Adoption of an advanced access model by residents

Evidence-based care and best practices

Murray and Tantau⁵ maintain that advanced access is difficult to introduce in settings where general practitioners work fewer than 6 half-days a week—a common feature of FPUs whose staff also have clinical duties at an institution or university. In spite of this, a randomized trial conducted in a teaching setting⁶ demonstrated substantial—and surprising—improvements in the functional organization of the teaching setting and its wait times. In addition, a study conducted in 2004 demonstrated that having residents participate in improvement initiatives makes it possible to increase the number of registered patients and to increase the efficiency of a team.⁷

In addition to addressing issues with access, the advanced access model helps residents build skills in CanMEDS–Family Medicine⁸ roles, including the following:

• Collaborator—sharing activities with nurses;

• Communicator—simplifying the appointment model and enabling the initial contract to evolve;

• Manager—effective management of patients, time, supply, and demand; and

• Professional—greater autonomy and less wait list pressure.

Teaching tool

We developed a pilot project to enable 2 residents in their final year of training at our FPU to implement the advanced access model. To increase the likelihood that our project would be a success, we developed criteria for implementation (Box 1). First, our teachers had to adopt the model so that they could then guide the residents through the process; this meant that the administrative staff and nursing staff also became familiar with the concept. Second, we standardized our scheduling practices (length of appointments, percentage of time dedicated to open scheduling); this reduced the effect of the change on the team. Third, we clearly defined the practice population of each of the residents, so that their use of the model would resemble their supervisors’ use of the model as much as possible.

When the change was implemented, all of the teachers at the FPU were informed of the initiative and made aware of the potential effect on supervision and the unpredictability of filling appointments. As soon as the model was implemented, the physician leading the project began follow-up meetings with the residents and supervisors to make any necessary adjustments.

Tools and resources from the project

A number of different factors contributed to the success of our experiment (Box 2). First, the residents were enthusiastic and open to the changes. This was also true of the teaching team, who offered all of the support and understanding that we hoped they would. Clearly defining the residents’ practice populations and having them conform to the practising physicians’ practice populations also proved to be very important.

However, we did encounter a number of obstacles. The greatest obstacle was the availability of nursing staff to support the practice. The problem was not a lack of interest on their part; it was a lack of resources commensurate with the number of physicians who had adopted the model. Some patients found the model difficult to understand; this could have been addressed by providing them with a written explanation beforehand. It was more difficult to provide prompt access to an appointment during the months when the residents were away performing rotations and only performing half-day returns; this could have been addressed by arranging for the residents to cover for each other.