Profile of an improvement champion: Dr. Mark Brown

In 2007 Moose Jaw's Dr. Mark Brown was struggling to keep up with his 2,500-patient caseload. He was often booking appointments two weeks ahead and double-booking urgent patients into an already saturated schedule, to ensure he was providing continuity of care. Read on to find how Brown has improved his patients' access to appointments and achieved a better work/life balance.

Where are you originally from? How did you come to practise in Moose Jaw?

I grew up on a farm in South Africa and in fact, my family still runs the farm. After my medical training at the University of Cape Town in South Africa, I worked for a short while in Cape Town and then went to England for two years to earn foreign currency to help pay off student loans. After that, I took the opportunity to do a locum in Moose Jaw, Saskatchewan for six months. That was 10 years ago and I'm still here because I like it so much.

How did you first hear that there might be a better way to run your practice?

In December 2006, I met a family physician named Dr. Jeff Harries from Penticton who had recently implemented Advanced Access* in his practice. He piqued my interest because I was looking for ways to be more efficient and provide better service to my patients.

* Editor's note - Advanced Access is an approach to scheduling based on the premise that, in most clinical practices, capacity is actually greater than demand for appointments. Advanced Access involves managing scheduling more appropriately, to eliminate wait times and begin seeing patients the same day they call.

How quickly did you start applying the principles of Advanced Access in your office?

I didn't do anything with it immediately. I gave some of the articles I'd read to my medical office assistant, but she was reluctant; it seemed like a drastic change from the way we were working. Almost a year later, as the practice got busier and busier and in turn more stressful for me and my staff, she said she was ready to try it.

What are the keys to success with Advanced Access?

You need a team approach. I have a medical office assistant and a front desk receptionist; the three of us work very well as a team. Communication is also extremely important. Our team meets every morning for 10-15 minutes first thing every day, to update one another on who's sick or in hospital, who delivered a baby, etc. Communication with the people we serve is also very important, as the changes we were making affected them, too.

What was your biggest challenge in adopting Advanced Access?

Actually, it's been a lot easier than I thought it was going to be. But the toughest part is in the beginning, during the "boot camp" period, when you have to work down the backlog and try to see everyone who calls that day.

What is your biggest "aha" so far?

I wish I had done more to measure the effects of Advanced Access on my patients and on my practice. My experience is entirely anecdotal, but I can tell you it has transformed my work and reduced my stress significantly. If I was to do it again, and what I'd suggest to others, is to take measurements before and after so that you can show that you're providing a better service for your patients.

What looks different now that you've switched to Advanced Access?

I used to pre-book 80-90% of appointments. Now I only pre-book 30-35% of spots. As a result, we're seeing fewer multiple-problem visits. I don't see fewer people in a week. I just see them right when they have a problem.

How has Advanced Access changed your work/life balance?

Most days I am home at 5:00 and I take Friday afternoons off. I have three young children at home and older physicians have said to me that I should spend time with my kids when they're young and I've taken their advice to heart. I'm working smarter now so that I can spend more time with my family.

Why aren't more Saskatchewan doctors using Advanced Access?

They may be reluctant to go through the boot camp phase. Physicians may also worry that they won't maintain their income when they're only pre-booking only a third of appointments.

Has implementing AA affected your income?

There's been no change in my income, even though I'm working shorter hours. This may be because I am treating more people for single problems. I feel that I'm more available to the people I look after.

Any ideas on how to encourage more doctors to try Advanced Access?

Adjusting the fee schedule to encourage adoption of Advanced Access may help. It doesn't have to be a large incentive, just enough to convince people to wade in and try it.

What do your staff think about the new model?

They wouldn't go back to the way we were working before.

Do you have any AA mentors?

Dr. Mark Murray and Catherine Tantau. I attended their workshops in Vancouver and have read a lot of their articles.

What do you wish you would have known when you were just getting started with Advanced Access?

I wish I would have known more about the importance of measurement. When the impact of Advanced Access has been measured by others, they have found that it reduces the number of emergency room visits, specialist consults, orders for special tests, prescriptions for drugs, admissions and length of stays in hospital. Improved continuity of care and increased patient satisfaction are other proven benefits. There is no doubt in my mind that I would have found similar results had I measured these indicators; I just wish I had the evidence to prove it.

Has your work in AA led you to try other changes to improve care or patient flow?

I'm trying to implement some Lean principles alongside Advanced Access, by mapping patient flow and looking at our processes and how to improve them. For example, my medical assistant has moved into my office so that I'm not running back and forth to front area when I need her. That has saved a lot of steps and time. My team is not afraid to bring up ideas for new ways of doing things, especially for things that are tedious, or difficult. Now we sit back and look at how we're doing things and come up with new ideas. We're also using Plan Do Study Act cycles; we try things, and if they work, we carry on, if they don't work, we throw it out and try something else.

What other changes are you planning for your practice?

We're in the process of switching over to an electronic medical record (EMR) system, which has its challenges. But, because of the experience we've had with Advanced Access, we know the tough times are temporary and that we will soon see the benefits of our efforts. Adopting the EMR is long overdue and it will allow me to provide better quality of care. I will be able to pull data out of the records to see how I'm caring for people with diabetes, for example. It will give me feedback on how I'm doing.

What would you say to physicians who may be considering trying Advanced Access?

It will improve continuity of care and be cost-effective, it improves your quality of life, and reduces stress. As a first step, get a firm grasp of the principles of Advanced Access; the principles are basic and mostly common sense.

For more information on Advanced Access:

• The Institute for Healthcare Improvement presents the 11th Annual International Summit on Redesigning the Clinical Office Practice on March 7-9, 2010, in Washington, DC. The Summit will bring together revolutionary thinkers and innovative practitioners who are launching a new era in the scope and ambition of local care delivery. This event will fill you and your team with the energy, optimism, ideas, and practice solutions necessary to successfully manage your 2010 quality improvement agenda. For more information, visit the IHI website: www.ihi.org.

• Contact Sinead McGartland / (306)668-8810, ext. 143 or Jennifer Burkitt-Hiebert / (306)668-8810, ext. 136.

Photo caption: Dr. Mark Brown and family.

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