Adavanced access webinar #3 v2 jc

Welcome to the AETC NCHCMC Webinar January 31, 2012

To join the teleconference call 1-­‐877-­‐668-­‐4493 and enter the event number 668 246 315. If you are prompted for an access code, please press #.

This webinar will be recorded and posted in the Virtual Learning Lab.

Users must seek permission from the author of these slides if you wish to use them in your own presenta5on.

Improving Access; What’s it All About?

Catherine Tantau, BSN, MPA

Welcome!

Schedule of Webinars 1.

2.

3.

Jan 17 Pre-­‐work Review, Baseline measures Jan 24 Coaching Q and A Jan 31 AA: What’s it all About?

IntroducRon to Advanced Access 4. Feb 7 Coaching Q and A 5. Feb 14 AA: How to Make it Work Part 1…

Matching Demand and Supply 6. Feb 21 Coaching Q and A, discussion 7. Feb 28 AA: How to Make it Work Part 2…

Backlog Reduc5on 8. Mar 6 Coaching Q and A 9. Mar 13 AA: How to Make it Work Part 3…

Final High Leverage Changes 10. Mar 20 Closing Remarks and Ac5on Planning

copyright Tantau Associates

3

Objectives • Recognize the Gold Standard for Appointment access.

• Learn the characteris5cs, piValls and benefits of three Access models.

The Messenger Challenge‌

Your Resources…

• Presenta5ons • Advanced Access Informa5on Series – AA; What’s in it for Me? – What is Advanced Access?

• Ar5cle: Accessing Pa:ent Centered Care Using the Advanced Access Model, Catherine Tantau, Journal of Ambulatory Care Management • PCMH

What if….

…you could offer your paRents an appointment with the physician of their choice at a Rme that was convenient for them?

“I had to think about this for awhile before I jumped in. I realized everything in medicine has changed steadily constantly looking for better ways to diagnose and treat patients. But, office flow has stayed the same for 50 years. It is about time we pay attention to it “ Waiting list of 4 months for 26 years. Eliminated in four months— 50% now booked same day, 50% next day “Minor changes in flow can help greatly with a very busy schedule.”

3rd next available 15 days to 5 days in 4 months.

“I have seen that it works in other places so we have adapted the principles in our service.”

Achieved access goals in 5 months.

Access

An access problem is‌ Delay problem System property

The longer patients/families wait, The harder we work‌.

Established Patient Calls (Most) PCP Receptionist (4) #

New Patient Calls

(1/wk/MD)

Switchboard Admin.

- Q & A - Page Pedi MA - Assist patient

Hold Busy

Answer N.A.

recept

Appt. req.

Bounce to others when PCP recept. fall

Note: - No triage on phone - Occas. triage walk in

Check insur. & confirm on 2 systems new patients longer

Q & A Sick?

Not sure +

-

- Book it w/PCP - Overflow MD if walk in when avail

Next avail. w/PCP

Mesg. To MD min. -hours or lost

MD calls patient Q & A

+ Book it

30" hrs.

Advise

Note: Always see pts.

Appt.

Emerg. - ED

Admin. to resolve - non PCP - 1st available

- Add on sooner - Occas. Msg to MD or

Advanced Access AA is…

• No delays for an appointment.

• CONTINUITY for paRents and providers.

• Doing today’s work today

AA is Not… • Holding appts in anRcipaRon of same day urgent demand.

• A Walk in Clinic or Urgent Care Clinic.

• 100% open schedule each day • Telling pts to all back tomorrow

Advanced Access is the ability of a practice to…

…Offer paRents/families an appointment with the provider of their choice at a Rme that is convenient for them.

Start with an Aim The Gold Standard

Primary Care

Offer an appointment today for any problem (urgent or rou5ne) with the PCP or teammate in the absence of the PCP.

© Tantau & Associates.com

Feeling overwhelmed?

Gold Standard; Why Today ????

• • • •

Constant tension between medical definiRon of Urgent and paRent definiRon.

Nice for pts.

TransformaRve for the prac5ce Room to grow prac5ce TODAY. Compe55ve advantage

16

Advanced Access

NUMBER OF CALENDAR DAYS UNTIL 3RD APPT

2/28/06

1/31/06

12/31/05

11/30/05

10/31/05

9/30/05

8/31/05

7/31/05

6/30/05

100 80 60 40 20 0

5/31/05

• Innova5ve model • Primary, specialty care x 15 years.

• System wide applica5ons

Source: Providence CHC

PEDI OB/GYN I MED

Capitol Hill CHC - Providence, Rhode Island Decrease No Show rate CHHC NO SHOW RATE 2005-2006

AP RIL MA Y JU NE JU AU L Y GU ST OC SEPT T NO OBE R VE DE MBE CE R MB E JA NU R A FE BR RY UA R MA Y RC H AP RIL MA Y JU NE JU LY Au g Se pt Oc t No v De c

35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0%

PEDI OB/GYN I MED

Delay

What’s a “3rd Next Available”?

rd 3

next available appt…

• Anchor Measure for Access • Delay for a Rou5ne Appointment • 3rd more reliable indicator of access

3rd NEXT AVAILABLE PHYSICAL Carillion 3rd NEXT AVAILABLE PHYSICAL Medical Group 1 Carillion Medical Group Team Team 1 160

140

120

What’s a “3rd Next Available”?

100

80

HARCUS LEWIS PRINCE STAMBAUGH YOUNG ZIMMER

60

40

9/18/02

9/11/02

9/4/02

8/28/02

8/21/02

8/14/02

8/7/02

7/31/02

7/24/02

7/17/02

7/10/02

7/3/02

6/26/02

6/19/02

6/12/02

6/5/02

5/29/02

5/22/02

5/15/02

5/8/02

4/24/02

4/17/02

0

5/1/02

20

3rd Next Available Appointment (Standard Project Measure) Everett Clinic Team 30.0 25.0

Day s

20.0 15.0 10.0 5.0

1

0.0 12/1/2002 3/1/2003 7/1/2003 9/29/2003 11/11/2003 10/1/2002 1/15/2003 5/1/2003 9/1/2003 10/22/2003 1/1/2004 Month [Family Practice]

[Internal Med]

[Peds] 22 Â

Radiology Mammo 3NXA Appt

30 Days

20 10 0

6/9/03 6/23/03 7/7/03 7/21/03 8/4/03 8/18/03 9/2/03 9/15/03 10/6/03

Critical Access Design Elements 1. Con5nuity / familiarity 2. Appointment capacity 3. Demand and Supply equilibrium

1. Continuity Satisfaction Ratings Comparison of Provider Ratings (Qs 56- 65) by Demographics 1996 90

100 Ethnicity

Gender

80

Age

Educ

Health Status

Care Type

# of Visits

Tenure

Range PCP

90

Familiar Stranger

70

60

50

70

40 60

30

50 20

10

Am Africian Hispani White Indian Am. c

Range

19.8

21

23.3

PCP

78.5

81

79.5

Familiar

71.9

75

69.1

Stranger

58.7

60

56.2

Other Asian

Other

Male

Female

< 18

18-34

35-44

45-64

65+

LT 12

H School

PostSec.

College G.

Grad Sch.

Poor

Fair

Good

V. Good

1

2-3

4-5

6+

LT 1

1-2

3-5

6-10

11+

20.5

22.9

23.3

22.7

22.1

20.6

22.1

27.2

18.4

19.3

16.6

14.5

19.7

22.3

22.1

21.4

20.6

21.6

21.9

22.5

21.9

22.2

19.5

20.7

21.4

20.7

16.6

16.7

20.3

22.1

24.1

21.5

23.6

22.2

21.24

20.14

84

72

75.7

80.8

71.3

80

82.6

81.4

85.7

73.4

79.3

81.5

82.3

78.1

80.7

82.9

81.4

84.4

76.6

74.5

77.5

83.8

88.3

81.4

82.4

83.8

79.6

78.4

78.9

81

82.2

83.2

80.9

80.8

80.1

81.99

82.67

78

64.5

67

70.5

61.4

72.8

76.3

74.8

71.1

70.3

73.2

78.9

82.2

73.8

73

75.6

75.4

78.7

73.4

70

71.8

76.9

79.4

77.1

75.6

79.8

70.3

75.4

73

74.5

75.4

76.3

70.1

69.3

72.8

75.45

77.98

63.4

51.5

52.8

57.5

48.6

57.9

62

59.3

58.5

55

60

64.9

67.8

58.4

58.4

60.8

60

63.8

55

52.6

55

61.9

66.1

61.9

61.7

62.4

58.9

61.8

62.2

60.7

60.1

59.1

59.4

57.2

57.9

60.75

62.53

20.6

Chines Japane Filipino e se

ŠTantau & Associates

Excelle Prevent Contin Emerg Routine Urgent nt ive uing ency

40

%VG/EX

Range (Max_Min)

80

What is Continuity?

The rate at which patients see their PCP when coming in for primary care visit.

• Con5nuity decreases: • Hospitaliza5ons and LOS • ER visits • UC visits • Referrals • RX’s • Tests • Demand for appts.

• Con5nuity increases: • Pt, provider and staff sa5sfac5on ©Tantau & Associates

2. Capacity (appt supply) % Open Next Four Weeks

45% 40% 35% 30%

Dr. S

25%

Dr. T Dr. V

20% 15% 10% 5% 0% Sep-99

Oct-99

Nov-99

Dec-99

Jan-00

Appointment Availabilityâ&#x20AC;ŚCapacity Family Medicine Clinic Average Percentage of Appointments Open at 8:00 a.m.

60%

51%

48%

50%

56%

49% 46%

40%

33% 30%

35% 29%

28%

20%

42%

40%

37%

18% 10% 7%

7%

Dec-00

Nov-00

Oct-00

Sep-00

Aug-00

Jul-00

Jun-00

May-00

Apr-00

Mar-00

Feb-00

Jan-00

Dec-99

Nov-99

Oct-99

Jul-99

ŠTantau & Associates

Sep-99

4%

0%

Aug-99

10%

Patient / Physician Continuity Family Medicine Patient / Provider Continuity 90%

80%

75%

77%

75%

70%

70%

66%

77% 69%

69% 66%

60%

60%

70%

65%

60%

50%

53%

40%

36% 30%

20%

24%

17% 14%

10%

0% Jul-99

ŠTantau & Associates

Sep-99

Nov-99

Jan-00

Mar-00

May-00

Jul-00

Sep-00

Nov-00

Jan-01

#3 Demand and Supply Equilibrium • No Shows • Triage • Rework • Call backs • Messages • Testing • Rx’s

Demand

DELAY

Evidence of a stable reservoir ???

Supply

Access Continuum • Tradi5onal Model • Carve Out Model • Advanced Access Model

Traditional Model • Saturated schedules • Triage & rework; expensive resources (MD and RN) • Mul5ple appointment types, 5mes • Urgent , Rou5ne juggled • Capacity: Overbook, over there • Con5nuity: sacrificed, delayed

Carve Out Model • Smoller’s formula • Predict demand for Urgent • Reserve space for Urgent demand (carve out) • Rou5nes delayed; no space for intermediate care • Con5nuity: fair to poor • Capacity: Future filled or held

Carve Out Model Flaws • “Call back tomorrow” • Black market • Self – destruct

“Do some of today’s work today”

Advanced Access • Paradigm shio: No dis5nc5on between Urgent & Rou5ne • Evidence of stable reservoir • Backlog eliminated (good vs. bad) • Con5nuity: System property • Capacity: Future is open not held • Pull into today vs push in to future

Advanced Access • Fears: – Saturated schedules – Demand is insa5able – Panel size • PiValls: – Panel size – Supply side varia5on

“Do today’s work today.”

Traditional and Carve-outs In order to protect today, we push work to tomorrow.

Advanced Access In order to protect tomorrow, we pull work into today.

Results of Advanced Access • Reduced delays for appointments • Decreased Urgent Care and ED visits • Improved con5nuity for pa5ents and providers • Improved clinical outcomes • Enhanced compliance with guidelines • Reduced No Show rates • Growth opportuni5es and financials • Increased pa5ent, physician and staff sa5sfac5on.

ŠTantau & Associates

5/1/00

4/17/00

4/3/00

3/20/00

3/6/00

2/21/00

2/7/00

1/24/00

1/10/00

12/27/99

12/13/99

11/29/99

11/15/99

11/1/99

10/18/99

10/4/99

Days

Delay Reduced

3rd Next Avail. Appt. for PE Appt. with PCP

30.0

25.0

20.0

15.0

10.0

5.0

0.0

IPC2 White Earth source: Lori Sampson

Apr 17-21

Mar 13-17

Feb 14-18

Jan 17-21

Dec 20-24***

Nov 22-26

Oct 25-29

Sept 27-Oct 1

Aug 30-Sept 3

Aug 2-6

10 9 8 7 6 5 4 3 2 1 0 June 28 - Jul 2

May 31-June 4

April 26-Apr 30

Mar 29-Apr 2

Before Advanced Access

Mar 1-5

Feb 1 - 5

Jan 4-8

Dec 7-11

Nov 9-13

Delay for Appointments Wisconsin Group 1 Days to 3rd Next Available Appointment

After Advanced Access

Target Level

Days til 3rd Available Routine Appointment

ŠTantau & Associates

Emergency Department Visits ER Visits per 1000 Patients in Panel 20 18 Group 2

16 14 12 Group 1

10 8

Mar-99 Apr-99 May-99 Jun-99 Jul-99 Aug-99 Sep-99 Oct-99 Nov-99 Dec-99 Wisconsin Group ŠTantau & Associates 54% 53%

Delay dropsâ&#x20AC;Ś No Show rate drops

Source: Emory

Improved Clinical Outcomes 2000 1Q

120% 110% 100% 90% 80%

97%

97%

94%

88%

99%

98%

96% 88%

1999 Q4

86%

86%

93%

70% 60% 50% 40% 30%

1998 Q4

20% 10%

Lipids Colorectal BP - diag.

Tetanus Influenza Pneumovax Breast Ca Cervical Ca Tobacco Use Tobacco users advice % of serv. Complete

©Tantau & Associates

1998 Q 4 59% 50% 88% 50% 52% 65% 69% 76% 70% 93% 60%

1999 Q4 92% 74% 100% 80% 100% 92% 70% 95% 97% 90% 87%

2000 Q1 88% 97% 94% 97% 96% 88% 86% 98% 99% 86% 93%

Complete

% of serv.

advice

Tobacco users

Tobacco Use

Cervical Ca

Breast Ca

Pneumovax

Influenza

Tetanus

BP - diag.

Colorectal

Lipids

0%

Interventions: v Health prompt v Continuity v Advanced Access

Change in Visit Utilization

April 1995-March 1997 Sacramento

250,000

2.250

Visits

194,305 170,746

200,000

2.200

Visit Rate

Visits

2.150

150,000

100,000

Impaneled Members

2.100

83,867

86,896

(-8.3 %)

50,000 End Year 1

Visits / Impaneled Member

2.050

End Year 2 1.950

4/95 to 3/96

4/96 to 3/97 Year

ŠTantau & Associates

Avg. # Impaneled

2.000

Initiated Second Generation

-

Primary Care Visits

“Over and Under” Appointments

©Tantau & Associates

Getting Startedâ&#x20AC;Ś

The Big Picture: High Leverage Changes for Access Improvement • Balance demand and supply daily • Reduce backlog • Decrease appointment types, 5mes • Develop con5ngency plans • Reduce demand for visits • Op5mize the Care Team

Tools for Next Steps

Low Risk, High Impact Tools for Next Steps….

• Set an Aim…start thinking about this!

• Measure Delay; 3rd Next Available RouRne appt.

• Measure Appt Demand and Supply for each Provider

Tool #1: How to Measure Delay for 3rd next available appt.

• • • • • • • • • • •

Anchor Measure for Access Delay for a RouRne Appointment for each Provider Number of calendar days to third next available rou5ne appointment.

Pick appt type or length most delayed (physical?) to track Or, measure Long appts and Short appts. If that is more meaningful to you.

3rd Next Available a reliable reflec5on of system’s availability. 1st or 2nd appt likely due to cancella5on or random event.

Use your scheduling system; computerized or manual. Count number of days from today to the day when 3rd next appointment is available.

Measure for each Provider.

Measure same day and 5me each week … 7:30 Monday morning is good.

Plot the number of calendar days to the third 3rd next available appointment, each week An example of a Delay run chart …..

3rd NEXT AVAILABLE PHYSICAL Carillion 3rd NEXT AVAILABLE PHYSICAL Medical Group 1 Carillion Medical Group Team Team 1 160

140

120

What’s a “3rd Next Available”?

100

80

HARCUS LEWIS PRINCE STAMBAUGH YOUNG ZIMMER

60

40

9/18/02

9/11/02

9/4/02

8/28/02

8/21/02

8/14/02

8/7/02

7/31/02

7/24/02

7/17/02

7/10/02

7/3/02

6/26/02

6/19/02

6/12/02

6/5/02

5/29/02

5/22/02

5/15/02

5/8/02

4/24/02

4/17/02

0

5/1/02

20

Delay: 3rd Next Available Routine Appt NUMBER OF CALENDAR DAYS UNTIL 3RD APPT

2/28/06

1/31/06

12/31/05

11/30/05

10/31/05

9/30/05

8/31/05

7/31/05

6/30/05

5/31/05

100 80 60 40 20 0

PEDI OB/GYN I MED

Tool #2 How to Measure Appt.

Demand and Supply

Demand • Look at historical data?

• True Demand Formula: External Appointment requests, called in and appted regardless of day appted. To (today or future)

+ Walk-ins for appts. + Other portals of entry ?(email, fax,”add-ons” etc.) + Deflections (UCC etc, if possible) Internal

+ Returns booked today for the future

Total Demand © Tantau & Associates

56

Appointment Demand Worksheet Appointment Demand Worksheet Date: ____________

Care Unit 3

Patients calling today, requesting appt, regardless of day appted to (External)

Walk-Ins today appted (External)

Deflections, eg UCC, if trackable

Return appts booked today as pts leave today’s appt.

(External)

(Internal)

Total Demand

Provider A Provider B Provider C Total

Note: • Appt booking transactions are counted.

• What is on today’s schedule booked prior not counted.

Optional; Pts turned away, not booked.

Do not add into Demand

How to Track…

How long to track…

• Tic Marks vs Electronic tracking

• 4-­‐6 weeks and then forever

• Separa5ng Internal from External 58

Measured demand Monday Tuesday Wednesday Thursday Friday

Calls for visits 44 34 29 30 37

Other external demand 2 5 8 3 1

Internal demand 29 25 35 18 31

# appt per day 75 64 72 51 69

Appointment Capacity versus Demand Provider capacity

Measured demand

100

Provider capacity Monday Tuesday Wednesday Thursday Friday

# appt per day 70.125 61.5 87 58.875 84

90 80 70 60 50 40 30

VISIT RATE Provider A Provider B Provider C Provider D Provider E Provider F HOURS per session Provider A Provider B Provider C

20

Visits per hour 3 3 2.25 3 3 3

10 0 Monday

Mon AM 3.5

Mon PM 4

2.5

4

Total 22.5 0 14.625

Tues AM 2.5

Tues PM 4 3

Total 12 16.5 0

Wed AM 3.5 2.5

Tuesday

Wed PM 2 3 4

Wednesday

Total 16.5 16.5 9

Thursday

Friday

Thu AM

Thu PM 4

3.5

4

Total 12 0 16.875

Fri AM 3.5 2.5

Measured demand Monday Tuesday Wednesday Thursday Friday

Calls for visits

Other external demand

Internal demand

# appt per day 0 0 0 0 0

Appointment Capacity versus Demand Provider capacity

Measured demand

1 Provider capacity Monday Tuesday Wednesday Thursday Friday

VISIT RATE Provider A Provider B Provider C Provider D Provider E Provider F HOURS per session Provider A Provider B Provider C Provider D Provider E Provider F

0.9

# appt per day 0 0 0 0 0

0.8 0.7 0.6 0.5 0.4 0.3

Visits per hour

0.2 0.1 0 Monday

Mon AM

Mon PM

Total 0 0 0 0 0 0

Mon Total

0

Tues AM

Tues PM

Total 0 0 0 0 0 0

Tue Total

0

Wed AM

Tuesday

Wed PM

Total 0 0 0 0 0 0

Wed Total

0

Thu AM

Wednesday

Thursday

Thu PM

Total 0 0 0 0 0 0

Thu Total

0

Fri AM

Friday

Fri PM

Total 0 0 0 0 0 0

Fri Total

0

Supply • Macro Supply dept level …PCP’s and day5me UCC? • Deployment of Supply…bookable, clinical hours • Measures – Measure when schedule is released before booking.

– Appts per session for each day of week per provider.

– Es5mate % long and shorts based on prior schedules

– Hours per session ?

– Produc5vity standard?

– Office FTE modifica5on

• Process of Supply; later – What is the work?

– Who does the work? PCP and day5me UCC? – What can we try doing differently?

61

Appointment Supply Worksheet Appointment Supply Worksheet Week of:____________ Provider

Mon

Tues

Wed

Thurs

Fri

Sat

Provider A Provider B Provider C Total

Fill in numbers when schedule released

62 Â

Total Supply

Measured demand Monday Tuesday Wednesday Thursday Friday

Calls for visits 44 34 29 30 37

Provider capacity Monday Tuesday Wednesday Thursday Friday

# appt per day 70.125 61.5 87 58.875 84

Other external demand 2 5 8 3 1

Internal demand 29 25 35 18 31

# appt per day 75 64 72 51 69

Appointment Capacity versus Demand Provider capacity

Measured demand

100 90 80 70 60 50 40 30

VISIT RATE Provider A Provider B Provider C Provider D Provider E Provider F HOURS per session Provider A Provider B Provider C

20

Visits per hour 3 3 2.25 3 3 3

10 0 Monday

Mon AM 3.5

Mon PM 4

2.5

4

Total 22.5 0 14.625

Tues AM 2.5

Tues PM 4 3

Total 12 16.5 0

Wed AM 3.5 2.5

Tuesday

Wed PM 2 3 4

Wednesday

Total 16.5 16.5 9

Thursday

Friday

Thu AM

Thu PM 4

3.5

4

Total 12 0 16.875

Fri AM 3.5 2.5

Tracking Demand and Supply source: YKHC, Bethel Alaska

Supply & Demand 350 300 250 200 150 100 50 0 1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

Day of the Month Demand

Supply

S&D Average A pr-­‐05

Demand Supply

197 171

May-­‐05

186 179

J un-­‐05

J ul-­‐05

174 159 195 179

A ug-­‐05 S ep-­‐05 Oct-­‐05 Nov-­‐05

161 159 201 176

Dec-­‐05

156 164

J an-­‐06 F eb-­‐06 Mar-­‐06 A pr-­‐06 Average

216 211 192 174

168 146 176 150 118 173

Demand Supply

M 261 193

Weekly Averages W TH F 235 208 184 162 195 175

T 240 190

Average Weekly Supply and Demand

Family Medicine Supply & Demand Daily Average by Month 300

250

250 200

200 150

150

100 50

100

0 M

50

T

W Demand

0 Apr-05 May-05 Jun-05

Jul-05

Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 Average Demand

Supply

TH Supply

F

30

Your Next Steps Exercise….

• Set an Aim…

• Measure Delay; 3rd Next Available RouRne appt.

• Measure Appt Demand and Supply for each Provider

XXXX

Last Chance?

Whatâ&#x20AC;&#x2122;s next????????

Advanced Access Sequencing Steps

Foundation Steps

Empanel pts

Empanel pts

Set Access Aim…Gold Standard Measure delay…3rd next available routine appt Measure Demand, Supply, Actual Match Demand, Supply, daily and weekly

Action Steps

Reduce Backlog Simplify appt types/times Contingency planning Reduce Demand for visits Optimize the Care Team At every step…

Track and display data weekly.

Celebrate successes and failures!

© Tantau & Associates

Schedule of Webinars 1.

2.

3.

Jan 17 Pre-­‐work Review, Baseline measures Jan 24 Coaching Q and A Jan 31 AA: What’s it all About?

Introduc5on to Advanced Access 4. Feb 7 Coaching Q and A 5. Feb 14 AA: How to Make it Work Part 1…

Matching Demand and Supply 6. Feb 21 Coaching Q and A, discussion 7. Feb 28 AA: How to Make it Work Part 2…

Backlog Reduc5on 8. Mar 6 Coaching Q and A 9. Mar 13 AA: How to Make it Work Part 3…

Final High Leverage Changes 10. Mar 20 Closing Remarks and Ac5on Planning

copyright Tantau Associates

68

References…

•

• •

•

•

•

• •

Tantau, Catherine, Accessing Pa:ent Centered Care Using the Advanced Access Model, Journal of Ambulatory Care Management, Winter, 2009 Managing the Unexpected, Karl E. Weick and Kathleen M. Sutcliffe, University of Michigan Business School, 2001

Kilo, C.M., Trifflew, P., Tantau, C., & Murray, M. (2000). Improving access to clinical offices. The Journal of Medical Prac5ce Management, 16(3):126:132.

Tantau, Catherine. Same-­‐Day Appointments Create Capacity, Increase Access. Execu5ve Solu5ons for Healthcare Management, February 1999.

Tantau, Catherine, Murray, M., Sept 2000. Same-­‐day appointments: Exploding the access paradigm. Family Prac5ce Management, 7(8):45-­‐50. Retrieved January 15, 2004: huxp://www.aafp.org/fpm/ 20000900/45same.html.

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