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.

Booster Shot

Sometimes I wonder: Is there anyone else out there?

When I go for a stretch without connecting with anyone who's engaged in quality improvement work, I feel a little isolated.

But I’ve had a great couple of weeks, with plenty of chances to connect with people who are truly excited about the quality improvement opportunities they’re pursuing.

I started out at HQC’s Clinical Practice Redesign (CPR) school. Participants from clinics and health regions are learning to apply QI techniques in their clinical work.

And they ask some tough questions, like “What would you do differently, if you could do Advanced Access over again?”  Ummmm…2 things.

First, I would ask for more time set aside for this project. When I took on the Urology Division head position, I asked for a half-day every month to pursue administrative activities. I usually split that into two 2-hour chunks. At the time, I thought that was a lot to ask, given that our practice is fee-for-service and administrative work doesn’t pay the bills.

Ha! What a rube! I got owned… big time.

Spice of Life

Last week’s post brought some interesting responses. I had suggested that a large hotel’s elevator system was a good model for managing health care queues. A couple of people commented that, in principle, it might be advantageous to have a system that automatically assigns patients to the shortest wait list. However, they wanted to have a choice of which physician they saw.

They point out that personalities and skills vary among physicians, and some people will choose to wait longer so they can see someone they have confidence in.

I agree that it’s important to let patients choose their physician – recognizing that their choice may result in a longer wait. Our recently implemented "default" referral system recognizes this. As of May, all new referrals to our practice are considered "pooled" and go to the urologist with the shortest wait time. If the patient requires subspecialty attention, we set up the appointment with the appropriate urologist. However, the patient or referring physician can request ("No substitute") a specific urologist, with the understanding that there may be a longer wait.

Returning to the elevator analogy, some people may prefer the "services" of a specific elevator. Most of the elevators were glass-walled and faced out over a 40-storey atrium. Anyone with a fear of heights would be very uncomfortable with that ride and would prefer to wait for one of the enclosed elevators.

So, choice is important. But, it's not the only solution to this problem. And perhaps not the most desirable one, either.

Going Up

My wife and I spent last week in New York City. And I couldn't stop thinking about Advanced Access!

Our hotel had 49 floors and 16 elevators. I was intrigued by the elevator triage system. Rather than pressing the button and waiting for an elevator to show up, you punched in your floor number and the display directed you to the next elevator that was going to that floor. The lobby was so busy that the traditional system (pick an elevator, stand in front of the doors and elbow your way in when it shows up) would have been chaotic and inefficient. Some people would have long waits, both in the lobby and in the elevator, as it made a milk run to the 49th floor.

The hotel's automated (dare I say "expert"?) system grouped people according to their destinations, for example, batching all those going to floors 30-39 together, so the lower floors could be bypassed.

Part of my fascination with the elevators was pure yokel, i.e., in Saskatoon, we ain't got no real tall buildings. But I was also interested in the similarities between waiting for an elevator and waiting to see a specialist. In the traditional system, customers line up for an elevator/specialist without any idea of how busy that elevator/specialist is or how long they will wait. Some users, such as hotel staff/health care workers, may have inside information that helps them choose the shortest queue.

Users shouldn't need expert knowledge of the system in order to gain rapid access. There's an inherent inequity in a system that rewards expert/inside knowledge. The system should provide the expertise needed to get the user to their destination efficiently.