Practice Change: No Shows to Medical Appointments: Where Is Everyone?

The purpose of this practice change was to increase the percentage of patients attending their appointments with their health care providers at an urban health center serving female patients. When patients fail to attend their scheduled medical appointment it impacts the organizational efficiency, continuity of care, and can affect patient health care outcomes (Perron et al., 2010). The health center in this project had a patient no-show rate of approximately 13%. With input from the authors, the health center manager made the decision to use the innovation of having medical assistants make patient reminder telephone calls at 48 and 24 hours prior to all scheduled appointments. Evidence from research reports show this technique is effective in reducing the number of patient no-shows in various clinical settings. The practice change project was initiated after developing and reviewing a proposal with the health center manager. A Call Tracking Form was completed by the medical assistants making reminder phone calls in order to identify who was called, at what interval(s), and if the appointment was confirmed. During the nine-weeks of practice change implementation a total of 699 appointments were scheduled with fifty-seven percent of these patients receiving reminder phone calls at 24 and 48 hours. In a nine week period prior to implementing this change, forty five of the 355 scheduled patients failed to attend their scheduled appointment, for a no-show rate of 13%. This is compared to 72 of the 699 patients with scheduled appointments during the practice change failing to attend a scheduled appointment, for a post-change no-show rate of 10%. In conclusion, reminder phone calls were effective in increasing the number of patients who attended their scheduled medical appointments. The combined effect of the reminder phone calls reduced the no-show rate by approximately 3%. ______________________________________________________________________________ Background Managing missed patient appointments represent a challenge for those working in health care systems. Non-attendance at appointments decreases healthcare revenue, causes suboptimal use of clinical and administrative staff, can impact wait times for patients, and negatively affects continuity of care (Perron et al., 2010). Several innovations have had varying degrees of success in reducing the number of patients missing scheduled appointments (Chen, Fang, Chen, & Dai, 2008; Fairhurst & Sheikh, 2008; Liew et al., 2009; Perron et al, 2010; Stockwell et al., 2014). A review of the evidence conducted by the authors indicated instances where staff made personal appointment phone calls, mailed letters, used text messaging, and automated voice messaging to remind patients of their scheduled appointments (Chen et al., 2008; Fairhurst & Sheikh, 2008; Leong et al., 2006; Liew et al., 2009; Perron et al., 2010; Stockwell et al., 2014). This article describes a change in clinical practice conducted by the authors who were doctor of nursing practice-family nurse practitioner students with a goal to increase the percentage of patients attending their scheduled medical appointments at a women’s health clinic where the no-show rate was 13%. This practice change was approved by the University of Portland Institutional Review Board. Organizational Context The site targeted for this practice change project is a community-based, outpatient primary health care center primarily serving Caucasian and Hispanic female adult patients that is focused on women’s health care needs including family planning, ante/post-partum care services. The health center is located on the same campus as its parent organization and is part of a larger health care network. Strategic and financial objectives are typically disseminated from the parent company’s executive leadership through face-to-face director meetings and emails. The organization’s charity and financial policy is written to ensure a fair, equitable, and comprehensive system of distributing charity care to the financially burdened within the available resources of the hospital while also ensuring that the hospital is financially capable of providing the highest quality healthcare to the community. Personal Context The need for a practice change was identified by the health center’s manager who noted patient absences from their scheduled medical appointment. Ten medical assistants provide support services to the health center’s six health care providers. The medical assistant’s responsibilities include performing clinical procedures under the supervision of the health center’s physicians and midwives; escorting patients to exam rooms; interviewing patients and taking vital signs; ensuring reports, labs, and other patient information are updated in patient medical records; stock exam rooms with medical supplies and instruments; and make/take telephone messages to and from patients, providers, and other organizational staff. The health center manager started tracking patient no-shows to identify patterns in appointment times most often missed, what type of appointments were being missed, and which patients chronically missed appointments. With this information an informal test of change was started with one of the health center’s medical assistant being assigned to make reminder phone calls as a method of encouraging attendance. These phone calls were reportedly not made consistently, nor were they made for every scheduled patient appointment because of a lack of medical assistant time. Problem The recognition by the manager that the medical assistant’s efforts at making patient reminder phone calls made minimal change to the no show rate is what motivated the need to make a practice change by seeking an evidence-based solution to increase the number of patients who attend their scheduled medical appointments.