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					FINAL DOCUMENT Updated: 28 FEB 2005




               Navy Medicine EZ Access Implementation Guide




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FINAL DOCUMENT Updated: 28 FEB 2005

                                                Command EZ Access
                                                Implementation Guide


                                                      PREFACE

         With the emphasis on Productivity and Patient Access to care through out the Military Health System (MHS),
there is a need for standard process to ensure PT access and utilize standard metrics to evaluate the Military Treatment
Facilities (MTF) Appointment Systems. Policy is well documented in several publications from the Tricare
Management Authority (TMA). Due to shortcomings with historical access standards and failed implementation of the
Open Access system, EZ Access has evolved as a means of facilitating access. These same dynamics are affecting both
civilian and military practice. Enclosure (1), “Same-Day Appointments: Exploding the Access Paradigm”, is provided
as an excellent example of the challenges of implementing EZ-Access. EZ Access is defined as follows:

 “Patients will be offered a same day appointment or be offered a CHOICE of a future appointment .”
This manual puts forward a method to implement EZ Access and a tool box with demographics to assist managers at the
                MTF and Clinic Manager level with self evaluation of the appointment access process.




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                                    Record of Change Page




Date of Change          Change Number          Date Change Entered   Entered By




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                                                    Table of Contents

                                       Group 1. Description and Self evaluation:

Chapter One     -Introduction

Chapter Two     - Clinic Preparation

                        -Step 1, Self Evaluation (Seeking care at the lowest level possible)
                                 - Operant variables
                                 - Patient Utilization
                                 - Seasonal variability
                                 - Baseline expectations from BUMED
                                 - Evaluation Worksheet
                        -Step 2, FTE
                        -Step 3, Capacity Analysis
                        -Step 4, Demand Forecasting
                        -Step 5, Baseline Expectations from BUMED
                        -Step 6, Evaluation Worksheet

Chapter Three   -EZ ACCESS Appt Booking Business Rules

Chapter Four    - Appointment Utilization
                        -Utilizing EST Only
                        -Utilizing OPAC with Good Back log
                        -Combined Clinics
                Strategies available to mitigate no show and un-used appointment

                                                Group 2. CHCS Tools.

Section One             Profile Management

       Chapter One              Clinic Profiles
       Chapter Two              Provider Profiles

Section Two             Template Management

Section Three           Appointment Utilization/Schedule Management

Section Four            Access to Care and Data Quality

Section Five            Command Template Manager (CHCS Reports Menu Option)

       Chapter One              Appointment Management
       Chapter Two              Productivity Management

Section Six             Other reports/data available from CHCS not listed in the Command Template Manager Menu

Appendix A              Examples for Sections One through Four

                        1. Clinic Profile
                        2. Provider Profile
                        3. Appointment Type
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                       4. Provider Template

Appendix B     Report Format Tables

               1.   Data Quality Assist Visit
               2.   Unbooked Appointment Percentage Report
               3.   Unbooked Appointment Request Report
               4.   Frozen Appointment Request Report
               5.   Appointment Booking Report
               6.   Patient No Show Percentages
               7.   Available Appointments Report
               8.   Access to Care Report

Appendix C     Standard Instructions for Specific CHCS Modules

Appendix D     References/Training

Appendix E     Glossary of Terms




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                                                     Chapter One
                                                   INTRODUCTION


Introduction

The Assistant Secretary of Defense (Health Affairs) has promoted the process of Open Access appointing as a method
of improving both access to care and beneficiary satisfaction. A group of subject matter experts developed a variation
on the concept of Open Access called EZ Access. EZ Access appointing is defined as “patients are offered a same-day
appointment or a choice of a future appointment within TRICARE access standards.”

Navy Medicine has documented that outpatient utilization rates and unused appointment rates are higher than civilian
benchmarks. Preliminary data suggests that implementation of EZ Access appointing may result in reduced
unnecessary utilization and reduced no- show rates thereby reducing the cost of providing care to an enrolled
population. In addition, since improved access is one of eight critical elements in FY06 MTF Business Plans,
implementation of EZ Access will assist MTFs in attaining this business objective. Finally, observations from both
civilian and military health care systems suggest that staff satisfaction, customer satisfaction, and clinical outcomes can
all improve with the successful implementation of EZ Access.

The Navy Medicine EZ Access Integrated Product Team has developed this Primary Care EZ Access Implementation
Guide to provide guidance for military treatment facilities (MTFs) to ensure successful implementation and consistent
application across the claimancy. The self-evaluation (chapter 1) provides step-by-step instructions for the MTF to
conduct a patient demand/clinic capacity analysis to determine if EZ Access implementation is feasible at this time.
The self-evaluation should be completed in its entirety and submitted to the respective Healthcare Support Office
(HSO) for review. MTFs should be prepared to brief on how they plan to successfully undertake EZ Access or identify
corrective action plans to either decrease demand or increase capacity so EZ Access can be implemented within a
specified timeframe. In addition to the self-evaluation, the Implementation Guide contains business rules, guidance
regarding template management, and metric reporting procedures.

By completing all sections of this Guide, the MTF will be able to fully analyze their business processes to make an
informed decision regarding the potential for success, successfully implement, and allow for consistent monitoring of
metrics across Navy Medicine.




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                                                      Chapter Two
                                                  Clinic Self Evaluation

Section 1 - Self Assessment and Feasibility Evaluation

Using guidance provided in this section, MTFs must conduct a feasibility study to determine if they meet the criteria
(capacity greater than or equal to patient demand) for implementing the EZ Access appointing methodology within their
primary care clinics (Family Practice, Pediatrics). EZ Access appointing is defined as “patients are offered a same day
appointment or a choice of a future appointment within TRICARE access standards”. MTFs will need to consider
staffing, operational and facility constraints as well as historical patient utilization.

1.0 Describe the membership of your EZ Implementation Team
Provide names and positions of each team member. At a minimum, this team should consist of the following; other
representatives may be added as needed.
    • Team Leader,
    • Provider/Physician Champion
    • Clinic Manager
    • Nursing Representative
    • Template Manager
    • Appointing Representative
    • Corp staff representative
    • CHCS/IM/IT Representative
    • Ancillary Representative
    • Medical Records Representative


1.1 Provide a list of supporting and constraining factors. This list is not exhaustive, but provides categories to
consider.

Scale: (1 highly supportive to 7 highly constraining)

          1. Describe how the following aspects do or do not support the initiation of EZ Access at your facility.

Command Factors                         Description                                      Score
Leadership                              How does the command leadership support
                                        making changes to improve patient access to
                                        care?
Mission                                 How does the command mission support
                                        making changes to improve patient access to
                                        care? What is the evidence?
Staffing Factors
Provider non-clinical and indirect      What proportion of providers’ time is not        Actually accounted for in
patient care requirements               available for direct care (due to supervising    the provider availability
                                        residents, other training, collateral duties,
                                        department head, etc.)? How does this impact
                                        access to care and # of appointments
                                        available?
Clinical support staffing levels        How many clinical support staff, and what
                                        types, are available for each provider (by
                                        individual or by team, etc.)? Are more
                                        needed? What types and where?

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Reservist integration                   If primary care staff are deployed, will
                                        reservist backfill or other substitute providers
                                        be available (contract physicians, etc.)?
Operational unit organic medical        Will operational unit organic medical support
support                                 requirements impact our medical staff? If so,
                                        specifically how? How would this affect the
                                        number of appointments?
Physical Plant
Facility design for efficient patient    Are there two exam rooms for every provider
flow                                     who has clinic each half-day?
Computer and Administrative Support Tools (Systems that monitor set indicators and notify staff when
business rules are violated. e.g., enrollment exceeds capacity, too few appointments, End-of Day Processing not
performed, etc.)
Clinical support tools                   Is there a registry or database of patients (e.g.
                                         diabetics) available for providers to use?
Business support tools                   Tools for Managers
Information management tools             Knowledge Portal for Managers
Demand management tools
Demographic factors – Population List key factors of your population: age
health                                   demographics, “snowbird” population, out-of-
                                         state beneficiaries
Community Support                        Are patients seeking services at the lowest       (might delete this block in
                                         appropriate level possible? In your local         favor of the next section)
                                         community, are there requirements that could
                                         have an impact on appointments? Are
                                         services provided at a level higher than is
                                         necessary? (Must school physical forms be
                                         signed by a physician? Or may a registered
                                         nurse sign it? How do patients receiving WIC
                                         gain access to what they need? Must they see
                                         a physician?



1.2 Determine population demographics (Step one in Workbook or put table in text of guide?)
Identify your active duty, Prime and Plus beneficiaries in each of the proposed EZ Access clinics. Non-enrolled
beneficiaries must also be considered if they are provided care within the clinic. Examples of non-enrolled
beneficiaries include Reserve/Guard, transient eligible, foreign eligible, DoD employees (teachers), accession patients,
Secretarial Designees and civilian pay patients. The objective of this analysis is to define the beneficiary population so
demand can be predicted and compared to the clinic’s capacity. Insert the population data in the EZ Access Self
Evaluation Worksheet, section X.

1.3 Determine current Primary Care Manager (PCM) enrollment and distribution Each clinic must have the
capacity to provide for the daily demand of the enrolled panel. Enrollees should be distributed among providers so that
each PCM size is less than or equal to the provider’s capacity. If there are a substantial number of non-enrollees, their
impact must be considered.
Insert the enrollees per PCM data in the EZ Access Self Evaluation Worksheet, section X.

1.4 Identify Full Time Equivalents (FTEs) . PCM’s as an FTE must provide both daily access and continuity. PCM’s
which count as an FTE are defined as follows:
                    • PCMs must provide both daily access and continuity. MD/DO
                    • PA
                    • Advanced Practice Nurse (PNP, FNP, etc)

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                    •    IDC (AD personnel only)

An FTE is also the workforce equivalent of one individual working full-time for a specific period. An FTE has a value
of 1.0. From this value, reductions should be made to reflect actual availability for patient care. Commands should
develop their own list and include the kinds of recurring activities that providers might be required to perform as part of
their work. It is important to remember that each command needs to define the position description for their providers
that defines the work of their FTEs. The following recommended values are provided as examples and are not
intended to be definitive:
                     • Executive level provider - 0.75 FTE
                     • Department Head provider - 0.5 FTE
                     • Command level collateral duty - 0.1 FTE
                     • Readiness obligation - 0.1 FTE
                     • GME Activities – 0.5 FTE
                     • Research – 0.3 FTE
                     • Appropriate values for other, quantifiable obligations can be determined at the MTF.
         Using this system, a provider with 2 command collateral duties would actually be 0.8 FTE.

1.5. Perform a capacity analysis
The recommended panel size per FTE per the TRICARE 2000 “Focus on Performance” is:
                    • Civilian Provider - 1310 - 2425 patients/provider
                    • Military provider - 1205 - 2230 patients/provider
                    • Adjusted Value for AD providers: TRICARE has established 1 FTE: 1500 Enrollees per the
                        PCM Enrollment Model in the TRICARE 2000 “Focus on Performance”.
Complete table X in the EZ Access Workbook to determine your overall clinic capacity. MTFs may use 1500 as the
normal panel size or substitute their Command panel size standards if applicable.

NOTE: Baseline production expectations from BUMED:

        • 3-4 visits per enrollee per year
        • 36 hr/week, 45 weeks/yr, or 1,575 available clinic hours/year/provider
        • 1500 patients per FTE (
        • 44 Weeks per year
        Enrollees/PCM = (Enrollees Visit) X (# visits/hour) X (Hours/FTE) X (%FTE/PCM)

1.6 Forecast Patient Demand for Appointments:
Utilization rates for the military based on a 1997 health care survey of DoD beneficiaries (what healthcare survey, need
to be more specific, do we have anything more recent?) are as follows:

Beneficiary Category     MTF Utilization/year     Civilian Facility Utilization/year Total Visits/year

      • AD                    4.8                         0.5                                   5.3
      • Adult ADFM            5.2                         2.8                                   8.0
      • Retired <65yo         2.1                         4.8                                   6.9
      • Retired > 65yo        1.8                         8.6                                   10.4___________
An MTF may substitute different utilization rates if desired. The MTF must indicate how rates were determined.


Using the PCM enrollment report in CHCS, obtain your current enrollment by beneficiary category and insert in the EZ
Access Workbook. The workbook will calculate the projected demand for your current enrollment.

                Ben Cat          Visits/Year      Enrollment       Total
            •   AD               5.3     x        870    =         4,611
            •   Adult ADFM       8.0     x        1834 =          14,672
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            •    Retired < 65yo 6.8     x        1327    =       9,024
            •    Retired > 65yo 10.4    x        464     =       4,826
                TOTAL                            4,495   =       33,133 appt/year

The EZ Access Workbook will calculate the number of appointments per provider per day that will be needed to fulfill
the projected patient demand.

1.7 Compare Appointment Capacity and Demand Forecast.
Compare the clinic capacity identified in step 1.5 with the projected patient demand computed in step 1.6.

If your capacity is greater than or equal to the projected demand, provide the completed Upon their review, you can
proceed with your EZ Access preparations using the EZ Access Implementation Guide.

If your capacity is less than or equal to the projected demand, provide the completed Self Assessment and Feasibility
Evaluation (including EZ Access Workbook) and your analysis to your HSO representative for review. You will need
to develop corrective action plans to either increase your capability or decrease demand. Initiatives may
include…………




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                                                 Chapter Three
                                    DRAFT EZ Access Primary Care Business Rules

Military Treatment Facilities (MTFs) must adhere to the following guidance to ensure consist implementation, service,
and performance measurement:

1. MTFs must have a written process to ensure same day access during normal working hours. However, this should
not preclude the patient obtaining an appointment on the day of their choice.

2. Patients should never be told to call back because of appointment unavailability. An ample number of same day and
appointments on future days must be available to meet patient demand. Provider schedules must be available for
appointment clerks 28 days in the future.

3. Use of the Open Access (OPAC), or EST Appointment Type: The (OPAC), or EST standard appointment type will
be used to offer patients same day acute, routine, wellness or follow-up primary care services. Every effort will be
made to offer patients an appointment to see their Primary Care Manager (PCM) the same day requested by using the
(OPAC), or EST appointment type

4. Appointment Types Used for EZ Access Appointing. In addition to the (OPAC), or EST appointment type, the
standard appointment types “allowed” for EZ Access appointing are WELL, SPEC, PROC, GRP. If the other
“allowed” appointment types (other than OPAC) are utilized, they will be used in accordance with the operational
definition described in Appendix H, Commander’s Guide for Access Success
(http://www.tricare.osd.mil/tai/cguide.htm). The other “allowed” appointment types may assist clinic staff in setting
aside times to book patients for specific services. It is at the discretion of the clinic to use one or all of the appointment
types from this “allowed” standard appointment type group. The majority of the slots on the schedule should be coded
as the OPAC standard appointment type.

5. Good Backlog Appointment Definition. A good backlog appointment will be used for patients who decline an offer
for a same day OPAC appointment in favor of an appointment on a future date, or for provider directed appointments to
be scheduled at a future time (follow-ups, initial specialty visits, procedures, group appointments). Follow-up
appointments should be scheduled prior to the patient leaving the clinic whenever possible. Good backlog should not
be perceived as negative, patients will desire the scheduling of future appointments.

6. Good Backlog Template and Schedule Methods. Two methods are allowed to template and schedule good backlog
appointment slots:
       a. OPAC-GDBL comment is "used when the appointment type is changed to allow for an appointment beyond
       the 24 hour window.
       b. Use of EST appointment type vice an OPAC.

7. Cross Booking Detail Code/CB. The CB detail code can be used to designate appointment slots to be used when an
enrollee’s PCM is not available and they are booked to another PCM. The CB detail code should only be used during
the absence of one or more members of the clinic to ensure beneficiaries will not be without access to care. The CB
detail code appointment slots may be added to surrogate or team provider’s schedules to equal the same number of daily
appointments that would have been available if the missing provider were on the schedule.

8. Freezing Appointments

        8.1 Appointments may be frozen for a period not to exceed 24 hours to allow for day to day clinic personnel
        and resource fluctuations. To ensure adequate same day appointment availability, clinics should use the Wait
        Appointing Function.

        8.2 It is strongly recommended that appointment clerks have unrestricted access to all appointments within the
        business rules established by the MTF.

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9. Education and Training

       8.1 Internal staff must receive education and training to ensure a shared understanding of goals and processes
       involved with EZ Access.

       8.2 Appointing Clerks must receive training to ensure correct, consistent use of the appointing functions within
           CHCS as outlined in the EZ Access Implementation Guide.

*** Education and Training is an ongoing process. It is imperative that continuing education with all staff
personnel within a clinic be part of any program.

10. Guidance on Marketing. EZ Access should be promoted through performance not marketing. Marketing EZ
Access to beneficiaries is prohibited.

11. Measures of EZ Access Performance. Navy Medicine will monitor EZ Access activities with 2 metrics. These
metrics must be measured as directed in the EZ Access Implementation Guide and reported to the MTF’s Healthcare
Support Office by the 10th calendar day of the following month.

       11.1 Unmet Demand
       Unmet Demand reflects the percentage of time when the clinic was not able to offer a patient an appointment
       which met their requirements. The performance goal is less than 5 percent.

       11.2 Service Delivery Assessment (SDA) Question
       The SDA question is used as a proxy to measure patient satisfaction. The question is ““When you arranged
       your appointment over the telephone, were you able to schedule the appointment you needed, when you needed
       it, during your first call? The performance goal is greater than 95 percent.

       11.3 PCM Continuity
              Definition and performance goal TBD.




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                                                   Chapter Four
                                               Appointment Utilization


1. Appointment Utilization can be defined as the process of evaluating and utilizing available clinic resources to meet
the needs of the clinics internal and external customers. The main thing to remember is that the demand is fluid. It can
and sometimes does change on a daily basis. The focus for primarycare should be the utilization of existing resources
and the development of processes, to assist Managers with their day to day business decisions. Appointment Utilization
is the gateway to access.


A. OPTION 1, EST ONLY TEMPLATES:

        a. Limit template appointments types to the following:
            1) SPEC (Consultation appointments with specialists only)\
            2) PROC (Procedures only. Must also utilize the PBO detail code)
            3) EST – No access restriction (Shall comprise all other appointments scheduled for Primary Care)

        b. Limit detail codes to:
            1) PBO: Provider Book Only
            2) WEA: Web Access Available
            3) NPO: Nurse Practitioner Only
            4) TRICARE STANDARD ONLY

        c. Template Construction
            1) Limit all appointments to EST only
            2) Utilize the FUTURE access standard to search for all appointments.
            3) Merge appointments to meet time requirement as above.
            4) Utilize the “wait” function to reserve the known daily demand for same day until confident of model.

        b. Enrollment:
           1). Clinics shall enroll to the designated enrollment levels.
           2) Excess capacity shall be available to TRICARE Standard by detail code.

        c. Appointments shall be 15/ 20min increments. May be merged as needed to accommodate Adult Physical
exams, PAP/Women’s Health exams, Primary Care Appointment, Complex Patients with multi health problems as
noted in the remarks section of the Mini Registration.

        d. Schedules must be open 4-6 weeks out.

         e. Booking to be completed per the following hierarchy for patients who are ill today. No one gets turned away
if there are unused appts:
              1) PCM
              2) Team
              3) Clinic Directorate

         f. Double booking at 50% of established no rate and wave booking are authorized strategies to maximize
utilization.

        g. Monitoring:
               1). Utilize E&M/CPT reports to evaluate utilization vice the workload management tool. Provided
        monthly to the directorate.


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                 2) Seasonal Variability shall be monitored by utilizing 3 years of data from CHCS to trend historical
        workload. This allows managers to make access decision in a known context but should not interfere with
        incorporating changes in mission or beneficiary demand (large deployments, etc)
                 3) Unmet demand shall be the metric evaluated to assess same day access. (See Section 6). This shall
        be used to determine true demand, which allows demand forecasting with seasonal adjustment. If a clinic is
        opening with less than the established historical access, the clinic Business Manger must be notified NLT 0800
        for action. Reported as a command benchmark to the Governing Board monthly. Acceptable unmet demand is
        benchmarked at less than 5% of total appointments requested.
                 4) TAT shall be checked daily to evaluate access at T+7 days. If no EST appointments are available,
        must be brought to the attention of the Scheduling Officer for action.

B. OPTION 2, OPAC Primary

        a. . Limit template appointments types to the following:

            1) OPAC (For beneficiaries who request a same day appointment)
            2) EST – No access restriction (Shall comprise all appointments scheduled beyond the 24 hour OPAC
               window. for Primary Care)
            3) WELL – To be utilized by those clinics who require the separation of wellness visits for a recurrent
               clinic with multiple providers for the same patient on the same day i.e Asthma clinic, or same appt type
               through out the template i.e. well baby clinic, nutrition, weight, management..
            4) PROC - Used to schedule all procedures.
            5) GRP - Used for classes for multiple patients with the same provider at the same time.

        b. Limit detail codes to:

            1) PBO: Provider Book Only
            2) WEA: Web Access Available
            3) NPO: Nurse Practitioner Only
            4) GDBL: Good Back Log If you are using EST appt type to book future appts why is it necessary to use
               GDBL code???
            5) PAP: Pap/Womens’s Health exams only Not Necessary.

        c. Template Construction

            Template construction in this model should be mainly OPAC appts with the exception of WELL or GRP
            that will exist for a defined clinic as noted above. If demand forecasting calculations are accurate then daily
            demand should have been determined then the number of OPAC appts should meet the demand.
            .

        d. Appointments shall be set in 15/ 20min increments. May be joined as needed to accommodate Physical
exams, PAP/Women’s Health exams, Primary Care Appointment, Complex Patients with multi health problems as
noted in the remarks section of the Mini Registration.

         e. Appointing clerks must have the ability to change appt types at the time of scheduling to meet the needs of
the patient.

        f. Schedules must be open 6-8 weeks out.



C. OPTION 3, Combined Clinics Recommend deleting this option and place SPEC as an appt type under Option II for
OPAC since this option as written limits the accessibility of either the specialty patient or the prime patient to the
provider.
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         For those clinics (ex. Internal Medicine) which are both a Prime and a Specialty Clinic, it is recommended that
the two be separated within CHCS. One as a Prime clinic, and the other as a Specialty. In this way the scheduling is
simplified for EZ ACCESS.

Strategies available to mitigate no show and un-used appointment
            •   Different Scheduling formats
                •   Level Loading (dispersed evenly by appt type time)
                •   Front Loading (3 appts 15 mins apart front of ea hr)
                •   Wave Concept (stack a bunch beginning of hr)
                •   Modified Wave Loading (bunch a few & have regular flow rest of day)
                •   Accommodating Walk-ins (get a handle on & look at historical use)

SUMMARY
            •   Take a look at your templates in context of clinics’ mission
            •   Do Monthly Clinic Maintenance. Monitor unused appointments, as well as unmet demand.
            •   Use the tools to forecast demand adjusted, daily, weekly, seasonally
            •   Track the efficiency of anything you do with data (determine your own Metrics)
            •   Use the data vice first impressions to change the culture at your clinic.



** Note: The use of $ (Clinic book only) appointment types should be very limited if used at all.




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                                                  Chapter Five
                                               Template Management
A. Building Templates
    • Business Rules - should be known to clinicians, and appointing
    • Use BUMED guidelines (BUMED Commanders Guide)
B. Considerations:
       • Clinic start and stop times? Duration of Lunch?
       • How to accommodate Admin requirements?
       • Exercise during duty hours?
       • What qualifies as GME?
       • Where else do providers practice (e.g., ICU, OR ,etc.)
       • Who has authority to cancel appointments or provider schedules?
       • How many people can be gone at once on leave or TAD / TDY?

3. Building Templates
        • Estimate Demand for Appointments (using formulas noted in Chapter Two)
        • Historical data from CHCS Appointment Utilization Reports
        • Leakage to the network
        • HMO primary care demand (Health Care Advisory Board) estimates
        • Your best guess. Remember do the best you can and then adjust via schedule management

4. Building Templates
        • Estimate clinic capacity (using formulas noted in Chapter Two)
        • Flow diagram “arrival to check out”
        • Identify bottlenecks?
        • Dependent on a large number of variables ?????
        • Support personnel / provider - data valid only if people are assigned prudently - is the appropriate person
            assigned to the appropriate task?
        • Determine clinic objectives and agendas
        • Evaluate appointment time duration
        • Ensure that you are minimizing the number of appt types used
        • Evaluate and minimize appointment type mix

5. CRITICAL step!!!!!!!!!
       • Print out all present templates and see if they fit your guidelines
       • Modify or Develop new Templates
             o standardize naming conventions (name by provider and day)
             o same general pattern
             o Print out NEW Templates
             o Manage templates and schedules in real-time. React to events: an ongoing assessment of template
                 adequacy is essential
             o Requires daily look at schedules and ability to look into the future
             o If you are constantly changing appointment types to accommodate needs, you may need to adjust
                 your templates.




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6. The table below is a basic listing of factors that influence a provider and/or clinic schedule. This list is not all
inclusive, since other factors (e.g. deployments) can effect scheduling. (this should be included in the clinic self
assessment-not here)

Table 4-5.1

       Factor                                   Description

       Clinic Hours                             This is the patient treatment hours not the working hours of a clinic
       Provider Availability                    Is this Provider Full Time or Part Time in the clinic?
       Support Staff                            What is the level of Nurses, Corpsman, Admin support, etc.
       Facility                                 Is the provider using multiple treatment/exam rooms?
       Practice                                 Specialty, Family Practice, etc.
       Business Plan                            ** Productivity, Scope of Service, Value of Care, etc.


** Business plans for each clinical area have been developed. Updates of these plans are done, as a minimum
Annually.


7. Appointment types must be in the clinic profile and provider profile before they are built into a template. The
appointment type is designed to reflect how much time and type of appointment that is being set for the designated time
slot. See Appendix A for an example.

        When building a provider profile, the appointment types are added from the clinic profile. Each appointment
        type is then set for the specifics of the individual provider. Once the Profile and Appointment Types are set up,
        then a template is designed.

8. Summary: Template design is actually quite easy to do. A unique identifier is designed for each template for the
provider (ex. JONESTUE, JONESWED). Templates are set for day (Mon, Tue, etc.) and for week. All weekly and/or
monthly templates are built from the daily templates. Most providers will need no more than 5 daily templates.
Providers whose schedule would be the same, say 4 out of 5 days of the week may only need two templates. Most (if
not all) providers use the same appointment types on a consistent basis. See Appendix A for an example of a Provider
Template.


#7 and #8 above either need to be explained in more detail or omitted from this section. Those that manage templates
already have this information. If the intent is for others to understand this, much more detail of the process of creating
profiles and templates is needed.

A. Appointment Utilization can be defined as the process of evaluating and utilizing available clinic resources to meet
the needs of the clinics internal and external customers. The main thing to remember is that the demand is fluid. It can
and sometimes does change on a daily basis. The focus for primary care should be the utilization of existing resources
and the development of processes, to assist Managers with their day to day business decisions. Appointment Utilization
is the gateway to access.




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Strategies available mitigate no show and un-used appointment

•Different Scheduling formats.
 * Level Loading (dispersed evenly by appt type time)
 * Front Loading (3 appts 15 mins apart front of ea hr)
 * Wave Concept (stack a bunch beginning of hr)
 * Modified Wave Loading (bunch a few & have regular flow rest of day)
 * Accommodating Walk-ins (get a handle on & look at historical use)

SUMMARY
•Take a look at your templates in context of clinics’ mission
•Do Monthly Clinic Maintenance (monitor unused appointments, as well as unmet demand)
•Use the tools to forecast demand adjusted, daily, weekly, seasonally
•Track the efficiency of anything you do with data (determine Metric)
•Use the data to change the culture at your clinic - it is highly effective




                                                                                        Page 18 of 45
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1. OPTION 1, EST ONLY TEMPLATES:

        a. Limit template appointments types to the following:
            4) SPEC (Consultation appointments with specialists only)\
            5) PROC (Procedures only. Must also utilize the PBO detail code)
            6) EST – No access restriction (Shall comprise all other appointments scheduled for Primary Care)

        b. Limit detail codes to:
            1) PBO: Provider Book Only
            5) WEA: Web Access Available
            6) NPO: Nurse Practitioner Only
            7) TRICARE STANDARD ONLY

        c. Template Construction
            5) Limit all appointments to EST only
            6) Utilize the FUTURE access standard to search for all appointments.
            7) Merge appointments to meet time requirement as above.
            8) Utilize the “wait” function to reserve the known daily demand for same day until confident of model.

        b. Enrollment:
           1). Clinics shall enroll to the designated enrollment levels.
           2) Excess capacity shall be available to TRICARE Standard by detail code.

        c. Appointments shall be 15/ 20min increments. May be merged as needed to accommodate Adult Physical
exams, PAP/Women’s Health exams, Primary Care Appointment, Complex Patients with multi health problems as
noted in the remarks section of the Mini Registration.

        d. Schedules must be open 4-6 weeks out.

         e. Booking to be completed per the following hierarchy for patients who are ill today. No one gets turned away
if there are unused appts:
              4) PCM
              5) Team
              6) Clinic Directorate

         f. Double booking at 50% of established no rate and wave booking are authorized strategies to maximize
utilization.

        g. Monitoring:
               1). Utilize E&M/CPT reports to evaluate utilization vice the workload management tool. Provided
        monthly to the directorate.

                2) Seasonal Variability shall be monitored by utilizing 3 years of data from CHCS to trend historical
        workload. This allows managers to make access decision in a known context but should not interfere with
        incorporating changes in mission or beneficiary demand (large deployments, etc)

                 3) Unmet demand shall be the metric evaluated to assess same day access. (See Section 6). This shall
        be used to determine true demand, which allows demand forecasting with seasonal adjustment. If a clinic is
        opening with less than the established historical access, the clinic Business Manger must be notified NLT 0800
        for action. Reported as a command benchmark to the Governing Board monthly. Acceptable unmet demand is
        benchmarked at less than 5% of total appointments requested.



                                                                                                  Page 19 of 45
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                4) TAT shall be checked daily to evaluate access at T+7 days. If no EST appointments are available,
        must be brought to the attention of the Scheduling Officer for action.

2. OPTION 2, OPAC Primary

        a. . Limit template appointments types to the following:

            6) OPAC (For beneficiaries who request a same day appointment)
            7) EST – No access restriction (Shall comprise all appointments scheduled beyond the 24 hour OPAC
                window. for Primary Care)
            8) WELL – To be utilized by those clinics who require the separation of wellness visits for a recurrent
                clinic with multiple providers for the same patient on the same day i.e Asthma clinic, or same appt type
                through out the template i.e. well baby clinic, nutrition, weight, management..
            9) PROC - Used to schedule all procedures.
            10) GRP - Used for classes for multiple patients with the same provider at the same time.

        b. Limit detail codes to:

            1)   PBO: Provider Book Only
            6)   WEA: Web Access Available
            7)   NPO: Nurse Practitioner Only
            8)   GDBL: Good Back Log (Used to book OPAC appts in the future as needed)

        c. Template Construction

            Template construction in this model should be mainly OPAC appts with the exception of WELL or GRP
            that will exist for a defined clinic as noted above. If demand forecasting calculations are accurate then daily
            demand should have been determined and the number of OPAC appts should meet the demand.
            .

        d. Appointments shall be set in 15/ 20min increments. May be joined as needed to accommodate Physical
exams, PAP/Women’s Health exams, Primary Care Appointment, Complex Patients with multi health problems as
noted in the remarks section of the Mini Registration.

         e. Appointing clerks must have the ability to change appt types at the time of scheduling to meet the needs of
the patient.

        f. Schedules must be open 6-8 weeks out.


3. OPTION 3, Combined Clinics Recommend deleting this option and place SPEC as an appt type under Option II for
OPAC since this option as written limits the accessibility of either the specialty patient or the prime patient to the
provider.


         For those clinics (ex. Internal Medicine) which are both a Prime and a Specialty Clinic, it is recommended that
the two be separated within CHCS. One as a Prime clinic, and the other as a Specialty. In this way the scheduling is
simplified for EZ ACCESS.



** Note: The use of $ (Clinic book only) appointment types should be very limited if used at all



                                                                                                     Page 20 of 45
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         Clinic/Template Manager
 CHCS Appointment System Data Quality Manual
       And Recommended Guidelines




                                    PREFACE

     With the emphasis on Productivity through out the Military Health System
  (MHS), there was a need for standard metrics to evaluate Military Treatment
 Facilities (MTF) Appointment Systems. Policy is well documented in several
          publications from the Tricare Management Authority (TMA).
There have been no standard metrics available for in depth evaluation of a clinics
             day to day business, or standardized reporting formats.

 This manual puts forward several ways to evaluate and provide demographics to
    assist managers at the MTF and the Clinic Manager level as a data quality
  checklist for the appointment process. This is not all inclusive, but the metrics
presented are effective in assisting clinics with their day to day business practices.




                                                                      Page 21 of 45
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                                            Table of Contents

Section One            Profile Management

       Chapter One             Clinic Profiles
       Chapter Two             Provider Profiles

Section Two            Template Management

Section Three          Appointment Utilization/Schedule Management

Section Four           Access to Care and Data Quality

Section Five           Command Template Manager (CHCS Reports Menu Option)

       Chapter One             Appointment Management
       Chapter Two             Productivity Management

Section Six            Other reports/data available from CHCS not listed in the Command Template Manager
                       Menu

Appendix A             Examples for Sections One through Four

                       5.   Clinic Profile
                       6.   Provider Profile
                       7.   Appointment Type
                       8.   Provider Template

Appendix B      Report Format Tables

                9. Data Quality Assist Visit
                10. Unbooked Appointment Percentage Report
                11. Unbooked Appointment Request Report
                12. Frozen Appointment Request Report
                13. Appointment Booking Report
                14. Patient No Show Percentages
                15. Available Appointments Report
                16. Access to Care Report

Appendix C      Standard Instructions for Specific CHCS Modules

Appendix D      References/Training

Appendix E      Glossary of Terms




                                                                                      Page 22 of 45
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                                                Section One
                                            Profile Management

PROFILES establish the standards (ways of doing business) in Facilities, Divisions, Clinics, and for Health
Care Providers. This section provides an effective process of self evaluation for Command, Clinic and
Template managers. It is the first step in the process of ensuring accuracy within the CHCS appointment
systeme. Clinic and Provider profiles may be edited by the Clinic Manager and/or Clinic Template Manager,
as changes are needed. Facility and Division Profiles may NOT be edited by clinic Supervisors.


                                                 Chapter One
                                                Clinic Profiles

When evaluating a clinic profile ensure that it is completely and appropriately filled in. Detail codes if used
are listed, and that Appointment Types listed are the only ones used by the clinic. Not all clinics should or
will use all appointment types. (See Appendix A for an example of a clinic profile).

A guideline for profile evaluation is shown below. This table is a check off sheet for clinic managers and is
used by the clinic/template manager as part of the clinic evaluation process.

Table 1-1.1

Item #    Field Name                                       What to look for

   1.     Building Name and Number                        Current Name & Number
   2.     Street Address                                  Current Mailing Address
   3.     Clinic Location                                 Ex. 2nd floor north mall
   4.     Clinic Availability                             Current Clinic Hours
   5.     Telephone                                       Current Clinic Contact Phone Number
   6.     Self Referrals Allowed                          If this field is left blank or if “No” is entered no
                                                          referral or consult is required for appointing. If the
                                                          clinic requires referrals, prior to an appointment
                                                          being made “Yes” must be entered in this field.
   7.     Clinic Appointment Instructions                 This field is used for general information that is
                                                          presented to the beneficiary for all appointments
                                                          made in the clinic (ex. No extra children, or bring
                                                          OHI identification card)
   8.     Detail Codes Listing                            Are the listed Detail codes currently used. If not
                                                          inactivate those not used or activate/add needed
                                                          detail codes.
   9.     Appointment Type Listing                        Are the listed appointment types currently used by
                                                          the clinic. If not inactivate or activate as needed.
  10.     Appointment types                               Check each appointment type for correct
                                                          information. Duration, special instructions, etc.
Remarks: When reviewing appointment instructions at all levels, clinic, appointment type and provider,
ensure that they are not all the same. Each level should have only the instructions that apply.



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                                                  Chapter Two
                                                 Provider Profiles

* An individual does not have to be a privileged provider to have a profile and a schedule in CHCS.


Provider Profiles are built to reflect a specific providers clinical practice. The profile is a set of business rules
that give provider specific access information. The profiles are the base from which schedule templates are
built (see next section on templates) This includes appointment type’s specific to that provider. Not all
providers will use all appointment types listed in the clinic profile. A providers profile should have only
those appointment types used by the individual provider. (See Appendix A for an example of a Provider
Profile)

A guideline for profile evaluation is shown below. This table is a check off sheet for clinic managers and is
used by the clinic/template manager as part of the clinic evaluation process.

Table 1-2.1

Item #     Field Name                           What to look for

   1.      Provider                          Provider Name
   2.      Clinic Hours                      Days and hours provider is available in this clinic. Since some
                                             providers work in multiple clinics, each profile under the clinic
                                             concerned should show the availability for that clinic.
   3.     Location                           This is the clinic location where the provider is working (e.g.
                                             Peds, CHCC says nothing)
   4.     Max # of patient appts per day     This is the maximum number of patient appointments that a
                                             provider could see in this clinic per day. This will not
                                             necessarily be the same as the minimum number from
                                             productivity.
   5.     Appt Arrival advance time          Self Explanatory
   6.     Provider Instructions              This field gives specific instructions to the patient for this
                                             provider. It should not be the same as the Clinic instructions.
   7.     Print Roster with open appts       Self Explanatory
   8.     Inactivation Date                  This field will only be used when a provider is inactivated (no
                                             longer working in the clinic)
   9.     Title                              The title of the Provider (ex. Ped's Resident, Intern, Corpsman,
                                             Nurse, etc.)
  10.     Duty Phone                         This will be specific to the provider.
  11.     Home Phone                         This will be used only if the clinic policy requires.
  12.     Appointment Type                   Only those appointment types used by the provider should show
                                             on the list. Each appointment type will be tailored specifically
                                             to each provider.
            Provider appointment type management is addressed in the following chapter on Template
                                                     Management.
Remarks: When reviewing appointment instructions at all levels, clinic, appointment type and
provider, ensure that they are not all the same. Each level should have only the instructions that apply.

                                                                                                Page 24 of 45
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                                                Section Two
                                            Template Management

Template Management as a process can be and usually is subjective since management styles differ between
individuals. Various factors dictate a provider’s schedule template. These factors will seldom vary from
provider to provider or clinic to clinic. A providers template is built to reflect their clinical practice. The table
below is a basic listing of factors that influence a provider and/or clinic schedule. This list is not all inclusive,
since other factors (e.g. deployments) can effect scheduling.

Table 2-1.1

       Factor                               Description

       Clinic Hours                         This is the patient treatment hours not the working hours of a clinic
       Provider Availability                Is this Provider Full Time or Part Time in the clinic.
       Support Staff                        What is the level of Nurses, Corpsman, Admin support, etc.
       Facility                             Is the provider using multiple treatment rooms?
       Practice                             Specialty Delivery, Family Practice, etc.
       Business Plan                        ** Productivity, Scope of Service, Value of Care, etc.

** Business plans for each clinical area have been developed. Update of these plans are done, as a
minimum Annually.

Standard templates are built for a provider to reflect their daily patient schedule. As many templates as
necessary can be designed. However, only those that are in continuous, active use, should be kept on file in
the system.

Appointment Type Management goes hand in hand as part of the template management process.
Appointment type information could stay the same or they may be modified to reflect the changes in
scheduling that would be required. A good example would be a Family Practice clinic that would require
different times for OPAC appointment slots during the Flu season than would be required for a standard
appointment day or for school physical season. Schedules change as required to meet the needs of our
beneficiaries.

Appointment types must be in the clinic and provider profile before they are built into a template. The
appointment type is designed to reflect how much time and type of appointment that is being set for the
designated time slot. See Appendix A for an example.

       When building a provider profile, the appointment types are added from the clinic profile. Each
       appointment type is then set for the specifics of the individual provider. Once the Profile and
       Appointment Types are set up, then a template is designed.

Template design is actually quite easy to do. A unique identifier is designed for each template for the
provider (ex. JONESTUE, JONESWED). Templates are set for day (Mon, Tue, etc.) and for week. All
weekly and/or monthly templates are built from the daily templates. Most providers will need no more than
5 daily templates. Providers whose schedule would be the same, say 4 out of 5 days of the week may only
need two templates. Most (if not all) providers use the same appointment types on a consistent basis. See
Appendix A for an example of a Provider Template.

                                                                                               Page 25 of 45
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                                          Section Three
                           Appointment Utilization/Schedule Management

Appointment Utilization/Schedule Management can be defined as the process of evaluating and utilizing
available clinic resources to meet the needs of the clinics internal and external customers.

The main thing to remember is that the appointment system is fluid, it can and sometimes does change on a
daily basis. In this environment, a part of Appointment Utilization would be the conversion of appointment
types and the use of overbooking to meet the need(s) of the patient.

 (e.g. converting an EST into a SPEC, or a SPEC into an EST, etc.)

“This is the point where an efficient and effective administrative staff can ease the administrative concerns
of their Providers.”

If a provider needs to see patients and there are no available slots, appointments can be added via
overbooking. This is an option for Providers who want flexibility built into their schedule to allow for the
occasional increase in demand. This is built in as part of the Provider Profile. Each profile is set up to allow
for a Maximum number of patients per day (see Section One Profile Management).

The Command Template Managers primary focus should be the utilization of existing data sources and the
development of processes, to assist Clinic Managers with their day to day business decisions. Appointment
Utilization itself is an Access Issue that ebbs and flows with the needs of the beneficiary population.
Therefore, evaluations of a clinic’s utilization would depend on the type of service provided and the process
that a clinic is currently using.
.

                                              Section Four
                                     Access to Care and Data Quality

Access to Care issues will continue to be the largest part of the command template manager’s focus. This
manual has been developed to address the different parts of the process of access. Data Quality is one of the
most singular parts of Access. The documentation of beneficiary appointing and treatment is essential to
properly evaluate the patient flow process.

The Command Template Manager (CTM) is a member of the Data Quality Assist Team (DQAT). This team
is chaired by the head of the Data Quality Division. All members of the team supply an overview of a clinics
data to assist them in a self assessment of their progress.

The CTM utilizes a standard format in a Power Point Presentation to show the overall utilization of the
appointment system. The main source for this data is the spreadsheets posted on the Tricare Management
Authorities website (See Appendix D for the exact url). The spreadsheets supplied are an overall look at a
clinics usage. For a specific breakdown by appointment type, the appointment utilization report in CHCS is
used to present the information.




                                                                                            Page 26 of 45
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                                          Section Five
                                 Access Management Reports Menu
                                     (CHCS Reports Sub Menu Option)

 This Sub Menu Option is currently inclusive to Naval Medical Center Portsmouth. The Command
Template Manager at NMC Portsmouth is developing the Training and Operating Instructions. Once
              complete it will be made available through the MHS ADHOC system.

                                      For more information contact:

                           Stanley W. Jones at; swjones@mar.med.navy.mil

*** Access to the sub menu option is for the Command Template Manager, Command Access Manager and
Designated Clinic Managers. Access to specific data ADHOCS can be assigned on an as needed basis per
Directorate decision.

      ADHOC reports in CHCS have been designed as monitoring tools at the command level and
demographics for the management of the appointment system at the Directorate/Clinic level.

        Each of the reports has been developed to show specific aspects of the Appointment System. They are
not intended as the only source, but as an adjunct to the reports available from other sources. Each chapter
explains the available information pulled and recommended uses.

  Exact instructions for the Access Management Reports Menu will be supplied to each manager as a
separate Manual. A short training course will also be supplied by the Command Template Manager on
                                      the use of this data menu.

   The assignment of this Menu Option must be requested via the Command Access Manager or the
                                  Command Template Manager.


       All reports (except where stated otherwise) are downloaded from CHCS as delimited text files (the “^”
character is the column identifier). They are then imported into Microsoft Access for use.




                                                                                        Page 27 of 45
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                                                 Chapter One
                                   Appointment Management Menu Option

Planned Appointment Report            CHCS Access “TOLA”

       This report was developed to track changes to capacity and availability of the appointment system.
The data is pulled from the clinic Schedule Summary File.

       Data is pulled as a prospective at the first of the month and as a retrospective at the end of the month.
The information provided can be used in a variety of ways;

       1.   Available capacity by MTF
       2.   Available capacity by clinic
       3.   Available capacity by provider
       4.   A drill down by appointment type at each level as stated in 1 thru 3
       5.   A drill down with each of the 4 available fields for Detail Codes
       6.   A breakdown by Clinic book only

       Table 5-2.1 - Fields available in the TOLA Report

               Field Name          Description

               MTF                 Military Treatment Facility
               DMIS                MTF Identifier
               DIV                 Division of Clinic
               CLINIC              Clinic Name
               DEPT                Department of Clinic
               DAY                 Day of appointment
               Date/Time           Date and Time of Appointment
               Provider            Provider associated with the Appointment
               Appt Type           Appointment Type (OPAC, SPEC, EST, etc.)
               DC 1                First Detail Code
               DC 2                Second Detail Code
               DC 3                Third Detail Code
               DC 4                Fourth Detail Code
               Slot Status         Status of appointment slot (BOOK/OPEN)
               Max Booking         Maximum number of appointments for the slot
               Current Booking     Number booked as of the date and time the report was pulled


Frozen Appointments Report            CHCS Access “FROZ”

        Freezing Appointments is necessary for every clinic as an assist in schedule management. Historically
it has been shown that significant amounts of appointments are not “Unfrozen”. These unused appointments
affect the productivity of providers and access for our beneficiaries. Lost capacity cannot be regained.



                                                                                             Page 28 of 45
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         Frozen appointments show as blank spots on a clinics schedule. Therefore, there are times where a
clinic will add (Overbook) appointments in these time slots, unaware that there were appointments already
listed that could have been used instead.

        The frozen appt report can be run prospectively and submitted to clinics as a metric to assist in their
schedule management. It is recommended that this report be supplied on a weekly basis (Friday am would be
the optimum time).

       Using this report, clinics can review the available appointments and decide what if any changes need
to be made. The report to the clinic will give a breakdown by Provider, appointment date/time and
appointment type.

        A retrospective report will be provided on a monthly basis by the Command Template Manager and
posted to the Healthcare Business Operations web site on the Template Manager web page. The monthly
report will give a breakdown by Mtf and Clinic, with overall totals.


Table 5-2.2 - Fields available in the FROZ Report

Field Name                 Description

Clinic                     Name of Clinic
MEPRS                      MEPRS Code associated with Clinic
DMIS                       MTF DMIS Code
Provider                   Provider associated with appointment
Date/Time                  Date and Time of appointment
Appt Type                  Appointment Type associated with appointment (EST, SPEC, etc.)
Status                     Status of appointment (FROZ, Book, etc.)
Comments                   Comments by Clinic
Detail Codes               Detail Codes associated with the appointment

Next Available Appointment Reports           CHCS Access “NAV AND GNAV”


        These reports can be utilized to propagate the Command Access to Care (ATC) report for Specialty
Clinics. Both reports are downloaded in a Text file format. The information is then inserted in the ATC
report by hand.

       NAV Report             This data provides information on appointment availability by Provider/
                              appointment Type. The clinics may also run a canned report in CHCS (See
                              Section Five) for their specific clinic.

       GNAV Report            This data run will give you clinic summaries for the MTF by appointment type.
                              Although the NAV report gives a more comprehensive drill down, this report is
                              used to propagate the Access to Care (ATC) report. (This report is for the use
                              of the Command Template Manager).




                                                                                           Page 29 of 45
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Mtf vs. Contractor (Appointment Center) Booking Report             CHCS Access “TCBK”

       This report compares the amount of booking done by the Appointment Center and the clinics. It can
be supplied for any time period needed.

       This report is run on a weekly and monthly basis. The weekly report is supplied to the HBO
directorate and Clinic Managers. A monthly report is generated and placed on the HBO web site.

       The monthly report is run as a retrospective of the prior calendar month. Once complete the
information is placed in a power point. The monthly report is an overall percentage by MTF.

Table 5-2.3 - Fields available in the TCBK Report

Field Name                          Description

DMIS                                Number descriptive of the Military Treatment Facility
DIVISION                            Division Name of the Military Treatment Facility
MTF                                 Name of Military Treatment Facility
CLINIC                              Clinic within the MTF
APPT TYPE                           The appointment type for each appointment booked
TYPE OF CARE                        This field will always show unknown – Not Used
MTF BOOK                            Total number of appointments by appointment type booked within each
                                    clinic listed, by the clinic.
Appt Center Booked                  Total number of appointment by appointment type booked within each
                                    clinic listed, by the appointment center.


Unbooked Appointment Request (UAR) Report by Division              CHCS Access “NBA”


         When a clerk does not book an appointment, the system requires a reason for not booking. There are
12 standard reasons for not booking an appointment (see Table 5-2.4). With each reason, there is also a free
text field that can be utilized for comments. This report gives a summary of information that is contained in
the CHCS canned report

****   It is highly critical that proper entries be made by all personnel when utilizing the booking system!




                                                                                          Page 30 of 45
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       The data from this report is supplied, as a minimum for the following purposes:

       1. An indicator of Unmet Demand – This Demographic is being added as a business rule by BUMED.

                                           Formula for Unmet Demand

              UAR (Patient refusal + No appts available)
                    UAR + Booked Appointments            = Unmet Demand Percentage.


       2. Can be utilized by the Patient and Guest Relations office as part of documentation when
          researching patient complaints/concerns.
       3. The entries can also be utilized as an indication of the level of knowledge and training that may be
          needed by appointment personnel.

Table 5-2.5 - Fields available in the UAR Report


Field Name           Description

Date and Time        Date and Time the entry was made.
Booking Clerk        Name of the individual who made the entry
Appt Center/Clinic   Annotates where the booking clerk works (ex. MCSC Contractor, NMCP FP)
Pt Identifier        This field gives the FMP and the SSN associated with the transaction/entry
Clinic               Clinic associated with the entry.
MEPRS                MEPRS code of the Clinic associated with the entry.
MTF                  Military Treatment Facility
DMIS                 DMIS associated with MTF and Clinic
Access Category      Access category associated with the transaction (ex. ACUTE, FUTURE, etc.)
Reason Unbooked      Reason Unbooked. See Table 5.2.4
Comments             Comments associated with the reason unbooked.



** All information derived from this access requires that HIPPA guidelines be followed when information is
accessed.




                                                                                          Page 31 of 45
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                                             Chapter Two
                                        Productivity Management

Productivity by Directorate                  CHCS Access “PDIR”


This report gives exact information on the appointment system. It has various uses, including, but not limited
to information on, Patient and Facility cancelled, Kept, Walk-ins, Sick Call and No-Shows.


Field Name                    Description

DMIS                          Number descriptive of the Military Treatment Facility
DIVISION                      Division Name of the Military Treatment Facility
DIRECTORATE                   Directorate within the MTF associated with the clinic
CLINIC                        Clinic Name
MEPR                          4 Digit Code associated with the clinic
SPECIALTY                     Not Used
PROVIDER                      Specific name of the Provider associated with the appointment
TIME                          AM, PM or EVE associated with the appointment
APPT TYPE                     Appointment Type associated with the visit
BRANCH                        Military branch associated with the beneficiary on this visit
PATCAT                        Patient Category (N41, etc.)
TOTAL APPTS                   Total appointments associated with the provider
KEPT                          Self Explanatory
NOW SHOWS                     Self Explanatory
WALKINS                       Self Explanatory
CANC BY FAC                   Self Explanatory
SICK CALL                     Self Explanatory
CANC BY PAT                   Self Explanatory



Reports from this information are currently under development.




                                                                                          Page 32 of 45
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                                               SECTION SIX
                                                  CHCS

                        Other Reports/Data available from CHCS, not listed in the
                             Command Template Manager (Reports) Menu.

The items listed below were copied from the CHCS website. Each item lists the available reports and there
uses. There are so many different reports that it would be impractical to list and explain each one. As such, it
is recommended that they be looked at individually to see if they meet the needs of the evaluation that is
contemplated.

The url to access the below reports is:

http://www-nmcp.med.navy.mil/EduRes/CompMedia/chcs/nuggets/mgmtrpts.asp

Managed Care Program Menu - Outputs & Management Reports Menu

ERME -PCM Assignment Reports Menu
HRPT - Health Care Finder Reports Menu
PRM - Network Provider Reports Menu
PRPT - PCM Reports Menu
APAL - Address Label for Patient
DEMR - DEERS/NED Maintenance Reports Menu

How To Successfully Run Canned CHCS Reports

How to Print a Spooled Report in CHCS

Scheduling Supervisor Menu - Management Reports Menu

MGR - Miscellaneous Reports Menu
PMGR - Problem Avoidance Reports Menu
SMGR - Statistical & Workload Reports Menu




                                                                                            Page 33 of 45
GROUP 2 (Revised: 28 Feb 2005)
                                     APPENDIX A
Example of a Clinic Profile

                              CLINIC PROFILE LIST
Name: EXAMPLE CLINIC
================================================================================
                            Name: PEDS MTF NMCP
                    Abbreviation: PPEDS
                        Facility: NMC PORTSMOUTH
                        Division: NAVAL MEDICAL CENTER PORTSMOUT
                   Building Name: CHARETTE HEALTH CARE CENTER
                 Building Number: 2
                  Street Address: 620 JOHN PAUL JONES CIRCLE
                             ZIP: 23708
                            City: PORTSMOUTH
                           State: VIRGINIA
                 Clinic Location: 2nd floor north mall
             Clinic Availability: M-Th 08-1115, 13-16, 16-1930, F 08-11, 13-16
                       Telephone: (757) 953-7716
                Enrollee Lockout: NO
                    Type of Care: BOTH SPECIALTY AND PRIMARY CARE
                         Service: PEDIATRIC OUTPATIENT PNH
                      Department: PEDIATRIC DEPARTMENT PNH
                      MEPRS Code: BDAA
 ======================================================================================
             Wait List Activated: YES             Maximum Wait List Days: 365 DAY(S)
    Wait List Provider Mandatory: YES           Wait List Hold Duration: 364 DAY(S)
  Automatic Wait List Processing: YES             Schedule Hold Duration: 0 DAY(S)
   Prompt for Requesting Service:                    Patient Record Pull: 2 DAY(S)
                     Clinic Type: COUNT            Radiology Record Pull: 0 DAY(S)
              Check Holiday File: NO                   Roster Production: 1 DAY(S)
                  Cost Pool Code:                prepare Reminder Notices: 5 DAY(S)
               Activation Status: ACTIVATED           Available Schedule: 30 DAY(S)
        Access to Care Reporting: YES
          Self-Referrals Allowed: NO
        Clinic Appt Instructions: Bring Private Health Insurance Card
 ======================================================================================
Select Clinic Specialty:
   ADOLESCENT MEDICINE
   PEDIATRICS
========================================================================================
Select Detail Codes:
9-21     9-21 yr Age Range
BPPR     PRIME ENROLLEES ONLY, NO ACTIVE DUTY
WEA      WEB AND MCP BOOKABLE
0-21     define age
0-2W     define age group
4-18     AGE DEFINE
PAP      PAP SMEAR
PE       PHYSICAL EXAM
SCH      SCHOOL PHYSICAL
========================================================================================
Select APPOINTMENT TYPE:
      ACUT
      ACUT$
      EST
      OPAC
      OPAC$
      T-CON*

                                                                        Page 34 of 45
GROUP 2 (Revised: 28 Feb 2005)
Example of a Providers Profile

PROVIDER: JONES,STANLEY
CLINIC HOURS: M-F 0800-1700
LOCATION: Bldg 2
MAX # OF PATIENT APPTS PER DAY: 300
APPT ARRIVAL ADVANCE TIME: 15 minutes
PROVIDER INSTRUCTIONS:
PRINT ROSTER WITH OPEN APPTS: YES, SHOW OPEN APPT SLOTS
INACTIVATION DATE: THIS FIELD WILL NOT BE FILLED IN UNLESS THE LISTED PROVIDER
IS NO LONGER ASSIGNED TO THIS CLINIC.
==============================================================================
=
PROVIDER: JONES,STANLEY               SD HCP PROFILE -- CONTINUATION

TITLE: PEDIATRICIAN
DUTY PHONE: 953-2990
HOME PHONE:
PROVIDER: JONES,STANLEY               SD HCP PROFILE -- CONTINUATION
==============================================================================
=
 PROVIDER: JONES,STANLEY
CLINIC HOURS: M-F 0800-1700
LOCATION: Bldg 2
MAX # OF PATIENT APPTS PER DAY: 300
APPT ARRIVAL ADVANCE TIME: 15 minutes
PROVIDER INSTRUCTIONS:
PRINT ROSTER WITH OPEN APPTS: YES, SHOW OPEN APPT SLOTS
INACTIVATION DATE THIS FIELD WILL NOT BE FILLED IN UNLESS THE LISTED PROVIDER
IS NO LONGER ASSIGNED TO THIS CLINIC.
==============================================================================
PROVIDER: JONES,STANLEY               SD HCP PROFILE -- CONTINUATION

 Select APPOINTMENT TYPE:
 ACUT
 ACUT$
 EST
 EST$
 OPAC
 OPAC$
 PCM$
 PROC
 PROC$
 ROUT
ROUT$
T-CON*
****************************************************************************************



                                                                        Page 35 of 45
GROUP 2 (Revised: 28 Feb 2005)
Example of a Providers Daily Template

               NMC PORTSMOUTH                              12 Aug 2004@1221   Page 1
                                              Print Schedule Templates

                             Daily Template ID: JONESSCHED1MON
                                        Clinic: GASTRO NMCP
                                     Provider: JONES,STANLEY
                                               Day: Monday
==============================================================================
                                                =
Start Appt Wkl #per
Time Type Typ Slot Dur Detail Codes       Slot Comment
==============================================================================
                                                =
0830 PROC$ C 1 40 BPAP COLON 18-99
0835 PROC$ C 1 40 BPAP MANO/PH
0900 PROC$ C 1 40 BPAP EGD 18-99
0905 PROC$ C 1 40 BPAP HBT
0930 PROC$ C 1 40 BPAP COLON 18-99
0935 PROC$ C 1 40 BPAP MANO/PH
1000 PROC$ C 1 40 BPAP EGD 18-99

Example of an Appointment Type:

                  Appointment Type:     EST
                          Duration:     15 MINUTES (This time is specific for each provider)
                            Status:     ACTIVE
                     Workload Type:     COUNT   (With non-privileged providers this could
                                           `     show as Non-count)
                 Referral Required:     NO       (Depending on the appt type specialty
                                                 Clinics would have this at “Yes”)
               Pull Patient Record:     YES      (With the closed record system, the clinic
                                                 is required to pull records prior to the
                                                 appt.)
            Pull Radiology Record:      NO       (Self Explanatory)
           Produce Encounter Form:      YES      (Self Explanatory)
             Send Reminder Notice:      NO       (Self Explanatory)
             Total # of Overbooks:      10       (This sets the number of additional
                                                  Appointments that can be booked in a
                                                  Single day for this appointment type.
                                                  Remember however that the total # of
                                                  Overbooks per day are set within the
                                                  Provider profile.)
     Max # of Overbooks per Slot:       1        (This sets the number per time frame)
                    Instructions:                (Specific instructions for this appointment
                                                  Type. If necessary
                 Booking Authority:              (Used if only specific individuals are
                                                  Are allowed to use this appt type. A
                                                  Code is entered after being approved by
                                                  MID.)
    Appointment Change Authority:                (As Above)
              Overbook Authority:                (As Above)



                                                                                Page 36 of 45
GROUP 2 (Revised: 28 Feb 2005)

                                                   APPENDIX B
                                          Report Formats in Table Form

     There are currently two formats utilized to present the information, Microsoft Power Point and Microsoft
                                                       Excel.
                  The remarks at the bottom of each table will specify which program is utilized.
                                  See the printed examples for visual reference.

1.       Data Quality Assist Visit


Slide Slide Heading                  Data Source        Data Presented
         Data Quality Assist Visit N/A                  Report Header Slide. Change Clinic Name, Date and
 1.      Access Management                              Graphic.
 2.      General Information       N/A                  Presents general information. This will is in a generic
                                                        format and tailored to the specific clinic.
 3.      Overall percentage of       Access to Care     When doing a clinic use the percentage of unbooked
         unbooked appts for          Spreadsheet        from the specific line. When doing a full MTF/BMC,
         clinic/MTF                  from TMA           Total all categories then calculate the overall percentage.
 4.      Percentage Unbooked         Access to Care     This slide will be used to give a clinic by clinic charting
         appts Clinic.               Spreadsheet        when doing an MTF.
                                     from TMA
 5.   Percentage unbooked by         CHCS – Appt    This is a breakdown by appt type for the clinic, to
      appt type. (used on                           represent the under utilized area(s) of appointments.
                                     Utilization rept
      single clinics, not MTFs                      Occasionally it will be necessary to further drill down by
      unless specifically                           Provider.
      requested)
 Slides 4 and 5 can significantly increase the size of the presentation. The use of slide 5 will depend on
                       the unbooked percentages that present from the overall data.
 6. Appointment Booking           CHCS              The information presented is a percentage breakdown of
                                                    clinic book only appt types and appts booked by the
                                                    clinic and the Appointment center. Usually one to three
                                                    months data.
 7. Appointment                   N/A               General Information on the appointment standardization
      Standardization                               process.
 8. References                    N/A               Listing of important references on the appointment
                                                    system.
 9. Points of Contact             N/A               Specific points of contact within the Access
                                                    Management Department.
                           Slides 7, 8, and 9 are copied from the previous presentations.
                                      See examples of reports for exact format.

                                      This report is presented in Power Point.




                                                                                              Page 37 of 45
GROUP 2 (Revised: 28 Feb 2005)

2.     Unbooked Appointment Percentage Report


Slide Slide Heading                    Data Source   Data Presented
 1.    Unbooked Appointments as        TMA           Cover page
       a Percentage of Planned
       Appointments
 2.    Discussion                      N/A         This page presents an overall explanation of the data
                                                   presented. Including Point of Contact.
 3. Unbooked Percentages              TMA          There is a slide for each MTF, which presents the overall
                                                   Unbooked percentage for each. It is presented in a line
                                                   graph format.
    The intent of this report is to present information in a format as a quick look at how an MTF is
 utilizing the appointment utilization process. An excessive amount of unbooked appointments could
        present an inaccurate picture of the availability of patient treatment and/or asset usage.

           Template and appointment management is an integral part of clinic management.

                               This information is presented in Power Point.


3.     Unbooked Appointment Request (UAR) Report

This report is presented in two different formats:

       1. Weekly - within the HBO Directorate as a pivot table.
       2. Monthly - As a running report, in tables specific to each MTF. This table shows all 12 reasons
          with totals for each month within the year.

4.     Frozen Appointment Report

       There are several ways of reporting this information (see Table 5-2.2 for available data).

       1. Prospective – A weekly and/or Monthly future look at what appointments are currently frozen.
             a. These two formats would be utilized to give the Clinic Managers a tool to assist them in
                 their schedule management. The optimum time frame for sending the information would be
                 Friday am.
       2. Retrospective – A weekly and/or Monthly future look at what appointments are currently frozen.
             a. This format would probably be best used in a monthly format both in totals and a
                 percentage of planned appointments and/or as a percentage of unbooked appointments.

                          This information will be presented in a spreadsheet format.




                                                                                          Page 38 of 45
GROUP 2 (Revised: 28 Feb 2005)
5.       Appointment Booking Report

        This report is presented on a weekly basis and on a monthly basis. The format is the same for each
report. The appt booking report is a spreadsheet that shows the amount of appointments booked by the MTF
and the appointment center.

         If required or requested a drill down clinic by clinic is available from the data draw.

         For the format see the printed example. Presented in a spreadsheet format using Microsoft Excel.

6.       No Show Percentage Report

         This table is the proposed format for presentation.

Slide Slide Heading                     Data Source     Data Presented
 1.     Cover Page                      N/A         Introduction to the report
 2.     General Information             N/A         Explanation of the data presented and its importance.
 3.     Percentage of No Show           TMA         A running report in graphic format that shows the overall
                                                    appointment no show percentage of booked
                                                    appointments by MTF and Clinic.
      The slides will have the MTF overall then a separate slide per clinic under the MTF by MEPRS.

                                       Presented in Microsoft Power Point.



7.       Available Appointments Report

                Under Development.


8.       Access to Care Report

        The Access to Care (ATC) report is presented on a weekly basis, every Monday morning. This is a
prospective look at specialty clinic schedules. The main item of interest is the SPEC appointment type. The
access standard for New Patients (SPEC) is 28 days. The availability of SPEC appointments is crucial to the
Referral/Consult process.

         This report is presented using Microsoft Excel from data printed using the ADHOC GNAV. .




                                                                                              Page 39 of 45
GROUP 2 (Revised: 28 Feb 2005)
                                              APPENDIX C
                      Standard Instructions for Specific CHCS Modules


       The following is the Standard Operating Guidelines for Unbooked Appointment Request
entries.


   1. Added to Waitlist:

      Not all clinics utilize the wait list option in CHCS. As such, this code will ONLY be used at the
      CLINIC level.

   2. All Appointments Refused:

   3. Use this code when the beneficiary refuses all available appointment options. Also, use the comments
      section, if appropriate, to document beneficiary concerns.

   4. Appointed to Network:

       NO LONGER APPLIES. DO NOT USE!

   5. No Appointments Available:

      Used by the Clinic to annotate that the beneficiary’s request, could not be met at the time of the
      session. Use the comments section, if appropriate, to document beneficiary concerns.

   6. No Appointments Available to Contractor:

      Used by the Appointment Center to document that the beneficiary’s request could not be met at the
      time of the session. Use the comments section, if appropriate, to document beneficiary concerns.

   7. Patient Requested to Call Back:

      Utilize this code if the beneficiary wants to call back at another time.

   8. Request Referred to MCSC (Managed Care Support Contract):

      Utilize this code if the patient is required to contact the Appointment Center.

   9. Request Referred to MTF Clinic:

      The appointment center will utilize this code if they refer a beneficiary to the Clinic.

   10. Self Care Recommended:

      The Appointment Personnel “WILL NOT” use this code. Only specified individuals at the clinic
      level may use this code.


                                                                                            Page 40 of 45
GROUP 2 (Revised: 28 Feb 2005)

      11. Unsuccessful Telephone Transfer:

         Self Explanatory.


      12. Just Looking:

         This code should only be used if the beneficiary or the booking clerk does not intend to book an
         appointment and is only looking at the availability of appointments.

         * This is an overused option. Booking Clerks should strive to be more accurate in the data entry.
         One way of doing this is to question the beneficiary prior to entering the booking screen to ensure
         that the beneficiary actually wants an appointment.

         ** When looking at schedule availability, Managers should use the Other Option, then annotate
         in the comments section “Clinic/Template Manager reviewing appointment availability”.

      13. Other:

         If this code is used, an explanation should be entered into the comments section. Examples of
         Comments: Training, wrong access entry/entry error, manager checking schedule availability, etc.

Table 5-2.4 - Unbooked Appointment Request Codes

                             Unbooked Appointment Request Codes
             Reason appointment not booked                      Comments
 1       Added to waitlist                         Clinic use only.
 2       All appointments refused                  Utilize this code if the beneficiary refuses all available
                                                   appts.
 3                  Appointed to Network                  NO LONGER APPLIES. DO NOT USE!
 4       No appointments available                 Clinic use only.
 5       No appointments available to contractor   Utilized by the appointment center ONLY.
 6       Patient requested to call back            Self-explanatory.
 7       Request referred to MCSC                  Clinics use this code if the beneficiary is required to
                                                   contact the Appointment Center.
 8       Request referred to MTF clinic            Self-explanatory. Used by the Appt Center
 9       Self-care recommended                     Appointing personnel will not use this code.
 10      Unsuccessful telephone transfer           Self-explanatory.
 11      Just looking                              Use if appropriate.
 12      Other                                     Use if no other code applies. Annotate in the
                                                   comments section the reason for using this code.
         Comments Section                          If appropriate, utilize the comments section for each
                                                   unbooked appointment code to document
                                                   beneficiary/Clinic concerns.



       A weekly report is supplied to the HBO Directorate and Clinic Managers. A monthly report is
compiled and placed on the Command Template Manager web page.




                                                                                                                Page 41 of 45
GROUP 2 (Revised: 28 Feb 2005)
                                                 APPENDIX D
                                                  References

   This is a basic listing. Other references may be made available or become available and are subject to
                                                   change.


                             WEB SITES

       Access to Care Management Data

       http://www.tricare.osd.mil/tools/

       Tricare Operations Center (TOC) Tool for an up to date daily look at Clinic and Provider Schedules

       http://toc.tma.osd.mil/dap/tmaportal_login.html


                             POINTS OF CONTACT

       Each command should input their own POC’s for these categories.

       Healthcare Business Operations


       Data Quality (Progress and Statistics):


       Medical Information Department (MID):


       CHCS Training:

Documents/Training:

   Appointment Standardization – Commanders Guide to Access Success
   Appointment Standardization Phase III – This documentation is supplied on the main CD. The
documentation consists of release notes from CHCS and Power Point Presentations from the 19 March 04
upgrade, including, a Desktop Cookbook.

       http://www.tricareu.tricare.osd.mil/fundcourse/toc.html




                                                                                        Page 42 of 45
GROUP 2 (Revised: 28 Feb 2005)

                                          Appendix E
                                          Acronyms
ACUT                             Acute Care Appointment Type
AD                               Active Duty
ADS                              Ambulatory Data System (Or ADM – Ambulatory Data Module)
AOP                              Appointment Order Process
APS                              Appointments Standardization
APV                              Ambulatory Patient Visit
ASIPT                            Appointments Standardization Integrated Product Team
ATC                              Access to Care
BPAD                             Active Duty Access Type
BPAP                             Active Duty and Prime Access Type
BPAPS                            Active Duty, Prime, TRICARE Plus, and Special Programs Access Type
BPGME                            Graduate Medical Education Access Type
BPPR                             Prime Access Type
BPNAD                            No Active Duty Access Type
BPNAP                            No Active Duty, No Prime Access Type
BPNPR                            No Prime
BPSP                             Special Program Patients and TRICARE Plus Access Type
BPTS                             TRICARE Standard/CHAMPUS Access Type
CAEC                             Catchment Area Executive Committee
CBT                              Computer-based Training
CHCS                             Composite Health Care System
CITPO                            Clinical Information Technology Program Office
CONOPS                           Concept of Operations
CPET                             Change Package Except Training
CPT                              Current Procedural Terminology
DEERS                            Defense Eligibility Enrollment Reporting System
DMIS                             Defense Medical Information System
DoD                              Department of Defense
DOES                             DEERS On-Line Enrollment System
ER                               Emergency Room
EROOM                            Emergency Room Fixed Appointment Type
EST                              Established (Follow-up) Appointment Type
FEHBP                            Federal Employee Health Benefit Plan
FOCUS-PDCA                       Find, Organize, Clarify, Uncover, Start – Plan, Do, Check, Act
FPC                              Family Practice
GAO                              General Accounting Office
GME                              Graduate Medical Education
GRP                              Group/Class Appointment Type
GS                               Government Services
HA                               Health Affairs
HCF                              Health Care Finder
HEAR                             Health Enrollment/Evaluation Assessment Review
HSOSD                            Health Services and Operational Support Division
HSR                              Health Services Region
IAW                              In Accordance With
                                                                                Page 43 of 45
GROUP 2 (Revised: 28 Feb 2005)
                                      Appendix E (Cont.)
                                         Acronyms
ICD                              International Classification of Diseases
IGCE                             Independent Government Cost Estimate
IPT                              Integrated Program Team
IT                               Information Technology
JCAHO                            Joint Commission on Accreditation of Healthcare Organizations
LA                               Lead Agent
MCP                              Managed Care Program
MCSC                             Managed Care Support Contractors
MEPRS                            Medical Expense and Performance Reporting System
MHS                              Military Health System
MOA                              Memorandum of Agreement
MTF                              Medical Treatment Facility
NATO                             North Atlantic Treaty Organization
NED                              National Enrollment Database
OA                               Open Access
OASD                             Office of the Assistant Secretary of Defense
OASD (HA)                        Office of the Assistant Secretary of Defense (Health Affairs)
OPAC                             Open Access appointment type
OPEN ACCESS                      Scheduling patients to see the provider on the day they call
                                 for an appointment.
OPS                              Operations
PA                               Physician Assistant
PAS BOK                          Patient Appointing and Scheduling Booking
PAT                              Process Action Team
PCM                              Primary Care Manager
PCMBN                            Primary Care Manager By Name
PDCA                             Plan, Do, Check, and Act Process
PM                               Program Manager
PO                               Program Office
POC                              Point of Contact
PROC                             Procedure Appointment Type
RMC                              Regional Medical Command
ROUT                             Routine Appointment Type
SG                               Surgeon General
SPEC                             Specialty Appointment Type
STS                              Specialized Treatment Service
SPP                              Special Program Patients
TAI TRICARE                      Access Imperatives Web Site
TAT                              Template Analysis Tool
TBD                              To Be Determined
TDQM                             Total Data Quality Management
TMA                              TRICARE Management Activity
TOL                              TRICARE On-Line
TOC                              TRICARE Operations Center
TRICARE                          Tri-Service Health Care
TRO                              TRICARE Regional Office
                                                                                   Page 44 of 45
GROUP 2 (Revised: 28 Feb 2005)
                                      Appendix E (Cont.)
                                         Acronyms
UCAPERS                          Uniform Chart of Accounts Personnel Reporting System
USFHP                            Uniformed Services Family Health Plan
USTF                             Uniformed Services Treatment Facility
WELL                             Wellness Appointment Type




                                                                                 Page 45 of 45

				
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