REDUCING NO SHOWS
SreyRam Kuy, MD (Assistant Chief, General Surgery, The Overton Brooks VA Shreveport, LA) presented several papers centered around access improvement in clinic and the operating room:
"Why we don't come to clinic: Patient perspectives," “It takes a village: referring providers impact patient no shows,” “The myth of Sisyphus: is reducing surgery clinic no-shows impossible?” and “Reducing Surgery Cancellations in a Tertiary Hospital: A Three-year review.”
Missed opportunities in clinic and the operating room (OR) can account for significant overall inefficiencies in provision of access in the VA. Missed opportunities can vary widely by facility and service but nationally averages 12.3% for clinics (8-18% by surgery specialty) and 8.6% for the OR (8-13% by surgery specialty). (National Surgery Office Report FY16 Quarter 1) Over 50% of missed opportunities are due to patient-controllable factors such as last second cancellation or no-shows. Dr. Kuy’s group presented data to suggest that a reduction missed opportunities by one-third could shift $188 million annually towards other uses. That is, by occupying those slots with patients who show for their appointment, in lieu of having empty slots, patients and money should be diverted away from non-VA care.
Dr. Kuy revealed that at the start of their study in February 2015, their general surgery clinic had a monthly missed opportunity rate of 25%. After implementing her intervention, by February 2016, the general surgery clinic missed opportunity rate was reduced by over 50% to 10.8%.
Her success in reducing missed opportunity rates was due to a combination of having caring dedicated staff committed to the service of veterans, supportive leadership in our medical center, and a systems redesign approach driven by LEAN management strategies. They brought together veterans, clerks, nurses, technicians, physicians, and the leadership from the Surgical Service, the business office, and volunteer services to systematically determine the key factors contributing to patient missed opportunities, and then mapped these factors in a flow diagram. They presented a display of their process Systems Redesign-LEAN management assessment.
They next conducted a series of pilot studies to test these factors. One pilot study surveyed veterans who “no-showed” to clinic as to reasons for no-show. Another study reviewed the clinical indications for a surgical consult, referring provider factors, and demographics of patients who no-showed for the past six months in that clinic. Moving forward, they next designed a series of interventions, targeting patients, referring providers, and the clinic system. For patient interventions, they utilized the altruistic camaraderie shared by veterans, incorporating a slogan suggested by a veteran member of our systems redesign team, “Never leave a battle buddy behind”. They created a veteran-centric slogan, “Save a Spot, Give a Slot to Your Battle Buddy!” and educated patients with “Save a Spot, Give a Slot to Your Battle Buddy!” themed clinic appointment notification letters, posters which were placed by elevators in the medical center, posted on the medical center’s social media, throughout the clinic, at check-in and check-out sites by the clerks’ desks, and in clinic rooms.
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Next they targeted referring providers, by educating referring providers about the importance of informing patients about the consult placed, and revising their CPRS consults to include a mandatory check box verifying providers have communicated the need for the consult with their patient.
They also recruited volunteer services to assist with reducing patient no shows, enlisting volunteer help to make live calls to all clinic patients days before clinic, remind them of their appointment, and if any patients were identified as being unable to keep their appointment, a list of those patients were given to our clinic nurse manager to reschedule.
As part of the discussion following her presentation, we suggested involving the VSOs in the goal of decreasing veteran no shows, avoiding overbooking when scheduling appointments.
Dr. Kuy concluded her presentations by emphasizing that by creating a culture of accountability, and tapping into this phenomenal sense of comradery among veterans absolutely a positive impact will be made on decreased clinic and OR cancellations, as well as improved on time OR first start rates.