Improving Care for Urgent
Dermatology Appointments
Margaret Bell, MPH, R.N.
Carol Drucker, MD
Before the change….
Example of a Problem Identified:
• 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
• Temporary hold placed on “new” patients
• 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.
• Increased liability
• Lost revenue opportunities
• High patient dissatisfaction
• High provider and staff dissatisfaction.
ORIGINAL 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
• 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 scheduling clerk.
• Develop a wait list with sufficient information
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
New Prioritization Process
• Patients prioritized to high/low risk by
RN/MD
• Form developed to communicate risk to
scheduling clerk
• Appointments types changed to
accommodate risk
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
• Scheduling clerk reschedules appointment up to
3 times
• Business Center verifies insurance each visit
• All patients given 15 minute appointment
Televox
• A patient call reminder system
“HOLES”
Tools
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.
Process
Missed Appt Process for RN
MA Process Long Term
A new world ………
•
•
•
•
•
•
Improved work flows
Difficult problems tackled
Work together better
Improve working conditions
Improve access for your patients
Employees smile when they come to work
Final Results
•
AIM: To decrease wait time for urgent appointments in
Dermatology Cancer Prevention Center by 10% from July
2007 to December 2007.
•
INITIAL RESULTS:




Improved by 91.14%
Access less than 48 hours for urgent patients
Urgent wait list gone
Initial savings Televox $18,100 for 1st year.
Current Results
• Sustained original results
• Physician production increased to 11.13 patients
resulting in a net increase of 589 patients per year
• Televox was expanded to all out patient centers
• CPC general screening and mammogram
appointments generated
• Downstream revenue:
1531 additional pathology specimens
~26 patients were treated (GELB)
Patients per 4hr-Session
CPC Dermatology
14
FY11 Median 11.13
Patients per Session
12
10
Baseline MEDIAN (min) = 9.3
8
Post Measure MEDIAN (min) = 8.6
6
Data
Median
4
2
0
J- A- S- O- N- D07 07 07 07 07 07
J- F- M- A- M- J- J- A- S- O- N- D- J- F- M- A- F- M- A- M- J- J08 08 08 08 08 08 08 08 08 08 08 08 09 09 09 09 11 11 11 11 11 11
Missed Appointments Rate
CPC Dermatology
35%
Hurricane Ike
Missed Appointment Rate
30%
25%
Baseline MEDIAN (min) = 16%
20%
Post Measure MEDIAN (min) = 13%
15%
Data
Median
10%
FY11 10.3%
5%
0%
J- A- S- O- N- D07 07 07 07 07 07
J- F- M- A- M- J- J- A- S- O- N- D- J- F- M- A- F- M- A- M- J- J08 08 08 08 08 08 08 08 08 08 08 08 09 09 09 09 11 11 11 11 11 11
Time in Days to Urgent Appointment
in CPC Dermatology
140
Baseline MEDIAN (min) = 120
120
80
60
40
20
Post Measure MEDIAN (min) = 1
Aug-11
Jul-11
May-11
Mar-11
Jan-11
Nov-11
Sep-11
Aug-11
0
Feb-11
Days
100
Data
Median
ROI
Calculation Summary
Initial Cost
Cost of Capital
9%
Investments/Costs
$ (2,500.00) $
Benefits/Revenue
$
Annual Net Benefit/Revenue (Costs) $ (2,500.00) $
ROI
Net Present Value
Internal Rate of Return
Modified Internal Rate of Return
$1,088,293.57
Year 1
(10,656.00) $
441,579.19 $
430,923.19 $
Year 2
(10,656.00) $
441,579.19 $
430,923.19 $
3743%
$1,088,293.57
17237%
709%
3743%
Year 3
10,656.00
441,579.19
430,923.19
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
ADDENDUM