Third Next Available (TNA) - A Tool for Patient Scheduling?

Third Next Available, abbreviated as TNA or 3NA, is a calculation commonly used in medical practices to measure patient accessibility, or provider availability. The idea is to determine, at a specific point in time, the third available appointment slot for a specific appointment type. This represents a realistic time patients will have to wait on average to get an appointment with that provider for that specific appointment type (New Patient, Follow-up, Annual Wellness Visits, etc.). The reason to use the third next available and not the first next available is that the first next may have become available a few moments ago due to a cancellation or reschedule, so third next give a reasonable margin of error in calculating provider availability. The concept is to reduce the 3NA value to as low as possible, depending on the specialty, in order to improve patient accessibility to an optimum level.

The concept of appointment availability introduces a possibility of schedulers to think that this is an effective tool to use for scheduling. However, one must not forget that as soon as the first appointment is booked, the 3NA number could change considerably depending upon the new third next available appointment. It is best to use the actual provider schedule within the practice management system for determining the next available appointment. 3NA is a tool to be used for trending by calculating this week after week on the same day/time, and helps only t determine how busy the provider schedule is on an average. Based on this trend, the practice administration can determine if the provider schedule needs to be tweaked, or more resources need to be made available, or add another provider is appropriate. Keep in mind that 3NA makes sense for each appointment type individually, and comparisons between providers of similar specialties provides a better criteria to work off of.

It can, thus, be concluded that 3NA is not an effective tool to be used for patient scheduling, rather it is a measure of provider capacity to see patients in a timely manner or, in other words, patient access to a provider.

Excel Snippets - Grouping people by age groups

Every once in a while, every excel user would need to group people in a list by age group. The prerequisite for this task is either an age column, or date of birth (DOB).

In case you have the DOB column. the first step is to add and populate the age column. the quick and easy solution is using the following formula:

 =INT(YEARFRAC(birthdate, TODAY()))

Basically, this formula fetches the integer part of year fraction of difference between the birthdate cell and today's date.

Now comes the actual grouping part. This approach assumes a fixed number of years groups and an upper max (optional). For example, we may need to group from 1 to 15, 16 to 30... and so on till 61 to 75, and finally 75+ (everyone older than 75 years). To achieve this, add another column to the table and name it "What was I thinking?" or anything you feel like. Then add the following formula assuming  H2 is the first record cell for Age that you got from the formula above:

=IF(H2>75,"75+",INT((H2-1)/15)*15+1&"-"&(INT((H2-1)/15)+1)*15)

Copy this formula to all the other cells in the Age group column using the auto-fill feature of excel, i.e. double clicking on the lower right corner of the original formula cell (where the cursor changes to a +). It should automatically convert the formula reference of H2 to the corresponding row numbers like H3, H4, H5.....

A little explanation of what happens in the formula, in case you are one of those who really need to know:

1. H2 is the cell address from where age value is picked up. 
2. H2>75,"75+" adds 75+ to the group column if the age is greater than 75
3. If H2 is not greater than 75 then the second part kicks in.
4. INT((H2-1)/15)*15+1 calculates the lower limit of the 15 years interval in which H2 falls.
5. &"-" adds a hyphen after the lower limit value.
6. (INT((H2-1)/15)+1)*15) calculates the upper limit of the 15 years interval in which H2 falls.

Remember, we decided in the beginning that we want to group into 15 years intervals with an upper limit of 75+. You may modify the formula to any other grouping simply by changing the 75 with whatever you want the upper limit to be, and replace all the 15s by the group intervals in years. For example, if you want to group into 5 years intervals with an upper limit of 55 years, your formula would be:

=IF(H2>55,"55+",INT((H2-1)/5)*5+1&"-"&(INT((H2-1)/5)+1)*5)

So there you go, age grouping conquered, next we move onto adding a wildcard search term in the IF statement to identify columns containing a certain text string anywhere within the cell contents.

METRICS and OMTM

Definition as it pertains to businesses:

A business metric is a quantifiable measure businesses use to track, monitor and assess the success or failure of various business processes. The main goal of measuring business metrics is to track cost management, but the overall point of employing them is to communicate a company's progression toward certain long- and short-term objectives.

Consideration for business metrics:

1. Should be a Rate or a Ratio, mere numbers/quantities do not provide a sense of good, bad or better performance.
2. Should be a comparison over a period of time, or with other sites, segments.
3. Should be easily understandable, complex metrics create misunderstandings.
4. Should lead to change in behavior towards better performance.

One that matters -- One Metric That Matters (OMTM):

Identify the most important Metric to measure the overall health of the department.

1. Not a One Size Fits All metric. Every department, organization and situation will influence what is most important at the point in time.
2. Once selected it is not set in stone and is subject to change based n prevalent conditions.
3. Not a set it and forget it metric. Continuous monitoring and tweaking required.
4. Not a Carte Blanche to forget all other lesser important metrics.

Move on...

 We have email notifications turned on for our hoe phone, so we get an email for all incoming calls showing the number and CLI if available. We have been debating giving up the land line at home and utilize a google call number instead for this purpose. The sole reason for retaining the phone line is that the FIOS Triple Play package for phone, internet and cable is cheaper than just getting the cable and internet. Go figure why a bottle of water costs more than a bottle of soda. At some point when we may decide to give up cable all together we will drop the phone line as well. Currently we have the lowest tier local TV channels without the set top box, another cost saving factor.

 Yesterday at work around noon my Samsung S2, on loan from my son, while he un-jailbreaks his phone for the watch to work, buzzed on my wrist indicating a new email has arrived and when I tapped on the notification it showed a call at home number from Nick's school. I remembered that if there is an emergency they would call Sara or me on our cell phones. since it was close to noon, I waited for the lunch break and then asked Sara and indeed she had received a call from school about Nick bumping into a pole but nothing serious, just a bit shaken up. Sara had talked to him and all was okay.

 Back home in the evening after dinner I was sitting in the living room next to Nick sipping my after dinner tea slowly and enjoying its soothing effect. he was doing his online homework on the laptop, when I remembered the phone from earlier in the day. So i asked him where he got hurt and he point at the backside of his head, and that it doesn't hurt any more. I was a bit intrigued  how he bumped into a pole and hurt the back side of his head, so asked him how exactly he bumped into the pole.He got up and demonstrated by moving backwards a couple of steps and then hitting an imaginary pole. I immediately identified an opportunity for a lesson and got into the time to teach (TTT) mode. I asked, " So what did you learn?". Nick replied, "Learn when?". Me, "during the PE period". Nick, "in PE we just play, we don't learn anything". I was still too deep into my TTT mode and decided to rephrase my question, "I meant what did you learn from the accident?". Nick responded, "What accident?", and I clarified, "when you bumped your head into the pole". I was very confident that Nick will be wise enough to say " I learned that I should watch where I am going so I don't get hurt". Nick started off, " I learnt that..." and my chest expanded another 2 inches with pride and anticipation of accomplishing my goal, "... that when you bump your head into hard things, it hurts for a while." He continued, " it doesn't hurt any more and i had almost forgotten about it until you reminded me. Can we talk about something else?". And that's when the teacher became the pupil and I realized that a 7 year old taught me to live in the present, and move on from things that don't matter any more, and enjoy life more instead of evaluating everything that happened and deducing conclusions.

We should be grateful for the life we have and move on from the little bumps n life. I am pretty sure Nick will still walk backwards, and did not need a lecture from me to learn that he should be careful while walking backwards and clear out his path before doing that. But the bigger lesson he learned and taught me was that bumps in life hurt a little for a little while and then all will be fine unless you keep thinking about it.

Thank you Nick.....

Kaka....

The timing of our FSc. Exams at PAF College Sargodha left us in the middle of nowhere and the authorities in a quagmire to figure out what to do with us. We could not join CAE in the middle of a term/semester, and we had nothing to do at Sargodha College. Against all our hopes of getting prolonged vacations, the authorities planned to keep us in Sargodha and planned various activities (read route marches) to keep us busy. Our daily route marches constituted of donning cotton coveralls and going in random directions, roaming around aimlessly under the supervision of GST staff. Picking oranges from the numerous orange groves in the area, and playing cricket in a dirt stadium became our favorite activities. Finally, the day came when everybody got tired of us and decided to give us a brief vacation before reporting to CAE Korangi Creek in March of 1984.

Incidentally, we reported to CAE during the end semester break and there was hardly anybody in the cadets mess. We got a pretty laid back welcome and soon realized that Sargodha had dumped their problem of what to do with us over to CAE. We were subjected to some mild activities including morning assemblies, marching over to the Academics block and spending time filling up random forms in the college auditorium. They even came up with an idea of turning off the lights and asking us to take naps. Quite frequently we were left on our own and checking back occasionally to give us the notion of being supervised.

Gotten bored of just sitting in the darkly lit auditorium, one of our course mates decided to try his skills at making an airplane, something we all had aspired to when we applied to study aeronautical engineering. With the limited resources and even more limited knowledge, the result was a paper airplane that flew in loops before spiraling down to the floor. Then someone suggested to make the paper rocket  plane that had a longer range compared to the smaller plane which had more endurance. The suggestion was well received and our friend took a couple of minutes to come up with the final product. It was now time for the first flight. The test pilot held the mean machine from the rear bottom end and blew a couple of times into the tail, maybe that helped start the after burners, and launched it from the stage at the front of auditorium towards the double doors at the rear end along the center aisle. It flew straight and fast and must have reached Mach 2  by the time it was only 10 feet away from the door, and everybody was anticipating it would crash into the doors and gently fall to the floor, ready for the next flight. It was closing in at the furious speed of 2 ft./sec. towards the door when the doors suddenly flew open and in walks a human figure resembling the Terminator (Arnold Schwarzenegger) as the rear end of the room was at a higher level and the light source was behind the person creating a larger than life profile of the person entering the auditorium. The rocket plane hit him smug on the chest, executed a loop and made perfect landing on the floor.

"Kaka! come here!!" came the command and our aspirant Aeronautical Engineer jumped off the stage and briskly ran towards the Terminator. "Pick it up and come outside with me"… they both walked out with the plane in the potential engineer's hand. The doors were left open and by now we had our eyes adjusted to the light outside and we could make out that our friend was with the GSTO in the area between the Commandant's Office / Jetty and the Hilton  / Avionics block. "Fly it Now" came the orders and our friend thought it was a rhetoric command not meant to be carried out and stood still in proper attention position, chest out belly in and arms locked by the side and sweat starting to flow down the left side of his face. "I said fly it!!!" and it was clear by now that he actually wanted him to fly the plane. The jet was let loose into the steady ocean breeze and landed graciously after a couple of seconds of flight. "Fly it again" and off it went for another trip. "Keep doing that until I return…. and keep in mind I can see you from my office", and off went  Kaka to his office on the other side of H&S Department, while our friend honed his flying skills in the hot and bright sun, enjoying the freebie of dried fish smell from the neighboring Goth Ibrahim Haidri village.

Third Next Available Appointment - TNA

Third Next Available Appointment – TNA

I heard this term being used in the healthcare circles when I moved from an HMO to a clinical group and wasn't sure what it meant and why does it matter, so I went about exploring the significance of this term and how it matters.

My first interpretation was a literal definition of this term, or sentence. I ended up with the third available appointment slot. This came out to be a pretty accurate definition but still did not make sense as to why do we need to skip the first two appointments. may be to keep slot open for last minute or urgent  appointments, but that would result in two slots being kept vacant for every appointment and that did not make much sense.

So after digging through a few links from google I was able to have a better understanding of the concept, its application and importance in the healthcare setting. The definition basically stays the same:

"TNA is the number of days from the current day to the third available appointment for a physician." 

Essentially, the first two available appointments are skipped, and the reason for this will become apparent shortly as we go further into the concept of TNA. This measure represents how quickly a patient can be scheduled for an appointment with a particular doctor, and this measure gives a good idea of how loaded is the doctors schedule. Simply put, it is a nice way of comparing available appointments (supply) versus appointment requested (demand).

The TNA should be measured at the same time and day at regular intervals (ideally weekly), to see the trend and compare it with other doctors within the practice. Another thing to take care of is to measure TNA by appointment types, for example new patient appointments, annual wellness visits, follow-up visits, etc. should be kept separate. Also, while counting the days, if third next available is available the same day of measurement then TNA is zero, if it is available the next day then it is 1 and so on. Holidays and weekends are generally not counted, but provider's days off are counted. Some practices do include the weekends and holidays to get a true measurement of how soon a patient is expected to be seen from time of appointment request. This is a patient focused approach as against the provider focused when these days are excluded.

High TNA numbers indicate an overloaded schedule and patients healthcare suffer due to delayed availability, and continuity of care is affected too. Target goals for primary care physicians are ideally set at zero and for specialists it is set at 2.

TNA reduction can be achieved by adopting certain measures but these vary from practice to practice:

·                     Have patients call in for next appointment instead of pre-scheduling.

·                     Extend re-visit intervals.

·                     Review current schedule and cancel/remove unnecessary appointments.

·                     Transfer patients to other physicians or APPs within the group.

·                     Use technology to offset face to face interactions/visits: this may include emails, live chats, patient portals, secure messaging, etc.

·                     Utilize patient care teams more effectively for services where interaction with the physician is not deemed necessary. These services may include refills, referrals, labs interpretations and results, preventive care and patient education, etc.

In conclusion, keeping TNA as close to goal as possible gives the physician a healthy work-life balance, the patients get timely healthcare services, and the panel size of physicians can be expanded by delegating certain services to technology and patient care team. Remember, not to use TNA as a tool for patient scheduling.

Team Based Primary Care - Part 1 : Why Team Based makes sense

Patient healthcare in a Primary Care model is owned by the Primary Care Physicians (PCP) as they receive all notes, labs and refill requests for their patients. Patients select their PCPs who then become responsible for every aspect of their healthcare. The workload on a PCP is measured in terms of the "panel size", defined as the number of unique patients under the PCP care. Generally, this count is based on the last 18 months, though occasionally a 12 month period is used. the 12 month period may result in under estimation as not every patient visits their PCP in a given 12 month period.

An ideal panel size under the traditional Primary Care model is about 1000. The US national average panel size for PCPs is about above 2000. The reason for such large panel sizes is the number of PCPs available for the patient population, which is at 1 PCP available for every 1500 patients, and this includes those physicians who are not working full-time.

The demand and supply differential causes variation in panel sizes. Demand is the number of patients seeking primary healthcare services and supply is the number of available appointment slots. Ideal situation is when Demand equals Supply.

Demand = number of unique patients seen by PCP in the last 18 months X visits per patient per year.
Supply = Appointment slots available per day X Provider days per year.

In the current situation with less number of PCPs available and more patients seeking primary care, the demand supply balance is tilted heavily towards demand, and the supply side has to overload themselves to keep it balanced.

One way to balance the panel size is to increase the supply, meaning increase the number of PCPs, which is only possible by a long time concerted and consistent effort and depends  upon more physician willing to join the PCP ranks.

Another option is to offload the PCPs by adding Nurse Practitioners and Physician Assistants to provide primary care by maintaining their own panels. This can be augmented by delegating those services that do not require clinician level training, to non-primary care personnel and to technology. Primary candidates for such delegated services are preventive and chronic care. Hence, it becomes a team based model where a team of care professionals and technology combine to share the load thereby offsetting the imbalance between demand and supply. In a team based primary care model, the panel size can be maintained between 1200 and 1500 for a PCP, which actually corresponds to the current supply of PCPs in the US. 

Additional costs incurred for implementing a team based model are training and technology. Exact numbers would vary depending upon the patient population age and health spread.

Implementing a team based primary care model requires a cultural and structural change in the practice, including clinicians' mindsets, training, re-mapping of workflows and most importantly patient education. Primary Care payment system would also require modification. 

Successful team-based Primary Care healthcare services result in increase in patient satisfaction, better overall health and wellness in the patient community, and at the same time providing a reasonable work life for all members of the Primary Care Team.