Improving Care for Urgent Dermatology Appointments Margaret Bell

Improving Care for Urgent Dermatology Appointments Margaret Bell, MPH, R. N. Carol Drucker, MD

Before the change….

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 nonexistent 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.

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

Fishbone Analysis

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

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/RN’s

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

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

Televox • A patient call reminder system “HOLES”

Tools Derm Appointment Types PSC Communication Tool

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.

Process Missed Appt Process for RN MA Process Long Term

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

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 1 st year.

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)

ROI $1, 088, 293. 57 3743%

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 Apr 07

ADDENDUM