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      Waiting time reduction in intravitreal clinics by optimization of appointment scheduling: balancing demand and supply

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      BMJ Quality Improvement Reports
      BMJ Publishing Group Ltd.

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          Abstract

          This study was designed guided by the Model for Improvement framework to reduce waiting times and visit duration in the intravitreal therapy clinic, while improving patient and staff experience. In our aim to provide good quality, patient-centred care and constantly improve, we optimised the appointment profile and patient flow.

          We involved a multidisciplinary team (one consultant, junior doctors, staff nurses, technicians, and receptionist), as well as patients and relatives, to try to understand the main delays in the clinic. Process mapping, a fishbone diagram, run charts, together with feedback from patients and staff, provided an insight on the possible roots of the delays experienced by our patients. The results of the inquiry led us to take actions focused on optimising appointment scheduling.

          After implementing the new scheduling profile (with a gap in the middle of the session), various cycles of plan-do-study-act and a comparative, qualitative study by interviewing 10 patients demonstrated that the waiting times decreased, and patients and staff experience improved.

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          Advanced access: reducing waiting and delays in primary care.

          Delay of care is a persistent and undesirable feature of current health care systems. Although delay seems to be inevitable and linked to resource limitations, it often is neither. Rather, it is usually the result of unplanned, irrational scheduling and resource allocation. Application of queuing theory and principles of industrial engineering, adapted appropriately to clinical settings, can reduce delay substantially, even in small practices, without requiring additional resources. One model, sometimes referred to as advanced access, has increasingly been shown to reduce waiting times in primary care. The core principle of advanced access is that patients calling to schedule a physician visit are offered an appointment the same day. Advanced access is not sustainable if patient demand for appointments is permanently greater than physician capacity to offer appointments. Six elements of advanced access are important in its application balancing supply and demand, reducing backlog, reducing the variety of appointment types, developing contingency plans for unusual circumstances, working to adjust demand profiles, and increasing the availability of bottleneck resources. Although these principles are powerful, they are counter to deeply held beliefs and established practices in health care organizations. Adopting these principles requires strong leadership investment and support.
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            How outcomes are achieved through patient portals: a realist review.

            To examine how patient portals contribute to health service delivery and patient outcomes. The specific aims were to examine how outcomes are produced, and how variations in outcomes can be explained. We used a realist review method, which aims to describe how 'an intervention works, for whom, and in what circumstances' by analyzing patterns between context, mechanism, and outcomes. We reviewed 32 evaluation studies of patient portals published since 2003. The reviewed evaluations indicate that as a complement to existing health services, patient portals can lead to improvements in clinical outcomes, patient behavior, and experiences. Four different mechanisms are reported to yield the reported outcome improvements. These are patient insight into personal health information, activation of information, interpersonal continuity of care, and service convenience. The vast majority of evaluations were conducted in integrated health service networks in the USA, and we detected no substantial variation in outcomes across these networks. Patient portals may impact clinical outcomes and health service delivery through multiple mechanisms. Given the relative uniformity of evaluation contexts, we were not able to detect patterns in how patient portals work in different contexts. Nonetheless, it appears from the overwhelming proportion of patient portal evaluations coming from integrated health service networks, that these networks provide more fertile contexts for patient portals to be effective. To improve the understanding of how patient portals work, future evaluations of patient portals should capture information about mechanisms and context that influence their outcomes. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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              Evaluating change in health care practice: lessons from three studies.

              Implementation and evaluation of evidence-based practice are high on the policy agenda in the UK National Health Service. Over the last 30 years evaluation of practice in the health services has moved from a (medical) profession-led mode to a politically and managerially led mode in which objectives are pre-set by those who legitimate and fund the services. Against this background we describe three recent evaluations of nursing practice as examples to illustrate challenges encountered when evaluating changes in practice developments in health care. If evaluations are to contribute to improvements in practice, a shift is needed from an over-reliance on one-off outcome evaluations to those that have a cumulative component and take account of context and process as well as outcome. The merits of realistic evaluation are suggested as a solution to the methodological limitations of traditional approaches and to developing generalizable theory.
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                Author and article information

                Journal
                BMJ Qual Improv Rep
                BMJ Qual Improv Rep
                bmjqir
                BMJ Quality Improvement Reports
                BMJ Publishing Group Ltd.
                2050-1315
                2015
                19 June 2015
                : 4
                : 1
                : u208924.w3618
                Affiliations
                Moorfields Eye Hospital
                Author notes
                [Correspondence to ] Marta Ugarte mugarte@ 123456doctors.org.uk
                Article
                bmjquality_uu208924.w3618
                10.1136/bmjquality.u208924.w3618
                4695962
                f00d6742-bc69-4e39-b4cd-9a5584c9558f
                © 2015, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ http://creativecommons.org/licenses/by-nc/2.0/legalcode

                History
                : 7 June 2015
                : 18 June 2015
                : 19 June 2015
                Categories
                BMJ Quality Improvement Programme
                1820

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