Same-Day Scheduling for Doctors

| Comments (3) | Misc
I wanted to point to Marina Krakovsky's interesting Slate article about the same-day appointment movement for doctors (sometimes called advanced or open access). The basic idea is that whenever patients call, you try to offer them an appointment the same day. Most of the doctor's schedule is kept open for appointments the same day so you can afford to do this. I go to the Palo Alto Medical Foundation, which uses this policy for their general practititioners, and I can attest that it works quite well. I don't always get to see my own doctor, but I generally get to see someone almost immediately, which is really nice. They don't seem to have the same policy for specialists, and it's pretty noticeable when you want to see one.

One essential feature is that the doctor's practice needs to accept some overcapacity. A detailed description of the issue can be found is here but the basic problem is the discreteness of the time units. Say you scale your capacity to match average load. On days when you exceed your average load you need to turn people away. This creates a backlog, but on days when you are under your average load, you generally can't call people in off that backlog, so you gradually build up a larger and larger backlog.

It would be of interesting to know how the overcapacity required to make open access work compares to the overcapacity required to make scheduled appointments work. Obviously, in a perfectly scheduled system, you can work with basically no overcapacity, bringing in an extra person to help out when the backlog starts to get too bad. But real systems have two forms of variance: emergency appointments and no-shows. Emergency appointments require you to keep some overcapacity to service them (the carve-out model), or deny service. By contrast, no-shows produce unintended overcapacity (airlines deal with this by overbooking, but if you're a doctor you can't really tell someone in your waiting room that you can't see them and compensate them with a free trip anywhere in the US). This means that you end up just being idle and doing paperwork, going home, or whatever.

I haven't done any kind of literature search for this, but it seems like a relatively straightforward operations research/queueing theory question.


The efficiency will depend to some degree ok scale. The reason you can hey a same day appointment but not necessarily with your own doc is that they are optimizing the scheduling over all the GPs at PAMF. A smaller outfit would have a harder time handling the overcapacity but of you have LPGA of docs and lots of patients, it helps smooth put the lumpiness and turns it into an actuarially simple problem.

Stupid iPhone auto-complete. LPGA = lots.

It's quite possible to at least be ready to cover emergencies without wasting time starting at the ceiling. One system that I saw in use, and usually working quite well, is to make the individual appointment time slightly less than the average, and then leave an empty appointment at relatively close intervals. For example, have an appointment every 10 minutes, and leave the last 10 minutes of each hour free. (Obviously this is not practical for professions where you need really long appointment times for most patients, but in most cases this, or a close variation, is good enough. I'll use these figures as example in this comment.).

The doctor can then vary a little bit based on expected load. They can often talk, or explain things, a little bit more, or a little bit less. And many patients arrive a little ahead of time, so if you have an already short-than-average patient, you can let the next one in, and then have more explanation/social time with them until the next appointment.
Usually, in this setting, if everything works well, the last patient will not need to wait for their appointment more than 5-10 minutes maximum, which most people take quite easily.

And if you do have a minor emergency pop in, they'll have to wait 50 minutes at the worst case. Which is admittedly quite a lot, but still the same day and won't have to be turned back. Or you can slide them in, and have the other patients suffer a delay. But in this case it won't push take the entire day, just the 5 patients max.

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