Friday, June 27, 2008

Calling All Patients

It had been a month since our last team meeting, so I was happy – and a little relieved – to meet again last week. Now that we’ve distilled our project team down to just members of our office staff and physicians, there’s a temptation to let regular meetings slide.

I had a proposal for our next mini-project: reducing our no-show rate. Our no-show rate usually runs between 10-15%. That’s unused capacity that could help get rid of our backlog, reduce wait times and, as a bonus, increase revenues.

Great idea, right?

Amanda had already thought of it. And, as part of her Clinical Practice Redesign (CPR) School work, had carried out a test of change. And she showed us the results.

Since the week of May 12, a staff member has been confirming appointments by calling all patients a week in advance.

Since implementing that change, our no-show rates have all been below the median (10.88%).

But, that's a lot of phone calls. Maybe we can target people at "high-risk" of not keeping appointments. Perhaps we only need to remind new referrals, or people from out-of-town. We'll take a look at some of the characteristics of our no-shows to see if we can cut down the number of calls needed.

If that doesn't work, and we decide that routine reminder calls are valuable, Amanda has heard (through her CPR classmates) of online automated telephone messaging services we may want to explore.

While the no-show rate is one of our project's benchmarks, a lower no-show rate doesn't necessarily translate to reduced wait times. Our no-show rate is the number of no-shows divided by the total number of patients scheduled. It doesn't include empty appointment slots. So, if we've phoned our patients and identified those who aren't planning to attend their appointment, we'll reduce our no-show rate, but may be left with unfilled slots. If the staff responsible for booking appointments aren't notified about those newly-opened slots, the time remains unused. That's wasted capacity.

Perhaps "wasted" is the wrong word. One of my partners took me to task for describing unfilled appointment slots as wasted time. He pointed out that no-shows give him the chance to return phone calls and catch up on paperwork. I've heard similar comments from other physicians during Advanced Access discussions. That is, they're not really upset about no-shows because there's always plenty of other work to fill in those time slots.

It's really useful to hear these comments. If docs value "free" time during their office day, they may not support efforts to decrease no-shows. Cutting down our no-show rates might even worsen patient care, because phone calls and lab results aren't being dealt with promptly!
If we can consistently reduce the no-show rates and fill any open slots, we could try building "catch-up" time slots into the office schedule. This would eliminate the unpredictability of free time arising from no-shows. I suspect this would be well received by our docs! Plus, it's a nice reminder of the (sometimes-intangible) payoffs of Advanced Access. As a start, we could try leaving unfilled some of the slots that open up as a result of reminder phone calls.

Will we need to continue with phone reminders indefinitely? After all, reducing our wait times was supposed to cut down no-shows (presumably because patients don't forget their appointments) without an additional investment of resources. If we decide to continue with phone reminders for now, then when our wait times drop further, we'll stop the reminders and see if no-show rates stay down.

Last post, I mentioned hearing about another Saskatoon Health Region (SHR) group's efforts to improve patient access. Thanks to Judi Whiting for sharing SHR's diabetes education service experience with CPR. SHR has 2 endocrinologists providing specialist consultation for diabetics.

According to Judi, "This is what happened to wait times when we pooled the two endocrinologists' waiting referrals. One endocrinologist is an academic appointment, the other is community based. The community based endocrinologist works like the diabetes clinicians – he has a profile of expected new and review appointments. He has more appointment slots per week or month than the academic physician."

Mmmmmm...  Pooled referrals!

Back on the topic of no-shows, here’s the diabetes team's stats for no-shows (DNS) and cancellations for nurse (RN) and dietician (RD) visits.

Judi’s notes on this graph:

"We also track cancellations and ‘no shows’ Literature usually indicates ‘no shows’ for diabetes programs to be about 20-30%. Ours is much lower -? Related to the letter sent with appointment.

Survey done of cancellations to see if we can improve our processes. Reasons related to location of service or sufficient notice for service did not apply. The most common reason for a cancellation was due to some aspect of a person’s work. Do we need to consider an evening service?"

A few months ago, I blasted the blame-the-patient approach to no-shows on Plain Brown Wrapper. Judi’s team is taking the ask-the-patient approach. They’re even considering changing their service in order to accommodate their clients. Way to go!

P.S. Also last post, I griped about not having enough time to work on administrative duties and CPR tasks. I convinced myself to ask my partners for more protected time. They obliged! That's a generous commitment of resources, given our fee-for-service practice.


  1. Calling up patients is effective, but can be a time consuming process.
    An effective alternative is to use an SMS appointment reminder service, such as Schedule an SMS reminder message 24 hours before the appointment is the most effective way of making sure patients show up.

  2. does anyone know the patient phone number to centegra behavioral health also called south street in woodstock?