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Advanced Clinic Access: Enhancing Access by Reducing Clinic Wait Times

Reducing wait times for clinic appointments is a high and visible priority for VA, and has been for several years. In 2000, in an environment of growing demand for VA health care and long wait times for clinic appointments in many areas, VA launched a national program, the Advanced Clinic Access (ACA) Initiative, to reduce wait times in targeted clinic areas across the system.

ACA, by now widely-recognized across VA, is a well-established set of 10 clinical operational practices called key change principles for organizing and managing clinics so that patients have access to the medical care they need--when and where they want it. To encourage and support the use of these principles, the ACA Initiative, working originally with the Institute for Healthcare Improvement (IHI), built an extensive infrastructure, including: a national steering committee, a full-time national clinical director, a person designated to lead ACA in every VISN and most medical centers, and a network of clinical access coaches to stimulate peer networks of advocacy and support. As intended, the infrastructure has continued to strengthen and expand and is now referred to as VHA Systems Redesign.

An important component of the original ACA Initiative was a comprehensive evaluation of the implementation and effectiveness of ACA. The evaluation, based on the experience of clinics in 78 VAMCs in 2003, was commissioned by the ACA Steering Committee and conducted by the HSR&D Management Decision and Research Center (MDRC), now the Center for Organization, Leadership, and Management Research (COLMR).¹

The evaluation found that successful ACA implementation, defined as the use of a high proportion of the ACA principles, was significantly associated with shorter wait times, with the relationship stronger in primary care than across specialty clinics. Underlying this overall good news, however, was substantial variation across clinics and medical centers in the extent to which the ACA principles were implemented. In order to implement ACA more consistently, it is important to understand the factors that account for this variation: Why were some clinics more successful in implementing ACA principles than others?

Local Factors Affect Successful Implementation of ACA

While the ACA infrastructure provided important resources and support for ACA, local factors were also important. The ACA efforts at the national and VISN levels interacted with people, processes, and structures within medical centers and their clinics. One source of variation in factors affecting implementation is the six clinic areas targeted by ACA (primary care, orthopedics, eye care, cardiology, audiology, and urology). Each of the six clinic areas is based in its own professional history and practices, and each clinic area approached ACA differently. However, across target clinic areas, five factors were significantly associated with successful ACA implementation:

• Strong management support for ACA, as demonstrated in concrete actions of: appointing an ACA oversight body to elevate the visibility of ACA, incorporating ACA into facility priorities, holding managers accountable for improvement-related performance, explicitly designating champions for each clinic area, reporting on ACA progress and lessons at meetings of senior managers, and targeting resources to remove obstacles to ACA implementation.
• Clinic teams having the knowledge and skill needed to do their work well and make changes successfully, as reflected in: seeking information and effectively using that information; using data regularly to design, test, and track process improvements; regularly assessing team progress; and learning from efforts of others to implement ACA.
• Clinic staff review of ACA wait time performance data that is trustworthy and timely so that clinic teams providing care can assess the current level of the problem and monitor the impact of improvement efforts.
• Adequate clinic resources, reflected in primary care by more exam rooms and in specialty care by greater use of consulting physicians.
• High demand for care in primary care (but not specialty care), as evidenced by a high number of patients on the wait list, suggesting that greater unmet demand provides an impetus for change. Attention to these factors promises not only to strengthen future implementation of ACA, but also to offer lessons in implementing other complex clinical innovations.

References

1. Lukas CV, et al. Implementation of a Clinical Innovation: the Case of Advanced Access in the Department of Veterans Affairs. Journal of Ambulatory Care Management, 2008; 32(2): 94-108.