Sustainability of improvements in access to outpatient specialist care in the Netherlands

Abstract

Objectives

To improve access to specialist outpatient clinics without adding capacity, Dutch hospitals applied the concept of ‘Advanced Access’. Our aim was to determine whether initial improvements are sustained for three years and to identify the factors that influence sustainability.

Methods

Qualitative case studies in 14 outpatient specialist clinics. Access measurements at the start, finish and three years after the project were compared. Analysis of sustained and new interventions. Interviews with 52 practitioners, analysed with the constant comparative method to identify general factors that influence sustainability.

Results

Eleven out of 14 clinics were able to sustain or improve their reduced delays; two did not and for one it is uncertain. The clinics maintained the majority of the interventions and all introduced new interventions. Three generic factors emerged that influenced their ability to sustain the results: increased responsiveness to better match supply and demand; clinical leadership and incentives; and a shared belief that they can and should control access together.

Conclusions

Reduction of delays in access can be sustained if the way of thinking and the planning system becomes demand driven and flexible and if care providers experience benefits. Unlike previous studies, senior management support and formal training was not relevant though clinical leadership and informal socialization was. Making multidisciplinary teams responsible for improvement appears to be vital.

Keywords

management operational research quality improvement

Introduction

Delays in access to specialist outpatient clinics are a common problem for general hospitals.^1,2 Dutch hospitals have successfully reduced delays by applying the ‘Advanced Access’ model.^3,4 But are such achievements sustainable, and which factors influence sustainability?

A common assumption is that solving delays requires additional capacity such as more doctors. In industry, logistical principles have been successful in minimizing delay without adding capacity, such as the principle of ‘pull logistics’ in which the day-to-day demand determines what is produced compared with a push system where production is based on exogenous criteria.⁵ ‘Advanced Access’ aims to ‘do today’s work today’ by improving the way demand and supply of appointments are matched and thus reduce unnecessary fluctuations in supply and increase the responsiveness to fluctuations in the volume of demand.³ It was translated and introduced to specialist outpatient clinics in the Netherlands as ‘Working without a waiting list’. Earlier research of 18 clinics showed that they were able to reduce delays by 55% on average, from 47 to 21 days.⁴

The limited research available on the long-term effects of redesigning care processes suggests that initiatives easily decay and lose their gains.^6–8 Organizations often are unable to maintain new work practices, as people soon fall back on old routines.⁹ Organizations may also fail to adapt to changing circumstances. Sustainability is therefore an important issue to be able to understand how changes can create long-term desired effects. Buchanan et al.⁶ identified several categories of factors that affect sustainability: individual, managerial, leadership, organizational, financial, cultural, political, processual, contextual, temporal and the change substance. Within these categories, there are several key factors: a shared vision, champions, motivation, feedback and a supporting culture.^10–13 However, according to Savaya et al.,¹⁴ ‘precise assessments of program sustainability are impossible to make on the basis of existing literature’.¹⁴

Fourteen specialist outpatient clinics applied Advanced Access between 2002 and 2005. They participated in Breakthrough collaboratives where multidisciplinary teams learn about Advanced Access and the required change methodology with the aim of reducing delays to less than a week.⁴ Over the course of one year, they exchange experiences and receive limited guidance to analyse processes and test interventions.

Our aim was to determine whether the clinics sustained the reduction in delays three years after the project and sustained their new work practices, and to identify the factors that influence sustainability.

Methods

Clinics were selected from 40 that participated in the ‘Advanced Access’ Breakthrough collaboratives using the following criteria (based on earlier findings that all statistically significant improvements in these projects were at least 30%⁴): a reduction in delay of at least 30% at the end of their project; standardized data on access at the start and end of their project is available; and detailed information is available on the introduced work practices.

We conducted qualitative case studies in 14 specialist outpatient clinics in 12 general hospitals in the Netherlands. The clinics included eight medical specialities (Table 1).

Table 1.

Mean delay (days) in each clinic at the start and end of the improvement project and three years later.

Specialism		Access delay
Specialism		Start project	End project	3 years later	Start to 3 years change (%)
1	Paediatrics	15	1	1	93
2	Rheumatology	43	10	5	88
3	Dermatology	35	3	7	80
4	Cardiology	56	32	13	77
5	Orthopaedics	128	81	45	65
6	Rheumatology	65	44	23	65
7	Neurology	5	1	2	60
8	Orthopaedics	31	17	13	58
9	Orthopaedics	63	20	30	52
10	Urology	21	10	12	43
11	ENT	38	20	28	26
12	Cardiology	32	13	26	19
13	Dermatology	33	19	28	15
14	Neurology	15	8	14	7
Average		41	20	18	57

Data were collected during the improvement projects and again three years later. To avoid research bias the clinics were at the time of the initial data collection not informed that there would be a follow-up three years later. We chose three years as in that time it is probable that clinics had to deal with new circumstances that can threaten sustainability.

Interviews were conducted with 52 people who are involved in managing access in each clinic: 17 medical specialists, eight support staff, 17 team leaders or department heads and 10 quality improvement staff. Each informant was asked 35 closed and open questions concerning: the current application of interventions; whether they consider their results sustainable and which factors they consider most influential for sustainability. We asked in detail how measurements are used to match supply and demand, how problems are addressed, who is responsible to keep delays in access low and how new colleagues learn how to match supply and demand. In preparation, we analysed the project reports to identify which interventions were applied during the project. We asked open questions about factors influencing sustainability and also used the categories of factors identified by Buchanan et al.⁶ as topics.

To determine the level of sustainability of access, we used two data sources. First, each clinic measured access during three weeks before they were interviewed. Access is defined as the average of the third available appointment for new and for follow-up appointments for each specialist. Second, each respondent was asked what the access had been over the years after the project, whether the current access is representative for that period and if they could provide additional data.

The constant comparative method of qualitative data analysis was used to identify the recurrent factors that influenced the sustainability of the results.¹⁵ Codes were developed based on the review, interpretation and comparison of verbatim quotations. Two researchers performed line-by-line review and coding of the interview transcripts. First, data of four clinics were coded independently and then discussed to negotiate consensus. If consensus could not be reached, a third researcher reviewed the data. This resulted in a preliminary list of codes. Second, all transcripts were coded using the preliminary list, and also by adding new codes until no new codes emerged. This list was used to categorize the data. These categories were further analysed and discussed to identify the general factors that influence sustainability.

Results

Access three years after the project

The average access after three years is 18 days, slightly less than the 20 days at the end of the projects (Table 1). Each clinic still has less delay in access than before the projects and for 10 clinics it is more than 30% less.

Respondents from all but two clinics stated that their current access was representative of the past three years. Those two clinics stated that access had been substantially better (clinics 12 and 14). Clinic 12 supported this claim with measurements of 50 weeks that showed an average access of 16 days, representing 50% improvement compared to the start. Based on the current measurements, 11 clinics (1–10 and 12) seem to have sustained their improved access or even improved it further. Two clinics (11 and 13) have not been able to sustain their results and for one clinic it is uncertain (14).

Figure 1 categorizes the clinics by their access at three years compared to the end of the project: shorter (at least 30% less); similar; longer but still at least 30% better than at the start of the project; longer, similar to start and longer than at the start of the project.

Figure 1.

Distribution of clinics as regards access after three years compared to access at the end of the improvement project.

Sustaining work practices or continuous improvement

Table 2 displays the interventions introduced during the project and which are present three years later. Ten clinics were still applying all interventions while four clinics stopped several interventions, but still apply the majority. All the clinics applied new interventions after their project, on average three per clinic. Most of these were implemented in the year after the project. No new interventions have been invented.

Table 2.

Improvement interventions carried out in each clinic.

1		2		3		4		5		6		7		8		9		10		11		12		13		14
Interventions	Paed		Rheum		Derm		Cardio		Ortho		Rheum		Neuro		Ortho		Ortho		Uro		ENT		Cardio		Derm		Neuro
PROJECT	3 YEARS	PROJECT	3 YEARS	PROJECT	3 YEARS	PROJECT	3 YEARS	PROJECT	3 YEARS	PROJECT	3 YEARS	PROJECT	3 YEARS	PROJECT	3 YEARS	PROJECT	3 YEARS	PROJECT	3 YEARS	PROJECT	3 YEARS	PROJECT	3 YEARS	PROJECT	3 YEARS	PROJECT	3 YEARS
Matching supply and demand
1. Weekly measurement of access time	√	X	√	√	√	√	√	√	√	√	√	X	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√
2. No cancelling of sessions within 6 weeks	√	√	√	√	N	√	X	√	√	√	√	√	√	√	√	√	√	√	√	N
3. Minimize number of queues¹	√	√	√	√	√	√	√	√	√	X	√	X	N	N	√	√	√	√	√	√	√	√
4. Anticipate fluctuations in demand	N	N	√	X
5. Short planning horizon	N	N	N	N	N
6. Create possibility of extra sessions on a short notice	N	√	√	N	N	N	√	√	√	√	N	√	√	√	√	N/X
Increase efficiency
7. Proactively fill empty slots	N	√	√	√	X	N	N	N	√	√	√	√	N	√	√	N
8. Delegation of non-medical tasks	N	√	√	√	√	√	√	N	N	√	√
9. Delegation of medical tasks	√	√	√	√	√	√	√	X	N	√	√	N	N	√	√
10. Appointment length based on measured times	N	N	√	√	N	N	N	N	√	√	N
Reduce demand
11. Patient initiated care for follow-up appointments²	√	X	√	√	√	X	√	√	√	√	√	√	√	√	N	N
Number of interventions	3	5	7	9	6	9	5	5	4	5	4	2	2	4	5	9	5	9	6	7	3	4	5	7	5	9	3	6

√

: intervention carried out during the project (in column ‘project’) and three years later (in column ‘3 years’); N: new intervention after the project; X: intervention that is stopped after the project; N/X: new intervention that started after the project and stopped again.

¹A queue is a part of capacity that is reserved for a specific use, for example, time slots that can only be used to book a new appointment or a session that is only for a certain type of pathology.

²Patient initiated care refers to enabling patients to decide when they need a follow-up appointment.²⁰

Three years after the project, the results are sustained and the clinics still apply the new work practices. The respondents state that demand did not decrease since the project and the number of specialists did not increase. So how were they able to reach this level of sustainability?

Increased responsiveness to better match supply and demand

Some clinics have sustained a short access with few interventions (e.g. clinics 4, 5 and 6), while others have sustained it with many (e.g. 2 and 3) (Table 2). The same diversity is apparent for the clinics whose access has declined: clinic 13 still applies 10 interventions, while clinic 11 applies four. Despite this diversity, each of the successful clinics increased their responsiveness to better match supply and demand by making access visible and increasing flexibility.

Making access visible

Most clinics closely monitor access by making it visible as a key indicator. Nine clinics still measure access weekly and convert these data into graphs. This not only enables a fast response to increasing delays but also helps to keep doctors aware of the consequences of cancelling sessions. ‘Access needs to be well monitored. That’s why I never stop measuring. If there is no monitoring or nothing is mentioned everybody starts to act according to his or her individual agenda’. (medical secretary, clinic 2)

Five clinics make the access data for each specialist available to everyone to create social pressure. ‘We measure every week and we mail it to each doctor. He knows his own access, but also that of his colleagues. That creates a nice form of competition’. (department manager, clinic 9)

Two clinics, with one week access, are able to respond quickly without measuring access because it is immediately obvious when access increases.

Flexibility of capacity

Many respondents identify flexibility of capacity as a crucial requirement to minimize delays. They distinguish three types of flexibilities. First, flexibility in the number of sessions per week. The clinics look for possibilities to run extra sessions when access increases, requiring extra work. ‘What we try to do is to run sessions when they are needed … That means working on a free afternoon or day. I think that sustainability is about being conscious of your actions and about being flexible to adapt’. (doctor and medical manager, clinic 3)

In some clinics, the decision to add extra sessions has been delegated to the support staff. ‘We have agreed that an assistant can, without asking, plan an extra session. That is actually a great result in itself’. (department manager, clinic 9)

Lack of flexibility to perform extra sessions is mentioned by one clinic as a cause why improved delays are not sustained. ‘We don’t perform extra sessions anymore when access increases. I’m frustrated, because we can’t offer an appointment to patients when they want it and we feel the pressure increasing’. (team leader, clinic 11)

The second type of flexibility involves the mix of appointments per session. Before the projects, all clinics had a fixed number of slots for each type of appointment. For example, a session always had six new and 12 follow-up appointments. This provided practical advantages. However, if eight patients ask for a new appointment and 10 for a follow-up, the number of fixed slots does not match demand. This will either lead to unused slots or a delay in access to ensure fully booked sessions. Almost all clinics made the appointment mix flexible and still do (Table 2). ‘We have changed the schedule for our sessions from fixed numbers of new and follow-up appointments to completely flexible with only five minute slots in which the supporting staff have full control to fill our sessions’. (doctor, clinic 9)

And third, clinics maintain buffer capacity to absorb fluctuations in demand. For example, two clinics plan 10% more sessions than anticipated demand. The efficiency gains of their project made this possible. ‘When you plan more time than needed on average, you have more flexibility … everything revolves around that’. (doctor, clinic 2)

One of the clinics stopped planning 10% extra capacity, and as a consequence delay started rising. ‘[After the project] we started planning a bit more than 100%… then someone started thinking the other way round and it goes wrong again … We don’t have enough flexibility anymore’. (quality manager, clinic 13)

The efficiency gains enabled clinics to meet growing demand. Some, however, think they have reached the limits.

There is more demand this year. When you consider all changes that we have made, there is not much room for further efficiency improvement. It has become a capacity problem. I feel we are really at the edge of our possibilities now. (doctor, clinic 3)

Clinical leadership and incentives

Increased responsiveness can only be sustained if a support structure is in place, based on clinical leadership and incentives. Making access visible is used not only to monitor demand, but also as an incentive for doctors by creating social pressure and competition. Another important incentive is the direct benefit experienced as a result of a short access: ‘The best motivator is the stress level when access increases. It’s very important that they feel an effect on them personally’. (quality manager clinic 3)

When delay increases, the support staff experience the pressure first. General practitioners start calling, patients complain and it takes much more time to plan appointments. Some clinics ensure that the doctors feel the pressure by transferring calls and complaints directly to them. Another incentive is that the respondents feel proud to deliver a good service. ‘It creates stability and it is a gesture towards patients and that is most important … That’s what I like about it. It’s patient friendly’. (doctor, clinic 2)

Some also state that a short access is needed because of increased competition between hospitals. ‘Our short access is the key to our success. Nothing else. Not because we operate well, not because we are friendly. It’s about accessibility’. (doctor, clinic 8)

In every successful clinic, at least one doctor is committed to minimize delays and invests time and energy to sustain the results. This doctor regularly checks access and takes action. ‘I track our access times and free agenda space. When I think that we will run into problems I ask colleagues to run extra sessions’. (doctor, clinic 2)

These committed doctors confront other doctors when they do not uphold proper work practices such as cancelling sessions at short notice. In addition, they enable support staff to uphold the required work methods, even when other doctors try to change it.

I once deliberately let it all go wrong. Then those who are least active came to complain … I explained how it was their own fault. It all depends on how you plan your holidays and conferences … We have a mutual responsibility for keeping access short, but that also entails an individual responsibility. I think they got the message. But once in a while someone needs to be reminded. (doctor, clinic 2)

‘I believe, if the doctor would stop … well, I doubt we could continue. Someone must support it with a lot of energy and faith.’ (assistant clinic 2)

No respondent mentioned the contribution of senior management as a relevant factor for sustaining results. Several doctors continue despite the lack of senior management support. ‘You get a pad on the back by the senior management and that’s about it. It becomes a bit tiresome’. (doctor, clinic 4)

During the projects senior managers were usually involved as sponsors. After the projects they did not change incentives and did not establish supportive structures to sustain the results.

In one of the two clinics that did not sustain their results, several respondents argue that this is caused by a lack of motivation and clinical leadership among doctors: ‘The doctors don’t seem to consider access important anymore. Their attitude is ‘that’s temporarily, it will correct itself’. But we see that access has become permanently longer’. (team leader, clinic 11)

A shared belief that they can and should control access together

Besides leadership and incentives, the respondents also emphasize the importance of a shared belief that they are able to control access, even that it is wrong not to. This belief is shared among the doctors as well as the support staff.

The project teams had made their own analysis of demand and supply, tested interventions, involved their colleagues and measured results. This involvement created a firm belief in the work practices and their own ability to control access. As a result, delay is no longer seen as the result of too much demand, but of bad planning. ‘Long waiting lists used to be a status symbol, because it implied that you are a good doctor. Now it states: “why are you not able to organize your clinic?”’ (doctor, clinic 10)

Many respondents demonstrate an intrinsic drive to sustain access. They continue because they believe in it. This does not imply that everyone agrees with each new working practice. However, the shared belief overrules individual preferences and the return of old habits.

The clinics that did not sustain results state factors outside their influence that frustrate their efforts; they feel unable to control access and less responsible.

We have all been convinced the past years of the importance of it all and how nice it is to work with a short access … Doctors want to perform more sessions, but there are not enough nurses and supporting staff … the motivation drops. There are people who say ‘if we just let the waiting lists rise again, we are likely to get more support. (doctor, clinic 13)

Discussion

Main findings

Eleven, maybe 12, out of 14 clinics sustained their reduced delays for at least three years. The clinics also sustained the majority of the work practices. The clinics focussed mainly on sustaining their results, not on further improvement. New interventions were introduced only during the aftermath of the project. No new work practices were devised.

The ‘Advanced Access’ concept advocates that an outpatient clinic needs to change the system by which demand and supply are matched, to prevent the return of the backlog.^3,4 Our results confirm that the clinics have remained flexible in the volume of their supply and respond quickly to fluctuations in demand with the use of feedback signals. In system terms, they apply pull methods.⁵ The clinics that did not sustain their results stopped being responsive. These findings are consistent with recommendations from other research on improving flow in care processes and on managing variation in demand.^5,16 Our research shows that pull methods are not only effective to reduce delays, but also to sustain the results.

In order to be sustainable, system change needs to be supported by incentives, clinical leadership and a shared belief that they can and should control access. The care providers are motivated by directly experiencing benefits from reduced delays. These are both rewards for maintaining changed behaviour (patient satisfaction, beating the competition) and disadvantages when returning to old habits (pressure, stress). This is consistent with other research.^7,17

It has been suggested that measuring results is an incentive.^14,18 Our study shows that it is important to make the consequences of actions visible; measuring results is one way to achieve this. Perhaps most important is clinical leadership; a doctor who persistently supports the interventions and who confronts those who waver. This is consistent with previous studies on the importance of champions.^7,8,11 Noticeably, the champions in our study are doctors. They are better able to address their colleagues as peers to uphold agreed work methods and ask for extra efforts. Furthermore, the respondents show a consistent belief that together they are able to control access, even that it is wrong not to. This shared belief legitimizes confronting and overruling doctors and others who do not uphold new work practices. These findings are also consistent with studies on sustainability that show the importance of cultural changes that support the relevant goals and work methods.¹⁷

Inconsistent with previous studies is the finding that respondents did not identify senior management support as a relevant factor.¹⁹ Perhaps this can be explained by the high level of influence of doctors on decisions in Dutch hospitals. However, when sustainability becomes dependent on changes in the larger hospital system or if clinical leaders leave, absence of senior management support could risk sustainability. More senior management involvement in an earlier phase of these projects might have supported sustainability by providing better monitoring and control access. But if it involved setting targets and controlling results, the impact could be negative. The respondents show a real sense of responsibility; it is their project, their targets and their results. Senior management involvement might have compromised this sense of responsibility and hence sustainability.

Another difference from other studies is that formal training and education did not appear necessary to sustain the lessons learned during the project.^17,20,21 The knowledge transfer seems to work effectively through informal socialization only. This may, however, be dependent on the continued presence of the initiators.

The question that remains is why these factors were present in most of these clinics. We speculate that the change strategy of the ‘breakthrough collaborative’ was important. Part of the strategy is to make a multidisciplinary team responsible for their own implementation process. They are taught the principles by their own peers, choose and test their own interventions, measure results and adapt these interventions. In each outpatient clinic, members of the improvement team still act as ambassadors of the principles and as clinical leaders.

Limitations

The study might have benefited from a longitudinal approach in which work practices and access is tracked continuously. However, a continuous presence could introduce bias and effect sustainability. Also, we did collect data during multiple time points and reports from the projects were available, plus most of our respondents worked in the clinics during the entire period.

We have compensated for subjective bias and recall bias by using different sources: outcome measurements, interviews with different respondents from different sites and project reports to confirm findings (triangulation). Still, subjective bias and recall bias may have influenced the results.

Recommendations

The role of senior management deserves more attention. Longitudinal studies could be adapted, if it were possible to prevent researchers influencing the clinical practice.

Improvement processes, without adding capacity, can sustainably replace access delays not only in specialist outpatient clinics but throughout hospital systems in general. This requires care providers to become more demand driven and the system to become more flexible in its response to fluctuations in demand. Investing resources in approaches that do not challenge conventional thinking and way a system is designed are unlikely to achieve sustainable results.

Care providers are able to control access once they understand the causes of delays and ways of tackling them. In addition, when they experience direct benefits in their work and if there is a clinical leader who takes strong ownership sustainable improvement is more likely. Policy makers and senior management do not need to lead, but should provide a supporting structure.

Footnotes

Acknowledgements

We are grateful for the interviews that were performed and transcribed by Daphne Metaal, Linda de Jong, Paulien Schoneveld, Anita de Nooijer and Claire Hostmann.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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