Improving outpatient services - Reference list
1. Alamo ST, Wagner GJ, Sunday P, Wanyenze RK, Ouma J, Kamya M, et al. Electronic
medical records and same day patient tracing improves clinic efficiency and adherence to
appointments in a community based HIV/AIDS care program, in Uganda. AIDS and behavior.
2012;(2):368-74.
Abstract: Patients who miss clinic appointments make unscheduled visits which compromise
the ability to plan for and deliver quality care. We implemented Electronic Medical Records
(EMR) and same day patient tracing to minimize missed appointments in a community-based
HIV clinic in Kampala. Missed, early, on-schedule appointments and waiting times were
evaluated before (pre-EMR) and 6 months after implementation of EMR and patient tracing
(post-EMR). Reasons for missed appointments were documented pre and post-EMR. The
mean daily number of missed appointments significantly reduced from 21 pre-EMR to 8 postEMR. The main reason for missed appointments was forgetting (37%) but reduced
significantly by 30% post-EMR. Loss to follow-up (LTFU) also significantly decreased from
10.9 to 4.8% The total median waiting time to see providers significantly decreased from 291
to 94 min. Our findings suggest that EMR and same day patient tracing can significantly
reduce missed appointments, and LTFU and improve clinic efficiency
2. Crane S, Collins L, Hall J, Rochester D, Patch S. Reducing utilization by uninsured frequent
users of the emergency department: combining case management and drop-in group medical
appointments. Journal of the American Board of Family Medicine: JABFM. 2012;25(2):18491.
Abstract: BACKGROUND: Patients with complex behavioral health and medical problems
can have a disproportionate impact on emergency departments
3. Kallen MA, Terrell JA, Lewis-Patterson P, Hwang JP. Improving wait time for chemotherapy
in an outpatient clinic at a Comprehensive Cancer Center. Journal of Oncology Practice.
2012;(1):e1-e7.
Abstract: Purpose: We conducted our study at the Ambulatory Treatment Center (ATC) of the
MD Anderson Cancer Center, a network of six outpatient treatment units for patients
receiving infusion therapies. Excessive patient wait time for chemotherapy was a primary
source of ATC patient dissatisfaction. ATC employees expressed frustration, because often,
patients arrived physically on time but were not treatment ready. Additionally, ATC staff
emphasized challenges associated with obtaining fi- nalized treatment orders for
prescheduled appointments (ie, placeholder appointments without associated physician
treatment orders). We aimed to decrease mean patient wait time from check-in to treatment
in one ATC unit by 25%. Methods: We studied appointment cycle time in the ATC Green Unit,
stratifying appointments by type (ie, prescheduled [no finalized treatment orders] and
scheduled [finalized treatment orders]). We obtained mean wait times at baseline (control)
and again after our intervention period. We conducted interviews and observations in ATC
Green, from which we developed a three-part plan to reduce wait time: increase process
efficiency within ATC Green, enhance communications with MD Anderson clinics and
centers, and incorporate information technology applications. Results: After our intervention,
we observed a 15% decrease in wait time for patients with prescheduled appointments and a
29% decrease for those with scheduled appointments. Overall, there was a 26.8% reduction
in mean patient wait time relative to baseline (control). Conclusion: We observed a
significantly decreased mean patient wait time after implementing our intervention. This
decrease may improve patient satisfaction, relieve employee frustration with appointment
scheduling, and create opportunities for increasing institutional revenue. Copyright 2012 by
American Society of Clinical Oncology
4. O'Neill S, Calderon S, Casella J, Wood E, Carvelli-Sheehan J, Zeidel ML. Improving
outpatient access and patient experiences in academic ambulatory care. Academic Medicine.
2012;87(2):194-9.
Abstract: Effective scheduling of and ready access to doctor appointments affect ambulatory
patient care quality, but these are often sacrificed by patients seeking care from physicians at
academic medical centers. At one center, Beth Israel Deaconess Medical Center, the authors
developed interventions to improve the scheduling of appointments and to reduce the access
time between telephone call and first offered appointment. Improvements to scheduling
included no redirection to voicemail, prompt telephone pickup, courteous service, complete
registration, and effective scheduling. Reduced access time meant being offered an
appointment with a physician in the appropriate specialty within three working days of the
telephone call. Scheduling and access were assessed using monthly "mystery shopper" calls.
Mystery shoppers collected data using standardized forms, rated the quality of service, and
transcribed their interactions with schedulers. Monthly results were tabulated and discussed
with clinical leaders; leaders and frontline staff then developed solutions to detected
problems. Eighteen months after the beginning of the intervention (in June 2007), which is
ongoing, schedulers had gone from using 60% of their registration skills to over 90%,
customer service scores had risen from 2.6 to 4.9 (on a 5-point scale), and average access
time had fallen from 12 days to 6 days. The program costs $50,000 per year and has been
associated with a 35% increase in ambulatory volume across three years. The authors
conclude that academic medical centers can markedly improve the scheduling process and
access to care and that these improvements may result in increased ambulatory care volume
5. Patrick J. A Markov decision model for determining optimal outpatient scheduling. Health
Care Management Science. 2012;15(2):91-102.
Abstract: Managing an efficient outpatient clinic can often be complicated by significant noshow rates and escalating appointment lead times. One method that has been proposed for
avoiding the wasted capacity due to no-shows is called open or advanced access. The
essence of open access is "do today's demand today". We develop a Markov Decision
Process (MDP) model that demonstrates that a short booking window does significantly
better than open access. We analyze a number of scenarios that explore the trade-off
between patient-related measures (lead times) and physician- or system-related measures
(revenue, overtime and idle time). Through simulation, we demonstrate that, over a wide
variety of potential scenarios and clinics, the MDP policy does as well or better than open
access in terms of minimizing costs (or maximizing profits) as well as providing more
consistent throughput
6. Spellman KS, Timm N, Farrell MK, Spooner SA. Impact of electronic health record
implementation on patient flow metrics in a pediatric emergency department. Journal of the
American Medical Informatics Association. 2012;19(3):443-7.
Abstract: Implementing electronic health records (EHR) in healthcare settings incurs
challenges, none more important than maintaining efficiency and safety during rollout. This
report quantifies the impact of offloading low-acuity visits to an alternative care site from the
emergency department (ED) during EHR implementation. In addition, the report evaluated
the effect of EHR implementation on overall patient length of stay (LOS), time to medical
provider, and provider productivity during implementation of the EHR. Overall LOS and time
to doctor increased during EHR implementation. On average, admitted patients' LOS was 620% longer. For discharged patients, LOS was 12-22% longer. Attempts to reduce patient
volumes by diverting patients to another clinic were not effective in minimizing delays in care
during this EHR implementation. Delays in ED throughput during EHR implementation are
real and significant despite additional providers in the ED, and in this setting resolved by 3
months post-implementation
7. Stubbs ND, Geraci SA, Stephenson PL, Jones DB, Sanders S. Methods to reduce outpatient
non-attendance. American Journal of the Medical Sciences. 2012;344(3):211-9.
Abstract: Non-attendance reduces clinic and provider productivity and efficiency,
compromises access and increases cost of health care. This systematic review of the English
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language literature (November 1999-November 2009) compares telephone, mail, text/short
message service, electronic mail and open-access scheduling to determine which is best at
reducing outpatient non-attendance and providing net financial benefit. Telephone, mail and
text/short message service interventions all improved attendance modestly but at varying
costs. Text messaging was the most cost-effective of the 3, but its applicability may be
limited. Few data are available regarding electronic mail reminders, whereas open-access
scheduling is an area of active research
8. Vilallonga R, Fort JM, Iordache N, Armengol M, Cleries X, Sola M. Use of images in a
surgery consultation. Will it improve the communication? Chirurgia (Bucuresti).
2012;107(2):213-7.
Abstract: INTRODUCTION: The interviews and interactions with patients are part of everyday
health care provider. However, there is sometimes a difficulty in communication, linked to
several factors. For this reason, the use of images to illustrate the medical conditions in the
outpatient clinic can improve patient communication. We report our initial experience with the
use of images to manage the quality of care to surigcal patients
9. Brosan L, Hoppitt L, Shelfer L, Sillence A, Mackintosh B. Cognitive bias modification for
attention and interpretation reduces trait and state anxiety in anxious patients referred to an
out-patient service: results from a pilot study. Journal of Behavior Therapy & Experimental
Psychiatry. 2011;42(3):258-64.
Abstract: It is well established that anxious individuals show biases in information processing,
such that they attend preferentially to threatening stimuli and interpret emotional ambiguity in
a threatening way. It has also been established that these biases in attention and
interpretation can causally influence anxiety. Recent advances in experimental work have
involved the development of a paradigm known as Cognitive Bias Modification (CBM), a
constellation of procedures which directly modify bias using computerised tasks. Excitingly,
these procedures have been shown to reduce bias in attention to threat (CBM-A), and to
promote a positive interpretive bias (CBM-I) in anxious populations; furthermore, these
modifications are associated with reductions in anxiety. We believe that these techniques
have the potential to create a real clinical impact for people with anxiety. Initial studies
involved volunteer participants who reached criteria for clinical diagnoses to be made, but
emerging evidence suggests that patients referred for therapy also benefit. For the purposes
of experimentation researchers have normally looked at one procedure at a time. In order to
try to maximise the potential clinical impact we wished to investigate whether the combination
of the procedures would be more effective than either alone. We also wished to investigate
whether the procedures could be carried out in routine clinical settings with patients referred
to an out-patient psychological treatment service. We therefore carried out a pilot study using
a combined approach of CBM-A and CBM-I with a sample of 13 anxious patients referred to
an out-patient psychology service for cognitive therapy. The results showed successful
reductions in threat related attentional and interpretive bias, as well as reductions in trait and
state anxiety. Participant reports describe the procedures as acceptable, with the attentional
task experienced as boring, but the interpretive one experienced as helpful. While
recognising the methodological problems of the pilot study we believe that these results give
indications that the techniques could provide an effective intervention for anxiety, and that
further study is well justified. Copyright Copyright 2011 Elsevier Ltd. All rights reserved
10. Brown S. Implementation of a computerized, automated referral system in improving
participation rates to outpatient cardiac rehabilitation. Journal of Cardiopulmonary
Rehabilitation and Prevention. 2011;(var.pagings):E2-August.
Abstract: Introduction: Despite American College of Cardiology and American Heart
Association performance measures which state that patients with a primary diagnosis during
hospitalization of chronic stable angina, MI, CABG, valve surgery, or cardiac transplantation
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are to be referred to an outpatient cardiac rehabilitation program, it has been well-established
that both referral and participation rates in Phase II Cardiac Rehabilitation after
hospitalization are low. To enhance participation to a broader population of patients, an
automated, computerized referral system was implemented in a large, multi-hospital system.
Purpose: To determine the efficacy of an automated, computerized referral system as
compared to a traditional, non-automated referral strategy. Design: Systematic review with
analysis of referral data pre and post intervention via a manual tracking method. Methods:
Referral and enrollment rates to Phase II Cardiac Rehabilitation were analyzed before and
after implementation of the computerized, automated referral system. Enrollment and
participation data was tracked manually over an eight month period through utilization of a
computerized database. Results: Prior to implementation of the automated, computerized
system, an average of 58 patients per month were referred to outpatient cardiac rehabilitation
after hospitalization following an MI, CABG, heart valve surgery or PTCA procedure via a
traditional referral strategy. Of these, only 12 patients per month enrolled in the outpatient
cardiac rehabilitation program (20.6% participation rate). After implementation of the
automated, computerized system, an average of 200 referrals per month were received
(increased referral rate by 243%). When sorted to exclude inappropriate patients (i.e.: those
out of town or with an inappropriate diagnosis), enrollment increased to average 20 patients
per month, which was a 67% increase. Conclusions: The implementation of a computerized,
automated referral system significantly improved physician referral and patient enrollment
rates. The results of this study support broad implementation of automated referral systems
in providing evidence-based care to a wider population of patients
11. Cao W, Wan Y, Tu H, Shang F, Liu D, Tan Z, et al. A web-based appointment system to
reduce waiting for outpatients: a retrospective study. BMC Health Services Research.
2011;11:318, 2011.:318.
Abstract: BACKGROUND: Long waiting times for registration to see a doctor is problematic in
China, especially in tertiary hospitals. To address this issue, a web-based appointment
system was developed for the Xijing hospital. The aim of this study was to investigate the
efficacy of the web-based appointment system in the registration service for outpatients
12. Corrigan MA, McHugh SM, Murphy RK, Dhillon P, Shah A, Hennessy I, et al. Improving
surgical outpatient efficiency through mobile phone text messaging. Surgical Innovation.
2011;18(4):354-7.
Abstract: INTRODUCTION: Currently, 175,000 people are on outpatient waiting lists in Irish
hospitals. Many clinic slots are taken by patients returning for routine review postoperatively
13. Ellanti P, Manecksha RP, Flynn R. The use of text messaging to reduce non-attendance at
outpatients clinic--a departmental experience. Irish Medical Journal. 2011;104(1):28-9.
14. Hasvold PE, Wootton R. Use of telephone and SMS reminders to improve attendance at
hospital appointments: a systematic review. Journal of Telemedicine & Telecare.
2011;17(7):358-64.
Abstract: Patients failing to attend hospital appointments contribute to inefficient use of
resources. We conducted a systematic review of studies providing a reminder to patients by
phone, short message service (SMS) or automated phone calls. A PubMed search was
conducted to identify articles published after 1999, describing studies of non-attendance at
hospital appointments. In addition, we searched the references in the included papers. In
total, 29 studies were included in the review. Four had two intervention arms which were
treated as independent studies, giving a total of 33 estimates. The papers were analysed by
two observers independently. A study quality score was developed and used to weight the
data. Weighted means of the absolute and the relative changes in non-attendance were
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calculated. All studies except one reported a benefit from sending reminders to patients prior
to their appointment. The synthesis suggests that the weighted mean relative change in nonattendance was 34% of the baseline non-attendance rate. Automated reminders were less
effective than manual phone calls (29% vs 39% of baseline value). There appeared to be no
difference in non-attendance rate, whether the reminder was sent the day before the
appointment or the week before. Cost and savings were not measured formally in any of the
papers, but almost half of them included cost estimates. The average cost of using either
SMS, automated phone calls or phone calls was [Euro sign]0.41 per reminder. Although
formal evidence of cost-effectiveness is lacking, the implication of the review is that all
hospitals should consider using automated reminders to reduce non-attendance at
appointments
15. Prentice JC, Fincke BG, Miller DR, Pizer SD. Outpatient wait time and diabetes care quality
improvement. American Journal of Managed Care. 2011;17(2):e43-e54.
Abstract: OBJECTIVE: To examine the relationship between glycated hemoglobin (A1C)
levels and the number of days spent waiting for primary care appointments
16. Webster F, Saposnik G, Kapral MK, Fang J, O'Callaghan C, Hachinski V. Organized
outpatient care: stroke prevention clinic referrals are associated with reduced mortality after
transient ischemic attack and ischemic stroke. Stroke. 2011;42(11):3176-82.
Abstract: BACKGROUND AND PURPOSE: Organized inpatient stroke care decreases
mortality and morbidity irrespective of patient age, stroke severity, or stroke subtype. Limited
information is available on whether organized outpatient care models such as stroke
prevention clinics (SPC) improve outcomes after a transient ischemic attack or ischemic
stroke. We compared 1-year mortality and stroke readmission in patients with transient
ischemic attack or ischemic stroke referred versus not referred to an SPC
17. Woods R. The effectiveness of reminder phone calls on reducing no-show rates in
ambulatory care. Nursing Economics. 2011;29(5):278-82.
Abstract: The objective of this study was to determine the effectiveness of daily reminder
phone calls on reducing no-show rates in the ambulatory care setting. With the initiation of
reminder telephone calls over a 6-month period, the no-show rate dropped by 50% from 8%
to 4%. The no-show rate with reminder letters over 3 months was reduced by 29% from 8.5%
to 6%. Reminding patients by telephone call 1 day prior to their appointment significantly
increased the number of patients who arrived. Reminder phone calls also allowed patients to
cancel their appointments if they weren't able to attend, rather than not showing up. Patients
were given the option of rescheduling their appointments while on the phone at that time or
calling back to reschedule. Most patients took the opportunity to reschedule at that time
18. Chen BL, Li ED, Yamawuchi K, Kato K, Naganawa S, Miao WJ. Impact of adjustment
measures on reducing outpatient waiting time in a community hospital: application of a
computer simulation. Chinese Medical Journal. 2010;123(5):574-80.
Abstract: BACKGROUND: As an important determinant of patient satisfaction, waiting time,
has gained increasing attention in the field of health care services. The present study aimed
to illustrate the distribution characteristics of waiting time in a community hospital and explore
the impact of potential measures to reduce outpatient waiting time based on a computer
simulation approach
19. Daggy J, Lawley M, Willis D, Thayer D, Suelzer C, DeLaurentis PC, et al. Using no-show
modeling to improve clinic performance. Health Informatics Journal. 2010;16(4):246-59.
Abstract: 'No-shows' or missed appointments result in under-utilized clinic capacity. We
develop a logistic regression model using electronic medical records to estimate patients' noshow probabilities and illustrate the use of the estimates in creating clinic schedules that
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maximize clinic capacity utilization while maintaining small patient waiting times and clinic
overtime costs. This study used information on scheduled outpatient appointments collected
over a three-year period at a Veterans Affairs medical center. The call-in process for 400
clinic days was simulated and for each day two schedules were created: the traditional
method that assigned one patient per appointment slot, and the proposed method that
scheduled patients according to their no-show probability to balance patient waiting, overtime
and revenue. Combining patient no-show models with advanced scheduling methods would
allow more patients to be seen a day while improving clinic efficiency. Clinics should consider
the benefits of implementing scheduling software that includes these methods relative to the
cost of no-shows
20. Deckard GJ, Borkowski N, Diaz D, Sanchez C, Boisette SA. Improving timeliness and
efficiency in the referral process for safety net providers: Application of the lean six sigma
methodology. Journal of Ambulatory Care Management. 2010;(2):124-30.
Abstract: Designated primary care clinics largely serve low-income and uninsured patients
who present a disproportionate number of chronic illnesses and face great difficulty in
obtaining the medical care they need, particularly the access to specialty physicians. With
limited capacity for providing specialty care, these primary care clinics generally refer patients
to safety net hospitals' specialty ambulatory care clinics. A large public safety net health
system successfully improved the effectiveness and efficiency of the specialty clinic referral
process through application of Lean Six Sigma, an advanced process-improvement
methodology and set of tools driven by statistics and engineering concepts. 2010 Wolters
Kluwer Health Lippincott Williams & Wilkins
21. Graham UM, Magee GM, Hunter SJ, Atkinson AB. Diabetic nephropathy and chronic kidney
disease at a busy diabetes clinic: a study of outpatient care and suggestions for improved
care pathways at a subspecialty specialist diabetic renal clinic. Ulster Medical Journal.
2010;79(2):57-61.
Abstract: Prior to establishing a specialist diabetic renal clinic in our unit, we studied across
12 months all 1845 patients attending one of our diabetes clinics with a serum creatinine
>150 mumol/l. Diabetic control was examined along with renal function and cardiovascular
risk using current audit standards. 74 such patients were identified (male:female 54:20 mean
HbA1c 7.8% (sd +/- 1.45) and age 64.2 years (+/- 12.8). 30 patients had creatinine >200
mumol/l and 15 >250 mumol/l. Using the chronic kidney disease classification, 33, 28 and 6
patients were in groups III, IV and V with 7 patients undergoing renal replacement therapy.
65% of patients met JBS2 audit standards of blood pressure using a mean of 2.93 agents (sd
+/- 1.43). Ace-inhibitors or angiotensin receptor blockers were used in 81% and 81% were on
regular antiplatelet or anticoagulant therapy. Audit standard for total cholesterol and LDL
were met in 89% and 97% of patients respectively. All patients identified in our study were in
CKD class III-V and therefore we considered also alternative inclusion criteria. 136 patients
had a urinary ACR >= 30 mg/mmol. Using this and/or the serum creatinine level above
identified 197 patients from the clinic. This study shows that measurement of serum
creatinine alone is not sufficiently sensitive but extended criteria identified a 10% subgroup
who will now be offered detailed assessments and intensified therapies at a subspecialty inhouse renal clinic. eGFR has recently been added to our computerised proforma and will
enable us to further refine inclusion criteria
22. Kosmider S, Shedda S, Jones IT, McLaughlin S, Gibbs P. Predictors of clinic nonattendance: opportunities to improve patient outcomes in colorectal cancer. Internal Medicine
Journal. 2010;40(11):757-63.
Abstract: AIM: Colorectal cancer is one of the few tumour types, where routine patient follow
up has been demonstrated to impact significantly on survival. Patients who fail to attend
regular clinic reviews may compromise their outcome, but the frequency at which this occurs
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is unknown. Identifying the extent of this problem, and the factors that predict nonattendance, may provide opportunities to improve patient outcomes
23. Lehnert BE, Bree RL. Analysis of Appropriateness of Outpatient CT and MRI Referred From
Primary Care Clinics at an Academic Medical Center: How Critical Is the Need for Improved
Decision Support? JACR Journal of the American College of Radiology. 2010;(3):192-7.
Abstract: Purpose: The aim of this study was to retrospectively analyze a large group of CT
and MRI examinations for appropriateness using evidence-based guidelines. Methods: The
authors reviewed medical records from 459 elective outpatient CT and MR examinations from
primary care physicians. Evidence-based appropriateness criteria from a radiology benefit
management company were used to determine if the examination would have met criteria for
approval. Submitted clinical history at the time of interpretation and clinic notes and
laboratory results preceding the date of the imaging study were examined to simulate a realtime consultation with the referring provider. The radiology reports and subsequent clinic
visits were analyzed for outcomes. Results: Of the 459 examinations reviewed, 284 (62%)
were CT and 175 (38%) were MRI. Three hundred forty-one (74%) were considered
appropriate, and 118 (26%) were not considered appropriate. Examples of inappropriate
examinations included brain CT for chronic headache, lumbar spine MR for acute back pain,
knee or shoulder MRI in patients with osteoarthritis, and CT for hematuria during a urinary
tract infection. Fifty-eight percent of the appropriate studies had positive results and affected
subsequent management, whereas only 24% of inappropriate studies had positive results
and affected management. Conclusion: A high percentage of examinations not meeting
appropriateness criteria and subsequently yielding negative results suggests a need for tools
to help primary care physicians improve the quality of their imaging decision requests. In the
current environment, which stresses cost containment and comparative effectiveness,
traditional radiology benefit management tools are being challenged by clinical decision
support, with an emphasis on provider education coupled with electronic order entry systems.
2010 American College of Radiology
24. Lehnert BE, Bree RL. Analysis of appropriateness of outpatient CT and MRI referred from
primary care clinics at an academic medical center: how critical is the need for improved
decision support?.[Erratum appears in J Am Coll Radiol. 2010 Jun;7(6):466]. Journal of the
American College of Radiology. 2010;7(3):192-7.
Abstract: PURPOSE: The aim of this study was to retrospectively analyze a large group of
CT and MRI examinations for appropriateness using evidence-based guidelines
25. McGauran A. Service design. Break the back of outpatient waits. Health Service Journal.
2010;120(6218):18-9.
26. Parikh A, Gupta K, Wilson AC, Fields K, Cosgrove NM, Kostis JB. The effectiveness of
outpatient appointment reminder systems in reducing no-show rates. American Journal of
Medicine. 2010;123(6):542-8.
Abstract: BACKGROUND: Patients who do not keep physician appointments (no-shows)
represent a significant loss to healthcare providers. For patients, the cost includes their
dissatisfaction and reduced quality of care. An automated telephone appointment reminder
system may decrease the no-show rate. Understanding characteristics of patients who miss
their appointments will aid in the formulation of interventions to reduce no-show rates
27. Price RS, Balcer LJ, Galetta SL. Education research: a new system for reducing patient
nonattendance in residents' clinic. Neurology. 2010;74(10):e34-e36.
Abstract: BACKGROUND: Patient nonattendance in neurology and other subspecialty clinics
is closely linked to longer waiting times for appointments. We developed a new scheduling
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system for residents' clinic that reduced average waiting times from >4 months to < or =3
weeks. The purpose of this study was to compare nonattendance for clinics scheduled using
the new model (termed "rapid access") vs those scheduled using the traditional system
28. Song WT, Chih M, Bair AE. Improving the efficiency of physical examination services. Journal
of Medical Systems. 2010;34(4):579-90.
Abstract: The objective of our project was to improve the efficiency of the physical
examination screening service of a large hospital system. We began with a detailed
simulation model to explore the relationships between four performance measures and three
decision factors. We then attempted to identify the optimal physician inquiry starting time by
solving a goal-programming problem, where the objective function includes multiple goals.
One of our simulation results shows that the proposed optimal physician inquiry starting time
decreased patient wait times by 50% without increasing overall physician utilization
29. Verdouw-van Tol HC, Peltenburg HG, Koster T. Improved cardiovascular risk profile in
patients referred to a specialised vascular outpatient clinic: a cohort study. European Journal
of Cardiovascular Nursing. 2010;9(2):101-7.
Abstract: We carried out a prospective cohort study in patients referred to our vascular
outpatient clinic to see how their cardiovascular risk profile developed. The classical risk
factors were compared at first visit and one year later. The adapted Framingham Heart Risk
Score (FHRS) and the Heart SCORE (HS) were used to compare the cardiovascular risks.
There was a decline of 9 and 5 mmHg in mean systolic blood pressure in the hypertension
group and in the group with atherosclerotic disease, respectively. On average 0.6 and 0.8
antihypertensive agents were added. In the hypertension group mean LDL-level decreased
from 3.2 to 2.4 mmol/l. For the secondary prevention group mean LDL-cholesterol decreased
from 3.3 to 2.1 mmol/l. In the hypertension group, the 10-year relative risk of myocardial
infarction (FHRS) decreased by 28% (95% CI 25-30). The 10-year relative risk on a fatal
cardiovascular event (HS) decreased by 33% (95% CI 31-36). The absolute risk decreased
by 3.3% (95% CI 2.0-4.6) and 1.4% (95% CI 0.5-2.3) by using the HS. We conclude that the
cardiovascular risk profile of our patients significantly improved as shown by the FHRS or the
HS. These benefits were reached by a decreasing number of smokers, better blood pressure
control and a lower LDL-cholesterol. Copyright (c) 2009 European Society of Cardiology.
Published by Elsevier B.V. All rights reserved
30. Waldhausen JH, Avansino JR, Libby A, Sawin RS. Application of lean methods improves
surgical clinic experience. Journal of Pediatric Surgery. 2010;45(7):1420-5.
Abstract: BACKGROUND: A quality visit in high volume surgery clinics is challenging. There
is variability in numbers of patients seen and care provider behavior. Documentation,
regulatory and compliance issues and computerization of patient care systems may decrease
clinic efficiency and throughput. We tried to reduce variability and improve patient experience
31. Bungard TJ, Smigorowsky MJ, Lalonde LD, Hogan T, Doliszny KM, Gebreyesus G, et al.
Cardiac EASE (Ensuring Access and Speedy Evaluation) - the impact of a single-point-ofentry multidisciplinary outpatient cardiology consultation program on wait times in Canada.
Canadian Journal of Cardiology. 2009;25(12):697-702.
Abstract: BACKGROUND: Universal access to health care is valued in Canada but
increasing wait times for services (eg, cardiology consultation) raise safety questions.
Observations suggest that deficiencies in the process of care contribute to wait times.
Consequently, an outpatient clinic was designed for Ensuring Access and Speedy Evaluation
(Cardiac EASE) in a university group practice, providing cardiac consultative services for
northern Alberta. Cardiac EASE has two components: a single-point-ofentry intake service
(prospective testing using physician-approved algorithms and previsit triage) and a
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multidisciplinary clinic (staffed by cardiologists, nurse practitioners and doctoral-trained
pharmacists)
32. Castelnuovo B, Babigumira J, Lamorde M, Muwanga A, Kambugu A, Colebunders R.
Improvement of the patient flow in a large urban clinic with high HIV seroprevalence in
Kampala, Uganda. International Journal of STD & AIDS. 2009;20(2):123-4.
Abstract: Antiretroviral treatment roll-out programmes in Africa often have difficulties to cope
with the increasing number of clients. Based on the findings of a survey carried out in 2005
that showed long waiting times, innovative organizational changes (nurse visits and
pharmacy-only refill visits) were introduced in our clinic. In August 2007, the survey was
repeated to evaluate the impact of these changes. During both surveys we used the same
standardized questionnaire. In 2007, 400 patients visited the clinic on the study day
compared to 250 in 2005. The median time spent at the clinic decreased from 157 minutes in
2005 (range 22-426) to 124 minutes (15-314). All the waiting times for different services
decreased except the time between the visit to the triage nurse and the doctors' visit. A
similar methodology could be used by other health services to evaluate and compare
different models of care
33. Charlett SD, Bajaj Y, Kelly G. Informing patients of test results by letter: a measure to
improve access to outpatient services. Clinical Otolaryngology. 2009;34(2):173-4.
34. Doucette KE, Robson V, Shafran S, Kunimoto D. Improving access to care by allowing selfreferral to a hepatitis C clinic. Canadian Journal of Gastroenterology. 2009;23(6):421-4.
Abstract: BACKGROUND: Estimates suggest that more than 250,000 Canadians are infected
with hepatitis C virus (HCV), but less than 10% have been treated. Access to specialists in
Canada is usually via health care professional (HCP) referral and, therefore, may be a barrier
to HCV care. However, clinics that operate in conjunction with the Hepatitis Support Program,
Edmonton, Alberta, allow self-referral. It is hypothesized that this improves access to care
without increasing inappropriate referrals
35. Eminovic N, de Keizer NF, Wyatt JC, ter RG, Peek N, van Weert HC, et al. Teledermatologic
consultation and reduction in referrals to dermatologists: a cluster randomized controlled trial.
Archives of Dermatology. 2009;145(5):558-64.
Abstract: OBJECTIVE: To determine whether teledermatologic consultations can reduce
referrals to a dermatologist by general practitioners (GPs)
36. Finamore SR, Turris SA. Shortening the Wait: A Strategy to Reduce Waiting Times in the
Emergency Department. Journal of Emergency Nursing. 2009;(6):509-14.
Abstract: Abstract: Emergency Department crowding (EDC), extended wait times, and the
issues arising as a result are well described in the health-care literature. Accordingly,
reducing waiting times has become a focus across Canada. Less-urgent patient
presentations represent a large proportion of the individuals presenting for care in Canadian
emergency departments (ED). This patient population contributes to congestion in the ED. In
light of these issues, an innovative program is being trialed at Burnaby Hospital, in the lower
mainland of British Columbia. The goals of the program include: a reduction of EDC, a
shortening of the duration of time between patient presentation and treatment, and an
increase reported levels of patient satisfaction. 2009 Emergency Nurses Association
37. Helbig M, Helbig S, Kahla-Witzsch HA, May A. Quality management: reduction of waiting
time and efficiency enhancement in an ENT-university outpatients' department. BMC Health
Services Research. 2009;9:21, 2009.:21.
Abstract: BACKGROUND: Public health systems are confronted with constantly rising costs.
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Furthermore, diagnostic as well as treatment services become more and more specialized.
These are the reasons for an interdisciplinary project on the one hand aiming at simplification
of planning and scheduling patient appointments, on the other hand at fulfilling all
requirements of efficiency and treatment quality
38. Kim YK, Song KE, Lee WK. Reducing patient waiting time for the outpatient phlebotomy
service using six sigma. [Korean, English]. Korean Journal of Laboratory Medicine.
2009;(2):171-7.
Abstract: Background: One of the challenging issues of the outpatient phlebotomy services at
most hospitals is that patients have a long wait. The outpatient phlebotomy team of
Kyungpook National University Hospital applied six sigma breakthrough methodologies to
reduce the patient waiting time. Methods: The DMAIC (Define, Measure, Analyze, Improve,
and Control) model was employed to approach the project. Two hundred patients visiting the
outpatient phlebotomy section were asked to answer the questionnaires at inception of the
study to ascertain root causes. After correction, we surveyed 285 patients for same
questionnaires again to follow-up the effects. Results: A defect was defined as extending
patient waiting time so long and at the beginning of the project, the performance level was
2.61 sigma. Using fishbone diagram, all the possible reasons for extending patient waiting
time were captured, and among them, 16 causes were proven to be statistically significant.
Improvement plans including a new receptionist, automatic specimen transport system, and
adding one phlebotomist were put into practice. As a result, the number of patients waited
more than 5 min significantly decreased, and the performance level reached 3.0 sigma in
December 2007 and finally 3.35 sigma in July 2008. Conclusions: Applying the six sigma, the
performance level of waiting times for blood drawing exceeding five minutes were improved
from 2.61 sigma to 3.35 sigma
39. Parmar V, Large A, Madden C, Das V. The online outpatient booking system 'Choose and
Book' improves attendance rates at an audiology clinic: a comparative audit. Informatics in
Primary Care. 2009;17(3):183-6.
Abstract: BACKGROUND: The 'Choose and Book' system provides an online booking service
which primary care professionals can book in real time or soon after a patient's consultation.
It aims to offer patients choice and improve outpatient clinic attendance rates
40. Santibanez P, Chow VS, French J, Puterman ML, Tyldesley S. Reducing patient wait times
and improving resource utilization at British Columbia Cancer Agency's ambulatory care unit
through simulation. Health Care Management Science. 2009;12(4):392-407.
Abstract: We consider an ambulatory care unit (ACU) in a large cancer centre, where
operational and resource utilization challenges led to overcrowding, excessive delays, and
concerns regarding safety of critical patient care duties. We use simulation to analyze the
simultaneous impact of operations, scheduling, and resource allocation on patient wait time,
clinic overtime, and resource utilization. The impact of these factors has been studied before,
but usually in isolation. Further, our model considers multiple clinics operating concurrently,
and includes the extra burden of training residents and medical students during patient
consults. Through scenario analyses we found that the best outcomes were obtained when
not one but multiple changes were implemented simultaneously. We developed
configurations that achieve a reduction of up to 70% in patient wait times and 25% in physical
space requirements, with the same appointment volume. The key findings of the study are
the importance of on time clinic start, the need for improved patient scheduling; and the
potential improvements from allocating examination rooms flexibly and dynamically among
individual clinics within each of the oncology programs. These findings are currently being
evaluated for implementation by senior management
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41. Weiner M, El HG, Wang L, Dexter PR, Zerr AD, Perkins AJ, et al. A web-based generalistspecialist system to improve scheduling of outpatient specialty consultations in an academic
center. Journal of General Internal Medicine. 2009;24(6):710-5.
Abstract: BACKGROUND: Failed referrals for specialty care are common and often represent
medical errors. Technological structures and processes account for many failures.
Scheduling appointments for subspecialty evaluation is a first step in outpatient referral and
consultation
42. Akbari A, Mayhew A, Al-Alawi MA, Grimshaw J, Winkens R, Glidewell E, et al. Interventions
to improve outpatient referrals from primary care to secondary care. Cochrane Database of
Systematic Reviews. 2008;(4):CD005471.
Abstract: BACKGROUND: The primary care specialist interface is a key organisational
feature of many health care systems. Patients are referred to specialist care when
investigation or therapeutic options are exhausted in primary care and more specialised care
is needed. Referral has considerable implications for patients, the health care system and
health care costs. There is considerable evidence that the referral processes can be
improved
43. Augestad KM, Revhaug A, Vonen B, Johnsen R, Lindsetmo RO. The one-stop trial: does
electronic referral and booking by the general practitioner (GPs) to outpatient day case
surgery reduce waiting time and costs? A randomized controlled trial protocol. BMC Surgery.
2008;8:14, 2008.:14.
Abstract: BACKGROUND: Waiting time and costs from referral to day case outpatient
surgery are at an unacceptably high level. The waiting time in Norway averages 240 days for
common surgical conditions. Furthermore, in North Norway the population is scattered
throughout a large geographic area, making the cost of travel to a specialist examination
before surgery considerable. Electronic standardised referrals and booking of day case
outpatient surgery by GPs are possible through the National Health Network, which links all
health care providers in an electronic network. New ways of using this network might reduce
the waiting time and cost of outpatient day case surgery
44. Edward GM, Razzaq S, de RA, Boer F, Hollmann MW, Dzoljic M, et al. Patient flow in the
preoperative assessment clinic. European Journal of Anaesthesiology. 2008;25(4):280-6.
Abstract: BACKGROUND AND OBJECTIVE: Previous research has shown that a
preoperative assessment clinic enhances hospital cost-efficiency. However, the differences in
organization of the patient flow have not been analysed. In this descriptive study, we
evaluated the consequences of the organization of the patient flow of a preoperative
assessment clinic on its performance, by analysing two Dutch university hospitals, which are
organized essentially differently
45. Geraghty M, Glynn F, Amin M, Kinsella J. Patient mobile telephone 'text' reminder: a novel
way to reduce non-attendance at the ENT out-patient clinic. Journal of Laryngology &
Otology. 2008;122(3):296-8.
Abstract: BACKGROUND: Non-attendance at out-patient clinics is a seemingly intractable
problem, estimated to cost 65 pounds sterling (97 euros) per incident. This results in underutilisation of resources and prolonged waiting lists. In an effort to reduce out-patient clinic
non-attendance, our ENT department, in conjunction with the information and communication
technology department, instigated the use of a mobile telephone short message service
('text') reminder, to be sent out to each patient three days prior to their out-patient clinic
appointment
46. Gruber M, Smith D, O'Neal C, Hennessy K, Therrien M. Quality improvement project to
determine outpatient chemotherapy capacity and improve utilization. Journal of Nursing Care
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Quality. 2008;23(1):75-83.
Abstract: Nurses in chemotherapy administration settings are constantly challenged to
increase utilization while maintaining patient safety. A performance improvement project was
carried out to identify barriers to patient throughput and opportunities to improve utilization
while not compromising patient safety. We found ways to safely increase the number of
patients from 92 to 108 per day; however, patient tardiness and staff vacancies had a
negative impact on patient wait times and nursing staff overtime
47. Anderson BE, Marks JG, Jr., Downs E, Buckel T, Adams DR, Enterline J, et al. The Hershey
access clinic: a model for improving patient access. Journal of the American Academy of
Dermatology. 2007;57(4):601-3.
Abstract: BACKGROUND: When waiting times for new and return patient visits at Hershey
Medical Center's Department of Dermatology approached 4 and 2 months, respectively, the
Hershey access clinic was implemented to increase access for patients with acute problems
48. Elkhuizen SG, Das SF, Bakker PJ, Hontelez JA. Using computer simulation to reduce access
time for outpatient departments. Quality & Safety in Health Care. 2007;16(5):382-6.
Abstract: AIM: To develop general applicable models for analysing the capacity needed in
appointment-based hospital facilities
49. Kirsh S, Watts S, Pascuzzi K, O'Day ME, Davidson D, Strauss G, et al. Shared medical
appointments based on the chronic care model: a quality improvement project to address the
challenges of patients with diabetes with high cardiovascular risk. Quality & Safety in Health
Care. 2007;16(5):349-53.
Abstract: OBJECTIVE: The epidemic proportions and management complexity of diabetes
have prompted efforts to improve clinic throughput and efficiency. One method of system
redesign based on the chronic care model is the Shared Medical Appointment (SMA) in
which groups of patients (8-20) are seen by a multi-disciplinary team in a 1-2 h appointment.
Evaluation of the impact of SMAs on quality of care has been limited. The purpose of this
quality improvement project was to improve intermediate outcome measures for diabetes
(A1c, SBP, LDL-cholesterol) focusing on those patients at highest cardiovascular risk
50. Phillips SA, Ross PD, Chalmers K, MacDougall G. Can we improve dysphagia referrals?
Journal of Laryngology & Otology. 2007;121(6):584-7.
Abstract: We set out to examine whether a multidisciplinary out-patient dysphagia referral
triage service would shorten the duration of a patient's referral process and direct patients to
the correct specialty. A review was carried out of patients referred with dysphagia before and
after the introduction of a multidisciplinary out-patient dysphagia service, from February 2001
to April 2001 and from January 2002 to March 2002, inclusive. One hundred and eight
patients were referred in total. The length of time until the first appointment was reduced from
four to three weeks (median; range one to 23; p<0.001). The number of instrumental
investigations was reduced, with a median of one instrumentation per patient under the new
service, compared with two in those under the standard service (p<0.001). Attendance to
hospital was also reduced, with 45 per cent of patients under the new service requiring only
one appointment, compared with 13 per cent in those under the standard service (p<0.001).
The multidisciplinary out-patient dysphagia service was associated with significant reductions
in waiting times, in the number of instrumental investigations and in the duration of the
patient's referral process
51. Rodriguez PR, Negro Alvarez JM, Campuzano Lopez FJ, Pellicer OF, Murcia AT, Serrano
SE, et al. Non-compliance with appointments amongst patients attending an Allergology
Clinic, after implementation of an improvement plan. Allergologia et Immunopathologia.
2007;35(4):136-44.
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Abstract: BACKGROUND: Non-compliance is a common cause of failed medical action,
contributing to absence of regular check-ups. Our group has already published studies that
analyse the level of non-compliance with appointments amongst patients attending our
Allergology clinic, and we have made proposals for improvement
52. Bromage SJ, Napier Hemy RD, Payne SR, Pearce I. Outpatient follow up appointments: Are
we using the resources effectively? Postgraduate Medical Journal. 2006;82(969):-467.
Abstract: British Association of Urological Surgeons (BAUS) guidelines and government
initiatives have put pressure on the effective use of outpatient resources. Follow up
appointments need to be carefully managed to ensure efficient use of available resources.
The aim of this study was to audit outpatient follow up service with particular attention to the
appropriateness of the appointments made. All patients attending a general urology clinic
were assessed by a form completed for each individual appointment. The source of the
appointment and the time interval was recorded and each follow up appointment was judged
to be either appropriate or inappropriate by the person giving the consultation. For those
deemed to be inappropriate, justification was sought and the notes independently reviewed
by a different clinician to verify this categorisation. Of 164 appointments made, 143 patients
attended for follow up. A total of 131 appointments were considered to be appropriate (92%)
with only 12 deemed by the consulting clinician to be inappropriate (eight percent). The
commonest cause for an inappropriate appointment was failure to appreciate that follow up
had already been arranged for a different date. There was no correlation between the source
of the referral and an inappropriate referral. This audit suggests an effective use of the
outpatient follow up resource with respect to the appropriateness and timing of follow up
consultations. Other areas of resource management such as default rates should be
investigated in an attempt to improve the efficiency of a service. Cites five references.
[Journal abstract]
53. Burgess P, Bindman J, Leese M, Henderson C, Szmukler G. Do community treatment orders
for mental illness reduce readmission to hospital? An epidemiological study. Social
Psychiatry & Psychiatric Epidemiology. 2006;41(7):574-9.
Abstract: BACKGROUND: It has been suggested that community treatment orders (CTOs)
will prevent readmission to hospital, but controlled studies have been inconclusive. We aimed
to test the hypothesis that hospital discharges made subject to CTOs are associated with a
reduced risk of readmission. The use of such a measure is likely to change after its
introduction as clinicians acquire familiarity with it, and we also tested the hypothesis that the
characteristics of patients subject to CTOs changed over time in the first decade of their use
in Victoria, Australia
54. Crowder BF. Improved symptom management through enrollment in an outpatient congestive
heart failure clinic. MEDSURG Nursing. 2006;15(1):27-35.
55. Downer SR, Meara JG, Da Costa AC, Sethuraman K. SMS text messaging improves
outpatient attendance. Australian Health Review. 2006;30(3):389-96.
Abstract: OBJECTIVE: To evaluate the operational and financial efficacy of sending short
message service (SMS) text message reminders to the mobile telephones of patients with
scheduled outpatient clinic appointments
56. Hussey J, Gormley J, Bell C, Roche EF, Hoey H. Exercise tolerance and physical activity
levels in children referred to a weight reduction clinic. Irish Medical Journal. 2006;(2):46-7.
Abstract: The aim of this study was to investigate exercise tolerance and physical activity
levels in children with exogenous obesity. Measures included BMI, waist circumference,
exercise tolerance and self reported physical activity. Exercise tolerance was measured by
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the Modified Balke Treadmill Protocol and results were compared to normal values. Physical
activity levels were assessed by measuring energy expended in regular activities each week
over the past year and number of hours spent watching TV/video using an adaptation of the
'Modifiable Activity Questionnaire for Adolescents'. Details on transport to school were also
obtained. Forty five children between September 2002 and June 2004 were assessed. This
group comprised of 25 girls and 20 boys with mean ages (standard deviation) of 11.9 +/- 3.0
years and 13.7 +/- 2.5 years respectively. Exercise tolerance as a percentage of normal was
below minimal levels in 64% girls and 75% boys. Energy expended in regular activity was
less than the minimal recommendation in 80% girls and 65% boys. Seventy six percent of
girls and 70% of boys spent 2 hours or more per day watching television and 40% of girls and
70% of boys walked to school. The low levels of activity and exercise tolerance need to be
addressed in the managemeni of children with obesity
57. Kripke C. Improving outpatient referrals to secondary care. American Family Physician.
2006;73(5):803-4.
58. Kripke C. Improving outpatient referrals to secondary care: Cochrane briefs. American Family
Physician. 2006;(5):804-5.
59. Rao GN, Basnyat P, Taffinder N, Hudson C, Insall R. Reducing surgical outpatient waiting is
not the solution to meeting the 2005 colorectal cancer target. Colorectal Disease.
2006;8(2):135-9.
Abstract: OBJECTIVES: The majority of colorectal cancers (CRC) are not diagnosed through
the Rapid access route (RAR) and follow-ups (FU) may prolong outpatient-waiting time for
new referrals. The aim of this study was to assess the relative contributions of an efficient
colorectal clinic and a stringent colonoscopy booking system on the total journey time for
CRC
60. Coombes R. Remains of the day. Health Service Journal. 2005;115(5971):-24.
Abstract: The Healthcare Commission has found many trusts ti be worryingly inefficient in day
surgery, with 45 per cent of allocated theatre time going to waste. What's going wrong? The
author reports. [Journal abstract]
61. Downer SR, Meara JG, Da Costa AC. Use of SMS text messaging to improve outpatient
attendance. Medical Journal of Australia. 2005;183(7):366-8.
Abstract: OBJECTIVE: To evaluate the effect of appointment reminders sent as short
message service (SMS) text messages to patients' mobile telephones on attendance at
outpatient clinics
62. Ferschl MB, Tung A, Sweitzer B, Huo D, Glick DB. Preoperative clinic visits reduce operating
room cancellations and delays. Anesthesiology. 2005;103(4):855-9.
Abstract: BACKGROUND: Anesthesiologist-directed preoperative medicine clinics are used
to prepare patients for the administration of anesthesia and surgery. Studies have shown that
such a clinic reduces preoperative testing and consults, but few studies have examined the
impact of the clinic on the day of surgery. The authors tested whether a visit to an anesthesia
preoperative medicine clinic (APMC) would reduce day-of-surgery case cancellations and/or
case delays
63. Grimshaw JM, Winkens RA, Shirran L, Cunningham C, Mayhew A, Thomas R, et al.
Interventions to improve outpatient referrals from primary care to secondary care. Cochrane
Database of Systematic Reviews. 2005;(3):CD005471.
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Abstract: BACKGROUND: The primary care specialist interface is a key organisational
feature of many health care systems. Patients are referred to specialist care when
investigation or therapeutic options are exhausted in primary care and more specialised care
is needed. Referral has considerable implications for patients, the health care system and
health care costs. There is considerable evidence that the referral processes can be
improved
64. National Primary Care Research and Development Centre: Univeristy of Manchester.
Outpatient services and primary care : a scoping review of research into strategies for
improving outpatient effectiveness and efficiency [online]. 2005 Available from:
http://www.medicine.manchester.ac.uk/primarycare/npcrdcarchive/Publications/Studyinghealthcare_Roland_finalreport.pdf.
Abstract: This report was commissioned by the NHS Service Delivery and Organisation R&D
programme.
65. Vasilakis C, Kuramoto L. Comparing two methods of scheduling outpatient clinic
appointments using simulation experiments. Clinical & Investigative Medicine - Medecine
Clinique et Experimentale. 2005;28(6):368-70.
66. Fox AT, Palmer RD, Crossley JG, Sekaran D, Trewavas ES, Davies HA. Improving the
quality of outpatient clinic letters using the Sheffield Assessment Instrument for Letters
(SAIL). Medical Education. 2004;38(8):852-8.
Abstract: AIM: To improve the quality of outpatient letters used as communication between
hospital and primary care doctors
67. Parsons MB, Rollyson JH, Reid DH. Improving day-treatment services for adults with severe
disabilities: a norm-referenced application of outcome management. Journal of Applied
Behavior Analysis. 2004;37(3):365-77.
Abstract: We evaluated an outcome management program for working with staff to improve
the performance of adults with severe disabilities in a congregate day-treatment setting.
Initially, observations were conducted of student task involvement and staff distribution of
teaching interactions across students in four program sites. Using recent normative data to
establish objective goals for student performance, management intervention was warranted
in two of the sites. A six-step outcome management program was then implemented in the
two sites. The program involved defining desired student and staff outcomes, systematic
monitoring of the outcomes, staff training, and supportive and corrective feedback. The
outcome management program was accompanied by increases in student on-task behavior
and staff distribution of teaching interactions in both sites. The increases brought the levels of
on-task behavior above the normative average; on-task behavior was maintained above the
baseline average for over 1 year in both sites. These results are discussed in terms of the
benefits of relying on normative data for objectively evaluating and improving service delivery
systems. Discussion of future research needs focuses on applying the outcome management
program to other settings and services for people with disabilities
68. Sulaiman S, Wei CK, Gaudoin M. One-stop postmenopausal bleeding clinics reduce patient
waiting times and theatre costs. Scottish Medical Journal. 2004;(4):152-4.
Abstract: Background. Postmenopausal bleeding (PMB) is a common problem and reason for
referral to gynaecology clinics. Aims. The aim of this study was to compare patient
management and outcomes from a newly developed one-stop clinic for women with PMB
with traditional gynaecology outpatient clinics. Methods. Retrospective studying running from
January to July 2003 comparing the one-stop clinic with four traditional consultant-led
outpatient gynaecology clinics also seeing women with PMB running concurrently in the
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same hospital. Results. In the study period, 95 and 51 women were seen in each type of
clinic. There was no difference in patient demographics but the time from referral to first
consultation was shorter in the PMB clinic (p<0.001) and women bad fewer visits (p<0.001).
The mean time from first consultation to definitive treatment or discharge was also shorter
(p<0.001). Fewer hysteroscopies were generated from the PMB clinic (p<0.0001) and yet
there was no difference in the rates of abnormal histology between the two groups.
Conclusions. This study demonstrated that one-stop investigation of PMB, compared to
traditional outpatient clinics, reduced waiting times and theatre costs by reducing the number
of hysteroscopies. 2004 Scottish Medical Journal
69. Gormley GJ, Steele WK, Gilliland A, Leggett P, Wright GD, Bell AL, et al. Can diagnostic
triage by general practitioners or rheumatology nurses improve the positive predictive value
of referrals to early arthritis clinics? Rheumatology. 2003;42(6):763-8.
Abstract: OBJECTIVES: To determine whether diagnostic triage by general practitioners
(GPs) or rheumatology nurses (RNs) can improve the positive predictive value of referrals to
early arthritis clinics (EACs)
70. Lloyd J, Dillon D, Hariharan K. Outpatient clinics. Down the line. Health Service Journal.
2003;113(5837):22-3.
Abstract: A hospital with a 157-week wait for orthopaedic outpatient appointments has
introduced a telephone booking system which has reduced waiting by 53 weeks. The system,
introduced with a 23,000 Pounds grant from the local health group, has cut non-attendance
from 17 to 5 per cent and is estimated to have saved the orthopaedics department 216,000
Pounds. Two part-time clerical workers staff the initiative. Telephone booking is now being
rolled out to include outpatient clinics of other specialties and orthopaedic day case lists
71. Murray M. Waiting for healthcare. Physician offices can dramatically reduce how long
patients wait for appointments. Postgraduate medicine. 2003;113(2):13-4, 17.
72. Rave N, Geyer M, Reeder B, Ernst J, Goldberg L, Barnard C. Radical systems change.
Innovative strategies to improve patient satisfaction. Journal of Ambulatory Care
Management. 2003;26(2):159-74.
Abstract: A project was initiated at Northwestern Memorial Hospital in Chicago focusing on
patient satisfaction in the outpatient setting and how to improve it. Eight outpatient diagnostic
areas were selected and a steering committee was formed. The team used patient
satisfaction scores and patient and staff interviews to identify areas for improvement.
Innovations were implemented in communications and information technology, staff role
design, and process flow. Successes were realized in patient satisfaction above the 95th
percentile, improved staff satisfaction, productivity, and internal and external recognition. The
program serves as an organizationwide model supporting the hospital's Best Patient
Experience strategic goal. This patient-focused model is being replicated in other areas of the
hospital and can be replicated elsewhere
73. Reti S. Improving outpatient department efficiency: a randomized controlled trial comparing
hospital and general-practice telephone reminders. New Zealand Medical Journal.
2003;116(1175):U458.
Abstract: AIMS: This study aimed to ascertain whether or not telephone reminders reduce
non-attendance at hospital outpatient clinics and whether telephone reminders from general
practitioners are more effective than those made from hospitals
74. Saunders NC, Georgalas C, Blaney SP, Dixon H, Topham JH. Does receiving a copy of
correspondence improve patients' satisfaction with their out-patient consultation? Journal of
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Laryngology & Otology. 2003;117(2):126-9.
Abstract: It is standard practice to write to a patient's general practitioner (GP) following an
out-patients consultation. This study set out to assess whether sending a copy of this letter to
the patient improves their satisfaction with the consultation. Two hundred patients were
randomly assigned to receive or not to receive a copy of their GP letter. Their satisfaction
was then assessed by means of a postal questionnaire. The two groups were compared to
ensure that their was no significant difference between them with regard to any other aspect
of their consultation. Those who did not receive a copy letter had a median overall
satisfaction score of 7.75 whilst those who did had a median score of 9.0 (p = 0.014). The
only other factors predictive of overall satisfaction were receiving an explanation of the
problem and spending sufficient time with the doctor. Sending patients a copy of
correspondence to their GP is one means of aiding communication and improving overall
satisfaction
75. Curry C, Cossich T, Matthews JP, Beresford J, McLachlan SA. Uptake of psychosocial
referrals in an outpatient cancer setting: improving service accessibility via the referral
process. Supportive Care in Cancer. 2002;10(7):549-55.
Abstract: The object of this study was to identify factors which influence the uptake of
psychosocial services in an ambulatory cancer setting and to identify potential barriers to the
access of support services in the referral process. To this end, 202 individuals attending
outpatient clinics of a cancer hospital were randomised to the intervention arm of a study to
assess the impact of providing co-ordinated, targeted psychosocial referrals and
interventions. Qualitative and quantitative analysis of the reasons for failure to offer services
and for nonacceptance of services was undertaken. Individuals accepted 22% of offered
services, refused 38% of offered services, indicated that services were in place in 31% of
cases, and were not offered 9% of identified services. The major response from patients
refusing services was "not now". Female patients ( P < 0.01), and individuals with a moderate
to high level of depression ( P = 0.02), were more likely to accept services. A variety of
factors impact on decisions on utilisation of support services. Recommendations on how
individuals' access to these services might be improved are offered, based on an analysis of
the reasons given by patients for refusal
76. Appleby A, Lawrence C. From blacklist to beacon, a case study in reducing dermatology outpatient waiting times. Clinical & Experimental Dermatology. 2001;26(6):548-55.
Abstract: At its worst our dermatology department had a waiting list for routine appointments
of 57 weeks. As a result we started to lose contract income and consequently were unable to
replace a retiring consultant. The service faced fragmentation and loss of the inpatient ward.
Using a series of internally planned and driven initiatives it was possible to retrieve the
situation. Our efforts were recognized by a national waiting list Beacon award in 1999. This
study describes the methods used to increase new patient throughput, reduce demand and
hence reduce waiting time for new patient appointments. Change was achieved only when
medical, nursing staff, general practitioners, managers and health authorities were involved in
the process. The changes needed to be led by a consultant enthusiast and managed
effectively. There remains a constantly increasing demand for the service and reducing the
waiting list simply invites a further increase in referral. In a resource-limited health care
system the provider must be able to limit demand by using agreed referral exclusion criteria
in order to balance supply and demand
77. Gruber M, Kane K, Flack L, Weymier RE, Armstrong S. A 'perfect day' in ambulatory care.
Case study: a work redesign method to improve access. Mgma Connexion/Medical Group
Management Association. 2001;3(2):58-61.
Abstract: A nationwide network of community-owned health systems and their physicians
invited several health care practices in New York to participate in a collaborative effort to
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explore advanced-access scheduling to improve same-day appointment availability. Roswell
Park Cancer Institute, Buffalo, accepted
78. Hardy KJ, O'Brien SV, Furlong NJ. Quality improvement report: information given to patients
before appointments and its effect on non-attendance rate. British Medical Journal.
2001;323(7324):1298-300.
Abstract: The problem studied was wasted outpatient appointments as a result of clinic nonattendance exacerbating outpatient waiting times. The design was a single centre,
prospective, non-randomised, controlled study. The background and setting were diabetes
clinic in a district general hospital run by a consultant, one or two diabetes nurse specialists,
a dietician, and a podiatrist. Clinic receives 10-15 new referrals a week in a health district with
a population of 340,000. Key measure for improvement was non-attendance rate in 325 new
patients who attended after the intervention compared with 1,336 historical controls from the
same clinic in the three years before the scheme. Two weeks before their outpatient
appointment new patients were sent an information pack telling them when and where to
come, where to park, what to bring, who they will see, and what to expect. One week before
the appointment they received a supplementary phone call. Effects of change were telling
patients what to expect reduced non-attendance rate overall from 15% (201/1,336) to
4.6%(15/325, P<0.0001. Non-attendance rate was 7.3% (13/178) in those sent a pack but not
phoned and 1.4% (2/147) in those sent a pack and phoned, P=0.01. Giving new patients
detailed information reduces non-attendance to almost one percent. Cites seven references.
[Journal abstract]
79. Hashim MJ, Franks P, Fiscella K. Effectiveness of telephone reminders in improving rate of
appointments kept at an outpatient clinic: a randomized controlled trial. Journal of the
American Board of Family Practice. 2001;14(3):193-6.
Abstract: BACKGROUND: Clinic appointments in which patients do not appear (no-show)
result in loss of provider time and revenue. Previous studies have shown variable
effectiveness in telephone and mailed reminders to patients
80. Quinn DC, Graber AL, Elasy TA, Thomas J, Wolff K, Brown A. Overcoming turf battles:
developing a pragmatic, collaborative model to improve glycemic control in patients with
diabetes. Joint Commission Journal on Quality Improvement. 2001;27(5):255-64.
Abstract: BACKGROUND: Collaboration between primary care physicians (PCPs) and
endocrinologists should be the first step in improving care of patients with diabetes. However,
the coordination of care between specialists and PCPs often does not work well. At
Vanderbilt University Medical Center, a collaborative model between PCPs and
endocrinology was used in an effort to improve glycemic control for patients with diabetes
81. Wenzel SE, Morgan K, Griffin R, Stanford R, Edwards L, Wamboldt FS, et al. Improvement in
health care utilization and pulmonary function with fluticasone propionate in patients with
steroid-dependent asthma at a National Asthma Referral Center. Journal of Asthma.
2001;38(5):405-12.
Abstract: The impact of switching from other inhaled corticosteroids to fluticasone propionate
was studied in patients with severe oral-steroid-dependent asthma over a 1-year period. In
this open-label prospective study, patients on maintenance doses of oral and inhaled steroids
were referred to a national asthma treatment center and were switchedfrom their previous
inhaled corticosteroid to fluticasone propionate 880 microg BID. Compared with data
collected from the year prior to enrollment, treatment with fluticasone propionate resulted in
significant improvements in pulmonary function, oral steroid requirements, and health
resource utilization. In addition, five patients were completely weaned off oral steroids
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82. Hull A, Morrison A. "Failure of emergency out-patient appointments to reduce admission
rates". Health Bulletin 2000;58(2): 112-117. Health Bulletin. 2000;58(4):356.
83. Jain S, Chou CL. Use of an orientation clinic to reduce failed new patient appointments in
primary care. Journal of General Internal Medicine. 2000;15(12):878-80.
Abstract: Patients who fail to attend initial appointments reduce clinic efficiency. To maximize
attendance by newly referred outpatients, we introduced a mandatory group orientation clinic
for all new patients and determined its effects on no-show rates. Orientation clinic also
provided health care screening and opportunities for patient feedback. The new patient noshow rate for initial provider visits decreased significantly from 45% before institution of
orientation clinic to 18% afterwards (P<.0001). The total no-show (patients who failed to
attend orientation clinic or an initial provider visit) rate of the postintervention group was 51%
(P = .28, compared with before the intervention). This intervention improved the efficiency
and minimized the wasted time of our clinicians
84. Klopfenstein CE, Forster A, Van GE. Anesthetic assessment in an outpatient consultation
clinic reduces preoperative anxiety. Canadian Journal of Anaesthesia. 2000;47(6):511-5.
Abstract: PURPOSE: Preoperative anxiety in relation to anesthesia remains for many
patients a major subject of concern. The aim of the present study was to compare the level of
preoperative anxiety in patients assessed in an outpatient consultation clinic with the anxiety
level of those having been assessed by the anesthesiologist after entering the hospital
85. Plaut GS. The management of women with breast symptoms referred to secondary care
clinics in Sheffield: implications for improving local services. Annals of the Royal College of
Surgeons of England. 2000;82(5):359-60.
86. Ritchie PD, Jenkins M, Cameron PA. A telephone call reminder to improve outpatient
attendance in patients referred from the emergency department: a randomised controlled
trial. Australian & New Zealand Journal of Medicine. 2000;30(5):585-92.
Abstract: BACKGROUND: Poor compliance with attendance at outpatient clinic appointments
in patients referred from emergency departments (EDs) is a major problem in public hospitals
87. Speca M, Carlson LE, Goodey E, Angen M. A randomized, wait-list controlled clinical trial:
The effect of a mindfulness meditation-based stress reduction program on mood and
symptoms of stress in cancer outpatients. Psychosomatic Medicine. 2000;(5):613-22.
Abstract: Objective: The objective of this study was to assess the effects of participation in a
mindfulness meditation-based stress reduction program on mood disturbance and symptoms
of stress in cancer outpatients. Methods: A randomized, wait-list controlled design was used.
A convenience sample of eligible cancer patients enrolled after giving informed consent and
were randomly assigned to either an immediate treatment condition or a wait-list control
condition. Patients completed the Profile of Mood States and the Symptoms of Stress
Inventory both before and after the intervention. The intervention consisted of a weekly
meditation group lasting 1.5 hours for 7 weeks plus home meditation practice. Results: Ninety
patients (mean age, 51 years) completed the study. The group was heterogeneous in type
and stage of cancer. Patients' mean preintervention scores on dependent measures were
equivalent between groups. After the intervention, patients in the treatment group had
significantly lower scores on Total Mood Disturbance and subscales of Depression, Anxiety,
Anger, and Confusion and more Vigor than control subjects. The treatment group also had
fewer overall Symptoms of Stress; fewer Cardiopulmonary and Gastrointestinal symptoms;
less Emotional Irritability, Depression, and Cognitive Disorganization; and fewer Habitual
Patterns of stress. Overall reduction in Total Mood Disturbance was 65%, with a 31%
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reduction in Symptoms of Stress. Conclusions: This program was effective in decreasing
mood disturbance and stress symptoms in both male and female patients with a wide variety
of cancer diagnoses, stages of illness, and ages
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