National Meeting 2007

3052 — Systems Approaches to Reduce Missed Appointment Opportunities

Kuno E (Center of Excellence on Implementing Evidence-based Practice, Roudebush VAMC) , Flanagan ME (Center of Excellence on Implementing Evidence-based Practice, Roudebush VAMC), Ordin D (VA Office of Quality and Performance), Parlier RL (VHA Advanced Clinical Access Initiative), Schlosser J (Edith Nourse Rogers Memorial Veterans Hospital), Doebbeling BN (Center of Excellence on Implementing Evidence-based Practice, Roudebush VAMC)

Missed appointment opportunities have major impacts on VHA both administratively and financially. In Q4 FY2005, 17% of clinic appointments were “missed opportunities”, i.e., appointments canceled by the patient (3%) or the clinic (3%) after the appointment; or “no-shows” (11%). We sought to identify and document effective strategies used by high-performing VHA primary care clinics to improve missed opportunities.

Based on appointment metrics, 13 clinics across 9 VAMCs were selected as high-performers for in-depth interviews. High performing clinics were defined as: 1) consistent low missed opportunity rates in last year (lowest 10%), or 2) improvement measured by difference in annual missed opportunity rates from 2004 to 2005 (largest 5). We surveyed using open-ended questions to identify a range of strategies. In-depth phone interviews were carried out with key informants at high-performing clinics to examine which strategies they have implemented and to understand how they were integrated. Thirteen clinics across 9 VAMCs in 8 VISNs were selected, considering size and geographical location. Findings from 4 high performing primary-care (PC) clinics are presented, with missed appointment rates ranging from 8% to 14%.

High performing clinics have adopted multiple strategies. Survey responses (N= 107 facilities (75%) identified 17 strategies. The most frequently mentioned strategy was “reminder call by person” (53%), followed by “educational poster” (22%). Strategies common across each of the four PC clinics were: 1) automated reminder call, 2) scheduling with patients both for new and returning appointments, 3) turn off auto re-scheduling function, 4) contact with no-show patients to re-schedule, 5) coordinate with other clinics, 6) immediate cancellation, 7) communicate with patients about no-show, and 8) provider leave policy. Each PC clinic reported using a minimum of 14 strategies.

VA clinics with high performance in reducing missed opportunities have not implemented standardized strategies. However, they have achieved the improvement through locally developed systems approaches to successfully transforming the system toward patient-centered, efficient clinic operation.

In order to improve high missed opportunity rates, facilities should assess their own processes, and design and implement solutions targeted to their unique needs. Providing on-site technical assistance and enhancing engagement of patients and providers in the process are key steps.