Friday, July 24, 2009

Stick It

You can’t manage what you don’t measure.

Q:  What’s more annoying than a worn-out cliché?

A:  A worn-out cliché that keeps on proving itself right.

Measurement is a key component of Advanced Access. For us, it’s been a source of enlightenment and discovery. While we continue to use many of the same measuring sticks that we started off with, we’ve added some new measuring sticks that have yielded some surprises.

I’ve been telling you about our efforts to reduce recall rates/internal demand. Those tests of change (call them PDSAs if you must) arose after we tallied the number of patients each urologist was asking to come back for a repeat visit. I presumed that all of us had pretty similar practice habits, but some of our staff thought that those habits varied considerably. So we did some counting. The initial data is in “Bang for your Buck”. While we don’t know whether the higher rates or lower rates of recall are more clinically appropriate, our guess was that we could provide the same quality of care, yet have necessary follow-up provided in a setting other than a specialist office.

As I reported recently, we’ve had some success in bringing down recall rates, and the variation among our group. I was pleased to see that 6 out of the 8 urologists who were working in June had recall rates in the single digits. This means that our clinic average is staying around 11%, when it used to be around 15-17%. Thanks to an unexpected result of measurement.

We also recently realized that old measuring sticks need to be resurrected from time to time. Last year, we tried to reduce our no-show rates. Amanda tried several PDSAs to decide on the best strategy. When we experimented with making reminder phone calls to all patients, no patients, or just new patients, we found that calling new patients seemed to be most efficient. No-show rates dropped from 16.25% to 5.87% when new patients were called. We continue to make those reminder calls.

When the no-show rate was checked in June, however, it was back up to 11.5%. What happened? Is it just a chance variation? Perhaps people are so busy in June, with school ending and holidays beginning, that they just forget about medical visits. When we talked about it at our team meeting, the first conclusion we reached was that the increase in no-show’s must be due to recalled patients not keeping their appointments. After all, we’re already calling to remind new patients, and we know that those calls are effective in reducing no-show rates. Or, we know they were effective in the past.

So we counted the number of new patients vs. recall patients who missed their appointments: 55% were new patients and 36% were recalls (the other 9% had rebooked appointments already, so our tracking method couldn’t account for them). Our presumption about the culprits being recall patients wasn’t completely accurate, but they did account for a significant number of no-shows. Now we need to do something about it. In addition to following the no-show rate monthly, we’ll try calling all patients for the next few weeks. We want to get the no-show rate down so we avoid unused appointment slots/capacity, and also the extra effort our staff has to make when rebooking missed visits. We’ll also assess how much extra work it is for staff to make all those calls. Once the no-show rate drops again, we can experiment with calling only new patients again.

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