Advanced Access in Primary Health Care: experiences from Brazil and Canada

Access is the timely use of services in order to meet the needs of the user. As an alternative to the traditional model, the Advanced Access (AA) model appears in Canada , with schedules restricted to specific cases. Objectives: The purpose of this article is to analyze the existing scientific production about the Advanced Access model in Primary Health Care. Methods: Integrative literature review using the descriptors (1) “Health Care Accessibility” OR “Primary Health Care” AND and (2) "Advanced Access" in the PubMed, Scopus and BIREME databases. Selection criteria were studies published in the last five years, available in Portuguese, English or Spanish and dealing with the theme. Results: Eight studies were selected, six were grouped into two categories of analysis: “The Canadian experience with AA : a model in consolidation”; and “The Brazilian experience with AA: local experiments” and the other two contributed to enrich the discussion. The AA stands out to balance capacity and demand with physical infrastructure and adequate staff, both in the international arena, as the experiences of municipalities, improving the quality of APS. Conclusion: Studies that detail the AA in its practice, as well as the challenges and needs, can inspire other health units to study it and consider its implementation if it is appropriate for its context, aiming to improve the health and care of its population.

Development of a self-reported reflective tool on advanced access to support primary healthcare providers: study protocol of a mixed-method research design using an e-Delphi survey

IntroductionTimely access is one of the cornerstones of strong primary healthcare (PHC). New models to increase timely access have emerged across the world, including advanced access (AA). Recently in Quebec, Canada, the AA model has spread widely across the province. The model has largely been implemented by PHC professionals with important variations; however, a tool to assess their practice improvement within AA is lacking. The general objective of this study is to develop a self-reported online reflective tool that will guide PHC professionals’ reflection on their individual AA practice and formulation of recommendations for improvement. Specific objectives are: (1) operationalisation of the pillars and subpillars of AA; (2) development of a self-reported questionnaire; and (3) evaluation of the psychometrics.Methods and analysisThe pillars composing Murray’s model of AA will first be reviewed in collaboration with PHC professional and stakeholders, patients and researchers in a face-to-face meeting, with the goal to establish consensus on the pillars and subpillars of AA. Leading from these definitions, items will be identified for evaluation through an e-Delphi consultation. Three rounds are planned in 2020–2021 with a group of 20–25 experts. A repository of recommendations on how to improve one’s AA practice will be populated based on the literature and enriched by our experts throughout the consultation. Median and measures of dispersions will be used to evaluate agreement. The resulting tool will then be evaluated by PHC professionals for psychometrics in 2021–2022.Ethics and disseminationThe Centre Intégré de Santé et de Services Sociaux de la Montérégie-Centre Scientific Research Committee approved the protocol, and the Research Ethics Board provided ethics approval (2020-441, CP 980475). Dissemination plan is a mix of community diffusion through and for our partners and to the scientific community including peer-reviewed publications and conference presentations.

Interprofessional advanced access – a quality improvement protocol for expanding access to primary care services

Background The Advanced Access (AA) Model has shown considerable success in improving timely access for patients in primary care settings. As a result, a majority of family physicians have implemented AA in their organizations over the last decade. However, despite its widespread use, few professionals other than physicians and nurse practitioners have implemented the model. Among those who have integrated it to their practice, a wide variation in the level of implementation is observed, suggesting a need to support primary care teams in continuous improvement with AA implementation. This quality improvement research project aims to document and measure the processes and effects of practice facilitation, to implement and improve AA within interprofessional teams. Methods Five primary care teams at various levels of organizational AA implementation will take part in a quality improvement process. These teams will be followed independently over PDSA (Plan-Do-Study-Act) cycles for 18 months. Each team is responsible for setting their own objectives for improvement with respect to AA. The evaluation process consists of a mixed-methods plan, including semi-structured interviews with key members of the clinical and management teams, patient experience survey and AA-related metrics monitored from Electronic Medical Records over time. Discussion Most theories on organizational change indicate that practice facilitation should enable involvement of stakeholders in the process of change and enable improved interprofessional collaboration through a team-based approach. Improving access to primary care services is one of the top priorities of the Quebec’s ministry of health and social services. This study will identify key barriers to quality improvement initiatives within primary care and help to develop successful strategies to help teams improve and broaden implementation of AA to other primary care professionals.

Improving Administrative Outcomes in Physiotherapy by Adopting Open-Access Booking

Purpose: Long wait times for physiotherapy are associated with poorer health trajectories for clients. Clients’ experiences with physiotherapy services in Saint John were suboptimal; thus, this study explored making administrative changes to improve those experiences. All physiotherapy services adopted an administrative model called open-access booking (OAB), which blended elements of advanced access, triage, and centralized wait lists. Method: OAB was instituted in the first week of February 2017 and has been active since. The researcher accessed more than 20,000 anonymized case records spanning 5 years (February 2014–January 2019) and compared the 3-year pre-OAB phase with the 2-year OAB phase using interrupted time series analysis models. Results: OAB appeared to not be associated with changes in client volume, but it was associated with fewer “on-paper” clients, shorter wait times to first appointment, more consistent record keeping, a greater likelihood of being discharged after one appointment, and fewer appointments before discharge. There was less variability in these outcomes after the adoption of OAB, suggesting a more stable client experience with the physiotherapy system. Conclusions: OAB appears to be associated with improved administrative outcomes, but strict causality cannot be assessed. The results are promising but not conclusive.

After COVID-19: Improving the Patient's Outpatient Appointment Experience

As the COVID-19 pandemic diminishes, it is expected that patients will seek more outpatient appointments resulting in adverse patient and clinic experiences if there is a corresponding increase in missed appointments. This study's purpose was to determine if there was an association between advanced access scheduling, also known as open access or same day scheduling, and missed appointment rates for patients scheduled with preferred primary care physicians vis-a-vis nonpreferred primary care physicians. Patients prescheduled with primary care providers and over the age of 18 years were included in the study, which totaled 4815 visits. Study results demonstrated a statistically significant mean proportion difference between the national no-show rate and the study's no-show rate as well as a significant association between physician type and visit status. The results suggested the potential for improving the patient experience with advanced access scheduling if patients are scheduled with their preferred primary care physician. This study may promote positive patient experiences by providing patients and clinicians with an understanding of the significance surrounding advanced access scheduling thus decreasing missed appointments.

Changing nursing practice within primary health care innovations: the case of advanced access model

Background The advanced access (AA) model has attracted much interest across Canada and worldwide as a means of ensuring timely access to health care. While nurses contribute significantly to improving access in primary healthcare, little is known about the practice changes involved in this innovative model. This study explores the experience of nurse practitioners and registered nurses with implementation of the AA model, and identifies factors that facilitate or impede change. Methods We used a longitudinal qualitative approach, nested within a multiple case study conducted in four university family medicine groups in Quebec that were early adopters of AA. We conducted semi-structured interviews with two types of purposively selected nurses: nurse practitioners (NPs) (n = 6) and registered nurses (RNs) (n = 5). Each nurse was interviewed twice over a 14-month period. One NP was replaced by another during the second interviews. Data were analyzed using thematic analysis based on two principles of AA and the Niezen & Mathijssen Network Model (2014). Results Over time, RNs were not able to review the appointment system according to the AA philosophy. Half of NPs managed to operate according to AA. Regarding collaborative practice, RNs were still struggling to participate in team-based care. NPs were providing independent and collaborative patient care in both consultative and joint practice, and were assuming leadership in managing patients with acute and chronic diseases. Thematic analysis revealed influential factors at the institutional, organizational, professional, individual and patient level, which acted mainly as facilitators for NPs and barriers for RNs. These factors were: 1) policy and legislation; 2) organizational policy support (leadership and strategies to support nurses’ practice change); facility and employment arrangements (supply and availability of human resources); Inter-professional collegiality; 3) professional boundaries; 4) knowledge and capabilities; and 5) patient perceptions. Conclusions Our findings suggest that healthcare decision-makers and organizations need to redefine the boundaries of each category of nursing practice within AA, and create an optimal professional and organizational context that supports practice transformation. They highlight the need to structure teamwork efficiently, and integrate and maximize nurses’ capacities within the team throughout AA implementation in order to reduce waiting times.

Advanced Access scheduling in general practice and use of primary care: a Danish population-based matched cohort study

BackgroundAdvanced access scheduling (AAS) allows patients to receive care from their GP at the time chosen by the patient. AAS has shown to increase the accessibility to general practice, but little is known about how AAS implementation affects the use of in-hours and out-of-hours (OOH) services.AimTo describe the impact of AAS on the use of in-hours and OOH services in primary care.Design & settingA population-based matched cohort study using Danish register data.MethodA total of 161 901 patients listed in 33 general practices with AAS were matched with 287 837 reference patients listed in 66 reference practices without AAS. Outcomes of interest were use of daytime face-to-face consultations, and use of OOH face-to-face and phone consultations in a 2-year period preceding and following AAS implementation.ResultsNo significant differences were seen between AAS practices and reference practices. During the year following AAS implementation, the number of daytime face-to-face consultations was 3% (adjusted incidence rate ratio [aIRR] = 1.03; 95% confidence interval [CI] = 0.99 to 1.07) higher in the AAS practices compared with the number in the reference practices. Patients listed with an AAS practice had 2% (aIRR = 0.98; 95% CI = 0.92 to 1.04) fewer OOH phone consultations and 6% (aIRR = 0.94; 95% CI = 0.86 to 1.02) fewer OOH face-to-face consultations compared with patients listed with a reference practice.ConclusionThis study showed no significant differences following AAS implementation. However, a trend was seen towards slightly higher use of daytime primary care and lower use of OOH primary care.

Practical procedures

The final chapter provides instructions for practical procedures which support advice given in other sections. Techniques for managing difficult airways are explored including front of neck access (by surgical or needle cricothyroidotomy), intubating laryngeal mask insertion, awake fibreoptic intubation, lightwand-assisted airway management, and retrograde intubation. Meanwhile, techniques for chest drain insertion and one-lung ventilation are described. Methods of administering bronchodilators by in-circuit nebulization or metered dose inhaler are offered. Advanced access techniques for the circulation are also presented, including internal jugular catheters, femoral vein catheters, intraosseous needle insertion, and venous cut-down. Pacing is discussed within the contexts of initiating new pacing (internal and external) and providing anaesthesia for patients with pre-existing implantable pacing systems and cardioverter defibrillators. A final section gives guidance on transferring critically ill patients.

SERVICE QUALITY, CUSTOMER SATISFACTION AND LOYALTY IN BANKING SECTOR OF PAKISTAN

The major purpose of the research paper is to measure the quality of service offered by private banks operating in Pakistan. Moreover, it tries to investigate the relationship between service quality, customer satisfaction and loyalty. In order for a bank offer to reach the customers, there is a need for services. These services depend on the type of product and it differs in the various organizations. Service can be defined as an intangible offer by one party to another in exchange of money for Service quality in the management and marketing literature is the extent to which customers' perceptions of service meet and/or exceed their expectations. Thus service quality can intend to be the way in which customers are served in an organization which could be good or poor. A loyalty program may give a customer advanced access to new products, special sales coupons or free merchandise. Our study shows the three basic aspects of a customer in the banking sector which are service quality, customer satisfaction and banking loyalty in the banking sector. The findings of our study show that most of our respondents are well satisfied with banking services to provide by different commercial and Islamic banks such as HBL, UBL, NBP, MCB etc. in Peshawar sadder. The services provided by the banks particularly ATM machines are very praised by the customers. The loyalty provided to customers by the banks was also very good and most of the respondents were satisfy from that but there were also some major problems in these banking sectors for customers which should be handled as soon as possible for their good services we also find out that the banking policies for customer services and to maintain loyalty with customer should be enhanced more precisely