Proactive Overbooked Routines
Through Empiric Noshow Data
(PORTEND)
Ped Bunsongsikul MD 11/19/2013
Problem
• Patient No-shows impair our ability to provide excellent access
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 noshow 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
APPT_TIME
10/24/2013 8:30
10/24/2013 8:50
10/24/2013 9:30
10/24/2013 9:50
10/24/2013 10:10
10/24/2013 10:30
10/24/2013 11:10
10/24/2013 11:30
APPT_MADE_DATE apptnoshow apptcomplete
9/25/2013
0
4
10/21/2013
0
9
10/21/2013
0
8
10/16/2013
4
4
10/20/2013
0
12
10/17/2013
1
14
10/22/2013
7
18
10/21/2013
6
24
18
93
pcpnoshowrate =
totalappt apptnoshow/totalappt
4
0.00
9
0.00
8
0.00
8
0.50
12
0.00
15
0.07
25
0.28
30
0.20
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
Other methods
•
Calculating Member Historic NoShow Rate For each member
•
# of prior PCP appointment No Shows/Total # of prior PCP appointments
•
For each given W, that W’s Historic NoShowRate is calculated
•
All of the patients prior NoShows / Total # of prior PCP appointments for all the patients
•
This number is multiplied by the number of routine appointments to get the
AdjustedHistoricNoShowRate for the W
•
For each given W, that W’s Historic NoShowRate Sum is calculated
•
Sum of the members Historic NoShowRate for that W
•
Assuming that the WHistoricNoShowRate predicts the no show rate for each member,
the following equation is applied.
•
1 – (1- WHNSR) ^n
•
This gives the exponential method.
Where n = number of routine appointments.
Cumulative PPV vs Cumulative Addons
(6 months West Covina)
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%
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
1.51 - 1.75
Output Ranges
July 2013-June 2014 Baldwin Park Family Medicine Physician Providers
(23,564 Ws)
1.76 - 2.00
2.01 - 2.25
2.26 - 2.5
2.51+
6 Month Family Medicine Data
Family Medicine Baldwin Park 1/1/2013 - 6/30/2013
13853
Total Ws
0.592
% of W with NoShow
12869
Total NoShows
9.7
Pts Scheduled/W
8.8
Pts Seen/W
Threshold value 0.77
Had No-Show
Did not have No-Show
Sensitivity
PPV (223/241) =
P-Value (Chi 2 with Yates)
NoShow Compensation
Met Threshold
1805
395
2200
0.220
0.820
< 0.0001
0.171
Below Threshold
6395
5258
11653
8200
5653
13853
Variables
• Threshold
• The threshold level can be adjusted up or down to balance PPV vs Sensitivity
• Timing of report
• Reports can be run the week prior to allow for scheduling of routine
appointments.
• The earlier the report is run:
• There will be fewer Ws that will meet threshold (decrease sensitivity)
• there may be an increase in PPV as there will be more time for appointments to be
scheduled.
• Increased risk of cancellation which could disrupt the theoretical no-show probability
Other Variables that are not considered
• Timing of appointment (AM vs PM) – Not statistically significant
• # of supply in the W (I would like to factor it in to help in automation)
Prospective Predictions – Dry Run
8/26-9/27 Baldwin Park Family Med
Added Appointments by Clinic
Week of DMB
8/26/2013
4
9/2/2013
8
9/9/2013 16
9/16/2013 13
9/23/2013
5
SDM
24
12
13
17
9
WCO
42
27
31
25
16
MON
21
18
25
15
26
Adds
BPK
25
26
46
46
30
W
Overbooked
Department Clinic
W with
Measured
Total
Cancel Noshows
PPV
116
5
86
0.775
91
5
72
0.837
131
6
99
0.792
116
2
92
0.807
86
5
64
0.790
540
23
413
0.799
Total
Noshows
467
403
529
516
448
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
Original Process
• Report run on Thursday
• Schedules are adjusted by Thursday Afternoon
Current Process
• Report run on Wednesday.
• The schedules are adjusted by Thursday afternoon
Template
Rules
• If you have travel time or other held/IW time in the W, you will not
get the addon (IMPAAQT, Inbasket, and CSG IW do not count)
PORTEND Started- 9/30
WCO and Montebello Actual Data
PORTEND 9/30/2013 - 11/1/2013
MON 09-30
WCO 09-30
MON 10-07
WCO 10-07
MON 10-14
WCO 10-14
MON 10-21
WCO 10-21
MON 10-28
WCO 10-28
Total
Threshhold Added
21
17
19
19
17
17
16
14
21
16
20
17
21
15
23
22
14
10
18
17
190
164
Weekly Total
Clinic
Cancel
1
0
1
0
1
0
1
0
0
1
5
W Routines W No
Overbooked Shows
16
15
19
13
16
11
14
13
15
13
17
11
14
10
22
20
10
8
16
12
159
126
W No Show
Bad
Rate
Pt's Seen/W Days
0.94
9.2
0
0.68
8.6
0
0.69
9.1
1
0.93
9.4
1
0.87
8.5
1
0.65
8.6
0
0.71
10.1
1
0.91
8.5
1
0.80
10.6
1
0.75
9.6
1
0.79
7
Total
Added Appt/
Noshows
Total NS
Total Ws
92
0.17
101
109
0.17
158
67
0.24
113
97
0.14
138
82
0.18
122
104
0.16
145
60
0.23
111
125
0.18
148
88
0.11
104
115
0.14
135
939
0.17
1275
Clinic
Pt's
%W with NS Combine PPV Seen/W
0.62
8.6
0.48
0.8
7.9
0.45
8.1
0.56
0.8
8.5
0.53
7.7
0.51
0.75
8
0.43
7.4
0.58
0.83
7.4
0.54
7.1
0.56
0.77
7.6
• Overall 126/159 (79.2%) shifts had a no show
• 159 overbooked appointments to compensate for 939 noshows (17%)
• Bad Day defined as everyone showing up and 12 patients are seen in
the AM or 11 patients seen in the PM.
Physician Impact
• Increase in patients seen per half day
• Low probability for a ‘bad day’. (7/159 shifts)
Paneled Paneled
MDs
FTEs
Avg.
MidAvg.
Panel
Level Members
Size per
FTEs hip per W
W
Unassig
ned Rate
MD/DO
% 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
30
10
Routine
%
% of MDs
Booked w/ N3AA <
W/in
14
standard
80%
Medical Center Goal
Baldwin
Park
Diamond
Bar
San Dimas
West
Covina
% Able
(bonding
rate)
90%
100%
64%
64%
% Able
Preventiv
e
% Able
Routine
% Able
Same Day
85%
85%
40%
Leakage
to UCC
Waitlist
Volume
18
16.5
1.6
6.12
5.77
6%
5.8%
12.4%
2.8%
12.5%
8.7%
8.98 7.3%
11.0
8.0
75%
39%
98%
28%
58%
87%
76%
32%
13.3%
23
Sep-13
18
16.5
1.6
6.12
5.78
6%
11.0% 12.3%
5.9%
11.0%
5.7%
9.12 10.8% 12.0
9.0
70%
67%
99%
67%
61%
90%
79%
40%
12.8%
17
Oct-13
18
16.5
1.6
6.14
5.79
6%
11.9% 12.4%
5.6%
12.4%
6.0%
8.78 7.2%
10.0
7.0
72%
61%
99%
61%
64%
93%
82%
35%
12.6%
14
TOTAL
12.0%
YTD
8.84 9.8%
Aug-13
8
7.3
0.8
6.69
5.96
10%
8.0%
17.3%
4.5%
10.2%
5.4%
8.41 5.6%
12.0
8.0
77%
29%
95%
13%
56%
82%
71%
36%
9.2%
30
Sep-13
8
7.3
0.8
5.91
5.26
10%
10.0% 20.1%
5.5%
10.7%
5.6%
8.17 15.7% 11.0
8.0
78%
63%
99%
25%
58%
86%
76%
36%
9.3%
19
Oct-13
9
8.8
0.8
6.38
5.67
10%
19.6% 23.2% 15.1%
8.4%
3.5%
8.92 8.0%
12.0
7.0
78%
56%
100%
56%
63%
90%
78%
42%
8.4%
19
YTD
8.71 11.8%
20.0%
Aug-13
15
14.4
1.1
5.80
5.10
11%
14.1% 33.6% 12.5%
7.6%
1.9%
8.24 11.0%
8.0
7.0
73%
80%
99%
60%
65%
89%
80%
43%
8.6%
105
Sep-13
15
14.4
1.1
5.79
5.10
11%
11.1% 23.6%
8.6%
7.8%
3.3%
8.85 8.9%
9.0
7.0
72%
80%
99%
60%
66%
89%
82%
44%
9.0%
110
Oct-13
15
14.4
1.1
5.94
5.25
11%
15.7% 44.1% 16.1%
7.2%
2.9%
8.78 4.1%
7.0
7.0
74%
73%
99%
73%
69%
93%
82%
49%
8.5%
4
YTD
8.62 9.1%
TOTAL
20.4%
Aug-13
16
14.7
2.0
6.46
6
7%
11.0% 14.1%
6.0%
8.6%
3.1%
8.78 5.7%
7.0
6.0
77%
81%
99%
75%
69%
95%
87%
47%
8.9%
21
Sep-13
16
14.7
2.0
6.47
6
7%
12.0% 18.8%
8.1%
8.5%
3.5%
8.71 4.4%
6.0
6.0
81%
94%
98%
94%
69%
94%
87%
49%
8.5%
1
Oct-13
16
14.7
2.0
6.51
6.02
7%
13.4% 17.4%
9.3%
7.7%
3.1%
9.16 8.5%
6.0
5.0
81%
94%
98%
69%
71%
96%
87%
48%
8.7%
1
TOTAL
13.9%
YTD
8.87 8.0%
Aug-13
21
18.0
1.5
6.14
5.67
10%
10.8% 14.8%
5.4%
9.6%
4.1%
9.00 7.4%
7.0
6.0
75%
100%
98%
67%
67%
93%
90%
44%
12.9%
7
Sep-13
21
18.0
1.5
6.09
5.64
9%
15.9% 27.1% 10.2%
8.7%
2.2%
8.96 4.9%
7.0
5.0
81%
95%
99%
81%
70%
91%
90%
50%
13.1%
13
Oct-13
21
18.0
1.5
6.09
5.62
10%
16.1% 26.0% 11.7%
8.4%
3.1%
8.96 6.9%
5.0
4.0
88%
95%
99%
76%
69%
93%
89%
46%
12.5%
23
YTD
8.99 8.7%
TOTAL
Family
Total
% of MDs
Meeting
Bonding
Goal
Aug-13
TOTAL
Montebello
% New
Member
booked w/in
standard
17.1%
Aug-13
78
70.9
7.0
6.21
5.69
7%
9.9%
18.5%
6.5%
9.5%
4.4%
8.72 7.6%
9.0
7.0
75%
71%
98%
38%
64%
90%
82%
41%
10.9%
186
Sep-13
78
70.9
7.0
6.08
5.58
7%
12.0% 20.4%
8.0%
9.2%
3.8%
8.85 8.2%
9.0
7.0
76%
82%
99%
71%
66%
90%
83%
45%
10.9%
160
Oct-13
79
72.4
7.0
6.18
5.65
7%
15.4% 24.6% 11.2%
8.9%
3.8%
8.91 6.8%
8.0
6.0
79%
78%
99%
68%
68%
93%
84%
44%
10.5%
61
14.0% 21.0%
9.6%
3.0%
8.98 6.2%
8.0
5.0
84%
65%
92%
84%
37%
8.8%
YTD
8.84 9.2%
Region
TOTAL
16.0%
7.0%
99%
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)
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.
Specialties
Dermatology
Dermatology Baldwin Park 1/1/2013 - 6/30/2013
Total Ws
1017
% of W with NoShow
0.79
Total NoShows
1571
Pts Scheduled/W
13.4
Pts Seen/W
11.8
Threshold value 1.15
Had No-Show
Did not have No-Show
Sensitivity
PPV (223/241) =
P-Value (Fisher Exact)
NoShow Compensation
Threshold value 0.90
Had No-Show
Did not have No-Show
Sensitivity
PPV (335/370) =
P-Value (Fisher Exact)
NoShow Compensation
Met Threshold
223
18
241
0.277
0.925
< 0.0001
0.153
Below Threshold
583
193
776
806
211
1017
Met Threshold
335
35
370
0.416
0.905
< 0.0001
0.236
Below Threshold
471
176
647
806
211
1017
Specialty Cardiology
• Not useful
BPK Cardiology
Total Ws
% of W with NoShow
Total NoShows
919
0.242
278
Threshold value 1.00
Had No-Show
Did not have No-Show
Met Threshold
23
43
66
0.104
0.348
0.051
0.237
Sensitivity
PPV (335/370) =
P-Value (Fisher Exact)
NoShow Compensation
Below Threshold
199
222
654
697
853
919
Specialties
Neurology
Neurology Baldwin Park 1/1/2013 - 6/30/2013
Total Ws
899
% of W with NoShow
0.484
Total NoShows
800
Threshold value 1.00
Had No-Show
Did not have No-Show
Sensitivity
PPV (78/96) =
P-Value (Fisher Exact)
NoShow Compensation
Threshold value 0.96
Had No-Show
Did not have No-Show
Sensitivity
PPV (78/96) =
P-Value (Fisher Exact)
NoShow Compensation
Met Threshold
78
18
96
0.161
0.813
< 0.0001
0.120
Below Threshold
406
397
803
484
415
899
Met Threshold
87
18
105
0.180
0.829
< 0.0001
0.131
Below Threshold
397
397
794
484
415
899
Future Direction
• Improvements
• Join the Appointment Supply into the Terradata Query
• 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.
• Factors
• The Call Center software has been delayed until April 2014.
Staff
• Local Physician Lead: Ped Bunsongsikul, MD
• Local Support Staff: Alma Gallardo, Lisa Ordaz
• Schedulers: Gina Gallego, Iverica McDonough