Fabiane Erb, RHIA, VISN 2 Point of Contact for Advanced Clinic Access
John J. Sanderson, MD, Director, Primary Care, VA Western New York Healthcare System
Krishna Sharma, MD, Primary Care, VA Medical Center, Canandaigua, New York
Geoffrey McCarthy, MD, VISN 2 Care Line Director, Medical VA Care Line
Dee Anzalone, Administrative Officer, VA Outpatient Clinic, Rochester, New York
Daniel Brown, Administrative Officer, Medical VA Care Line, VA Western New York Healthcare System
Cynthia Rohe, RN, Nurse Manager, Outpatient Clinics, VA Western New York Healthcare System
Joseph Sacco, MD, Chief, Cardiology, VA Medical Center, Albany, New York
Mary Schohn, PhD, Clinical Coordinator, Behavioral Health Care Line, VISN 2
Martha Farber, MD, Chief Eye Clinic, VA Medical Center Albany, New York
Shirish Patel, MD, Lead Psychiatrist, VISN 2
Karen DeVolder, Behavioral Health Care Line, VA Medical Center, Bath, New York
Lisa Clifton, RN, Nurse Manager, Endoscopy Suite, VA Western New York Healthcare System
Susan Miller, Social Worker, Primary Care, VA Western New York Healthcare System
Sherrie Lenz, RN, Nurse Manager, Primary Care, VA Western New York Healthcare System
Catherine Harmon, Program Specialist, Primary Care, VA Western New York Healthcare System
Lucia McDonald, Administrative Officer, Medical VA Care Line, VA Medical Center, Albany, New York
Margaret Sardisco, Program Specialist, Medical VA Care Line, VA Medical Center, Albany, New York
Nancy J. Schmitz, RN, Nurse Manager, VA Medical Center, Albany, New York
Doris Whitbeck, RN, Nurse Manager, GI-Endoscopy, VA Medical Center, Albany, New York
Diane Bassett, RN, Practice Manager Primary Care VA Medical Center, Albany, New York
Julie Dugo, RN, Nurse Manager, VA Medical Center, Bath, New York
Judy Harris, RN, Patient Safety Manager, VA Medical Center, Bath, New York
Arlene Kelly, Public Affairs Officer, VA Western New York Healthcare System
Meryl Lefkowicz, RN, NP, Medical VA Care Line, VA Medical Center, Syracuse, New York
Jane Bujold, RN, Practice Manager, Geriatric Primary Care Clinic, VA Medical Center, Albany, New York
Michael Valerio, Audiology Manager, VA Medical Center, Syracuse, New York
Thomas Wisnieski, Diagnostics and Therapeutics Care Line Manager, VA Medical Center, Canandaigua, New York
Deborah Rioux, Primary Care Practice Manager, VA Medical Center, Syracuse, New York
Jacqueline Heaphy, Administrative Officer, Surgery, VA Medical Center, Syracuse, New York
Mary Ann Baumgartner, RN, Behavioral Health Care Line, VISN 2

• To assure that VISN 2 clinics meet VA timeliness standards of: 
  • Seeing patients within 20 minutes of scheduled appointment time 
  • Access to first appointments for new primary care or specialty clinic patients within 30 days
• To achieve same-day or "next clinic session" access for patients

• Access
• Demand
• Capacity
• Patient Flow (Efficiency — Cycle Time)
• Patient Satisfaction

VA Healthcare Network Upstate New York (VISN 2), part of the Department of Veterans Affairs (VA) Veterans Integrated Services Networks (VISN), has focused on measuring and improving waiting times and clinic timeliness since 1996 and, combined with use of process improvement tools and the IHI Framework for Spread, implemented Advanced Clinic Access (ACA) network-wide from July 1999 through September 2003 in nearly 1,300 clinics, for over 130,000 patients.

In late 1996, a network-wide workgroup began monthly measurement of waiting times for clinic appointments in VISN 2, as part of the efforts of the VISN 2 Customer Service Council. VISN 2 encompasses VA medical centers and community-based outpatient clinics in Upstate New York, ranging from Buffalo in the west to Albany in the east.

Once the regular monitoring and measurement cycle was established and regular reports were being provided to VISN 2 leaders and clinic staff, the effort shifted to sharing tools and techniques for improving the efficiency of outpatient clinic processes. VISN 2 established a requirement for clinic managers to respond to senior leaders with action plans to improve performance for any month in which their clinics did not meet threshold performance levels. To support the clinic managers, the Customer Service Council provided coaching and analysis workgroups. The Customer Service Council was the catalyst for a culture shift in VISN 2 — from staff-centered focus to a patient-centered focus.

From July 1999 through March 2000, VISN 2 joined VA’s national work with the Institute for Healthcare Improvement, in a National Collaborative on Reducing VA Clinic Waits and Delays. VISN 2 continues to use the model that the IHI designed and the VA applied as a strategy for spread that includes the following elements: 

• Organizational infrastructure
• Information about Advanced Clinic Access
• Communication

The Social System:

VISN 2 adapted the model and conducts "Internal Collaboratives" to spread the Advanced Clinic Access concepts and tools to all outpatient clinics in the VISN. A more informal approach using “peer-to-peer” discussions is also being used. As of September 30, 2003, VISN 2 has spread ACA concepts to 100 percent of VISN 2 clinics. VISN 2 uses the VA's "10 Key Changes" of Advanced Clinic Access:

• Work Down the Backlog 
• Reduce Demand 
• Understand Supply and Demand
• Reduce Appointment Types
• Plan for Contingencies
• Manage the Constraint
• Optimize the Care Team 
• Synchronize Patient, Provider, and Information 
• Predict and Anticipate Patient Needs at Time of Appointment 
• Optimize Rooms and Equipment

Results

• VISN 2 has presently attained Advanced Clinic Access for over 100,000 of our primary care patients
• VISN 2 was ranked #1 among VA’s 22 VISNs in the patient satisfaction category for Access in Fiscal Year 2002 and again in Fiscal Year 2003
• VISN 2 has led the VA for six years (1998-2003) in patient satisfaction related to waiting time to see provider at time of scheduled appointment

Lessons Learned 

• Strong leadership support is essential 
• A deliberate, persistent approach pays off
• Use of the IHI spread model for further implementation of ACA in VISN 2 clinics will continue, and must become "the way we do business"
• This is about changing culture and comes with all the usual resistance to change
• Using a framework such as the IHI developed spread model with tools (VA's 10 Key Changes) helped staff members develop awareness and expertise, and supported the implementation of Advanced Clinic Access
• Accountability is key — VISN 2 will test the applicability of this spread model in another improvement initiative for Optimizing Patient Flow through the Continuum of Care in 2004

Fabiane Erb, RHIA, Health Systems Specialist
VISN 2 Point of Contact for Advanced Clinic Access
VA Western New York Healthcare System
Fabiane.Erb@med.va.gov

[*Storyboard presentation at IHI's National Forum, December 2003]