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Improving Patient Access to the Veterans Health Administration’s Primary Care and Specialty Clinics
Joint Commission
Journal on Quality and Safety
Performance Improvement
Improving Patient Access to the Veterans Health Administration’s Primary Care and Specialty Clinics
Marie W. Schall Terrence Duffy, M.D. Anil Krishnamurthy, M.D. Odette Levesque, R.N., M.B.A. Prashant Mehta, M.D. Mark Murray, M.D., M.P.A. Renee Parlier Robert Petzel, M.D. John Sanderson, M.D.
n recent years there has been increased attention given to the use of “open access” in primary care office practices and clinics.1,2 In an optimal system of what the Veterans Health Administration (VHA) terms advanced clinic access, an organization provides enough openness or space (capacity) in the clinic for health services to meet the demand of its patient population at the time the demand occurs. There is, however, little published information about the application of open access to specialty practices.3,4 The VHA worked with the Institute for Healthcare Improvement (IHI) during an 18-month period from April 2001 through December 2002 to apply advanced clinic access for patients to both primary care and specialty clinics within its system—including primary care, cardiology, audiology, eye care, orthopedics, and urology. The project’s goal was to build a system that can achieve and sustain access levels that meet and exceed the VHA performance standards for waiting times (30 days for new and established patients) so that ultimately all veterans can receive the care they need, when and where they want it. The long-term goal in the VHA is to provide care to veterans on the same day of their request for primary care and within 7 days for specialty care. The VHA began its work to improve access because of the enormous pressure on its system to reduce waiting times for veterans requesting appointments in its outpatient clinics. Public Law 104-262, the Veterans Health
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Article-at-a-Glance Background: During the past four years the Veterans Health Administration (VHA) has been engaged in a national effort to improve access for patients to its 1,826 primary care, audiology, cardiology, eye care, orthopedics, and urology clinics by using the principles of open access or “advanced clinic access.” The strategy entailed the development of successful cases to demonstrate the methods of advanced clinic access and provide evidence of its benefits for providers as well as patients in primary care and specialty clinics. Results: Four clinics—one primary care clinic and three specialty care clinics—showed dramatic improvement in waiting times for appointments (reductions range from 20 days in urology to 78 days in primary care). Discussion: Beyond the four case studies, hundreds of other clinics in the VHA are also applying advanced clinic access principles in their work. The diversity across the VHA suggests that the principles of advanced clinic access are robust across settings and types of clinics. However, the experience of other organizations with different structures and patient populations needs to be reported to fully demonstrate the generalizability of these results. Many of the changes were put in place during the project’s final 18 months. Additional data will be needed to demonstrate sustained improvement.
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Care Eligibility Reform Act of 1996, mandated the VHA to establish and implement a national enrollment system to manage the delivery of health care services to veterans. This legislation generated a significant increase in enrollees and patient users and precipitated serious problems with access of patients to ambulatory care services. The first step in the VHA plan to improve access across its system was a national Breakthrough Series Collaborative on Reducing Delays and Wait Times, which involved 134 clinics from every region in the VHA system. During the course of this six-month collaborative (July 1999–March 2000), the median wait for an appointment for the 134 pilot teams decreased from 48 to 22 days, an improvement of 54% (26 days).5 After demonstrating that advanced clinic access could work in the VHA, the next step was to expand the improvements to the remaining 1,800 clinics in its system in the selected clinical areas through the Advanced Clinic Access Initiative. The work in the selected clinics described in this article took place between January 2000 and January 2002, which spanned both initiatives. The ultimate goal of any access initiative is to build a system in which patients have the opportunity to see their own providers when they choose. The heart of advanced clinic access is the concept of “doing today’s work today” and not pushing it off into the future. The VHA used three strategies—shape demand, match supply and demand, and redesign the system to increase supply—and a corresponding set of key changes to build a sustainable system for advanced clinic access. These strategies are now described, as are the most important process changes made by the four case study clinics to apply the strategies in their work. Case studies for each strategy show all the changes made by each clinic and the results it achieved.
Strategy 1: Shape Demand Improving access is all about increasing the ability of the system to predict and absorb demand (patients’ requests for care). Working down the backlog, reducing demand for unnecessary clinic visits, and lengthening the time (when clinically appropriate) between return appointments are changes that can be used in both primary care and specialty clinics to more easily absorb current or future levels of demand. Building service agreements
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between specialty and primary care clinics is an especially powerful strategy in helping specialty clinics improve the appropriateness of requested consults.
Work Down the Backlog—Dayton VA Medical Center, Orthopedic Clinic “Backlog” consists of the appointments that are already on the clinic schedule. These appointments include both return appointments requested by providers for follow-up care (as part of a planned approach to patient care) and patient-initiated requests for appointments that could not be scheduled on the day of the request. It is the appointments for “today’s” patients that have been put off into the future which providers seek to eliminate as they work down their backlog. These appointments unnecessarily clog clinic schedules, taking up slots that could be used for patients requesting appointments each day. Methods to work down the backlog are the same for primary and specialty clinics and were used in each of the case study clinics highlighted in this article. As an example, in the Dayton VA Medical Center Orthopedic Clinic, Dr. Anil Krishnamurthy, chief orthopedic surgeon, was able to reduce his backlog of new consults by more than half during a period of two to three months. First, Dr. Krishnamurthy and his team verified the reason for the scheduled consult and then contacted each patient. They found that many no longer still needed appointments; that is, they had already been seen at a neighboring VA facility, had gone to a provider outside the VA system, or no longer wanted the appointment. To prevent future backlog, they also eliminated the automatic rebooking system for patients who fail to show up for a scheduled appointment. The patients are now contacted first to see if they still want or need the appointment. Second, they identified patients who had been scheduled for an appointment without sufficient documentation (such as x-rays) or failure of a trial of physical therapy. They sent an electronic note to the primary care provider specified in the record, explaining what needed to be done for proper scheduling, or, in some cases, noting that, after review of the record, no consult appeared warranted. Primary care providers were invited to reschedule consults if they had new information about the patient’s needs.
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Once the backlog was reduced, Dr. Krishnamurthy’s team worked together with primary care providers to streamline the referral process, reducing the number of patients who are referred inappropriately or with incomplete test results. At the same time, he worked with his residents and physician assistants to schedule return appointments for clinically appropriate reasons and at appropriate time intervals rather than give everyone an automatic follow up appointment at three months, whether needed or not. Sidebar 1 (right) shows all the changes made in the Dayton Orthopedic clinic and the level of improved access.
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Sidebar 1. Dayton VA Medical Center, Dayton, Ohio. Anil Krishnamurthy, M.D., Chief Orthopedic Surgeon Results Waiting times for a next available appointment dropped from 55.6 days in October 2000 to 17 days in December 2002. Although new consults decreased somewhat over this same period, the gains in access (70% improvement) cannot be solely attributed to a decrease in demand (25% reduction).
Reduce Demand: Build Service Agreements Between Specialty and Primary Care—Fargo VA Medical Center, Urology Clinic To reduce demand, specialty clinics have to examine two sources of demand—that generated internally Major Changes (for example, follow-up visits) and the ■ Worked down the backlog by looking ahead into the schedule (elimidemand generated externally from nated patients no longer needing an appointment, those needing furreferring physicians. An effective ther tests, or those who could be cared for in other ways) method to reduce external demand ■ Developed a service agreement with primary care providers (diagnosisfor specialty clinics is to build service specific consult requests with specific tests required for each, and agreements between primary and speongoing dialog and education) cialty care. Like Dr. Krisnamurthy, Dr. ■ Consults screened by physician assistant by protocols (with review by Terrence Duffy, staff urologist at the orthopedist as needed) Fargo VA Medical Center (now at the ■ Consults for subspecialists screened by general orthopedist St. Cloud VA Medical Center, St. ■ Reduced appointment types to two (new visit and follow-up) Cloud, MN) built a partnership with ■ Restricted access to scheduling to authorized staff only the internal medicine/primary care providers to decide the following: ■ Eliminated automatic rebooking for no shows ■ The types of patients who would be referred to him ■ What procedures would be done prior to the visit each of the most common conditions generating a referral, ■ How to structure the communication between him with accompanying order sets. In addition, Dr. Duffy and the primary care providers encouraged the primary care providers to call him with Using the VHA’s computerized patient record system questions, and he met regularly with the primary care (CPRS), Dr. Duffy created five urology screens, one for providers to evaluate the process. The primary care
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providers were able to refer patients and have them seen by Dr. Duffy on the same day. The results associated with these and the other changes Dr. Duffy and his team made in the urology clinic are shown in Sidebar 2 (right).
Strategy 2: Match Supply and Demand The central principle of advanced clinic access is balancing or matching supply and demand. If the demand is greater than the supply, there is a delay in providing care. If the supply is greater than demand, then resources are being wasted. When supply and demand are matched, there is no delay in providing care. To match supply and demand, a clinic should use the following methods to measure each one: 1. Measure true demand by recording the total number of patient requests received on any given day from both internal (return visits generated today) and external sources (phone calls, walk-ins, deflections to urgent care, and other sources of patient requests for services such as faxes or e-mails). 2. Measure supply. Supply refers to the total resources (people, equipment, offices, and exam rooms) available to a clinic. When the total resources are managed well, a clinic creates openness in its schedule or space to care for patients. Patients experience this openness primarily as the availability of clinic appointments (capacity). Capacity is the total hours of clinician time devoted to appointments. 3. Match true demand and capacity. If there is enough total capacity in the system to meet the total true demand, then often some simple
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Sidebar 2. Fargo VA Medical Center, Fargo, North Dakota. Terrence Duffy, M.D., Staff Urologist Results Waiting times were reduced from 20.7 days in April 2000 to one day in January 2002. This was accomplished with some reductions in the number of new appointments (391 to 132 during the same period), which may be attributed to a new referral process that cut down on the number of unnecessary consults.
Major Changes ■
Worked down the backlog (temporarily added appointment slots)
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Eliminated automatic rebooking for no-shows
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Reduced appointment types to two (regular and procedure appointments)
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Discharged patients back to primary care once their problems were addressed
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Used phone follow-up for patients when clinically appropriate (automatic e-mail prompts physician to call patient)
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Developed service agreements with primary care providers (computerized order sets for common conditions, primary care refers only sildenafil failures, prompt response for referred patients, and easy access to the urologist for questions)
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Developed quick medication order sets
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Optimized the care team: expanded nurses’ responsibilities, for example, by managing biopsy patients
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steps, such as aligning provider schedules to coincide with peak demand periods each week, can match supply and demand and improve access. If there is a mismatch between total capacity and demand, then other steps can be taken to align them, such as the methods discussed below for managing a panel of patients for primary care providers, equitably distributing new consults to specialists, reducing appointment types, and optimizing the care team to gain additional capacity.
Panel Management—VA Western New York Healthcare System, Primary Care Clinics For primary care clinics, the heart of matching supply and demand lies in each provider managing a specific group or panel of patients. Matching patients with their own providers whenever possible enhances accountability, improves continuity and patient satisfaction, and reduces the need for a visit to one’s own provider after having been seen by someone else. From the physician’s perspective, equitable panel size ensures that he or she will be able to offer good care in a timely way to a reasonable number of patients. In Buffalo, New York, Dr. John Sanderson, as medical director for the primary care clinics, shifted the clinic system from appointment management to panel management as part of the implementation of advanced clinic access. While using target panel sizes of 1,200 active patients for physicians and 1,000 for nurse practitioners and physician assistants, he taught the providers how to make their practices more efficient, enabling them to care for their panel. This included ensuring that there were adequate numbers of support staff and that the staff had the skills necessary to be effective team members and to use alternative visit strategies. At the same time, he outlined the following specific expectations for the providers: ■ Do same day urgent care as needed ■ Plan ahead for vacation or sick time ■ Take care of as many needs as possible at each visit ■ Refer responsibly and by service agreements As a result, the Buffalo primary care clinics now have fewer clinically unnecessary visits and better continuity. In 1999 only 10% of patients who were triaged as needing an urgent care visit actually saw their own providers, while by 2002 some 80% did.6
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In addition to matching supply and demand by establishing panel management as a foundation for primary care, Dr. Sanderson and his team used the two other strategies for improving access: They shaped demand by using clinically appropriate return visit intervals and redesigned the system to increase supply (see “Strategy 3: Redesign the System to Increase Supply Optimize the Care Team,” pages 420–421) by optimizing the care team. They began scheduling patients for return visits on the basis of a careful assessment of patient needs instead of old habits. The visits per patient per year in primary care at Buffalo and the rest of the Western New York clinic system decreased from 3.52 to 1.98, translating into 40,000 appointment slots saved per year for other purposes. The reductions in average next available waiting time for the Buffalo primary care clinics and the other changes made as part of their advanced access work is shown in Sidebar 3 (page 420).
Equitable Distribution of New Consults for Specialists—Martinsburg VA Medical Center, Urology Clinic In primary care the expectation is that there is accountability for all the patients within the panel. In specialty care, whereas it is crucial to have continuity through the episode of care, the goal is to enable specialists to see as many unique patients as possible because the specialists are often the “rate-limiting step” or constraint in the system. In other words, it is the specialist’s capacity to see patients that determines how many patients can flow through the clinic on any given day. In the urology clinic at the VA Medical Center in Martinsburg, West Virginia, the chief of urology, Dr. Prashant Mehta, and his care team worked together to ensure that new consults were distributed fairly among the three urologists in the clinic. All consult requests were screened either by Dr. Mehta or his trained urology nurse on the day they were received. Returning patients were scheduled with their assigned providers to enhance continuity of care. New consults were assigned to one of the other urologists, with each urologist taking new consults in turn.
Reduce Appointment Types Having a wide variety of appointment types increases total delay in a system because each appointment type
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Sidebar 3. VA Western New York Healthcare System, Buffalo Primary Care Groups, Buffalo, New York. John Sanderson, M.D., Primary Care Medical Director Results Time to next available appointment was reduced from 44.9 days in January 2000 to 24.9 days in August 2002, while the number of enrolled patients per provider full-time employee equivalent (FTEE) more than doubled from just over 400 patients in 1994 to more than 1,200 patients in 2002.
Major Changes ■
Worked down the backlog by extending return-visit intervals (as clinically appropriate)
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Adjusted provider schedules to meet predicted periods of peak demand (specific days of the week)
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Used effective internal communication within the team to better respond to patient needs each day
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Adopted a policy that providers are responsible for a panel of patients and provided training and support for the clinic team
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Strategy 3: Redesign the System to Increase Supply Optimize the Care Team
Optimizing the role that every member of a clinic care team plays is one way to improve clinic efficiency, enabling more patients to be seen on any given day. Because it is usually the physician who is the constraint (the scarce resource) in the clinic system, any tasks that can be done safely and effectively by other members of the care team should be removed from the physician. Using the same principles, every staff member should also be allowed to work to the highest level of his or her expertise and training. This
Created alternatives to clinic visits (that is, nurse phone follow-up, nurse clinics, and treatment by phone via protocols)
creates its own queue and consequently its own inclusion and exclusion criteria; that is, the more criteria, the more time it takes to put people in the line for a particular type of appointment. For example, if a surgeon sees new consults only on Tuesday afternons, a patient may have to wait several weeks to see the surgeon if all the Tuesday afternoon new-consult
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appointments are full for a particular week. A simplified scheduling system—one, for example, that schedules requests for new consults as they come in—creates more flexibility, allowing patients to be seen more quickly. This change can be used equally effectively in primary care clinics and specialty clinics. To create a new clinic profile system at Martinsburg, Dr. Mehta and his urology-clinic team consolidated 14 different types of clinic visits (for example, follow-up, new patients, preoperative assessments, minor procedures) into two appointment types (new patients and follow-up appointments) for each of the three providers. The new scheduling system also helped to equitably assign new consults among the urologists because a quick review of the week’s schedule could easily verify that patients were being distributed equally. The reduction in average next-available waiting time in the Martinsburg urology clinic during the period when these changes (as well as additional changes) were being made is shown in Sidebar 4 (page 421).
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concept applies to both specialty and primary care clinics. This optimizing concept was used in the urology clinic at Martinsburg. At the beginning of the advanced clinic access work, Dr. Mehta personally reviewed all incoming consult requests. Over time, Dr. Mehta worked with his urology nurse so that she could take over much of the routine screening function (that is, deciding on the completeness and appropriateness of the request), requiring only a review by Dr. Mehta. In the future, Dr. Mehta expects to be involved primarily in reviewing only particularly problematic cases. The same concept was applied in the Buffalo primary care clinics. As an alternative to a traditional face-to-face visit, triage nurses began assessing the clinical needs that arose for patients between appointments and chose the most appropriate response; some patients were seen by the nurse or even treated over the phone by protocols. Nurse clinic visits were also used for such minor procedures as blood pressure checks, blood glucose checks, minor irrigation, and immunizations. Clerks and nurses linked patients directly with dietary, psychology, social work, and even pharmacy and were encouraged to ask for provider advice when it is needed.
Results The case-study clinics highlighted in this article suggest a connection between the strategies and specific changes to improve access and reduced waiting times for patients. Sidebars 1–4 show reductions in patient waiting times for appointments ranging from 20 days in urology
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Sidebar 4. Martinsburg VA Medical Center, Martinsburg, West Virginia. Prashant Mehta, M.D., Chief of Urology Results Waiting time for urology-clinic appointments were reduced from 92 days in January 2001 to 14.4 days in January 2003. These results were achieved without adding staff and while maintaining a relatively stable demand for appointments as measured by the number of new consults (2,489 in fiscal year 2001, as compared with 2,152 in fiscal year 2002).
Major Changes ■
Established a no-show cancellation policy
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Screened new consult requests (urology nurse assists urologist)
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Worked down the backlog (temporarily decreased surgery time, expanded number of appointments)
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Benchmarked data with other clinics
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Developed a service agreement with primary care providers (minimum requirements, referral algorithms, grand rounds and visits with providers, and direct access to a urologist for questions)
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Created alternatives to face-to-face visits (phone consultation, nurse clinics, written postoperative instructions, and test results provided by phone)
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New clinic profiles: — Reduced number of appointment types from 14 to 2 — Decreased appointment times from 40 to 30 minutes for new patients and from 20 minutes to 15 minutes for returning patients (spaced evenly throughout the day)
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Restricted access to scheduling to authorized staff only
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Transferred stable patients back to primary care
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Table 1. Application of the Changes to Primary and Specialty Care Clinics For Both Primary Care and Specialty Care Clinics ■ Work down the backlog of already scheduled appointments ■ Align provider schedules to match peak demand for appointments ■ Reduce the number of appointment types ■ Extend the time between return appointments ■ Use alternatives to office visits ■ Optimize the members of the care team Specifically for Primary Care Clinics Assign each primary care provider responsibility for a specific group of patients (a panel)
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Specifically for Specialty Clinics ■
■ ■ ■ ■
Establish service agreements between specialty clinics and primary care providers to clarify and streamline the referral process Screen consults as needed Transfer stable patients back to primary care Use protocols and medication order sets Equitably distribute new patients among all providers
to 78 days in primary care. There is some variation across clinics in the measure used to assess their progress— three of the clinics used time to next-available appointment, whereas the Buffalo primary care clinics used time to third-next-available appointment. Third-next-available appointment is the recommended measure because it eliminates the effect of last-minute cancellations or other events that may not accurately reflect the true “openness” in a clinic’s schedule. As long as comparisons across clinics are not being made (as is the case here), the nextavailable appointment serves as an adequate measure for within-clinic improvement tracking. These clinics demonstrate that the methods of advanced clinic access can be successfully adapted to both primary care and specialty clinic settings while also meeting the special characteristics and needs of each type of clinic. Table 1 (above) summarizes the application of the changes discussed in the article to each primary and specialty care clinic.
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Another result of the project was the emergence of the physicians and other clinicians involved in these (and other successful) clinics as experts in advanced clinic access who now mentor and train other clinical leaders throughout the VHA system. By serving as faculty on national and regional conference calls and at advanced clinic access meetings and other VHA events and as peer coaches giving advice and encouragement to their colleagues, they have become an internal resource to spread improved access to other clinics. This network of coaches also has opportunities to learn from one another about how to most effectively teach others about advanced clinic access through conference calls and meetings of their own. The VHA strategy is to continue to develop these experts as a group, constantly expanding their number to support additional clinics’ work on improving access for their patients.
Discussion The use of case studies such as the ones discussed in this article and the development of a network of access coaches as two key components of the VHA’s strategy to spread advanced clinic access are supported in the literature about the spread of innovation in systems. Everett Rogers discusses the attributes of a change that contribute to its adoption by others.7 One of those attributes is visibility. If others within the VHA can see from the case studies that advanced clinics access can work in the VHA, then they are more likely to try the advanced clinic access approach than they would be without the VHA case examples. The literature concerning the communication of technical information to support change supports the importance of an internal resource such as the network of access coaches in the VHA. Once a potential adopter has made the decision to adopt, the person needs detailed information about what to do and how to do it. Some of this information can be obtained from written material (for example, training manuals, documents), but often the adopter may need to ask a question of someone who is knowledgeable.8 The access coaches fill this role in the VHA. Although the results for the four clinics highlighted in this article are impressive, the question remains whether their gains are generalizable to other clinics in the VA and to clinics and office practices in other organizations. This article has focused on the four case studies, but hundreds
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of other clinics in the VHA are also applying advanced clinic access principles in their work. Currently 37% of the 1,800 clinics in all six clinic types targeted for the Advanced Clinic Access Initiative have implemented the entire set of key changes for advanced clinic access, with 75% reporting at least partial implementation.9 Systemwide improvements in access have also been made since the VHA began its efforts to improve access systemwide, the largest improvement occurring in primary care and urology, where waiting times were reduced by 53% and 48%, respectively, between 2000 and 2002.10 Although the clinics in the VHA system share some characteristics (employed providers and staff, a national clinic scheduling package, and a specific population of patients), there is much variation within the system. Some but not all VA medical centers have communitybased outpatient clinics, employ contract providers, or provide tertiary care and serve as referral centers for other facilities, and so on. This diversity suggests that the principles of advanced clinic access are robust across settings and types of clinics. However, the experience of other organizations with different structures and patient populations needs to be reported to fully demonstrate the generalizability of these results. There is also the issue of generalizability of results from urology and orthopedics to other specialties. Each specialty’s own unique characteristics may influence how best to adapt the strategies for advanced clinic access to their systems, such as referral sources and procedure-based versus non-procedure-based clinics. Yet the present case studies do not suggest that principles of shaping demand, matching supply and demand,
and redesigning the system to increase supply cannot be applied to other specialties. Finally, although the data reported in this article span a three-year period (fiscal years 2000–2002), many of the changes were put in place during the project’s final 18 months. Additional data will be needed to demonstrate sustained improvement over time. The VHA systemwide database provides the opportunity for ongoing tracking and feedback of these data. The results to date are encouraging. The VHA’s experience with the case-study clinics discussed in this article and with other clinics suggests a solid foundation for bringing advanced clinic access to every clinic and veteran in its outpatient system. J
Marie W. Schall is Director, Institute for Healthcare Improvement, Boston. Terrence Duffy, M.D., formerly Staff Urologist, Fargo VA Medical Center, Fargo, North Dakota, is Staff Urologist, St. Cloud VA Medical Center, St. Cloud, Minnesota. Anil Krishnamurthy, M.D., is Chief Orthopedic Surgeon, Dayton VA Medical Center, Dayton, Ohio. Odette Levesque, R.N., M.B.A., is Clinical/QA Liaison, Chief Network Officer, Department of Veteran Affairs, Washington, D.C. Prashant Mehta, M.D., is Chief of Urology, Martinsburg VA Medical Center, Martinsburg, West Virginia. Mark Murray, M.D., M.P.A., is President, Mark Murray and Associates, Sacramento, California. Renee Parlier is Program Manager for Advanced Clinic Access, Department of Veterans Affairs. Robert Petzel, M.D., is Network Director, Veterans Integrated Service Network 23, Minneapolis. John Sanderson, M.D., is Primary Care Medical Director, Buffalo Primary Care Groups, VA Western New York Healthcare System, Buffalo, New York. Please address requests for reprints to Marie Schall, M.A., [email protected].
References 1. Murray M., Berwick D.: Advanced access: Reducing waiting and delays in primary care. JAMA 289:1035–1049, Feb. 26, 2003. 2. Murray M. et al.: Improving timely access to primary care: Case studies of the advanced access model. JAMA 289:1042–1046, Feb. 26, 2003. 3. Williams M.: Help Me Now: Improving Access to Mental Health Services. California Coalition of Community Mental Health Agencies Newsletter, Oct. 2001, pp 23. 4. Murray M.: Reducing waits and delays in the referral process. Fam Pract Manag 9:39–42, Mar. 2002. 5. Department of Veterans Affairs: VHA/IHI Breakthrough Series Collaborative on Reducing Delays and Waiting Times: Summary Report (unpublished report). Washington, D.C.: Department of Veterans Affairs, May 15, 2000.
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6. Personal communication between the author [M.W.S.] and John Sanderson, M.D., Primary Care Medical Director, Buffalo Primary Care Clinics, VA Western New York Healthcare System, New York, Nov. 2002. 7. Rogers E.: Diffusion of Innovations, 4th ed. New York: The Free Press, 1995. 8. Bandura A.: Social Foundations of Thought and Action. Englewood Cliffs, N.J.: Prentice Hall, 1986. 9. Department of Veterans Affairs: Performance Monitor Reports. Washington, D.C.: Department of Veterans Affairs, Washington, D.C., Jan. 2003. 10. The Veterans Health Administration and the Institute for Healthcare Improvement: Advanced Clinic Access Initiative Final Report (unpublished). Washington, D.C.: Department of Veterans Affairs, Apr. 2003.
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Performance Improvement
Improving Patient Access to the Veterans Health Administration’s Primary Care and Specialty Clinics
Marie W. Schall Terrence Duffy, M.D. Anil Krishnamurthy, M.D. Odette Levesque, R.N., M.B.A. Prashant Mehta, M.D. Mark Murray, M.D., M.P.A. Renee Parlier Robert Petzel, M.D. John Sanderson, M.D.
n recent years there has been increased attention given to the use of “open access” in primary care office practices and clinics.1,2 In an optimal system of what the Veterans Health Administration (VHA) terms advanced clinic access, an organization provides enough openness or space (capacity) in the clinic for health services to meet the demand of its patient population at the time the demand occurs. There is, however, little published information about the application of open access to specialty practices.3,4 The VHA worked with the Institute for Healthcare Improvement (IHI) during an 18-month period from April 2001 through December 2002 to apply advanced clinic access for patients to both primary care and specialty clinics within its system—including primary care, cardiology, audiology, eye care, orthopedics, and urology. The project’s goal was to build a system that can achieve and sustain access levels that meet and exceed the VHA performance standards for waiting times (30 days for new and established patients) so that ultimately all veterans can receive the care they need, when and where they want it. The long-term goal in the VHA is to provide care to veterans on the same day of their request for primary care and within 7 days for specialty care. The VHA began its work to improve access because of the enormous pressure on its system to reduce waiting times for veterans requesting appointments in its outpatient clinics. Public Law 104-262, the Veterans Health
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Article-at-a-Glance Background: During the past four years the Veterans Health Administration (VHA) has been engaged in a national effort to improve access for patients to its 1,826 primary care, audiology, cardiology, eye care, orthopedics, and urology clinics by using the principles of open access or “advanced clinic access.” The strategy entailed the development of successful cases to demonstrate the methods of advanced clinic access and provide evidence of its benefits for providers as well as patients in primary care and specialty clinics. Results: Four clinics—one primary care clinic and three specialty care clinics—showed dramatic improvement in waiting times for appointments (reductions range from 20 days in urology to 78 days in primary care). Discussion: Beyond the four case studies, hundreds of other clinics in the VHA are also applying advanced clinic access principles in their work. The diversity across the VHA suggests that the principles of advanced clinic access are robust across settings and types of clinics. However, the experience of other organizations with different structures and patient populations needs to be reported to fully demonstrate the generalizability of these results. Many of the changes were put in place during the project’s final 18 months. Additional data will be needed to demonstrate sustained improvement.
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Care Eligibility Reform Act of 1996, mandated the VHA to establish and implement a national enrollment system to manage the delivery of health care services to veterans. This legislation generated a significant increase in enrollees and patient users and precipitated serious problems with access of patients to ambulatory care services. The first step in the VHA plan to improve access across its system was a national Breakthrough Series Collaborative on Reducing Delays and Wait Times, which involved 134 clinics from every region in the VHA system. During the course of this six-month collaborative (July 1999–March 2000), the median wait for an appointment for the 134 pilot teams decreased from 48 to 22 days, an improvement of 54% (26 days).5 After demonstrating that advanced clinic access could work in the VHA, the next step was to expand the improvements to the remaining 1,800 clinics in its system in the selected clinical areas through the Advanced Clinic Access Initiative. The work in the selected clinics described in this article took place between January 2000 and January 2002, which spanned both initiatives. The ultimate goal of any access initiative is to build a system in which patients have the opportunity to see their own providers when they choose. The heart of advanced clinic access is the concept of “doing today’s work today” and not pushing it off into the future. The VHA used three strategies—shape demand, match supply and demand, and redesign the system to increase supply—and a corresponding set of key changes to build a sustainable system for advanced clinic access. These strategies are now described, as are the most important process changes made by the four case study clinics to apply the strategies in their work. Case studies for each strategy show all the changes made by each clinic and the results it achieved.
Strategy 1: Shape Demand Improving access is all about increasing the ability of the system to predict and absorb demand (patients’ requests for care). Working down the backlog, reducing demand for unnecessary clinic visits, and lengthening the time (when clinically appropriate) between return appointments are changes that can be used in both primary care and specialty clinics to more easily absorb current or future levels of demand. Building service agreements
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between specialty and primary care clinics is an especially powerful strategy in helping specialty clinics improve the appropriateness of requested consults.
Work Down the Backlog—Dayton VA Medical Center, Orthopedic Clinic “Backlog” consists of the appointments that are already on the clinic schedule. These appointments include both return appointments requested by providers for follow-up care (as part of a planned approach to patient care) and patient-initiated requests for appointments that could not be scheduled on the day of the request. It is the appointments for “today’s” patients that have been put off into the future which providers seek to eliminate as they work down their backlog. These appointments unnecessarily clog clinic schedules, taking up slots that could be used for patients requesting appointments each day. Methods to work down the backlog are the same for primary and specialty clinics and were used in each of the case study clinics highlighted in this article. As an example, in the Dayton VA Medical Center Orthopedic Clinic, Dr. Anil Krishnamurthy, chief orthopedic surgeon, was able to reduce his backlog of new consults by more than half during a period of two to three months. First, Dr. Krishnamurthy and his team verified the reason for the scheduled consult and then contacted each patient. They found that many no longer still needed appointments; that is, they had already been seen at a neighboring VA facility, had gone to a provider outside the VA system, or no longer wanted the appointment. To prevent future backlog, they also eliminated the automatic rebooking system for patients who fail to show up for a scheduled appointment. The patients are now contacted first to see if they still want or need the appointment. Second, they identified patients who had been scheduled for an appointment without sufficient documentation (such as x-rays) or failure of a trial of physical therapy. They sent an electronic note to the primary care provider specified in the record, explaining what needed to be done for proper scheduling, or, in some cases, noting that, after review of the record, no consult appeared warranted. Primary care providers were invited to reschedule consults if they had new information about the patient’s needs.
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Once the backlog was reduced, Dr. Krishnamurthy’s team worked together with primary care providers to streamline the referral process, reducing the number of patients who are referred inappropriately or with incomplete test results. At the same time, he worked with his residents and physician assistants to schedule return appointments for clinically appropriate reasons and at appropriate time intervals rather than give everyone an automatic follow up appointment at three months, whether needed or not. Sidebar 1 (right) shows all the changes made in the Dayton Orthopedic clinic and the level of improved access.
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Sidebar 1. Dayton VA Medical Center, Dayton, Ohio. Anil Krishnamurthy, M.D., Chief Orthopedic Surgeon Results Waiting times for a next available appointment dropped from 55.6 days in October 2000 to 17 days in December 2002. Although new consults decreased somewhat over this same period, the gains in access (70% improvement) cannot be solely attributed to a decrease in demand (25% reduction).
Reduce Demand: Build Service Agreements Between Specialty and Primary Care—Fargo VA Medical Center, Urology Clinic To reduce demand, specialty clinics have to examine two sources of demand—that generated internally Major Changes (for example, follow-up visits) and the ■ Worked down the backlog by looking ahead into the schedule (elimidemand generated externally from nated patients no longer needing an appointment, those needing furreferring physicians. An effective ther tests, or those who could be cared for in other ways) method to reduce external demand ■ Developed a service agreement with primary care providers (diagnosisfor specialty clinics is to build service specific consult requests with specific tests required for each, and agreements between primary and speongoing dialog and education) cialty care. Like Dr. Krisnamurthy, Dr. ■ Consults screened by physician assistant by protocols (with review by Terrence Duffy, staff urologist at the orthopedist as needed) Fargo VA Medical Center (now at the ■ Consults for subspecialists screened by general orthopedist St. Cloud VA Medical Center, St. ■ Reduced appointment types to two (new visit and follow-up) Cloud, MN) built a partnership with ■ Restricted access to scheduling to authorized staff only the internal medicine/primary care providers to decide the following: ■ Eliminated automatic rebooking for no shows ■ The types of patients who would be referred to him ■ What procedures would be done prior to the visit each of the most common conditions generating a referral, ■ How to structure the communication between him with accompanying order sets. In addition, Dr. Duffy and the primary care providers encouraged the primary care providers to call him with Using the VHA’s computerized patient record system questions, and he met regularly with the primary care (CPRS), Dr. Duffy created five urology screens, one for providers to evaluate the process. The primary care
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providers were able to refer patients and have them seen by Dr. Duffy on the same day. The results associated with these and the other changes Dr. Duffy and his team made in the urology clinic are shown in Sidebar 2 (right).
Strategy 2: Match Supply and Demand The central principle of advanced clinic access is balancing or matching supply and demand. If the demand is greater than the supply, there is a delay in providing care. If the supply is greater than demand, then resources are being wasted. When supply and demand are matched, there is no delay in providing care. To match supply and demand, a clinic should use the following methods to measure each one: 1. Measure true demand by recording the total number of patient requests received on any given day from both internal (return visits generated today) and external sources (phone calls, walk-ins, deflections to urgent care, and other sources of patient requests for services such as faxes or e-mails). 2. Measure supply. Supply refers to the total resources (people, equipment, offices, and exam rooms) available to a clinic. When the total resources are managed well, a clinic creates openness in its schedule or space to care for patients. Patients experience this openness primarily as the availability of clinic appointments (capacity). Capacity is the total hours of clinician time devoted to appointments. 3. Match true demand and capacity. If there is enough total capacity in the system to meet the total true demand, then often some simple
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Sidebar 2. Fargo VA Medical Center, Fargo, North Dakota. Terrence Duffy, M.D., Staff Urologist Results Waiting times were reduced from 20.7 days in April 2000 to one day in January 2002. This was accomplished with some reductions in the number of new appointments (391 to 132 during the same period), which may be attributed to a new referral process that cut down on the number of unnecessary consults.
Major Changes ■
Worked down the backlog (temporarily added appointment slots)
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Eliminated automatic rebooking for no-shows
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Reduced appointment types to two (regular and procedure appointments)
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Discharged patients back to primary care once their problems were addressed
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Used phone follow-up for patients when clinically appropriate (automatic e-mail prompts physician to call patient)
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Developed service agreements with primary care providers (computerized order sets for common conditions, primary care refers only sildenafil failures, prompt response for referred patients, and easy access to the urologist for questions)
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Developed quick medication order sets
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Optimized the care team: expanded nurses’ responsibilities, for example, by managing biopsy patients
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steps, such as aligning provider schedules to coincide with peak demand periods each week, can match supply and demand and improve access. If there is a mismatch between total capacity and demand, then other steps can be taken to align them, such as the methods discussed below for managing a panel of patients for primary care providers, equitably distributing new consults to specialists, reducing appointment types, and optimizing the care team to gain additional capacity.
Panel Management—VA Western New York Healthcare System, Primary Care Clinics For primary care clinics, the heart of matching supply and demand lies in each provider managing a specific group or panel of patients. Matching patients with their own providers whenever possible enhances accountability, improves continuity and patient satisfaction, and reduces the need for a visit to one’s own provider after having been seen by someone else. From the physician’s perspective, equitable panel size ensures that he or she will be able to offer good care in a timely way to a reasonable number of patients. In Buffalo, New York, Dr. John Sanderson, as medical director for the primary care clinics, shifted the clinic system from appointment management to panel management as part of the implementation of advanced clinic access. While using target panel sizes of 1,200 active patients for physicians and 1,000 for nurse practitioners and physician assistants, he taught the providers how to make their practices more efficient, enabling them to care for their panel. This included ensuring that there were adequate numbers of support staff and that the staff had the skills necessary to be effective team members and to use alternative visit strategies. At the same time, he outlined the following specific expectations for the providers: ■ Do same day urgent care as needed ■ Plan ahead for vacation or sick time ■ Take care of as many needs as possible at each visit ■ Refer responsibly and by service agreements As a result, the Buffalo primary care clinics now have fewer clinically unnecessary visits and better continuity. In 1999 only 10% of patients who were triaged as needing an urgent care visit actually saw their own providers, while by 2002 some 80% did.6
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In addition to matching supply and demand by establishing panel management as a foundation for primary care, Dr. Sanderson and his team used the two other strategies for improving access: They shaped demand by using clinically appropriate return visit intervals and redesigned the system to increase supply (see “Strategy 3: Redesign the System to Increase Supply Optimize the Care Team,” pages 420–421) by optimizing the care team. They began scheduling patients for return visits on the basis of a careful assessment of patient needs instead of old habits. The visits per patient per year in primary care at Buffalo and the rest of the Western New York clinic system decreased from 3.52 to 1.98, translating into 40,000 appointment slots saved per year for other purposes. The reductions in average next available waiting time for the Buffalo primary care clinics and the other changes made as part of their advanced access work is shown in Sidebar 3 (page 420).
Equitable Distribution of New Consults for Specialists—Martinsburg VA Medical Center, Urology Clinic In primary care the expectation is that there is accountability for all the patients within the panel. In specialty care, whereas it is crucial to have continuity through the episode of care, the goal is to enable specialists to see as many unique patients as possible because the specialists are often the “rate-limiting step” or constraint in the system. In other words, it is the specialist’s capacity to see patients that determines how many patients can flow through the clinic on any given day. In the urology clinic at the VA Medical Center in Martinsburg, West Virginia, the chief of urology, Dr. Prashant Mehta, and his care team worked together to ensure that new consults were distributed fairly among the three urologists in the clinic. All consult requests were screened either by Dr. Mehta or his trained urology nurse on the day they were received. Returning patients were scheduled with their assigned providers to enhance continuity of care. New consults were assigned to one of the other urologists, with each urologist taking new consults in turn.
Reduce Appointment Types Having a wide variety of appointment types increases total delay in a system because each appointment type
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Sidebar 3. VA Western New York Healthcare System, Buffalo Primary Care Groups, Buffalo, New York. John Sanderson, M.D., Primary Care Medical Director Results Time to next available appointment was reduced from 44.9 days in January 2000 to 24.9 days in August 2002, while the number of enrolled patients per provider full-time employee equivalent (FTEE) more than doubled from just over 400 patients in 1994 to more than 1,200 patients in 2002.
Major Changes ■
Worked down the backlog by extending return-visit intervals (as clinically appropriate)
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Adjusted provider schedules to meet predicted periods of peak demand (specific days of the week)
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Used effective internal communication within the team to better respond to patient needs each day
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Adopted a policy that providers are responsible for a panel of patients and provided training and support for the clinic team
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Strategy 3: Redesign the System to Increase Supply Optimize the Care Team
Optimizing the role that every member of a clinic care team plays is one way to improve clinic efficiency, enabling more patients to be seen on any given day. Because it is usually the physician who is the constraint (the scarce resource) in the clinic system, any tasks that can be done safely and effectively by other members of the care team should be removed from the physician. Using the same principles, every staff member should also be allowed to work to the highest level of his or her expertise and training. This
Created alternatives to clinic visits (that is, nurse phone follow-up, nurse clinics, and treatment by phone via protocols)
creates its own queue and consequently its own inclusion and exclusion criteria; that is, the more criteria, the more time it takes to put people in the line for a particular type of appointment. For example, if a surgeon sees new consults only on Tuesday afternons, a patient may have to wait several weeks to see the surgeon if all the Tuesday afternoon new-consult
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appointments are full for a particular week. A simplified scheduling system—one, for example, that schedules requests for new consults as they come in—creates more flexibility, allowing patients to be seen more quickly. This change can be used equally effectively in primary care clinics and specialty clinics. To create a new clinic profile system at Martinsburg, Dr. Mehta and his urology-clinic team consolidated 14 different types of clinic visits (for example, follow-up, new patients, preoperative assessments, minor procedures) into two appointment types (new patients and follow-up appointments) for each of the three providers. The new scheduling system also helped to equitably assign new consults among the urologists because a quick review of the week’s schedule could easily verify that patients were being distributed equally. The reduction in average next-available waiting time in the Martinsburg urology clinic during the period when these changes (as well as additional changes) were being made is shown in Sidebar 4 (page 421).
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concept applies to both specialty and primary care clinics. This optimizing concept was used in the urology clinic at Martinsburg. At the beginning of the advanced clinic access work, Dr. Mehta personally reviewed all incoming consult requests. Over time, Dr. Mehta worked with his urology nurse so that she could take over much of the routine screening function (that is, deciding on the completeness and appropriateness of the request), requiring only a review by Dr. Mehta. In the future, Dr. Mehta expects to be involved primarily in reviewing only particularly problematic cases. The same concept was applied in the Buffalo primary care clinics. As an alternative to a traditional face-to-face visit, triage nurses began assessing the clinical needs that arose for patients between appointments and chose the most appropriate response; some patients were seen by the nurse or even treated over the phone by protocols. Nurse clinic visits were also used for such minor procedures as blood pressure checks, blood glucose checks, minor irrigation, and immunizations. Clerks and nurses linked patients directly with dietary, psychology, social work, and even pharmacy and were encouraged to ask for provider advice when it is needed.
Results The case-study clinics highlighted in this article suggest a connection between the strategies and specific changes to improve access and reduced waiting times for patients. Sidebars 1–4 show reductions in patient waiting times for appointments ranging from 20 days in urology
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Sidebar 4. Martinsburg VA Medical Center, Martinsburg, West Virginia. Prashant Mehta, M.D., Chief of Urology Results Waiting time for urology-clinic appointments were reduced from 92 days in January 2001 to 14.4 days in January 2003. These results were achieved without adding staff and while maintaining a relatively stable demand for appointments as measured by the number of new consults (2,489 in fiscal year 2001, as compared with 2,152 in fiscal year 2002).
Major Changes ■
Established a no-show cancellation policy
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Screened new consult requests (urology nurse assists urologist)
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Worked down the backlog (temporarily decreased surgery time, expanded number of appointments)
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Benchmarked data with other clinics
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Developed a service agreement with primary care providers (minimum requirements, referral algorithms, grand rounds and visits with providers, and direct access to a urologist for questions)
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Created alternatives to face-to-face visits (phone consultation, nurse clinics, written postoperative instructions, and test results provided by phone)
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New clinic profiles: — Reduced number of appointment types from 14 to 2 — Decreased appointment times from 40 to 30 minutes for new patients and from 20 minutes to 15 minutes for returning patients (spaced evenly throughout the day)
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Restricted access to scheduling to authorized staff only
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Transferred stable patients back to primary care
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Table 1. Application of the Changes to Primary and Specialty Care Clinics For Both Primary Care and Specialty Care Clinics ■ Work down the backlog of already scheduled appointments ■ Align provider schedules to match peak demand for appointments ■ Reduce the number of appointment types ■ Extend the time between return appointments ■ Use alternatives to office visits ■ Optimize the members of the care team Specifically for Primary Care Clinics Assign each primary care provider responsibility for a specific group of patients (a panel)
■
Specifically for Specialty Clinics ■
■ ■ ■ ■
Establish service agreements between specialty clinics and primary care providers to clarify and streamline the referral process Screen consults as needed Transfer stable patients back to primary care Use protocols and medication order sets Equitably distribute new patients among all providers
to 78 days in primary care. There is some variation across clinics in the measure used to assess their progress— three of the clinics used time to next-available appointment, whereas the Buffalo primary care clinics used time to third-next-available appointment. Third-next-available appointment is the recommended measure because it eliminates the effect of last-minute cancellations or other events that may not accurately reflect the true “openness” in a clinic’s schedule. As long as comparisons across clinics are not being made (as is the case here), the nextavailable appointment serves as an adequate measure for within-clinic improvement tracking. These clinics demonstrate that the methods of advanced clinic access can be successfully adapted to both primary care and specialty clinic settings while also meeting the special characteristics and needs of each type of clinic. Table 1 (above) summarizes the application of the changes discussed in the article to each primary and specialty care clinic.
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Another result of the project was the emergence of the physicians and other clinicians involved in these (and other successful) clinics as experts in advanced clinic access who now mentor and train other clinical leaders throughout the VHA system. By serving as faculty on national and regional conference calls and at advanced clinic access meetings and other VHA events and as peer coaches giving advice and encouragement to their colleagues, they have become an internal resource to spread improved access to other clinics. This network of coaches also has opportunities to learn from one another about how to most effectively teach others about advanced clinic access through conference calls and meetings of their own. The VHA strategy is to continue to develop these experts as a group, constantly expanding their number to support additional clinics’ work on improving access for their patients.
Discussion The use of case studies such as the ones discussed in this article and the development of a network of access coaches as two key components of the VHA’s strategy to spread advanced clinic access are supported in the literature about the spread of innovation in systems. Everett Rogers discusses the attributes of a change that contribute to its adoption by others.7 One of those attributes is visibility. If others within the VHA can see from the case studies that advanced clinics access can work in the VHA, then they are more likely to try the advanced clinic access approach than they would be without the VHA case examples. The literature concerning the communication of technical information to support change supports the importance of an internal resource such as the network of access coaches in the VHA. Once a potential adopter has made the decision to adopt, the person needs detailed information about what to do and how to do it. Some of this information can be obtained from written material (for example, training manuals, documents), but often the adopter may need to ask a question of someone who is knowledgeable.8 The access coaches fill this role in the VHA. Although the results for the four clinics highlighted in this article are impressive, the question remains whether their gains are generalizable to other clinics in the VA and to clinics and office practices in other organizations. This article has focused on the four case studies, but hundreds
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of other clinics in the VHA are also applying advanced clinic access principles in their work. Currently 37% of the 1,800 clinics in all six clinic types targeted for the Advanced Clinic Access Initiative have implemented the entire set of key changes for advanced clinic access, with 75% reporting at least partial implementation.9 Systemwide improvements in access have also been made since the VHA began its efforts to improve access systemwide, the largest improvement occurring in primary care and urology, where waiting times were reduced by 53% and 48%, respectively, between 2000 and 2002.10 Although the clinics in the VHA system share some characteristics (employed providers and staff, a national clinic scheduling package, and a specific population of patients), there is much variation within the system. Some but not all VA medical centers have communitybased outpatient clinics, employ contract providers, or provide tertiary care and serve as referral centers for other facilities, and so on. This diversity suggests that the principles of advanced clinic access are robust across settings and types of clinics. However, the experience of other organizations with different structures and patient populations needs to be reported to fully demonstrate the generalizability of these results. There is also the issue of generalizability of results from urology and orthopedics to other specialties. Each specialty’s own unique characteristics may influence how best to adapt the strategies for advanced clinic access to their systems, such as referral sources and procedure-based versus non-procedure-based clinics. Yet the present case studies do not suggest that principles of shaping demand, matching supply and demand,
and redesigning the system to increase supply cannot be applied to other specialties. Finally, although the data reported in this article span a three-year period (fiscal years 2000–2002), many of the changes were put in place during the project’s final 18 months. Additional data will be needed to demonstrate sustained improvement over time. The VHA systemwide database provides the opportunity for ongoing tracking and feedback of these data. The results to date are encouraging. The VHA’s experience with the case-study clinics discussed in this article and with other clinics suggests a solid foundation for bringing advanced clinic access to every clinic and veteran in its outpatient system. J
Marie W. Schall is Director, Institute for Healthcare Improvement, Boston. Terrence Duffy, M.D., formerly Staff Urologist, Fargo VA Medical Center, Fargo, North Dakota, is Staff Urologist, St. Cloud VA Medical Center, St. Cloud, Minnesota. Anil Krishnamurthy, M.D., is Chief Orthopedic Surgeon, Dayton VA Medical Center, Dayton, Ohio. Odette Levesque, R.N., M.B.A., is Clinical/QA Liaison, Chief Network Officer, Department of Veteran Affairs, Washington, D.C. Prashant Mehta, M.D., is Chief of Urology, Martinsburg VA Medical Center, Martinsburg, West Virginia. Mark Murray, M.D., M.P.A., is President, Mark Murray and Associates, Sacramento, California. Renee Parlier is Program Manager for Advanced Clinic Access, Department of Veterans Affairs. Robert Petzel, M.D., is Network Director, Veterans Integrated Service Network 23, Minneapolis. John Sanderson, M.D., is Primary Care Medical Director, Buffalo Primary Care Groups, VA Western New York Healthcare System, Buffalo, New York. Please address requests for reprints to Marie Schall, M.A., [email protected].
References 1. Murray M., Berwick D.: Advanced access: Reducing waiting and delays in primary care. JAMA 289:1035–1049, Feb. 26, 2003. 2. Murray M. et al.: Improving timely access to primary care: Case studies of the advanced access model. JAMA 289:1042–1046, Feb. 26, 2003. 3. Williams M.: Help Me Now: Improving Access to Mental Health Services. California Coalition of Community Mental Health Agencies Newsletter, Oct. 2001, pp 23. 4. Murray M.: Reducing waits and delays in the referral process. Fam Pract Manag 9:39–42, Mar. 2002. 5. Department of Veterans Affairs: VHA/IHI Breakthrough Series Collaborative on Reducing Delays and Waiting Times: Summary Report (unpublished report). Washington, D.C.: Department of Veterans Affairs, May 15, 2000.
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6. Personal communication between the author [M.W.S.] and John Sanderson, M.D., Primary Care Medical Director, Buffalo Primary Care Clinics, VA Western New York Healthcare System, New York, Nov. 2002. 7. Rogers E.: Diffusion of Innovations, 4th ed. New York: The Free Press, 1995. 8. Bandura A.: Social Foundations of Thought and Action. Englewood Cliffs, N.J.: Prentice Hall, 1986. 9. Department of Veterans Affairs: Performance Monitor Reports. Washington, D.C.: Department of Veterans Affairs, Washington, D.C., Jan. 2003. 10. The Veterans Health Administration and the Institute for Healthcare Improvement: Advanced Clinic Access Initiative Final Report (unpublished). Washington, D.C.: Department of Veterans Affairs, Apr. 2003.
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