Information Package

Advanced Access aligns with Manitoba’s Primary Care Improvement Initiatives:

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In November 2010 the Manitoba government announced that “every Manitoban will have access to a family physician by 2015”. As part of this commitment the government has introduced several initiatives including:

• Primary Care Networks
• QuickCare clinics
• Advanced Access
• Mobile Primary Care Units, and
• Recruitment and retention initiatives for doctors, nurses and other health care providers.

Primary Care Networks (PCNs) are seen as a key platform for building a strong primary care system in Manitoba. Each PCN must agree to a set of core services and functions of which patient access to appointments within 24-48 hours is a foundational deliverable.

Advanced Access is a practice improvement process that helps primary care clinics remove unnecessary waits and delays for patients, and redesigns the delivery of clinical care to maximize health outcomes. Experience in similar health system settings has shown that achieving these goals requires a clinic to learn quality improvement techniques and build a foundation that will support quality improvement over time.

Why Advanced Access/Practice Improvement?

Our health care system is burdened by delays. These delays adversely affect clinical outcomes, patient and staff satisfaction and cost.

Reducing delays and increasing access to providers has been thought to increase costs. In fact the opposite is true – delays as a result of poorly designed systems result in additional costs. It is possible for organizations to develop and implement changes that reduce delays without increasing costs.

Delays prevent providers and staff from providing optimal care. Thus reducing delays is essential to optimize system performance.

"Advanced Access has shown me the value of utilizing our multidisciplinary team to maximize the efficiency and quality of care that I can provide, especially for the high needs and chronic disease patients we serve, but also for the preventative patients in our practice.

Advanced Access has given our team the tools necessary to anticipate the demands and supply on our clinic."

Dr. Harold Nyhof
ACCESS River East

APPROACH

Manitoba’s Advanced Access initiative is based upon a proven process and set of principles designed to assist providers and staff by eliminating the need for a patient to wait to get an appointment and minimizing the amount of time a patient spends at an appointment. This is accomplished by predicting and managing patient demands.

Studies in this field have indicated that successful use of strategies to reduce delays leads to improved compliance with prevention guidelines, improved care for patients with chronic illness, and enhanced early detection of serious illness. These strategies are based on a fundamental understanding of patient and provider desire for continuity of care, the need to balance the demand for service with the supply of service, and the importance of measurement to clarify the current state and move toward an improved model of care.

The improvement framework is based upon the Institute for Healthcare Improvement’s Learning Model and Model of Improvement. It involves methodologies to:

• Reduce delays
• Increase continuity,
• Build and strengthen teams , and
• Implement decision support tools and improve quality outcomes.

Clinic staff work collaboratively with experts and Manitoba trained faculty to learn a new methodology for change, measure their progress and share ideas and knowledge that will result in the best patient health care.

Improvement teams will work together for approximately 11 months to design, test, and deploy new models of clinic practice and practice management and apply them to their own clinics. These changes will lead to improved performance levels, including improved access, improved office flow and efficiency, increased patient and staff satisfaction, clinical outcomes, improved financial outcomes and more effective interdisciplinary care teams.

"Advanced access allowed us to decrease our delay substantially and eliminated all of the extra work of trying to accommodate urgent patient needs and resulting complaints. With our improved access we also experienced, not only a significant improvement in patient satisfaction, but also a corresponding improvement in staff and physician satisfaction."

Jo-Anne Lutz
Clinic Manager
Burntwoord Community Health Centre

The Program

Participating clinic will be asked to commit to:

• Having an improvement team (three to eight people)
• Attend all learning sessions (4 – 1 ½ to 2 day sessions)
• Participate in regular conference calls
• Participate in improvement process activities
• Submit regular reports to the expert team for review and feedback

Readiness Workshop

The Readiness Workshop is designed to present Advanced Access in detail in order to provide information, meet the expert team and help clinics determine if they are ready to participate.

The Readiness Workshop is a 5 hour session (lunch is provided). Contact us for the next scheduled Readiness Workshop.

Clinics wishing to proceed will be given an application form to be completed at the workshop. Clinics will be notified of their acceptance within 5 days of submitting their application.

Pre-Work Phase

This phase is designed to assist clinics in building their improvement team and starting collection of measurement data.

Pre-work is done through two one-hour long lunch hour conference calls.

Pre-work call 1: 12:00 noon to 1:00 p.m.

• determining the right team, commitment, initiative overview

Pre-work call 2: 12:00 noon to 1:00 p.m.

• early measurement, access to panel data

Contact us for the next scheduled Readiness Workshop.

Learning Sessions

Four 1 ½ to 2 day long Learning Sessions have been scheduled to teach your improvement team about the tools, measure and methodologies required to implement Advanced Access. Learning sessions are one and a half to two days long, held approximately once every 3 months. Meals are provided.

Contact us for the next scheduled Readiness Workshop.

TEAM, AIM, CHANGE, MAP AND MEASURE

Manitoba’s Advanced Access improvement initiative is based upon four success factors:

• Creating a Team
• Defining Aims
• Making Changes
• Determining and Collecting Measures

Creating a Team

A clinic’s improvement team is a key component for success in implementing Advanced Access. Members of the team should be willing to change and to lead change within the clinic, should be knowledgeable of and involved in office processes.

The team is comprised of two essential components:

• The core improvement team (who will attend the in-person Learning Sessions and lead the improvement effort); and
• The additional clinic team (the rest of the staff at the office practice site).

Every core improvement team should include the following members (where available):

• Clinic manager
• Physician representative(s)
• Nursing representative(s)
• Other health care provider representative(s)
• Reception representative(s)
• Medical office assistant representative(s)

The core improvement leadership team will normally consist of three to eight staff (depending upon the size of the clinic). The entire improvement leadership team is expected to attend all of the in-person Learning Sessions. Other staff may wish to attend the Learning Sessions when sessions are relevant to their area of work or expertise.

There may be one or more individuals on the team, who fit each dimension, and one individual may fill more than one role, but each component should be represented to successfully drive change in the clinic. It is critical to have at least one physician champion on the team. This champion should have a good working relationship with colleagues and the day-to-day leader, and be interested in driving change in the system. The physician champion is an opinion leader in the office practice (an individual who is sought out for advice and who is not afraid to test change.)

"Advanced Access training was the catalyst for redefining team roles and ensuring team members work to full scope.
Advanced Access training gave us an insight into our practice and the processes that make use a team."

Renata Cook
Primary Care Coordinator
Nor’West Co-op Community Health Centre

Defining Aims

Improvement requires setting goals or aims. In other words; what are we trying to accomplish?

Teams will develop two primary aims, one specific to access and one specific to office efficiency. Teams may chose to develop additional aims in the areas of clinical improvement that fit their unique patient population and/or other initiatives they wish to undertake.

Making Changes

Improvement efforts require that changes be made to narrow the gap between the current and the desired performance. Teams will define their aims and measures, and then proceed to implement the changes. Small scale evaluations such as Plan-Do-Study-Act (PDSA) cycles will be employed to test the changes and determine their effectiveness. If successful the changes would be applied on a larger scale within the clinic. However, if the change does not result in improvement it can be adapted, retested or discontinued.

Determining and Collecting Measures

Measurement is a critical part of testing and implementing change and is continuous throughout the initiative and forever after.

Measure provide the baseline (starting point), assess progress toward the aim, and determine whether the changes are actually leading to improvement.

Teams are expected to monitor a core set of measures related to access and office efficiency. Measures include:

• Third next available appointment (delay)
• Continuity
• Supply
• No-shows
• Panel size
• Patient flow and cycle time
• Demand
• Activity
• Revisit rate
• Teamwork

Action Periods (time between Learning Sessions)

Between the Learning Sessions team members work in their clinics gathering data, implementing and testing multiple changes.

Clinics remain in contact with other Advanced Access clinic teams, the expert team and faculty through conference calls, group emails and by submitting reports on their progress. Faculty members provide written feedback and coaching on these reports.

During the action period it is expected that the entire clinic will participate in implementing, testing and measuring change.

Commitment

Clinics applying to participate in the Advanced Access improvement initiative will be committing to:

• Developing an improvement team of three to eight staff (including at least one physician and the clinic manager)
• Participation of the improvement team to attend all in-person Learning Session
• Participating in all scheduled teleconferences that will include all participants in the collaborative
• Preparing and submitting written reports and participating in one-on-one scheduled teleconferences with assigned faculty. The purpose of the reports will be to update team progress and receive assistance and feedback from faculty.
  Note: A report template will be provided to the clinics.
• Presenting a report on team progress at Learning Sessions.
  Note: A presentation template will be provided to the clinics.
• Committing clinic resources (time) to support participation in the initiative.
• Holding weekly/regular improvement team meetings to discuss changes and improvement, and plan activities relating to improvement aims.
• Allocating adequate resources from within the clinic to gather and enter data on a regular and ongoing basis to measure and support the improvements.
  Note: Spreadsheets will be provided to the clinics for data collection.
• Transferring learnings to and including all members of the clinic team in the improvement initiative.

Available Support

Clinics participating in the Advanced Access improvement initiative will have access to a variety of supporting resources, specifically:

• Four Learning Sessions with expert faculty
• Access to a variety of tools, articles and papers on subjects related to the concepts presented at the Learning Sessions through the Manitoba Pursuing Excellence website
• Assistance with setting aims, building skills in measurement collection, analysis and utilization of associated tools, reporting, holding meetings and team development
• Access to faculty and other participants for information sharing and problem solving during action periods
• Access to resources for assistance with spreadsheets, data collection and panel identification
• Access to secondary resources such as support for situations where team issues are a barrier to success
• Scheduled teleconferences with faculty and other participating clinics to share learnings and ideas
• Access to group email for posing questions and sharing information

Ongoing

At the conclusion of the collaborative process, clinics will be asked to identify activities that will help sustain Advanced Access principles within their clinics.

"I was as sceptical as any other physician about the benefits of Advanced Access and how this might apply to a full rural practice. By using tools that have been validated, I was amazed to see how we could pick apart the functions of a clinic and rebuild workflows to actually make things more efficient...and ultimately lead to better access for our patients. We are all happier for it."

Dr. Denis Fortier
VP Medical, Central RHA

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For more information:

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Health System Innovation Branch

Manitoba Health
1090-300 Carlton St.
Winnipeg, Manitoba
R3B 3M9

Roberta Vyse
roberta.vyse@gov.mb.ca
204-788-6340