The Crowded Clinic | IHI - Institute for Healthcare Improvement http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities...

Home / Education / IHI Open School / Activities / Activities / The Crowded Clinic

Activities
Case Study
Video Library » The Crowded Clinic Key Topics:

Case Studies Equitable care delivery, engage

» Kate Ellis, MD, Family Physician, Charles River Medical Associates; Morana
front-line staff in improvement, care
Games and » Lasic, MD, Clinical Instructor in Anesthesia, Harvard Medical School and coordination and transitions,
Exercises Brigham and Women’s Hospital avoidable ED visits, redesign
processes and systems, transitions
Patient Stories » Learning Objectives: At the end of this activity, you will be able to:
in care, prevention and wellness,
Publishing Your Discuss potential ways to improve scheduling patient visits at a community
» engage patients and families in
Work health center. care, engage patients and families
in improvement, office practice
Discuss the importance of getting to know the traditions, behaviors, and
operations – access, person- and
beliefs of the populations for which you care.
family-centered care, triple aim –
population health, cost control
List at least three ways to make health care more accessible and equitable
optimization.
for a diverse population.

Description: You are one of the health care practitioners in a community

health center that provides primary care to a multi-ethnic, multi-lingual urban
community. Many, but not all, of the patients live below the poverty line.
Physicians and nurses see a large volume of patients with challenging
medical and psychosocial issues.

Lately you have realized that the scheduling of patient visits has become
something of a nightmare. Because of the high volume of patients, the wait
for an appointment for routine care can be anywhere from six to eight months
or more. Even acutely ill patients often wait for two to three days to see a
health care provider. Out of frustration, many patients are walking in without
appointments, often during lunch hour or late in the afternoon when everyone
is getting ready to leave.

What makes the problem so challenging is that 20 to 40 percent of patients fail

to show up for appointments on a given day…

The Case:

You are one of the health care practitioners in a community health center that
provides primary care to a multi-ethnic, multi-lingual urban community. Many,
but not all, of the patients live below the poverty line. Physicians and nurses
see a large volume of patients with challenging medical and psychosocial
issues.

Lately you have realized that the scheduling of patient visits has become
something of a nightmare. Because of the high volume of patients, the wait
for an appointment for routine care can be anywhere from six to eight months
or more. Even acutely ill patients often wait for two to three days to see a
health care provider. Out of frustration, many patients are walking in without
appointments, often during lunch hour or late in the afternoon when everyone
is getting ready to leave.

What makes the problem so challenging is that 20 to 40 percent of patients fail

to show up for appointments on a given day. Because of this high no-show
rate, every other appointment on physicians’ schedules is double-booked with
the expectation that, out of the 30 to 35 scheduled patients, only 20 to 25 will
actually show up. Occasionally, however, most of the patients do show up –
and when a significant number of acutely ill patients also arrive, the work
environment becomes unbearably chaotic for everyone. Providers become

1 of 5 20/03/2022, 4:16 pm
The Crowded Clinic | IHI - Institute for Healthcare Improvement http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities...

harried and more likely to make mistakes, patients wait for long periods of
time in crowded waiting rooms, and the atmosphere becomes increasingly
hostile as the stress level mounts.

It is clear that the quality and experience of health care for many of these
patients is suffering partly because of a simple lack of access to care. And it
is becoming increasingly clear also that the better-insured and English-
speaking patients may be getting better access: they are more likely to get a
timely appointment because they are more demanding of the system, and
they are more likely to keep and show up for their appointments because of
better communication. You are interested in finding a way to promote more
equitable access to health care.

Case Analysis:

The main problem that everyone is experiencing in this clinic is the high rate of
no-shows. It would be very easy to simply label the clinic’s patients “non-
compliant.” But is it so? As health care providers, the burden is on us to find
the most effective ways to serve our patient population. One possible
approach to the problem at hand is to conduct a survey in an attempt to
identify some specific reasons that may be contributing to such a high
percentage of no-shows.

When patients are surveyed about their reasons for not coming to
appointments, a few common reasons may emerge:

A sick patient waited so long to be seen that she got better and didn’t need
the visit – or got worse and had to go to the emergency room.

A patient did not have a phone, or his phone number changed, so he never
received the reminder message the day before the appointment.

A patient showed up for the appointment, but at the wrong date or time. He
misunderstood because of a language barrier.

A patient was afraid to take time off work and risk losing her job. It would
have been much easier for her to make an evening or weekend
appointment.

How to address this welter of concerns? You can begin by clearing away the
backlog of appointments. One possible solution is a system called Open
Access. This system allows patients to schedule appointments, even for
routine well care, on the same day – usually with their own physicians. This
approach has cascading benefits. For instance, if visits are scheduled on the
same day, there’s no need to make phone call reminders, eliminating the
problem of patients’ not having phones or not receiving the messages.
Further, if patients can choose a convenient time to visit (including evening
and weekend hours when they are more likely to be off from work), they
eliminate the risk of losing their jobs.

There are a number of ways to get this clinic, currently swamped, to a point
where it offers Open Access. This work is not easy and the transition period is
often quite challenging. Physicians can provide more services during each
visit (even if it means that the visits are somewhat longer), reducing the need
for the patients to return. The staff can also spend a set period of time --
perhaps four to eight weeks – working through the backlog of patients and
opening up the schedule for same-day appointments. This may lead to a
significant patient overload, so there may be a need for overtime work and
creative staffing until the backlog is cleared out (i.e. staff lunches may be
staggered so that appointments are available at lunchtime). The hope is that
patients will receive timely care, that they will be more likely to be seen by
their own doctors instead of the most available physician, and that they will be
more likely to avoid going to the emergency room for issues that can easily be
handled in an outpatient clinic setting.

In addition to making appointment schedules more conducive to patient

needs, other ways to serve patients better involve creating an environment

2 of 5 20/03/2022, 4:16 pm
The Crowded Clinic | IHI - Institute for Healthcare Improvement http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities...

more welcoming to the patients and more inclusive of the various cultures,
languages, and issues of the various patient populations. There need to be
some staff members who can speak the main languages of the patients and
who are representative of the diversity of the patients. There should be efforts
to educate staff members about the various cultural beliefs of different patient
populations. If patients perceive that they can trust the staff and be open with
them, they are more likely to comply with the treatment regimens and to make
follow-up appointments. Thus their medical problems are more likely to be
successfully diagnosed and managed.

Discussion Questions:

1. As mentioned above, one aspect of patient-centered care is fostering a

culturally sensitive and diverse clinic environment that makes patients feel
more welcome. What are some ways in which this may be
accomplished?

2. In order to provide good care for a culturally diverse patient population, it

is important to gain some understanding of their ways of being (their belief
systems, their traditions, their feelings towards western medicine, etc.).
Can you think of a particular patient population in your area that may have
unique beliefs about health and illness that would be important to
understand?

3. How well do you know your patients? Can you think of a patient
population (a culture, ethnicity, religious group, sexual orientation) with
which you do not have much familiarity? How might this lack of
knowledge impact your care?

4. What are some ways in which you could be better educated in regards to
the beliefs and traditions of the patient population in your area? How
might that intervention benefit the patients?

AVERAGE CONTENT RATING (11 users)

Please login to rate or comment on this content.

USER COMMENTS
by Anabell Escobar 4/25/2021 1:36:07 PM
considero que los pacientes agudos se benefician de la atención abierta,
ya que son pacientes que buscan la atención prioritaria, pero para el
caso de pacientes con enfermedades crónicas controladas seria mas
eficiente la atención programada. orienta al paciente al autocuidado, si no
hay una adecuada introspección de su enfermedad el paciente crónico
puede acceder al servicio en un periodo muy prologando y esto puede
afectar su salud.

Did you find this user comment useful? yes | no

Report This »

by Tonie Greve 5/23/2019 5:14:07 PM

I have worked with diverse persons and those who have no job security
so afraid of missing work and losing job. If we truly are going to have
access to care it needs to be a clinic that is opened for working families
and those with school aged children. An idea clinic hours 8am-6pm Mon-
Friday would help the factory/laborers patients and working parents to get
in for healthcare.

1 out of 1 people found this user comment useful. Did you? yes | no
Report This »

by Angela Dunn 4/8/2019 11:46:53 PM

Article gives an excellent strategy to solve the staffing problem.

3 of 5 20/03/2022, 4:16 pm
The Crowded Clinic | IHI - Institute for Healthcare Improvement http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities...

1 out of 1 people found this user comment useful. Did you? yes | no
Report This »

by Debra Walsh 10/17/2018 7:26:57 PM

We have this problem where I work. We have an access to care problem
and several no shows. I would like to present these ideas to our clinic and
I believe it could be a start at solving our access to care.

0 out of 1 people found this user comment useful. Did you? yes | no
Report This »

by Amy Lara-Lowrey 10/12/2018 7:01:21 PM

useful information with diversity becoming a way of accommodating all
populations

0 out of 1 people found this user comment useful. Did you? yes | no
Report This »

by D Ryan 10/30/2017 4:57:06 PM

The article is oversimplified and more theoretical. It ignores the biggest
issues: inability for parents/patients to take time off from work (working
parents with job insecurities, transportation and childcare issues) or
taking older kids out of school. Guaranteed sick leave or time off is a
significant solution which does not entail altering traditional hours of
operation of a primary care practice (unless extended hours are offered).
Open Access sounds good but does not eliminate the root causes.

1 out of 2 people found this user comment useful. Did you? yes | no
Report This »

by Bruce Sobers 6/9/2016 11:41:20 PM

I've worked as a clinical coordinator for a busy IR department, so
scheduling is a very important role in keeping not only the patients
satisfied, but also keeping the physicians working.

1 out of 2 people found this user comment useful. Did you? yes | no
Report This »

by Jennifer Morrison-Diallo 9/15/2015 11:09:14 AM

Regarding discussion question #3, this is a major factor that needs to be
addressed with the population that the public hospitals serve. For
example, I work in behavioral health. In the hospital in which I work, we
serve a variety of patients from a very culturally diverse background.
Even though staff have training about how to be a more "culturally
diverse" provider, these trainings are not enough and many staff are left
with the problem that they don't know how to address some of the cultural
concerns that patients face. For example, a high percentage of patients
served are from West Indian and African countries which at times
presents a major barrier for treatment when family members of the
individual with a mental health diagnosis do not believe that the diagnosis
exists. What is usually done by the treatment team in these situations is
counseling with the family members about importance of consistence of
treatment and what characteristics the diagnosis has.

4 out of 4 people found this user comment useful. Did you? yes | no
Report This »

by Diane Overzat 2/22/2015 1:52:48 PM

Implementing the open access program is a very useful way to get
patients ti schedule their own appointments if they understand how to use
the program itself. Clearing out the backlog would be quite a task.
Language is a barrier, where I live , the popular language is Spanish,
Knowing the language of the populace would be a great advantage for
the clinic. Most Spanish speaking people are catholic and there beliefs
usually do not have a barrier to health care.

3 out of 3 people found this user comment useful. Did you? yes | no

4 of 5 20/03/2022, 4:16 pm
The Crowded Clinic | IHI - Institute for Healthcare Improvement http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities...

Report This »

by Vicki Cramm 2/10/2015 8:53:17 AM

Interesting. In response to question #1, maybe the centre could have
racially diverse pictures and have pamphlets written for other
culteres/languages in the waiting room.

1 out of 1 people found this user comment useful. Did you? yes | no
Report This »

Show M ore C omment s...

CONTACT US | SUPPORT | PRIVACY | TERMS

© 2022 Institute for Healthcare Improvement. All rights reserved.

5 of 5 20/03/2022, 4:16 pm