Eight Priorities for Improving Primary Care Access Management in Healthcare Organizations: Results of a Modified Delphi Stakeholder Panel

Providing access to healthcare is a fundamental primary care function and a necessary prerequisite for judging care quality.¹ Yet, translation of the substantial research on the importance and determinants of access into sustainable access improvement in healthcare delivery organizations has lagged. Few research address the needs of organization leaders and managers for continuous, comprehensive and sustainable access management approaches. Expert panels can provide a basis for moving forward when existing research evidence is insufficient.^2‐4 We initiated a systematic review of research evidence on diverse access management interventions⁵ and a qualitative study of the Veterans Health Administration (VHA) access manager initiative⁶ as part of a 2-year-long project capped by the modified Delphi panel process reported here. Our goal was to provide evidence-informed guidance on top priorities for improving management of patient access to primary care in integrated healthcare systems.

Access is a “wicked” problem.^{7, 8} Wicked problems require solutions that integrate across stakeholder perspectives and span relevant organizational programs and goals. No one solution to a wicked problem will succeed across organizational contexts or across time. All solutions require both trade-offs between alternative goals and ongoing monitoring. We therefore focused on access management as an ongoing organizational activity rather than on access as a once-and-done outcome. We aimed to identify the key organizational structures, processes, and outcomes⁹ that leaders and managers of healthcare delivery systems would need to consider for undertaking access management improvement.

Timely access to primary care is important to integrated healthcare systems, and has been the major focus of access-related performance measurement.⁵ Primary care provides first-line and preventive care, and is at the junction between patients and appropriate use of the wider set of available health services.¹⁰ The National Academy of Medicine identified timeliness as a fundamental aim for healthcare¹¹—and as the least well studied and understood.¹² However patient needs and preferences are at the foundation of optimal access, and from the patient’s point of view, improved access includes a broader range of considerations other than timeliness, such as availability, accommodation, affordability, and acceptability.¹³

Integration of patient considerations into management strategies is challenging. Patients have diverse perspectives on, for example, accessing primary care team members other than physicians, on group visits, and on non-face-to-face care such as telephone care or secure messaging. Patients may value being seen on a day of their choice, or by their continuity provider, more than they value being seen quickly—or vice versa.¹⁴ Finally, patients may weigh the effort required to achieve needed access, such as distance to clinic, waiting time, or ease of making appointments, in deciding whether and how to accomplish it.^{15, 16} It is thus not surprising that patient-reported access measures often do not align tightly with timeliness measures.^17‐20 Clearly, improving patient experiences related to access requires integration of patient and system perspectives.

Healthcare system leaders and managers as well as patients face trade-offs in approaching access improvement. The same open access actions that improve access in the short term can lead to increased demand that worsens access in the longer term.²¹ Maximizing timely access and continuity of care can be conflicting goals in the face of fixed primary care resources.^{8, 22‐24} In turn, both the supply of services and the demand for them will be influenced by multiple and continuously changing local, regional, and national factors.

In the work presented here, we viewed achieving optimal access as a management challenge within a complex adaptive system framework. In complex adaptive systems, the results of management actions will always be subject to uncertainty⁸ and to unintended consequences;^{25, 26} step by step improvement instructions may therefore not produce the desired result. We aimed instead to use a rigorous evidence base and modified Delphi panel methods to promote the development of targeted access management improvement agendas²⁷ by organization leaders and managers, and to promote future access management research. Our objectives were to (1) define access management; (2) identify access management priorities for action; (3) develop recommendations, suggestions for implementation, and references for each priority area; and (4) develop a panel-approved ready to use tool summarizing the results.

While access to healthcare has always been of paramount importance, responsibility for ensuring access has often been dispersed across many organizations, leaving none accountable overall. Integrated healthcare organizations such as the VHA and others, however, have both responsibility for enabling access to needed care of all types and population-based data for monitoring it. These circumstances make access challenges more visible and create opportunities for improvement. We initiated a formal systematic review of prior literature and a qualitative study of the experiences of VHA access managers to identify factors influencing access. We then engaged a broadly representative, evidence-informed stakeholder panel in a modified Delphi panel process to identify priorities for action based on their ratings of over 80 of these factors. The resulting eight priorities focus on structure, processes, and outcomes and address essential organizational access management targets. These priorities provide valid current guidance on access management improvement for healthcare organization managers and leaders.

Learning organizations aim to use evidence as the basis for improvement, yet decades of research on access provide limited assistance to healthcare organization leaders and managers as they confront ongoing access challenges.⁴⁰ The inevitability of continuous local and organizational changes in supply and demand, and of the need to integrate patient, provider team, and organizational considerations and preferences, precludes a one-size-fits-all approach. We therefore sought to develop a basis for improvement rather than a set of mandates, and to focus on North American integrated healthcare systems as our context. We think aspects of our work, however, can serve as a foundation for similar initiatives within other organizational contexts, such as practice networks or community-based improvement efforts,

Our systematic review found no studies addressing access as a “wicked” management and policy problem that must be addressed across organizational programs and boundaries.⁷ Most access management improvement interventions in our review focused only on the open access approach.⁵ Open or advanced access focuses on how to manage primary care visit schedules so that a patient is offered a prompt appointment whatever the reason for the visit request.²¹ Existing studies show that system improvement based on single access elements (such as open access²¹) is not only insufficient, but can result in negative consequences. Panelists viewed open access principles as methods for achieving the more fundamental priorities of better group practice management, care coordination, proactive demand management, and patient and provider experience (see recommendations, suggestions, and references for priorities 2, 4, and 6 in Online Appendix 1 focusing on open access) rather than as priority goals in themselves. Within this more comprehensive context, health systems could enlist open access^{24, 41, 42} alongside other relevant approaches as part of an overall access management improvement agenda.

Developing an agreed-upon implementation agenda, spanning organizational boundaries and taking account of local resources, have been shown to be associated with quality improvement initiative success.²⁷ The approach described here incorporates each of these features. Our access management tools (Online Appendices 1 and 2) provide concrete guidance on shaping agenda development and provide (Online Appendix 2) an approach for integrating research evidence, local data, and relevant stakeholder input. The priorities themselves span both professions (e.g., nurse, physician, administration) and organizational units (e.g., call centers, information technology, contracting).

In the last decade, many healthcare organizations have changed their access management policies;⁴³ most of these changes, however, have not been rigorously evaluated.^{5, 17, 18} Modified Delphi expert panel methods that take account of existing knowledge, while supplementing it with consensus across diverse perspectives, can provide valuable guidance for bridging gaps in research-based knowledge.^{2, 3, 34} A future study testing the effectiveness of achieving adequate performance across all eight priorities identified here, however, would be valuable.

All eight top priorities resulting from the panel met our criterion of endorsement by more than half of the panelists as both important and urgent. The exact level of agreement, however, varied. Interestingly, the most agreed-upon priority (100% agreement) was one that receives scant mention in access literature—i.e., the need for “routine evaluation of the degree to which patient telephone calls are (a) answered promptly and (b) routed accurately and appropriately, as judged in terms of patients’ clinical needs and preferences.” The high level of panelist agreement in the absence of available research strongly suggests a need for additional investigation.

As structure improvement targets, the panel identified interdisciplinary leadership at the local practice site level, with shared governance across physician, nurse, and administrative lines, and achievement of a clear group practice management structure originating at an executive level as top priorities. These targets reflected approaches for achieving the level of boundary spanning communication and decision-making across disciplines and programs required for optimal access management.

As process improvement targets, the panel identified two little-studied influences on access (high-quality telephone access, contingency staffing) and two more commonly referenced in open access and other literature (care coordination and optimizing provider visit schedules).

All panelists, with strong endorsement from the two patient representatives, saw telephone access as fundamental for ensuring appropriate patient safety, scheduling, and coordination.³³ While virtual or computer access is increasingly important (see priority 7, and suggestions related to priorities 3, 5, 7, and 8, Online Appendix 1), and can reduce patient and provider telephone burden, patient computer abilities and access vary, as do the abilities of provider teams to respond promptly to computer messages. For these and other reasons, computers cannot eliminate the need for high-quality telephone access. Yet healthcare literature provides sparse guidance on how primary care practices should structure or evaluate telephone services. Similarly, panelists identified contingency staffing as critical but often overlooked. They noted that without contingency staffing availability, delivery systems would either fail to deliver adequate access or would be continuously (and likely unsustainably) overstaffed.

In terms of outcomes, panelists viewed both patient and provider experiences of access as critical and intertwined. Because patient experiences of access can reflect all access modalities (e.g., telephone, online, and in-person), panelists judged improving patient experience to be the best overall outcome target for access improvement.

A theme among the panel priorities was the importance of nurse role development both as organizational leaders and as clinical care team leaders. Achievement of optimal nursing roles, as shown in panel recommendations (Online Appendix 1), will require training and role development.

We aimed to provide guidance to health systems, rather than individual primary care practices. However, we expect that, although the relative urgency and importance of the priorities may differ for smaller or unaffiliated practices, all eight priorities are potentially relevant even at the individual practice level. Smaller systems or practices could also consult the overall framework we provide (Table 2) or the survey based on it.³⁰

Our study had limitations. While our stakeholders were diverse in professional backgrounds, they represented only large managed care systems in North America. More than half of the panelists had VHA backgrounds. During panel discussions, however, non-VHA panelists re-iterated the extent to which priorities were common across delivery systems, differing mostly in the extent to which a priority was currently problematic or had already been adequately achieved. Additionally, our panel was designed to include only 20 participants. This size is maximal for an in-person modified Delphi panel. A future online larger panel may be helpful for addressing other contexts.³⁷ As another limitation, we did not achieve (and did not aim to achieve) full agreement among panelists; we followed strict procedures to identify rather than coerce consensus. However, disagreements on priorities were largely limited to whether a priority was both urgent and important, or simply important, and all participating panelists endorsed our final definitions, priorities, recommendations, and suggestions. We also did not assess the costs or methods for paying for enhanced access. Finally, our results are intended to be formative rather than definitive.

Our findings imply that the current healthcare organization focus on timeliness of access and on achieving open access goals is too narrow to succeed. Because it is often the factor upon which achievement of all others may depend, we recommend establishing cross-cutting access management (see structure-related priorities) as a starting point. We then recommend a formal process of assessing current accomplishments in each priority area and engaging stakeholders in addressing one or two (Online Appendix 2).

In summary, this study provides a valid foundation for action for achieving optimal access management within healthcare organizations, as well as providing a basis for future research. Our final eight key priorities are concise action points and are linked to relevant evidence and guidance on implementation in ready-to-use tools (Appendices 1 and 2). Our work as reported here can provide healthcare organization leaders and managers, particularly those in integrated healthcare organizations, with a foundation for undertaking access management improvement, while tailoring it to their own contexts.