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INTRODUCTION
As Alyssa Rege of Becker’s Hospital Review states, “U.S. Healthcare requires a lot of waiting”.

The idea of improving patient access or reducing patient wait times becomes more and more relevant as we monitor the trends in healthcare. Patient wait times are only expected to increase as the nation’s physician shortage increases.

It takes an average of 24 days to schedule a first-time appointment with a physician — a 30 percent increase since 2014, when the average wait time was 18.5 days, according to The 2017 Survey of Physician Appointment Wait Times and Medicare and Medicaid Acceptance Rates .

Because longer wait times result in more cancellations and no-shows, patient access has become a pressing issue for medical organizations nationwide. This guide was designed to showcase ways other organizations are fixing their patient access problems  - from manual workarounds to technology solutions.

Who is this guide for?
This guide was created for operations and schedulers managers to shed some light on the pro's and con's of the different types of waitlists. 
UNDERSTANDING THE PROBLEM
Meeting patient demand and reducing wait time go hand in hand. An analysis of over 4.2 million appointments by athenahealth demonstrated just how closely correlated cancellations rates are with the length of patient wait time. The report showed, on average, a new patient who waits more than a month for a first appointment is more than twice as likely to cancel and not reschedule as a new patient who is scheduled within a week.
Although long wait times can indicate a highly-renowned physician, they also arise as a result of the demand and supply imbalance. This imbalance can lead to prolonged patient suffering and dissatisfaction, physician burnout, and an increase in at revenue at risk.

Forbes reports, by 2030, the U.S. population of Americans aged 65 and older will grow by 55%, which makes the projected shortage especially troubling. As patients get older, they need two to three times as many services, mostly in specialty care, which is where the shortages are particularly severe, further exaboristrating the patient wait time. Thus, medical organizations started doing the only natural thing...adding patients to a waitlist.
COMMON WAITLIST WORKFLOWS
For organizations that have a waitlist option, there are traditionally two ways patients are added to a waitlist, practice-offered and patient-requested.

Practice-Offered Waitlists: Schedulers ask patients if they want to be put on a waitlist or be notified if an earlier appointment opens up.  This is often offered in response to a patient expressing dissatisfaction with the original  appointment.

Patient-Requested Waitlists: Require patients to ask if the office if they can be added to a waitlist. Not all patients are comfortable with initiating this request, so these lists are often shorter.
WORKFLOWS
Waitlist workflows vary drastically from organization to organization. Here is a breakdown of some of the most common waitlist workflows:
Waitlists outside of the medical scheduling software system

Keeping a waitlist outside of the medical scheduling software. Often times this is done via sticky notes, Microsoft excel, or a third party system.

Advantages

  1. Proactive - Patients are getting notified about earlier appointments by your staff.
  2. More accurate- Allows for schedulers to account for patient preferences around time and day of week which can improve the fill rate.
  3. Low cost- hard costs associated with this method are low but fill rates are also generally low (this does not account for the additional work required from staff and can impact your FTE hiring assumptions).
Disadvantages

  1. Disorganized - because there little to no set process across different offices or schedulers Managing a waitlist manually can lead to increased scheduler stress levels.
  2. Complex tracking- The ability ability to measure how many patients are in the waitlist or how many get off the waitlist is very complex, if possible at all.
  3. Time consuming - to be managed right it requires manual calling and manual rescheduling
  4. Siloed - schedulers may not be able to see all the patients on the waitlist, which could result in earlier appointments being offered to multiple patients.

Patient Call Back

Although this would not technically be called a waitlist, we hear from many medical organizations who are using this method as a way to reduce patient frustration. Patients are told to call back in, usually in the morning, to see if there are any last minute openings for that day.

Advantages

  1. Simple to manage - Staff do not need to maintain a waitlist.
  2. Fewer outbound calls – since staff do not need to call patients to fill cancellations, they have fewer outbound calls to make.
  3. Free - there are little to no hard costs associated with this method ( however, this does not account for the additional work required from staff)
Disadvantages 

  1. Disgruntled patients – patients are now asked to make more phone calls to ask to see the doctor earlier. They might even be told no repeatedly! Many won’t make the call, so they will be forced to wait weeks for an appointment or will look for care elsewhere.
  2. More inbound calls – the increase in call volume for the patients interested in earlier appointments will redirect schedulers attention from patients calling about new appointments or who need urgent help. Many of these patients will go elsewhere.
  3. Fewer filled cancellations – Instead of actively trying to fill cancellations, schedulers are relying on luck in the from right patient calling in at the right time.
  4. No Tracking - there is no ability to measure demand. Including, how many patients are on the waitlist or how many actually get an earlier appointment, which masks demand when when making personnel decisions.
Hacked waitlist software

Many organizations, regardless of whether their medical office software or medical scheduling software system has a waitlist, “hack together” a waitlist. Some examples we have seen include: scheduling appointments far in the future with a fake provider (eg. Dr.Waitlist) scheduling patients for a time when the office isn’t open, or adding certain text in the comment section (eg. #waitlist). This process is more organized than a waitlist outside the EMR but still leaves many holes and opportunities for error.

Advantages

  1. Ease of use - Staff is not required to manage multiple programs (or keep track of notes/documents), there is no switching between programs.
  2. Quicker to add patients to the waitlist- generally speaking, it is usually faster for schedulers to follow this method than adding patients to a “waitlist” (paper or electronic.
Disadvantages

  1. Human Component - Requires staff to change their workflow by scheduling these patients with a false appointment.
  2. Error Prone - the ramifications of an error is higher if a patient is scheduled with a fake doctor or time. If your staff is not able to reschedule them, they have a horrible patient experience.
  3. Time consuming - Still requires manually adding them to the list, calling and rescheduling of available appointments, which take 8 minutes per rescheduled appointment..
  4. Complex tracking- The ability to measure how many patients are on the waitlist or how many get off the waitlist is very complex, if possible at all.

Waitlist Software

Some scheduling systems have waitlist workflows built directly into the scheduling system allowing schedulers to add patients to a waitlist without leaving their scheduling system.

Advantages

  1. Ease of use - Staff is not required to manage multiple programs (or keep track of notes/documents), there is no switching between programs.
  2. Faster Rescheduling - having all the required information right in the scheduling system, reduces number of clicks to find and reschedule patients. Which will shorten the amount of time staff spends on rescheduling the patient.
  3. Increased Customization and Transparency - depending on the service provider, capturing information like patient time preferences and or creating staff alerts, help improve the success of using a waitlist.
  4. Scaleable and Reportable - all schedulers have access to all the patients on the waitlist in real-time. They can allot a portion of the day to calling patients and offering earlier appointments. They can also measure and track supply and demand. Ability to measure demand and how many patients are in the waitlist.
Disadvantages

  1. Human Component - Requires staff to change their workflow by add patients to a waitlist and managing that waitlist on a daily basis.
  2. Time consuming - Although staff will save some time on the rescheduling of the appointment with a waitlist in the scheduling system. Adding patients to a waitlist takes extra time per appointment booked. This process also requires manual calling and manual rescheduling of available appointments.

DOES THE WAITLIST WORK?
Although, often viewed as the primary way to improve patient access (without adding more providers), waitlists are often viewed as both a patient-pleasing and acceptable solution to the patient access problem. However, there are a few key reasons medical organizations are not successful when rolling out a waitlist process (1) when used, they only include a small fraction of the patients who would want an earlier appointment and (2) they create perpetual work, when you fill one appointment it creates another opening. (3) They add more work for you already overworked schedulers. The fluidity required of medical schedules is not conducive to manual work/human component.

We recently conducted a Status Report for a 40 provider practice before they went live with QueueDr. This is a group had a very disciplined processes for managing the waitlist. When we looked at 9,454 visits, we found they had one patient on the waitlist.


Customer Case Study: A customer of ours ran a test. They used QueueDr and told it to only text patients on the waitlist for one month. Then, the next month they used QueueDr, but allowed the product to text patients booked more than one week in the future who were clinically eligible.
The Results
Patient access improved in both cases but the difference is staggering. We found reaching all clinically eligible patients resulted in a 43x improvement in patient access over using a waitlist and resulted in 7x more appointments filled. 

Waitlist Only:  161 patients were contacted for earlier appointments. 41 appointments were filled.

Clinically Eligible Patients:  161patients were contacted for earlier appointments.appointments were filled.
SO THE WAITLIST DIDN'T WORK, WHAT SHOULD WE DO?
Apart from some technology, which we will get into later, here are some ideas you can implement today to help you improve patients access without burdening your staff (or patients).

Open access

Leave 30-50% of the schedule open every day for patients who call in. Once the day fills up, either book people out or have people call in the next day.

Upside: this allows sick patients and, when combined with good templating, newer patients to get in sooner. It will decrease  patient no-shows since patients are waiting less.

Downside: studies of open access find that it is quite taxing on the staff. Anecdotally, we’ve found that practices who do this, often oversimplify their appointment types, resulting in heavy disorganization that they have to later correct. Fundamentally this decreases patient access for anyone who schedules ahead, and rewards/prioritizes same day appointments.  This also puts more revenue at risk, same day calls need doesn’t match open appointments, otherwise you will have large fluctuations in your revenue at risk.

Telehealth

Any patient who is booked out far for a follow-up is seen earlier via telehealth.

Upside: Faster access to care for patients

Downside: it’s expensive and requires incredible coordination between staff and technology. We have not seen any group do this at scale.

More Providers

The theory is simple, if you have a waitlist, hire more providers – both mid-levels and MDs.

Upside: You shorten the wait!

Downside: Hiring more providers isn’t always an option and doesn’t account for patient preference. There is a decades old shortage of physicians and nurses and in many geographic areas it can be tough to attract talent. Furthermore, hiring more providers means adding more real estate which can be costly and require more management, leading to a slippery slope.

OnDemand Schedule Management

Automated services which allow you embrace the fluid nature of your schedule. These solutions allow you to offer earlier appointments to clinically eligible patients. Depending on the solution you will find these operate with very little to no human components (ie your staff does nothing). 
   
Upside: No waitlist or change to staff workflow. More patients brought in earlier and fuller schedules. Your at risk revenue is reduced.

Downside: IT procurement processes can be time consuming.
CONCLUSION
Patient access is only getting more important. Waitlists, regardless of type, will provide small improvements in patient access but come at a cost to your staff productivity and patient convenience. Running reports on cancellations and no-shows will help you fully understand your patient access needs and evaluate if a manual solution or an automated solution is a better fit for your organization. 


Bonus Content

Five things to look for when shopping for OnDemand Schedule Management Tools

    - A solution that is completely automated, any staff work will derail the success
    - A solution that meets the complex customization needs of your organization (examples include: location management to provider preferences and appointment type templating).
    - A solution that influences the entire patient access lifecycle (features include: appointment reminders, appointment management, transportation coordination, schedule balancing)
    - A solution that meets the demands of your patients in a consumer-driven healthcare environment.

Enjoy That Reading?
Check out The Definitive Guide to No-Shows.
Want to automate your waitlist away?
Schedule time with QueueDr.