Commentary

Access to care—defined by the National Academy of Medicine as ‘the timely use of personal health services to achieve the best health outcome’—represents one of the critical public health issues facing society across all populations.1 While barriers to access include those related to logistical coordination, insurance coverage, financial resources, social determinants and/or provider availability, the expedient delivery of healthcare has been well established as a key performance indicator of quality. However, data from the Agency for Healthcare Research and Quality continue to show that approximately 15% of adults in the USA cannot access healthcare in a reasonably rapid fashion.2 Indeed, wait times for appointments are not only frustrating and anxiety-provoking for patients but can adversely impact health outcomes. According to one survey from 2022, the average wait time for a new physician appointment in large metropolitan markets in the USA was a staggering 26 days.3 In areas plagued by physician shortages such as rural communities, the wait times are naturally even more pronounced. Moreover, data from other industrialised countries within the Organisation for Economic Cooperation and Development seem to suggest that the observed delays in obtaining health services may in fact be worsening.4–6

Due to the practical challenges and inconveniences inherently involved in scheduling appointments, same-day visits have been proposed as a patient-centric means of increasing access to care. On the surface, the proposition is an appealing one—it provides patients with an unprecedented opportunity to be seen by a provider seemingly within hours. In a world where everything from laundry cleaning, food delivery, automobile repairs, hair appointments and entertainment, among a litany of other services, can be scheduled at a moment’s notice, it makes fundamental sense that the one entity that individuals value more than anything— their health—should be prioritised in such a similar fashion. Considering that a recent study showed that a quarter of online shoppers would abandon a cart if same-day service was unavailable, the potential lessons with respect to healthcare visits are potentially profound.7 For health systems, the implications on cost-effectiveness are also significant as a large backlog of appointments invariably results in waiting and dispirited patients who are more likely to seek care elsewhere—leading to inefficiencies in the form of ‘no shows,’ decreased income, lost opportunity and wasteful spending. Given the current climate of value-based care in which most systems exist, the need to optimise efficiency by eliminating any incongruities between supply and demand seemingly should be prioritised. While the lessons from other industries speak volumes as to the allure of same-day services, healthcare has been innately sluggish in adopting such a model.

Sceptics of same-day access in healthcare have voiced questions regarding the feasibility of this approach, particularly with respect to operational coordination and workflow. And rightfully so. Since the capacity for scheduling new patients is already low at baseline at many clinics, the ability to pragmatically assimilate same-day appointments into daily practice is often uncertain. This can be glaringly problematic for systems facing staffing shortages. Additionally, the possibility of seeing patients with incomplete medical records and/or engendering mismatches between the patient and specialist with respect to disease expertise can worrisomely introduce new bottlenecks into processes that are often already cumbersome. However, studies clearly show that providers have long been accustomed to handling patients with less than complete medical records.8 Smith et al conducted a cross-sectional survey of 32 primary care clinics and showed that clinicians acknowledged missing clinical information pertaining to patient care in 14% of visits.9 While less than ideal, providers have learnt to adapt to these circumstances so that the patient encounter can be as meaningful as possible. Moreover, the widespread adoption of electronic medical record systems has promoted the centralisation and sharing of data which facilitates more cohesive patient care. In countries where nationalised patient registries have been developed and implemented, the ease of information exchange and operability across sites is often pointed to as one of its primary advantages.10

With respect to continuity of care, studies surveying the opinions and priorities of patients may provide additional insight.11–13 Kozikowski et al conducted a cross-sectional survey of 1388 individuals specifically polling them on potentially important factors and trade-offs in selecting a provider. Tellingly, the ability to be seen quickly was rated as ‘important’ by a higher proportion of respondents (87%) than provider experience (73%), provider type (72%), recommendation from others (55%) and online reviews (43%).11 Other studies have shown that patients value communication and shared decision-making above all else, even when continuity of care cannot be optimised and/or when certain specialists might not be available.14 15 While the possibility of inadvertently creating new operational inefficiencies related to care coordination with same-day access certainly cannot be discounted, the published literature thus offers some reassurance that these can be overcome with a transparent and thoughtful approach to disseminating information.

Lastly, the potential effect of same-day access on an already taxed workforce with respect to morale and burn-out warrants close consideration. In this sense, it is important to recognise that the ability to satisfy the needs of an expanding patient population is directly dependent on ensuring that enough providers are in place. While seemingly self-evident, workforce shortages are common bottlenecks in the ability to expand access, as patient backlogs inevitably lead to longer waits. Notably, this predicament does not just apply to physicians. Studies have shown that a lack of qualified ancillary staff including those related to nursing, front-desk support and medical assistants can significantly impede workflow—leading to operational delays which can choke patient flow and throughput.16 17 The potential utility of navigators, scribes and resource specialists has also been demonstrated, as these support staff can absorb much of the mundane, administrative aspects of work, thus enabling physicians to focus on direct medical management.18 19 Ultimately, a steady workforce allows a practice to run efficiently thereby creating a foundation for improving access. As such, the development of appropriate staffing models is a consideration that all healthcare organisations must pre-emptively address.

The associated expenses related to offering same-day appointments, particularly with respect to personnel recruitment and management, must also be acknowledged especially as health systems manoeuvre in increasingly resource-constrained environments where cost-effectiveness is often prioritised. Along these lines, the assimilation of dedicated intake teams into the clinical setting is critical in promoting access champions who ensure that patients can be scheduled and accommodated as seamlessly as possible. While sceptics will undoubtedly continue to raise concerns that the costs of same-day service might not be offset by the potential rewards, findings from numerous studies have demonstrated that streamlining patient flow, prioritising throughput and enhancing operational efficiency not only improve consumer satisfaction but also result in improved financial performance.20–22 Regardless, given the multitude of potential barriers that could obfuscate any benefits of same-day access, it is thus no wonder that health systems have been slow to adopt such a paradigm.

Since data on the feasibility of same-day access in healthcare had largely been limited to relatively isolated experiences, findings from a prospective experience with this strategy over the course of 2 years in outpatient radiation oncology were recently published.23 While same-day appointments were heralded as a patient-centric means of improving the healthcare journey and successfully reduced the time to treatment for patients with newly diagnosed cancer, the initiative also presented new challenges—both expected and unexpected—which needed to be overcome. Notably, the same-day access initiative was deliberately designed to be integrated into everyday workflow without the creation of new patient slots. This obviated the need to overhaul schedules or to construct any additional physician templates; instead, the programme optimised existing space in schedules through the elimination of inefficiencies and/or idle time, thereby preserving provider autonomy. With a relatively modest same-day appointment usage rate of 14%, enough vacancy was identified in the existing schedule to ensure the feasibility of this model. However, it is instructive to acknowledge that as utilisation rates increase, the reliance on an adequate provider pool will be essential to maintaining such a service. Anecdotally, the same-day access programme was briefly halted in later years after the initial 2-year analysis period because of a sudden, unexpected shortage of providers due to reasons such as retirement, medical leave and/or relocation. This again highlights the importance of forecasting any workforce shortages before they occur and to be pre-emptive with recruiting. Similarly, the recognition that a given provider might not always be available to accommodate a same-day appointment request demanded that contingencies be built into scheduling templates. For any given diagnosis, the intake team started with the first-priority physician referencing the existing schedule to see if openings existed. If availabilities were unavailable, the scheduler then proceeded to a second-priority, third-priority or fourth-priority provider if needed until the encounter was fulfilled. Importantly, physicians were provided the opportunity to decline a same-day request at their discretion. The use of an 11:00 hours cut-off after which same-day appointments were no longer offered to patients was designed to prevent clinical staff from having to rush in order to accommodate last-minute visits.

To gauge the success of the same-day access initiative, a plethora of health services-related metrics were tracked pertaining to its utilisation, effectiveness and impact on patient satisfaction. Access-related benchmarks such as time from diagnosis to treatment were monitored and reviewed on a monthly basis. Additionally, the impact of this access initiative on health equity, particularly with potentially addressing disparities among historically disadvantaged groups, was evaluated. This was especially germane given that numerous studies have shown that socioeconomic factors such as race and income drive many of the inequalities observed with respect to delays in care.24 25 The influence of the programme on the morale of clinical staff was also assessed regularly, as well as an examination of resources required to maintain ongoing operations. The effect of the same-day appointment programme on clinic workflow was also regularly monitored to ensure that previously unseen inefficiencies and delays were not being introduced. This was particularly important given that the same-day access initiative represented a dramatic departure from traditional clinic operations and thus required frequent and dependable feedback from patients and providers alike to refine processes moving forward. Ultimately, the goal was to ensure that the process of maintaining the same-day access initiative was analytical driven and based on continual analysis of real-time data. In this regard, the same-day access programme surpassed all expectations with respect to every practical metric. Most notably, a significant reduction in the median time from referral to consultation from 12 days to 3 days was observed after the initiation of the same-day access programme.

How the potential success of same-day access could be replicated and measured in other specialty-based clinics as well as the primary care realm will require an appropriate level of customisation depending on the specific needs and requirements of the respective patient population. In this regard, the importance of expedient care delivery, while consistently proven as an important quality indicator that influences outcomes, is not unique to patients with cancer, and the experience presented here can be extrapolated to other healthcare settings. However, since the same-day access paradigm is counterintuitive to traditional practice in which visits are generally scheduled based on a ‘first-come, first serve’ mentality (in the context of clinical acuity), the need to effectively manage culture change and to create an environment of shared purpose, trust and transparency cannot be overemphasised. Given the potentially disruptive nature of this delivery model, a 6-month preparatory phase was intentionally devised prior to going ‘live’. This allowed time to thoughtfully garner buy-in through town halls and workshops—with question-and-answer sessions designed explicitly to discuss concerns about the same-day access programme. Even after its roll-out, the outward committment of leadership to this initiative, focusing consistently on its transformative ability to drive patient care improvement, was critical to creating an “all hands” organizational effort. The steadfast promotion of standardised procedures with continual input from all stakeholders was useful to set and guide expectations-- and ultimately allowed the same-day access paradigm to become successfully operationalised and engrained into the workplace as the norm.

Published reports on the utility of same-day access in healthcare are relatively scarce. Roman et al reported on a 3-year experience with same-day access in the primary care setting within the US Veteran Affairs system, comparing the outcomes of 9909 patients seen prior to the development of the initiative to the 12 311 patients seen after implementation. Impressively, the median time to the initial primary care appointment was reduced from 96 days to 0 days with the introduction of same-day access. Relevantly, 92% of patients were able to obtain a same-day primary care appointment after the implementation of the programme compared with only 3% prior, demonstrating the feasibility and popularity of same-day access.26 Hawks et al similarly reported on the experience of the Australian public health system with a same-day ‘one-stop’ prostate clinic to provide assessment and diagnostic evaluation for men suspected of having prostate cancer.27 Over a 6-year duration, a total of 1000 patients, a significant proportion from rural backgrounds, used this service; and the programme resulted in savings of 543 travel episodes and reduced total costs for patients by over US$600 000. These experiences have shown that demand for same-day service when it comes to healthcare is robust and that the public, if given a choice, will use and embrace such a paradigm.

Without a doubt, a ‘new normal’ has emerged when it comes to the expediency of service expected by customers across all industries. For many companies, the ability to offer same-day or ‘on-demand’ service represents an integral part of their value proposition. Like it or not, the standards have been raised by the likes of Amazon, Netflix and a slew of other corporate titans, placing increasingly more pressure on incumbent players to adapt accordingly regardless of the sector. Indeed, the recent incursion of upstart high-technology companies (Teladoc Health, Zocdoc and Amwell, etc) into the healthcare space has upped the stakes even further as they seek to carve out a competitive advantage based on patient-centricity and consumer empowerment. If anything, this provides even more powerful evidence that patients are demanding a higher degree of customisation, convenience and timeliness than ever before with their care. Ultimately, it is no exaggeration to assert that same-day service, once considered a novelty, has become a standard in nearly every consumer-driven industry. Whether healthcare can continue to be the exception needs to be critically reappraised.