Timeliness
What should I know before beginning implementation?
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Individuals who have obligations (employment, household work, school) during typical facility operating hours are most likely to face barriers to access due to timeliness. As discussed in financial access as well, these patients may face substantial external costs if they must miss work or find alternative child care in order to access services which can in turn lead to catastrophic health expenditure.8
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There are many reasons why patients may not be able to access timely care. Some of these include:
Inconvenient Operational Hours
Facility hours may be a barrier to care for individuals who work or have regular obligations. This is most often the case when facilities do not offer evening or weekend hours. Few convenient hours of operation can also contribute to long waiting times, short consultations, and provider burnout.
A systematic review of public and private healthcare facilities in LMIC found that across multiple settings, waiting times, operational hours, and availability of staff were more favorable in private clinics compared to public ones.9
Inefficient Appointment Systems
Appointment systems – coupled with effective use of resources and high-quality care - may be an effective starting point for ensuring timely access to care. A 2016 review of primary care experiences in six Latin American countries found substantial gaps in performance regarding waiting times and appointment systems: one-fifth of respondents skipped an appointment due to problems with scheduling, one-third had to wait more than five days for an appointment, and 39% could not schedule an appointment by phone.10
Long Waiting Times
Long wait times may be attributable to diverse causes including insufficient human resources, inefficient or absent appointment systems, limited operational hours, and ineffective facility management regarding human resources or facility flow. Facility managers may choose to conduct activities such as process flow mapping (discussed in greater detail in the performance measurement and management module) in order to assess how and why patients are experiencing long waiting times.
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Facility Operational Hours
To ensure access to care, patients must be able to visit health facilities at times and days that are convenient to them and do not require substantial sacrifice in work or childcare. Because expanded days and hours of service may require more human resources, stakeholders must consider how they can reorganize the health system to accommodate these changes. The suggestions for reducing waiting times below may help facility managers rearrange service delivery to accommodate more hours of operation:
- Staggered shifts – Because increased hours may reduce the density of patients throughout the day, fewer providers may be scheduled on each shift in favor of extending the hours or days of operations. This may involve some pilot testing and observation of patient flow to optimize, and it is important to ensure that all services are staggered as well so patients still have access to comprehensive care.
- Integrated services – Often, clinics may have designated days for services such as antenatal care or antiretroviral therapy. Instead, clinics should ensure that patients can receive a comprehensive range of services at any time to optimize appointment time and minimize return visits.
- Increasing staff and/or expanding service delivery hours – Both of these considerations involve substantial financial inputs from the health system to direct funds to the compensation of additional staff or extended hours. Stakeholders should consider if they have the resources necessary to implement these changes. However, facility managers must ensure that staff receive adequate incentives and support to reduce provider burnout and maintain motivation. If staff are asked to work inconvenient hours, health systems may choose to consider additional incentives.
- On-call telephone systems – In areas where patients have access to phones or computer, clinics may choose to have providers available to provide remote consultations during non-clinic hours. Unless there is substantial telemedicine technology in place, these consultations may be limited to acute or emergency care.
Appointment Systems
Appointment systems can improve access to services at the point of care. These systems need not be complex but should be easy to use for both patients and providers, appropriately tailored to the internet connectivity and literacy in a given context, and adaptable to anticipate any changes in service delivery. These systems, if supported by a sufficient workforce, can improve waiting times and person-centeredness of service delivery. Appointment system options include:
- In-person or community-based appointment systems – In areas where some or all of the population does not have access to internet or phones, appointments should be able to be scheduled through in-person visits to the clinic. If the clinic is not conveniently located, appointment systems could be made available in the community. For instance, CHWs may make referrals or help schedule appointments during routine population outreach activities.
- Appointments made via SMS or telephone and linked with an appointment tracking system (paper or electronic) – In areas where patients have reliable access to telephones, appointments may be scheduled by calling or texting the facility. However, there must be an organized system for recording appointment availability for the clinic staff answering phones. Additionally, in low-literacy settings, texting cannot be the only system for requesting appointments.
- Electronic portals – Electronic portals may be an efficient option if patients have reliable access to computers or mobile devices and the internet. Additionally, systems must be in place to ensure that these portals remain up to date, and alternative means of scheduling should be available if any portion of the patient panel does not have access to the internet.
Even with efficient appointment systems, facility managers should ensure that patients can access care for urgent needs. This may be done by reserving specific days and/or times for walk-in visits or same-day appointments.
Waiting Times
While reduced waiting times will improve patient experience and access, they can also contribute to clinic efficiency. Patients who miss their appointments often do so because of long waiting times or the need to select an appointment time that is inconvenient for them.11 Thus, improved systems may reduce no-shows and ensure that the provider time is maximized. It is also important for facilities to have systems for triaging patients once they arrive in facilities. For instance, patients may be triaged between emergency, chronic, and acute care. Assuming that facilities have sufficient human and material resources to address demand, some strategies to make appointments more efficient and reduce waiting times—along with questions stakeholders may use to assess the appropriateness of the strategy for their context—include:
- Group visits – Are there any patient types whose needs are fairly standardized (certain chronic care conditions, antenatal care, etc.) and could receive care in a group context? What sort of logistics would need to be in place to organize these visits? How will this change be effectively communicated to patients?
- Effective delegation to different providers – Are there any services that are currently being provided by doctors that can be effectively provided by nurses or CHWs who are in greater supply? What kind of training (if any) would these providers need to receive to be able to provide a wider range of services? Can any of these services be provided outside of the facility?
- Options for telemedicine appointments – Does the patient panel have access to mobile devices and appropriate connectivity? What form of communication would be most efficient for patients and providers (text message, video conference, email)? Which providers would be responsible for telemedicine and how would their workflow need to change to accommodate this responsibility?
PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content on this website represents the position of the partnership a whole, it does not necessarily reflect the official policy or position of any partner organization.
What has been done elsewhere to improve financial access?
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In South Korea, the establishment of the National Health Insurance Service in conjunction with rapid economic development has increased access to services and improved health outcomes over the last few decades. However, there is evidence of high rates of overutilization of hospital services attributable to the absence of weekend access to PHC. In October 2013, South Korea instituted a program that pays General Practitioners (GPs) 30% beyond their normal compensation to provide care on Saturdays. This incentive proved sufficient to encourage GPs to work on Saturdays, improving patient access and reducing the volume of patients on other days of the week.12 Increased access on Saturdays also likely decreased utilization of emergency rooms for conditions treatable in primary care settings, though the evaluation was unable to measure this impact.
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Without an efficient appointment system, providers or administrative staff may face difficulties in tracking patients who do not return for follow up or are non-compliant in treatments, compromising coordination and continuity of care. This is particularly important for chronic diseases that require regular monitoring such as HIV or NCDs. There is evidence that one year retention rates for antihypertensive and antidiabetic medications are as low as 2% in parts of Africa. The International Network for the Rational Use of Drugs Initiative on Adherence to Antiretrovirals (INRUD-IAA) piloted an appointment system in Tanzania, Rwanda, and Kenya in conjunction with the HIV/AIDS control programs to improve patient attendance tracking and follow-up.13 In addition to the ability to track patients, these appointment systems facilitated other activities that benefited providers and patients alike. In Tanzania, the appointment system helped reduce waiting times and distribute patients throughout the day. Both Rwanda and Kenya used the appointment and patient tracking system to monitor performance. In Rwanda, these data were linked with performance-based financing related to patient attendance, and in Kenya, data were used to evaluate and plan during staff meetings. Following this pilot, all three countries incorporated appointment systems into national policies.13
Like many LMICs, Nigeria has experienced a shortage of human and material resources in primary care facilities, leading to overcrowding in outpatient waiting rooms, dissatisfaction with care, poor treatment outcomes, and overworked providers. A study in Lagos, a large city in Nigeria, evaluated patient perspectives on the acceptability, feasibility, and willingness to adopt a SMS service for appointment scheduling to increase efficiency of appointments and improve waiting times.14 This feasibility study found widespread support for the technology among providers; most participants indicated that they would pay for and use the service, and even those without a cell phone or with limited literacy indicated that they would be able to find ways to utilize a SMS appointment system. Though this study did not subsequently implement and evaluate such a program, it highlighted the demand and utility of such a service in a resource-constrained setting.
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Shared medical appointments are not only more efficient from a facility flow perspective but can also help patients develop supportive communities. This is particularly true for antenatal (ANC) and postnatal care, where women attend group visits with women of a similar gestational age, sharing information and forming relationships within and outside of the facilitated group visit. Compared to individual visits, women are able to spend more time with providers, form relationships with providers and other mothers, and reinforce knowledge with one another.15 A group ANC curriculum was implemented in Ghana using seven lesson modules designed by the American College of Nurse-Midwives. Each of the sessions was 60 minutes and involved story-telling, peer support, and demonstration with a focus on delivering information to women with limited literacy. This design was compared to individual ANC with the same providers, and women who received group ANC care were more likely to discuss delivery arrangements and transportation with midwives, have saved money for birth, report positive exclusive breastfeeding practices, and discuss newborn problems with midwives. Thus, group visits for ANC can contribute to facility efficiency while better equipping women with maternal knowledge.15
Shared medical appointments have been used extensively for NCD management in high income countries to limit repetition of educational medical appointments and build cohorts of patients with similar needs and concerns.16 A study of shared medical appointments for diabetes in The United States found that the success of these programs depended on patients’ motivation and willingness to learn and could contribute to improved patient satisfaction and productivity.16 While there is limited evidence of shared medical appointments for NCDs in LMICs, the success of shared appointments for ANC suggests that shared medical appointments may continue to be a strategy for improving clinic efficiency.
PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content on this website represents the position of the partnership a whole, it does not necessarily reflect the official policy or position of any partner organization.
What questions should be considered to begin improvements?
The questions below may be a useful starting place for determining if Timeliness is an appropriate area of focus for a given context and how one might begin to plan and enact reforms:
- How do patients perceive waiting times both to the next available appointment and once they arrive at a facility, and are these prohibitive to seeking care when needed?
In order to determine how and when services need to be extended, it is important to qualitatively understand patient experience with waiting times before and during appointments and to assess the feasibility and acceptability of potential solutions with them.
- If availability on specific days or times of day is an area of weakness, is there flexibility in existing facility operations and workforce to extend hours or days of operation?
Expanding hours or days of operation within a facility is a clear solution if facility operational hours pose barriers to the population. However, this may not be feasible in all settings. It is important for facility managers and assess the existing facility operations and workforce to understand how expanded hours would impact the facility, and it may be useful to begin with a pilot.
- Is there an existing system for scheduling appointments and are there scheduling options available to all individuals within the catchment area regardless of their access to technology or physical proximity to the facility?
Contextual realities such as technology and literacy may be a limiting factor when developing appointment systems. Appointment systems do not need to be complex, but the presence well-designed systems can contribute to improved facility efficiency. It is important to robustly evaluate patients’ access to relevant technologies before implementing a system.
PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content on this website represents the position of the partnership a whole, it does not necessarily reflect the official policy or position of any partner organization.
What elements should be in place to support effective improvements?
In order for interventions aimed at improving Timeliness to be most successful, the following elements of the PHCPI Conceptual Framework should be in place or pursued simultaneously:
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Regardless of financial, geographic, and timely access to services, it is unlikely that patients will access care if they perceive that providers lack competence, services are not tailored to their needs, and care is not delivered with trust and respect. Additionally, if patients do seek care that is not high quality, it is unlikely to result in improved outcomes. Thus, if patients are not accessing services, it is important to understand whether it is due to perceived quality of care or accessibility, and if both are lacking, they may have to be addressed in tandem to improve utilization of care and subsequent positive health outcomes and impact.
Learn more in the Provider Competence and High-Quality Primary Health Care Improvement Strategies modules.
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Certain approaches to improving access require logistical changes within a facility, such as scheduling outreach activities, adopting new appointment systems, or shifting provider schedules to facilitate greater coverage. For all of these changes to be effectively integrated, facilities must have strong leadership and management to communicate, implement, monitor, and adapt necessary changes with internal and external stakeholders.
Learn more in the Facility Management Capability and Leadership Improvement Strategies module.
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As with any changes to a health system, it is important to have a clear system in place to evaluate the efficacy of a given intervention. Performance measurement and management systems with clear targets, measurement activities, and plans for improvement should be designed in conjunction with service delivery changes to monitor changes in access and adapt approaches as needed.
Learn more in the Performance Measurement and Management Improvement Strategies module.
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As with other service delivery changes intended to improve access to care, improved timeliness may result in an influx of patient demand. Therefore, there must be sufficient human resources within facilities to serve the population. Additionally, workforce organization and establishment of care teams may make services more efficient, thus facilitating timely access.
Learn more in the Workforce and Team-Based Care Organization Improvement Strategies modules.
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Improving facility flow or establishing appointment systems requires adequate integration of information systems. Providers or administrative staff who would be responsible for facility planning should have clear information systems use expectations and training. If patients are also expected to use information systems for scheduling appointments, these should be clearly communicated during facility visits or during community-based care.
Learn more in the Information System Use Improvement Strategies module.
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In addition to engaging community members in the identification of barriers to care and potential interventions to improve access, social accountability mechanisms should be in place to ensure that community members are able to monitor and react to health systems interventions and changes.
Learn more in the Social Accountability Improvement Strategies module.
PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content on this website represents the position of the partnership a whole, it does not necessarily reflect the official policy or position of any partner organization.
References:
- Stremikis K, Squires D, Schoen C. Mirror, mirror on the wall: How the performance of the U.S. health care system compares internationally [Internet]. The Commonwealth Fund. 2014. Available from: http://www.commonwealthfund.org/~/media/files/publications/fund-report/2014/jun/1755_davis_mirror_mirror_2014.pdf
- Flood D, Rohloff P. Comment Indigenous languages and global health. Lancet Glob Heal [Internet]. 6(2):e134–5. Available from: http://dx.doi.org/10.1016/S2214-109X(17)30493-X
- Tappis H, Koblinsky M, Doocy S, Warren N, Peters DH. Bypassing Primary Care Facilities for Childbirth: Findings from a Multilevel Analysis of Skilled Birth Attendance Determinants in Afghanistan. J Midwifery Womens Health. 2016;61(2):185–95.
- Tanahashi T. Health service coverage and its evaluation. Bull World Health Organ. 1978;56(2):295–303.
- Leaving no one behind in the context of subnational health system strengthening in Mongolia [Internet]. 2016. Available from: http://www.wpro.who.int/mongolia/publications/20171214-mongolia-report-leaving-no-one-behind.pdf
- World Health Organization (WHO). Innov8 approach for reviewing national health programmes to leave no one behind: technical handbook. 2016;246. Available from: http://www.who.int/life-course/partners/innov8/innov8-technical-handbook/en/
- Reynolds H. Mixed-Method Evaluations Lend Rigor to Design [Internet]. MEASURE Evaluation. [cited 2018 Sep 19]. Available from: https://www.measureevaluation.org/resources/newsroom/blogs/mixed-method-evaluations-lend-rigor-to-design
- Shrime MG, Dare AJ, Alkire BC, O’Neill K, Meara JG. Catastrophic expenditure to pay for surgery worldwide: A modelling study. Lancet Glob Heal [Internet]. 2015;3(S2):S38–44. Available from: http://dx.doi.org/10.1016/S2214-109X(15)70085-9
- Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D. Comparative performance of private and public healthcare systems in low- and middle-income countries: A systematic review. PLoS Med. 2012;9(6):19.
- Macinko J, Guanais FC, Mullachery P, Jimenez G. Gaps In Primary Care And Health System Performance In Six Latin American And Caribbean Countries. Health Aff (Millwood) [Internet]. 2016;35(8):1513–21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27503978
- Safety Net Medical Home: Enhanced access - implementation guide. 2013;
- Ha HJ, Han K-T, Kim SJ, Sohn TY, Jeon B, Park E-C, et al. Changes in Saturday outpatient volume and billings after introducing the Saturday incentive programme to clinics in South Korea: a longitudinal cohort study using claims data from 2012 to 2014. BMJ Open. 2016;6(6):e011248.
- Chalker JC, Wagner AK, Tomson G, Johnson K, Wahlström R, Ross-Degnan D. Appointment systems are essential for improving chronic disease care in resource-poor settings: Learning from experiences with HIV patients in Africa. Int Health. 2013;5(3):163–5.
- Adedokun A, Idris O, Odujoko T. Patients’ willingness to utilize a SMS-based appointment scheduling system at a family practice unit in a developing country. Prim Health Care Res Dev. 2015;1–8.
- Lori JR, Ofosu-Darkwah H, Boyd CJ, Banerjee T, Adanu RMK. Improving health literacy through group antenatal care: a prospective cohort study. BMC Pregnancy Childbirth [Internet]. 2017;17(1):228. Available from: http://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-017-1414-5
- Sanchez I. Implementation of a Diabetes Self-management Education Program in Primary Care for Adults Using Shared Medical Appointments. Diabetes Educ [Internet]. 2011;37(3):381–91. Available from: http://journals.sagepub.com/doi/10.1177/0145721711401667
