Improving Access to
Dermatology Appointments in
the Cancer Prevention Center
Carol Drucker, MD
Margaret Bell, MPH
Before the change….
Problems Identified:
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Time to first open appointment: 142 days
Patients with urgent problems were dealt with one by one,
interrupting scheduler, nurse and doctor to look for a nonexistent place in the schedule to put them.
Urgent problems were on an appointment "wait list." for 79 days
Clinics ran late routinely
No lunch for the doctors, overtime for the nurses, and
dissatisfaction and stress for all.
Over 200 "missed appointment reschedules" were backlogged.
Temporary hold placed on “new” patients
Increased liability
Lost revenue opportunities
High patient dissatisfaction
High provider and staff dissatisfaction.
Improving Access to
Dermatology Appointments in
the Cancer Prevention Center
AIM:
To decrease wait time for urgent
appointments in Dermatology Cancer
Prevention Center by 10% from July 2007
to December 2007
Fishbone Analysis
Potential Changes/Interventions
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Develop a process working in patients
with urgent problems
Develop a process of differentiating
appointment types
Revamp the missed appointment
process
Develop a process for working in
patients with urgent problems
 Restrict
appointment in cancellation slots
to a designated PSC
 Develop a wait list with sufficient info to
know who should be worked in
 Develop a system of prioritizing of the
patients with urgent problems on the
urgent list
 Develop tools for PSC/RN’s
Patient Prioritizing Method
New Prioritization Process
 Patients
prioritized to high/low risk by
RN/MD
 Form developed to communicate risk to
PSC
 Appointments types changed to
accommodate risk
List of High Risk Factors
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Excessive sun exposure and/or sunburns
History of actinic keratoses
History of basal cell skin cancer
History of squamous cell skin cancer
Having over 50-100 moles
History of dysplastic (atypical) moles
History of melanoma
Family History of melanoma
Other
Current Missed Appointments
Process
Current process :
 Annual low risk screenings given same weight as
high risk
 Three phone calls to patient missing
appointment by RN
 PSC reschedules appointment up to 3 times
 Business Center verifies insurance each visit
 All patients given 15 minute appointment
Televox
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A patient call reminder system helped identify last minute
appointment slots.
“HOLES”
Hi-Ho! Hi-Ho Off to work we go
Missed Appt Process for RN
MA Process Long Term
Derm Appointment Types
PSC Communication Tool
New Process
Instead of 3 calls and 3 reschedules:
 Low Risk: Only letter without reschedule
 High Risk: Letter reminder at risk with
factors identified
 Undiagnosed: Individually follow up by
MD or RN.
Appointment Type
Reduced annual low risk savings by 23.9%
Final Results
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AIM: To decrease wait time for urgent appointments in
Dermatology Cancer Prevention Center by 10% from
July 2007 to December 2007.
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RESULTS:
 Improved by 91.14%
 Access less than 48 hours for urgent
patients
 Urgent wait list gone
Why go through the effort?
Aim: Improve
access for urgent
appts.: 91.1%
improvement
Decrease in
missed appts.:
Televox process
ROR 1925%
More
appointments
available
Predictable days
Transferable
Reduction of risk
liability savings:
$40,000 -$240,000
Missed appts.
Dropped 9.49%
*751 Additional new
Standardization of
practice and
decrease in
variation
Use of forms to
achieve
standardization
Staff more content,
get lunch breaks, less
interruptions, able to
start new day without
bringing backlog of
work with them
Practice changes
started with one MD
moved to all MD’s
patients /year
*40 Additional F/U
patients /year
*939 Additional CPC
patients appts/year
Wait list for urgent
appointments gone
Urgent patients
seen in less than 48
hours
*PAS time saved for
financial clearance
*RN time saved for
documentation and
calling
*PSC time saved for
scheduling appts.
1502
Additional
Derm. Procedures/year
259
Additional
Colonoscopies/ year
6 % newly
diagnosed cancer
patients referred to
other centers for
cancer treatment
Gross Annualized Revenue
Volume Annualized
Service
Annualized Gross Revenue
751
New Patients (PRS, Tech)
$262,099
40
Follow up patients (PRS, Tech)
$ 11,480
939
Other screening (PRS, Tech)
$271,859
1502
Dermatology procedures (PRS, Tech
without pathology)
$887,667
59
Colonoscopies (Downstream
revenue)
$222,843
48
Newly Diagnosed Cancers:
Breast, Colon, Melanoma*
(Downstream revenue)
$4,275,006
Personnel Time Savings (RN, PSC,
PAS)
$ 17,647
Total New Income
$5,948,601
*Based on a rate of 6% although average cancer diagnosis in center is 14.4% (to be conservative with projections as percentage of patients
treated here is not known). In addition, lowest institutional estimates for cancer diagnosis treatment cost were utilized as patients are generally
diagnosed at an earlier stage (a mix of 50% breast in situ, 45% simple melanoma and 5% colon.
** Based on 2 biopsies per patient. Generally new patients average 3-4 or higher. Does not include photography charges, extensive procedures or
Cryosurgery.
*** EIW was data source and institutional charge master was source for charge estimates.
Sustaining the Gain
“What ultimately makes any project
sustainable is local ownership from the
beginning in designing the project,
establishing the priorities.”
James
- Rebviltlraq Projects
Found Crumbling
NY Times. Sun 29 Apr07