Proactive Overbooked
Routines Through Empiric
Noshow Data (PORTEND)
Ped Bunsongsikul MD 1/24/2014
Problem
• Patient No-shows impair our ability to provide excellent
access
• 59% of any given Family Medicine W will have a noshow. (based on historical data)
Potential Solutions
• Automatic Overbooking to compensate for anticipated
No shows
• Change provider mindset to the thought that no-shows
are undesirable.
Overbooking Intelligently
• Development of a method to calculate a number that is
assigned to every W. This number is based on the
historic no-show pattern for the members scheduled.
(Done through a Terradata Query)
• That number correlates to the probability that there will
be a no-show for that W. If the number reaches a
threshold, there is an 80% chance that there will be a
no-show for the W.
• For these Ws, one of the existing routine appointments
is converted to an Overbook. This frees up a routine
slot that can be booked by the call center as a routine.
Calculation of the PORTEND output
pcpnoshowrate =
APPT_TIME
APPT_MADE_DATE apptnoshow apptcomplete totalappt apptnoshow/totalappt
10/24/2013 8:30
9/25/2013
0
4
4
0.00
10/24/2013 8:50
10/21/2013
0
9
9
0.00
10/24/2013 9:30
10/21/2013
0
8
8
0.00
10/24/2013 9:50
10/16/2013
4
4
8
0.50
10/24/2013 10:10
10/20/2013
0
12
12
0.00
10/24/2013 10:30
10/17/2013
1
14
15
0.07
10/24/2013 11:10
10/22/2013
7
18
25
0.28
10/24/2013 11:30
10/21/2013
6
24
30
0.20
18
93
111
1.05
Threshhold : Sum of pcpnoshowrate => 0.77
Exclusion: if sum of apptnoshow < 4
Exclusion: if sum of total appt < 6
*The Terradata Query is found in the Notes of
this slide
Data - 1 Year BPK Family Med
Positive Predictive Value And Sensitivity versus Output Range (Output Interval 0.25)
1 yr data Friday Prior
Positive Predictive Value versus Output Range
1
Sensitivity
100%
0.9
Positive Predictive Value
0.8
0.7
60.8%
0.6
0.5
41.9%
0.4
0.3
25.9%
0.2
14.9%
0.1
8.4%
4.1%
2.0%
1.0%
0.5%
2.01 - 2.25
2.26 - 2.5
0.2%
0
0.00 - 0.25
0.26 - 0.50
0.51 - 0.75
0.76 - 1.00
1.01 - 1.25
1.26 - 1.5
Output Ranges
July 2013-June 2014 Baldwin Park Family Medicine
Physician Providers (23,564 Ws)
1.51 - 1.75
1.76 - 2.00
2.51+
6 Month Family Medicine Data
Prospective Predictions – Dry Run
8/26-9/27 Baldwin Park Family Med
Added Appointments by Clinic
Adds
W Overbooked
Department Clinic
W with
Measured
Total
Week of DMB SDM WCO MON BPK
Total
Cancel Noshows
PPV
Noshows
8/26/2013 4
24
42
21
25
116
5
86
0.775
467
9/2/2013 8
12
27
18
26
91
5
72
0.837
403
9/9/2013 16
13
31
25
46
131
6
99
0.792
529
9/16/2013 13
17
25
15
46
116
2
92
0.807
516
9/23/2013 5
9
16
26
30
86
5
64
0.790
448
540
23
413
0.799
2363
Appts
Added/Total
NS
0.184
0.179
0.187
0.178
0.143
0.175
Overfilled Ws
Total Estimated (11 pts were
Shifts Overbook%
seen)
530
20.9%
6
451
19.1%
5
607
20.6%
8
595
19.2%
8
564
14.4%
5
2747
18.8%
32
Friday Report
Friday Report
Friday Report
Thursday Report
Thursday Report
Thursday Report
Procedures
Current Process
• Report run on Wednesday.
• The schedules are adjusted that same day
• The latest booked routine slot is converted to an overbook.
• The original overbook slot is converted to an unblocked routine
slot. The slot in the same period becomes an unblocked routine
slot as well. Net effect is 2 additional routine slot available for
the call center to book. -2 potential same day appointments. The
overbook slot is “pre-booked”.
Template
The latest booked routine slot is
converted to an overbook.
The original overbook slot is
converted to an unblocked routine
slot. The slot in the same period
becomes an unblocked routine slot
as well. Net effect is 2 additional
routine slot available for the call
center to book. Minus 2 potential
same day appointments. The
overbook slot is “pre-booked”.
AM
Existing Template
8:30 Slot 1
8:50 Slot 2
9:10 Slot 3
Slot 4
9:30 Slot 5
9:50 Slot 6
10:10 Slot 7
10:30 Slot 8
10:50 Slot 9 (SD) Overbook Slot
11:10 Slot 10
11:30 Slot 11
AM
Changes
8:30 Slot 1
8:50 Slot 2
9:10 Slot 3
9:30 Slot 5
9:50 Slot 6
10:10 Slot 7
10:30 Slot 8
10:50 Slot 9 (Routine)
11:10 Slot 10
11:30 Slot 11
PM
1:30 Slot 1
1:50 Slot 2
Slot 3
2:10 Slot 4
2:30 Slot 5
2:50 Slot 6
3:10 Slot 7
3:30 Slot 8 (SD) Overbook Slot
3:50 Slot 9
4:10 Slot 10
4:30 Doctor Time
PM
Changes
1:30 Slot 1
1:50 Slot 2
2:10 Slot 4
2:30 Slot 5
2:50 Slot 6
3:10 Slot 7
3:30 Slot 8 (Routine)
3:50 Slot 9
4:10 Slot 10
4:30 Doctor Time
Slot 4
Slot 12
Slot 3
Slot 11
Additional Exclusion Rules
• If you have travel time or other held/IW time in the W,
you will not get the addon (At discretion of the
scheduler)
• Need at least 9 appointments available in the supply.
It takes about 2 hours for the schedulers to make the
changes each week.
Implementation Timeline
• 8/26/2013-9/27/2013 Dry Run. 540 appointments
added. 79.9% of the identified shifts actually had a noshow.
• 9/30/2013 West Covina and Montebello went live
• 10/30/2013 San Dimas went live
• 12/4/2013 Baldwin Park, Diamond Bar went live
PORTEND Summary
• 9/30/2013-12/27/2013
• 522 Ws were adjusted with an Overbooked Routine
• 19 Ws Clinic Canceled (Leaving 503 W affected)
• 416 of 503 Ws had at least one noshow (82.7%)
• 266 Ws had more routines booked than supply
• (Actual routine appointments created)
PORTEND Summary Continued
Defined by Supply
• 33 ‘Bad days’ out of 503 Ws 6.6%
• Where pts seen is greater than supply
• Compare to 592 ‘bad days’ out of 6656 Ws without adds = 8.9%
Selection bias is present because, as the PORTEND Ws are more likely to have no-shows.
PORTEND Summary Continued
• 4766 total Provider Ws for the clinics affected
• 503 of 4766 Ws were affected (10.6%)
• 503 of 3976 No shows compensated for (12.7%)
• 266 of 3976 True compensation (6.7%)
• Sensitivity = 416/2665 Ws with a NS = 15.6%
• Actual W No Show Rate = 2665/4766 = 55.9%
Measures
ASQ Trends as MOBs went live on PORTEND
MOB
West Covina
Montebello
San Dimas
Baldwin Park
Diamond Bar
PORTEND START
October 2013
October 2013
November 2013
December 2013
December 2013
ASQ - Oct 2013
8.96
8.78
9.16
8.78
8.92
ASQ - Nov 2013
9.09
8.63
8.76
8.95
8.96
ASQ - Dec 2013
9.26
9.15
8.96
8.96
8.73
ASQ - Jan 2014
9.2
9.35
9.12
8.84
8.62
MOB Live on PORTEND
ASQ affected by PORTEND (ASQ score typically lags 2 months)
ASQ - Feb 2014
9.11
9.01
9.33
9.18
9.08
Measures
• Time to 3rd available appointment
• Fam Med Dept: % of MD’s with Next 3rd Available < 14 days
• 78% (Oct) -> 84% (Nov) -> 90% (Dec)
• Booking Utilization (booked/supply)
• 101.7% (Portend) vs 93.9% (Unadjusted)
• Actual Supply Utilization (pt’s seen/supply) – (selection bias)
• 86.4% (Portend) vs 83.8% (unadjusted)
• Net Loss
• Fam Med Dept: 15.4% (Oct) -> 15.2% (Nov) -> 13.4% (Dec)
Measures
Downside
• Providers might need to see more patients
• Decrease supply of Same Day appointments
Adult Primary Care Access Scorecard
Paneled MD/DO %
MDs
Appt Loss
Mid-Level %
Appt Loss
% Un
Booked
% No
Show
% of
Overbook
Appts
Regional Standard
ASQ
Appt
Access
ASQ
Contact
>1 for
Appt.
>9
< 7%
ADW
ADW
Preventa
Routine
tive
Routine
%
% of MDs
Booked w/ N3AA <
W/in
14
standard
30
10
80%
Medical Center Goal
Baldwin
Park (Dec)
Oct-13
18
11.9%
12.4%
5.6%
12.4%
6.0%
8.78 7.2%
10.0
7.0
72%
61%
Nov-13
18
10.5%
7.1%
4.9%
12.0%
6.7%
8.95 6.1%
10.0
7.0
75%
61%
Dec-13
18
11.0%
10.1%
5.5%
12.9%
7.3%
8.96 6.3%
10.0
7.0
75%
78%
YTD
8.86 9.1%
11.1%
Diamond
Bar (Dec)
Oct-13
9
19.6%
23.2%
15.1%
8.4%
3.5%
8.92 8.0%
12.0
7.0
78%
56%
Nov-13
9
20.4%
20.5%
15.1%
9.1%
3.6%
8.96 9.1%
11.0
6.0
83%
67%
Dec-13
9
16.7%
15.8%
11.4% 10.0%
5.0%
8.73 2.8%
11.0
7.0
80%
67%
YTD
8.74 10.5%
16.4%
Montebello
(Oct)
Oct-13
15
15.7%
44.1%
16.1%
7.2%
2.9%
8.78 4.1%
7.0
7.0
74%
73%
Nov-13
15
17.0%
38.4%
15.3%
7.9%
2.5%
8.63 14.3%
7.0
6.0
80%
87%
Dec-13
15
16.6%
24.5%
11.5%
9.1%
3.4%
9.15 5.8%
8.0
6.0
79%
93%
YTD
8.72 9.2%
17.2%
Adult Primary Care Access Scorecard
Paneled MD/DO %
MDs
Appt Loss
Mid-Level %
Appt Loss
% Un
Booked
% No
Show
% of
Overbook
Appts
Regional Standard
Routine
%
% of MDs
Booked w/ N3AA <
W/in
14
standard
ASQ
Appt
Access
ASQ
Contact
>1 for
Appt.
>9
< 7%
30
10
80%
ADW
ADW
Preventa
Routine
tive
Medical Center Goal
San Dimas
(Nov)
Oct-13
16
13.4%
17.4%
9.3%
7.7%
3.1%
9.16 8.5%
6.0
5.0
81%
94%
Nov-13
16
12.9%
21.5%
8.8%
8.0%
2.7%
8.76 3.5%
6.0
5.0
83%
94%
Dec-13
16
8.2%
11.2%
4.9%
8.9%
5.3%
8.96 4.0%
7.0
5.0
86%
100%
YTD
8.87 7.3%
8.5%
West
Covina
(Oct)
Oct-13
21
16.1%
26.0%
11.7%
8.4%
3.1%
8.96 6.9%
5.0
4.0
88%
95%
Nov-13
21
15.4%
20.9%
9.6%
9.2%
3.0%
9.09 10.2%
5.0
5.0
85%
100%
Dec-13
20
14.7%
19.7%
8.8%
9.6%
3.4%
9.26 6.0%
7.0
5.0
83%
100%
YTD
9.02 8.6%
15.0%
Family
Total
Oct-13
79
15.4%
24.6%
11.2%
8.9%
3.8%
8.91 6.8%
8.0
6.0
79%
78%
Nov-13
79
15.2%
21.7%
10.3%
9.2%
3.7%
8.88 8.6%
7.0
6.0
81%
84%
Dec-13
78
13.4%
16.2%
8.2%
10.1%
4.8%
9.04 5.2%
8.0
6.0
81%
90%
14.0%
20.0%
8.0%
10.1%
3.0%
9.04 6.6%
8.0
5.0
86%
YTD
8.86 8.8%
Region
13.0%
Limitation
• This method identifies the shifts that are likely to have a
no-show. However, it does not identify which patient
will no-show.
Comments
BPK Same day appointment protocol includes a Round
Robin. This ensures adequate same day access.
IMPAAQT is also being done in the BPK Family Medicine
(Montebello and West Covina). Currently on hold due to
the flu season.
Conclusion
• It is possible to predict which shifts have a high
likelihood of having a no-show.
• By overbooking these shifts, it is possible to partially
compensate for the anticipated no-shows with only a
small chance of overscheduling the providers.
• There may be a better overbooking process to minimize
the work required by the schedulers. (Takes 1-2 hours a
week to make changes to 70-100 schedules)
Future Directions
• Expand to other primary care departments (internal medicine)
• Improvements
• Join the Appointment Supply into the Terradata Query (done)
• Increase frequency of the runs (will increase sensitivity)
• Automation
• The PORTEND output number is calculated automatically for each W
• For any W that reaches the threshold, the overbook slot becomes
bookable by the call center for routine appointments.
• Would need a proper schedule template. Planning for July 2014.
• To place an overbook slot on an unblocked slot.
• Factors
• The Call Center software has been delayed until April 2014.
• Preparing a report to present to Region and perhaps publish in the
Permanente Journal.
Staff
• Local Physician Lead: Ped Bunsongsikul, MD
• Local Support Staff: Alma Gallardo, Lisa Ordaz
• Schedulers: Gina Gallego, Iverica McDonough