed analyses of provider schedules to identify under-utilized time slots. To anticipate problems, approximately 6 months were spent in the preparatory and planning phase interviewing various stakeholders prior to going live. Once the same day access program was up-and-running, the possibility of seeing patients with incomplete medical records or who’s diagnostic evaluation had been less than thorough also needed to be acknowledged so that action plans could be developed to gather any missing records that were unavailable at the time of the same day appointment. In some cases, ancillary personnel were tasked with acquiring information either immediately before or after the same day appointment. Lastly, given the significant investment devoted to the same day access initiative, it was imperative that successful patient encounters be shared early so that the public could see that the program could in fact be successful. This also had the effect of building confidence among the team while silencing any potential naysayers. The reports of positive patient experiences provided reinforcement that all of their collective efforts were worthwhile and recognized. This momentum helped gradually build pride in the program in a realistic and consistent manner.

Seek balance

Achieving the appropriate balance between being quick and hurrying involved aligning all stakeholders towards the common goal of successfully being able to offer same day appointments for any patient who elected to enroll. Given that the same day access program represented a dramatic shift in culture, numerous aspects of workflow were expected to be affected. To build support, town halls with question-and-answer sessions were devised in advance explicitly to discuss concerns, especially with how to attain balance between accommodating same day visits while maintaining normal operational activity. Customary workshops were held with staff to provide coaching and guidance on logistical coordination. The importance of physician input, particularly with respect to the scheduling template and the practical integration into the process of daily clinical workflow, was critical to promote alignment. A key feature was that the initiative was not mandatory and was designed with the intent of not creating additional pressure for physicians during a busy day. This alleviated physician fear of losing control over autonomy. Additionally, having an 11am cut-off after which same day appointments were no longer offered provided reasonable assurance that rushing and scrambling to accommodate last-minute appointments would not occur. Lastly, it was agreed upon that the same day access initiative would initially proceed on a preliminary trial basis as a 3-month pilot study to gauge feasibility. Overall, the ability to strike a balance meant ensuring that providers and staff were working as one team with common expectations and purpose.

Commit with decisiveness

Once a go-live date was announced for same day access, the decision was made to proceed in a universal fashion. Being quick meant setting a commitment to a path of action and to constantly move forward, even in the absence of perfect information or certainty. In this sense, every patient was to be offered a same day appointment, without exception. It was an “all or nothing” proposition in which intake coordinators were repeatedly instructed to use the same verbiage with all patients (“Would you like to be seen by one of our disease-specific specialists today?”) to ensure that consistency was prioritized. This practice ensured that all patients were offered the opportunity to be seen with a same day appointment without fail. The all-encompassing nature of the rollout not only helped reinforce standardization, but it also contributed to cementing expectations. Not long thereafter, the same day access program was on “autopilot” as the initiative was normalized to be a routine service offered to all patients. There were no more doubts of whether it was feasible to do same day service, it had already been done. As with many new initiatives, successful implementation of the same day access initiative was dependent on champions driving the vision. In this case, a medical director was tasked with engaging all stakeholders to ensure concerns were addressed and to serve as the point-person to which questions would be targeted. This physician effectively checked in with all stakeholders on a consistent and visible basis, reminding everybody of the merits of the program. To publicize the same day access program once it officially went live, a variety of forums were utilized. Email blasts were routinely sent to high-volume referring providers. Opportunities to present the initiative at health system functions were embraced. The headline of the clinic webpage was changed to feature this service. Ultimately, the goals were to remove hesitation and indecisiveness, replace them with focused energy and action, and guard against wasting time on activities that would not produce results.

Prepare to pivot

As with basketball, adjusting to changes—quickly and anticipatorily—once a novel initiative is introduced is imperative to success. With the same day access program, the need for contingency planning cannot be overstated. For instance, recognizing that a given provider might not always be able to accommodate a same day appointment request, it was necessitated that a system of back-ups be built into the model. For any given diagnosis, the intake team was instructed to start with the first-priority physician referencing the existing schedule to see if openings existed. If openings were unavailable, the scheduler then proceeded to the second-priority provider, and the process was repeated, moving to the third-priority provider if needed. The template was designed as such because not all physicians were expected to be available in clinic due to regular administrative days, research obligations, and/or personal time. Additionally, this multiple-physician prioritization scheme allowed for buffer to account for vacation and sick days. Similarly, since providers were often notified just a few hours prior to the scheduling of a same day appointment, the need to ensure that medical records and other health information were available had to be prioritized. The use of dedicated staff who worked alongside providers to gather missing material were valuable. In cases where patients were seen with incomplete information, the provider team had to be prepared to adapt and to nimbly work with the staff to pivot in a less-than-ideal scenario. While these scenarios were relatively uncommon, they did have the potential to disrupt normal operations and thus had to be reconciled when they arose. Ultimately, the ability of the team to “think on their feet” with the flexibility of the same day scheduling model were keys to success.

Continually re-evaluate

Any new quality improvement project requires continuous analysis of data to gauge its operational success so that modifications can be made in a positive manner. For the same day access initiative, a plethora of metrics were tracked related to its utilization, effectiveness, and impact on patient satisfaction. Access-related benchmarks such as time from diagnosis to treatment (a metric particularly important for cancer patients) were monitored and reviewed on a monthly basis. Other analytics that were tracked included the proportion of patients seen within 5, 7, and 14 days of referral. These allowed for not only gauging the success of the same day access initiative but for also making minor refinements in template design, for instance, which permitted the program to function more smoothly. The effect of the same day appointment program on potentially improving access for historically underserved patients was also evaluated. Ultimately, the goal was to ensure that the process of maintaining the same day access initiative was data-driven and based on continual analysis of real-time data. Since this paradigm is counterintuitive to traditional practice in which visits are scheduled based on a “first-come, first serve” mentality, exercising patience was key. Even after rollout, the initial plan was to perform a 3-month preliminary pilot study, halt the program, and evaluate preliminary findings. Additionally, constructive feedback was continually sought by all stakeholders to ensure that they all felt a sense of ownership over the program and had an opportunity to voice suggestions as well as share frustrations—so that continuous quality improvement could be achieved. Both provider and patient satisfaction ratings with the program were monitored. However, due to the enormous popularity from both patients and providers alike, the decision was made collectively to abandon any hiatus. In this sense, the importance of regular “look backs” to identify any sticking points and to troubleshoot these issues moving forward were vital to process improvement.

Conclusions

The development of a patient-centric, same day access program, like the game of basketball, required methodical planning and meticulous execution. As demonstrated through this PDSA analysis, the 5 lessons outlined illustrate the importance of planning (#1 and #2), doing (#3), studying (#4), and acting (#5). While the benefits of moving quickly and effortlessly were obvious, the fine line between doing so thoughtfully and recklessly needed to be respected. To reconcile this divide, the 5 lessons reviewed above, focusing on strategy, alignment, execution, adaptation, reflection, respectively, provided a valuable framework for the design of a same day access initiative in the ambulatory setting. In some ways, the similarities between basketball and health care are not surprising. Most notably, both are critically dependent on the cohesiveness of the team. Similarly, efficiency in both is paramount to success. However, it is critical that quality not be sacrificed for expediency. Additionally, factors related to leadership, culture, and attention to detail can often mean the difference between success and failure. In retrospect, the implementation of a same day access initiative did not happen overnight, nor could it be hurried in any manner. By balancing speed with deliberateness, the same day appointment program was embraced by all stakeholders and resulted in tangible benefits to patients. Given the inherently disruptive nature of this paradigm, the ability to plan and execute with concerted focus (“be quick”) while exercising patience (“don’t hurry”), in accordance with the principles espoused by Coach Wooden, ultimately led to the success of the same day access program.

Acknowledgments

Funding: None.

Footnote

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-55/prf

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-55/coif). A.M.C. reports that he was awarded an honorarium in association with the 2022 John Wooden Leadership Fellowship by the University of California, Los Angeles- Anderson School of Management. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Hill A, Wooden J. Be Quick - But Don't Hurry: Finding Success in the Teachings of a Lifetime. New York, NY: Simon and Schuster; 2001.
2. Institute of Medicine. Committee on Monitoring Access to Personal Health Care Services. Access to health care in America. Washington, DC: National Academy Press; 1993.
3. Lee AA, James AS, Hunleth JM. Waiting for care: Chronic illness and health system uncertainties in the United States. Soc Sci Med 2020;264:113296. [Crossref] [PubMed]
4. Cone EB, Marchese M, Paciotti M, et al. Assessment of Time-to-Treatment Initiation and Survival in a Cohort of Patients With Common Cancers. JAMA Netw Open 2020;3:e2030072. [Crossref] [PubMed]
5. Nottingham QJ, Johnson DM, Russell RS. The effect of waiting time on patient perception of care quality. Qual Manag J 2018;25:32-45. [Crossref]
6. Merritt Hawkins. 2022 Survey of Physician Appointment Wait Times. Dallas, TX: Merritt Hawkins; 2022.
7. Baxley EG, Weir S. Advanced access in academic settings: definitional challenges. Ann Fam Med 2009;7:90-1. [Crossref] [PubMed]
8. Finkelstein SR, Liu N, Rosenthal D, et al. When open access might not work: Understanding patient attitudes in appointment scheduling. Health Care Manage Rev 2018;43:348-58. [Crossref] [PubMed]
9. Abou Malham S, Touati N, Maillet L, et al. The challenges of implementing advanced access for residents in family medicine in Quebec. Do promising strategies exist? Med Educ Online 2018;23:1438719. [Crossref] [PubMed]
10. Chen AM, Garcia AD, Alexandrescu M, et al. Effect of a Same-Day-Appointment Initiative on Access-Related Benchmarks in Radiation Oncology. Pract Radiat Oncol 2024;14:12-9. [Crossref] [PubMed]