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Sometimes when I discover what's been happening, steam comes out of my ears.

We think we've got a terrific plan, a change that's going to really fix some problem, but if you're not continuously vigilant, things can get away from you.

Yesterday morning, one of the staff supervisors for our practice walked through my open door, turned, and closed it behind him -- never a good sign.

He had just completed the morning huddle with the registrars, our front desk staff members who schedule patients for appointments, answer the phones, and process referrals for our patients.

In addition to their usual administrative review, the topic of the morning huddle was appointment availability. Apparently the demand for appointments at our practices is far outstripping availability, and patients, along with those trying to get them appointments, have become increasingly frustrated.

The registrars told him that they are bombarded with phone calls every day from patients requesting same day or semi-urgent appointments, and they repeatedly have to tell patients there is no one available to see them.

'Go to the ER'

The most concerning part, however, was that he discovered they were telling patients that if they wanted to be seen today they should go to the nearest emergency room.

I was a little stunned to discover that these staff members were providing any sort of medical advice, especially in light of the fact they been told not to even think about triaging calls, and we have a whole system in place to assess patient's needs for urgent appointments.

Over the past several months we've developed an Access Team, in which all messages from patients requesting evaluation for acute illnesses are routed through to a nurse and a resident for clinical assessment.

But how, in a practice that has a no-show rate around 30%, can we not have appointment availability for same-day visits?

When we look back at the schedules after a practice day, we see providers with incredibly variable show rates, ranging from 100% all the way down to zero.

Surely somebody can be freed up to see the volume of patients calling and needing to be seen today, to avoid sending them to local urgent care centers or emergency rooms?

We especially want our residents to see these as learning opportunities, and so the idea of overbooking their schedules to account for a no-show rate is problematic. When a resident has a busy schedule, and admirably overbooks one of their patients, they're often busy and working long hours, but feel satisfied that they were able to provide the care their patients needed.

And when schedules are booked with appointments that are inappropriately made, such as a patient scheduled for a routine follow-up or annual physical with someone who is not their primary care provider, simply because they had an opening in that time slot, I think the quality of care tends to suffer; people tend to push things off to let the primary care provider (PCP) handle this at a later date.

We know that patients get better care, and are more satisfied with the quality of the care they receive, when they're seeing their continuity PCP, rather than someone filling in for them. In addition, provider satisfaction is higher when they're caring for their own patients rather than providing interim care.

But when you have a sore throat, or a rash, or some other new acute complaint that you feel needs to be addressed, you want to be able to be seen by some provider, any provider, in whatever context will get you the care you need, when you need it and want it.

Crowding Across the Street

Interestingly, on discovering that our front desk staff has been telling patients that we have no appointments and that they should go to the emergency room, we've been receiving numerous complaints from the emergency department at our hospital across the street that our patients are arriving with what are known as "primary care-sensitive conditions", things that are much better managed in the outpatient setting rather than the emergency department, at a much higher rate than they are used to seeing.

In the best-case scenario, someone would be able to contact us from the emergency room and simply re-route our patients back to us. But once the patients have been registered in their system, they are obligated to provide care, and rightly feel that these issues that should be managed in the outpatient setting are leading to overcrowding of their emergency department, and misallocation of precious resources.

To mirror this, our transitions program, which expedites the urgent and semi-urgent follow up care of patients being discharged from the inpatient floors or the emergency room, has noticed a disturbing trend. They have been looking at the quality of the appointments made for patients into these reserved slots for next-day or few-days-out appointments.

The major issue they've discovered is that a vast majority of these appointments do not really need to be seen in the timeframe selected by the transitions team on the inpatient service, but may be better put off until later, to provide optimal care.

A medicine has barely had time to work. Or they have not even started it yet.

Some of them don't need to be seen here at all. Many patients arrive here for their urgent transitions appointment and essentially say, "I don't know why I'm here, I'm feeling fine, but they told me that to be able to leave the hospital I had to have an appointment here."

Another scenario has been that patients already have a primary care provider in the community who they've seen for years, and who takes great care of them, but the inpatient or emergency room team was unable to obtain an appointment for them in the time frame requested, and thus the emergency room navigators said, "Well, we can get you seen at this practice tomorrow", and placed them on our schedules.

Working at Cross-Purposes

So here we have it again, two teams that seem to be working in opposition, both trying to get our patients the best care we can, butting up against each other in the name of who knows what.

Our front desk staff members see no appointments available for today on the scheduling system -– so they send the patients to the ER.

The emergency room navigators can't reach someone's primary care provider for follow-up – so they make them an initial visit appointment the next day with us here.

It's time as we continue all these practice improvement and care management programs that we get everybody on the same page, that we make sure we're not duplicating efforts, that we make sure were always doing what's best for the patients and building a system where all the moving parts work together.

Recreate the wheel, but make sure it's still round and rolls.

When we all get in the same room and talk about what our goals are, no one will admit that they're dumping work onto somebody else, that we're taking the easy way out because we can't find an appointment so we'll send them somewhere else just to close the loop and mark the task as done.

We are trying to fix the system because we're tired of failing. As challenging as it can be to make sure that these best-laid plans, these honorable intentions, actually lead to better outcomes, we need to continually be mindful of where these things can go wrong, how the innovations that we put into place that we think are helping are really only producing headaches for someone else at a different location.

When we provide a pressure release valve, something that can allow the system to let off steam, we may need to make sure that we're not burning someone else.

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