Improving Care for Urgent Dermatology Appointments

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Improving Care for Urgent Dermatology Appointments

• Margaret Bell, MPH, R.N.
• Carol Drucker, MD

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Before the change.
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Example of a Problem Identified

• Time to first open appointment 142 days
• Patients with urgent problems were dealt with one
  by one, interrupting scheduler, nurse and doctor
  to look for a non-existent place in the schedule
  to put them.
• Urgent problems were on an appointment "wait
  list." for 79 days
• Temporary hold placed on new patients
• Clinics ran late routinely
• No lunch for the doctors, overtime for the
  nurses, and dissatisfaction and stress for all.
• Over 200 "missed appointment reschedules" were
  backlogged.
• Increased liability
• Lost revenue opportunities
• High patient dissatisfaction
• High provider and staff dissatisfaction.

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• ORIGINAL AIM
• To decrease wait time for urgent appointments in
  Dermatology Cancer Prevention Center by 10 from
  July 2007 to December 2007

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Fishbone Analysis

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Potential Changes/Interventions

• Develop a process working in patients with urgent
  problems
• Develop a process of differentiating appointment
  types
• Revamp the missed appointment process

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Develop a process for working in patients with
urgent problems

• Restrict appointment in cancellation slots to a
  designated scheduling clerk.
• Develop a wait list with sufficient information
  to know who should be worked in
• Develop a system of prioritizing of the patients
  with urgent problems on the urgent list
• Develop tools for PSC/RNs

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New Prioritization Process

• Patients prioritized to high/low risk by RN/MD
• Form developed to communicate risk to scheduling
  clerk
• Appointments types changed to accommodate risk

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Current Missed Appointments Process

• Current process
• Annual low risk screenings given same weight as
  high risk
• Three phone calls to patient missing appointment
  by RN
• Scheduling clerk reschedules appointment up to 3
  times
• Business Center verifies insurance each visit
• All patients given 15 minute appointment

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Televox

• A patient call reminder system
• HOLES

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Tools

• Derm Appointment Types

• PSC Communication Tool

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New Process

• Instead of 3 calls and 3 reschedules
• Low Risk Only letter without reschedule
• High Risk Letter reminder at risk with factors
  identified
• Undiagnosed Individually follow up by MD or RN.

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Process

• Missed Appt Process for RN

• MA Process Long Term

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A new world

• Improved work flows
• Difficult problems tackled
• Work together better
• Improve working conditions
• Improve access for your patients
• Employees smile when they come to work

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Final Results

• AIM To decrease wait time for urgent
  appointments in Dermatology Cancer Prevention
  Center by 10 from July 2007 to December 2007.
• INITIAL RESULTS
• Improved by 91.14
• Access less than 48 hours for urgent patients
• Urgent wait list gone
• Initial savings Televox 18,100 for 1st year.

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Current Results

• Sustained original results
• Physician production increased to 11.13 patients
  resulting in a net increase of 589 patients per
  year
• Televox was expanded to all out patient centers
• CPC general screening and mammogram appointments
  generated
• Downstream revenue
• 1531 additional pathology specimens
• 26 patients were treated (GELB)

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ROI
1,088,293.57
3743
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Sustaining the Gain

• What ultimately makes any project sustainable is
  local ownership from the beginning in designing
  the project, establishing the priorities.
• James
• - Rebviltlraq Projects
• Found Crumbling
• NY Times. Sun 29 Apr07

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ADDENDUM