Wave SchedulingOptimize Clinic Flexibility and Efficiency

1. Recommends an outpatient scheduling approach that maximizes clinic capacity and flexibility while minimizing running behind schedule

2. Offers a solution to see more of your patients with same-day or next-day needs

3. Promotes greater flexibility to meet more of your needs for work-life integration

The approach practices follow to schedule patient visits contributes to the quality of patient care and physician job satisfaction. A well-constructed outpatient schedule will accommodate patients requiring more time and allow the repurposing of unused time when patients need less. By scheduling the appointments within each hour on a wave—or front-loading—your practice can optimally manage the tension between access and timeliness, facilitating improved continuity and financial stability while reducing frustration and waste.¹

1. Recognize Predictable Unpredictability in the Schedule

2. Schedule on a Wave

3. Use 2 or 3 Exam Rooms

4. Build in Buffer Time

5. Schedule the Next Visit at the End of This Visit

6. Open Schedules 13 to 18 Months in Advance and Add Placeholders

7. Plan for Telehealth Visits

8. Avoid Over-Paneling in Ambulatory Practices

9. Incorporate Practice Fundamentals to Maximize Panel Capacity and Schedule Flexibility

Patient needs are inherently variable and unpredictable; it is not always clear in advance who will need 15 minutes and who will need 45 minutes with their care team. What is predictable is that some patients will require more time and some less. In addition, some patients will not arrive on time for their appointments, and some won't show up at all, while other patients will need to be seen on an urgent same-day basis. This is predictable unpredictability; you can adapt if your practice schedules are flexible.

One of the challenges of the traditional scheduling model is that it assumes the amount of time each patient needs is consistent. Traditional scheduling also assumes it is possible to proactively match the time a patient needs to a predetermined, standardized visit type.

Practices that follow traditional schedules of predetermined appointment time slots often deviate from the actual scheduled appointment duration.² One study found that visits scheduled for less time tend to run over while visits scheduled for more time tend to end early.² While the common sentiment may be, “it all evens out eventually,” rigid block scheduling does not support repurposing leftover time from a visit that ended early. Visits that run over the allotted time lead to delays later in the day's schedule.

Front-loading the patient volume at the beginning of an hour, rather than as a series of rigid time blocks, allows your practice to use time not needed for one patient for another. This is known as scheduling on a wave and builds in flexibility to meet the varied patient needs on any given day. Said another way, a small buffer is built into each hour to help keep physicians from falling behind or to reallocate their time to other tasks.

How to schedule on a wave

The specifics of wave scheduling vary depending on the specialty, skills, and training of the care team and practice workflows. For many physicians in non-procedural specialties such as internal medicine, scheduling 2 patients on the hour to form the wave's crest and 1 on the half-hour at the wave's trough works well (Figure 1). Of the patients scheduled on the hour, 1 might be a new patient or an established patient for a Medicare Annual Wellness Visit (AWV), and the second patient on the hour is scheduled for follow-up evaluation and management of chronic conditions (Figure 2). New patients and those for AWV typically require more care team time to room and more physician time in the exam room. The physician starts the hour with whichever patient is ready first; the established patient being seen for follow-up care is usually roomed faster.

For specialties where more patients are typically seen per hour, such as orthopedics, 2 patients on the hour, 1 on the quarter-hour, and 1 on the half-hour can work well (Figure 3). Much like in the internal medicine setting, patients expected to require more care team time to prep, such as those having an in-office procedure, would be scheduled in 1 of the 2 appointments on the hour.

The number of patients seen per hour will vary depending on the specialty, the patient population served, the number of care team members supporting the physician, and the efficiency of the underlying workflows. For example, practices with less than 1 medical assistant (MA) per physician may see fewer patients in a 4-hour session than practices with 2 registered nurses (RNs) per physician. Your practice can vary its template accordingly while still incorporating the principle of hourly front-loading that powers wave scheduling.³

The key is to break free from scheduling approaches that perpetuate physician and care team stress with 2 incorrect assumptions:

1. All patients will be ready to be seen at precisely their scheduled time

2. All patients will need to be seen for the same amount of time

Give yourself more flexibility!

Physicians should have at least 2 exam rooms, preferably 3 if they have a skilled team completing much of the pre-visit and post-visit work. With 2 exam rooms, a physician can be with 1 patient while a care team member rooms the next patient. With 3 exam rooms, a physician can be with 1 patient while the next patient is being roomed, and another care team member performs post-visit tasks for a third patient. Having 3 exam rooms works especially well in practices performing tests (eg, exercise oximetry, electrocardiograms, pulmonary function tests, etc.), procedures (eg, immunizations, endometrial biopsy, suturing lacerations, joint injections, etc.), or where care team members provide education and self-management support to patients. More rooms allow the care team to keep the flow of patients moving, even when 1 of the 3 rooms is being used for one of these services.

A buffer is an hour or so of reserved, unstructured time each day. During the buffer time, there are no pre-scheduled appointments, so the care team knows they can schedule additional same-day appointments to meet occasional surges in patient demand. On days when this buffer time is not required for patient visits, your practice can use the time to respond to inbox messages, return patient phone calls, work on panel management, or other tasks. Figure 4 reviews tips for building in buffer time.

If you consistently use up your buffer time with direct patient care, you may be over-paneled for available resources (see STEP 8).

Setting up the patient's next visit as the current visit concludes (an element of pre-visit planning) can save time and improve adherence to care recommendations. When the discharge process includes arranging lab tests before the next visit, that future visit becomes more meaningful while reducing the volume of post-visit follow-up work (ie, inbox work). In some models, clinical support team members schedule follow-up visits in the exam room. In other models, clerical team members at the front desk enter orders for pre-visit labs as directed by the physician.

Scheduling the next appointment at the end of the current appointment eliminates redundant work (ie, a team member reviewing the chart a week before the appointment to arrange for pre-visit labs) and fragmented work (ie, by allowing the physician to address the lab results in context at the visit, rather than as individual results come in post-visit). It also means patients are more likely to keep follow-up visits, which promotes continuity and increases adherence to disease prevention and chronic illness monitoring. This will improve your patient satisfaction and quality metrics performance and reduce the number of care team outreach touches required compared to relying on a patient care registry to catch care gaps.

To successfully reappoint patients during the current visit, it is best to open your schedule more than a year in advance. Consider a time frame of 13 to 18 months to allow you to schedule follow-up or wellness appointments for patients who may only need a yearly visit. Even patients who are appropriate for annual visits may not be able to return in exactly 12 months.

It can be tricky for your practice and patients to schedule that far in advance, but it will save everyone time. You won't know the exact days you will take off in the next 18 months. Still, you probably have a rough sense of your total vacation days, continuing medical education (CME) time, meeting or conference dates, and personal days. Block off this number of days somewhere in your schedule where you anticipate taking them; these are placeholder days. It is much less work to reschedule a few of these days or weeks once your schedule is finalized than to schedule them all twice because every patient was first added to a tickler file. Adding placeholder days eliminates a multi-touch process for the majority of your appointments. That is a lot of time saved!

Placeholder days or weeks on the schedule at regular intervals, such as every other month, ensure that patients who have to be rescheduled due to physician time off won't have to wait several months for another appointment. If the placeholder days end up being the days you actually take off, fewer patients will need to be rescheduled. If the placeholder days aren't taken off, holding them reserves a place to reschedule patients from the actual days away rather than trying to reschedule those patients into an already full template.

Scheduling 13 to 18 months in advance is also respectful to patients because it gives them a reserved appointment to plan around. Automated texts, phone calls, or emails help practices remind patients of these appointments as they approach, decreasing no-shows without requiring extra work for the care team. On the contrary, it is often helpful for patients to have a reserved appointment to plan around well in advance. Another tip is tracking which patients fail to show up for scheduled pre-visit labs. Practice team members can then contact those patients and ask if they plan to keep their appointment with the physician. If so, the patient can still go in for a lab draw. If not, the appointment time can be opened up for another patient.

Telehealth has become integral to the daily workflow in nearly all ambulatory practices. Most use 1 of 2 methods for scheduling virtual visits:

1. Intersperse telehealth visits among in-person visits

2. Schedule all telehealth visits into dedicated blocks of time

Both approaches have pros and cons.^4,5 Be open to trialing one approach and adjusting as needed.⁶

Pros and cons of interspersed telehealth visits

Some physicians and care teams welcome the variety of virtual visits mixed with in-person visits. This approach makes integrating team-based principles into telehealth easier for a more seamless workflow. It also makes offering whichever modality best suits each patient's needs on any given day easier. Care team members are able to replicate what they do for an in-office visit in a telehealth visit—the processes and workflows can be the same even though how they are completed will be necessarily different due to the virtual platform.

Ideally, each schedule template slot will be able to accommodate either an in-office or virtual visit. Some physicians feel increased stress associated with going back and forth between in-office and telehealth visits. Difficulty staying on time, reliability of virtual platform technology, and inadequacy of virtual evaluation for some patient complaints can contribute to this feeling. If utilizing wave scheduling, consider preferentially placing telehealth visits at the top of the hour since they often require less time for the care team. Held buffer time can also be used for acute, same-day virtual visits. Telehealth visits, like in-person visits, have a high degree of variability in the time required for completion. Wave scheduling can help blend virtual and in-office care more efficiently than standard templates.

Pros and cons of blocks of telehealth visits

Other physicians and care teams prefer the convenience of a series of virtual visits from the office or off-site, such as from home. Working from home has advantages, including opening up space in the office for a colleague to see patients in person or supporting those with children who need to be at home after school. Doing telehealth off-site requires more sophisticated planning to ensure that tasks the care team usually does—such as medication review, care gap closure, and order pending—aren't left undone or left to the physician. There is also a risk of a patient coming to the office expecting an in-person visit when they are scheduled for virtual.

A significant threat to scheduling success is having too many patients. This is true for primary care and subspecialties involving longitudinal care, such as endocrinology, rheumatology, gastroenterology, etc. Given available resources, a practice is likely overpaneled if the unstructured buffer time outlined in STEP 4 is consistently used for direct patient care. No scheduling system can fully compensate for an overpaneled practice. Panel size incongruent with physician and care team capacity contributes to a chaotic clinical environment, patient frustration, and physician burnout.

Overpaneling typically occurs for 1 of 3 reasons:

1. Prioritizing seeing new patients over existing patients.

   For example, when a health system prioritizes seeing new patients in primary care to bring in downstream procedural and subspecialty care revenue without increasing capacity within primary care.

2. Reducing clinical full-time equivalent (FTE) without a corresponding reduction in panel size.

   For example, reducing FTE to take on a leadership role or voluntarily reducing FTE to cope with an overwhelming workload without reassigning a proportionate number of patients to a different physician. Typically, the overpaneled physician continues to try to manage the same patients in less time—an impossible task.

3. Having a panel size that exceeds care team capacity.

   For example, a practice that has not prorated the number of patients a physician can reasonably be expected to care for to that physician's clinical FTE and the care team's size, skill level, and stability. The number of patients alone doesn't accurately represent the effort required to provide their care. The panel capacity for a physician with 2 RNs and 3 exam rooms fundamentally differs from that of a single physician with 1 MA and 2 exam rooms.

Practice characteristics that influence panel size capacity include^4,7- 11:

The stronger the care team and the more efficient the workflows, the greater the panel capacity that can be safely managed without overwhelming the physician and team. When the number of patients on a panel exceeds the team's capacity, there is pressure to provide a higher proportion of the care through patient portal messages and phone calls, which often increases work outside of work (ie, pajama time).

The strength of the care team (eg, skills, abilities, and training) and the efficiency of practice workflows will influence panel capacity and how much flexibility can be built into a clinical team's schedule.

In most primary care practices, physicians spend at least an hour on non-visit-based tasks for every hour of patient-scheduled time. It doesn't have to be this way! Most practices can save several hours of physician time each day by reengineering how the work is done and by strategically delegating work to an upskilled care team. The higher the staffing ratios and the greater the skill level of team members, the more patients the physician can safely manage in a day and the greater flexibility the practice will have to provide same-day appointments.

In a team-based care model, team members other than the physician (eg, MAs or RNs) perform delegated visit-related tasks. These tasks may include^12,13:

• Extended intake (or advanced rooming)

• Addressing health maintenance and care gaps

• EHR documentation

• Prescription management

• Entering orders

• Pre-visit planning

Empowering team members to do more of the standardized, predictable “production line” work lets physicians focus on the “solution shop” work they are uniquely trained and qualified to do.¹⁴ For a practice that uses team-based care, an appointment that might otherwise require 40 minutes of physician time may only require 20 minutes (Figure 5 and Figure 6). With this extra time back, physicians may be able to:

• Care for more patients in a day

• Accommodate more same-day appointments

• Address inbox messages between patient encounters rather than after hours

• Improve work-life balance and go home earlier

Investments to improve patient experience, system efficiency, and physician and health care worker well-being must be viewed as what they are—investments: time, effort, and money spent to gain a favorable return. Considering opportunities to enhance the design and operation of patient scheduling is a worthwhile investment for everyone. Schedule optimization and shifting from rigid appointment slots to scheduling on a wave support continuity of care, contributing to professional fulfillment, patient satisfaction, and safer, less costly, and higher quality care.

Toolkits and Playbooks

• Saving Time Playbook

• Private Practice Playbook

• Telehealth and Team-Based Care Toolkit

• Identifying the Optimal Panel Sizes for Primary Care Physicians Toolkit

• Panel Management Toolkit

• Team-Based Care Toolkit

• Simplified Outpatient Documentation and Coding Toolkit

• Medicare Annual Wellness Visit (AWV) Toolkit

• Medical Assistant Professional Development Toolkit

Podcasts

• One practice's success in implementing advanced team-based care

• Improve patient care with collaborative care team models

• Team-based care model

• Telemedicine is a team effort

• Telemedicine and team-based care

• Training medical assistants as “Encounter Specialists”

• Reducing pajama time and work outside of work (WOW)

• Private Practice: Attending to Business, episode three—Practice efficiencies

• Private Practice: Attending to Business, episode five—Telehealth services for private practice

• About the AMA's Debunking Regulatory Myth series

• Medical assistant recruitment and retention

• Medicare Annual Wellness Visit

Success Stories

• Working Smarter in Primary Care Means Transitioning to In-Room Physician Support

• Effective Team-Based Care Could Save 8 Hours of Free Time Per Week

• Encounter Specialist Model Promotes Physician and Team Satisfaction

• Leverage Standing Orders and Protocols to Ease In-Basket Burdens

• Team Approach to Visit Documentation Saves Time

• Panel Management Case Report: Bellin Health System

• Panel Management Case Report: Marshfield Clinic Minocqua Center

• Panel Management Case Report: Erie Family Health Center

Webinars and Videos

• Telehealth and Team-Based Care: How to Engage Support Staff to Implement Team-Based Care in Telehealth

• Telehealth and Team-Based Care: The Shift to Telemedicine and Navigating Through Pitfalls

• A Review of Telehealth Trends: Informing the Future of Virtual Care

• Medical Assistants: Recruitment and Retention