Reducing No-Show Rates at UIC Department of Otolaryngology
Introduction
Background to the Organization
The University of Illinois Department of Otolaryngology has been in operation for the last 150 years. Currently, it is the longest serving ENT department in the entire United States. The department is located in the Illinois Eye and Ear Infirmary (EEI), which was initially in Chicago. Currently, it is situated in the Illinois Medical District since 1963. The department offers comprehensive care in various specialty areas, including plastic and reconstructive surgery, ontology and neurology, speech and voice care, general otolaryngology, neck cancer and sinus and nasal allergy care. For its services, the hospital is known to offer a leading-edge training program as well as outstanding care quality. Currently, the department is led by a team of professionals comprising of professors, assistant professors, and many professional doctors, who offer specialized care to patients. According to its website, the purpose of the department is to offer “patient and family focused commitment to all patient Ear, Nose and Throat needs.” The residency program, therefore, continues to attract the personnel in the medical education program and is expected to continue growing.
Currently, the department is led by Dr. Barry Wenig. The hospital’s staff members usually contribute significantly to its performance fostered by the support from different stakeholders, including the alumni. Such support helps the personnel to not only offer personalized care to patients but also ensure sustainable ENT health services improvement. The alumni, particularly help with ensuring the availability of cutting edge technology in all the facilities. The objective of this project is aligned to the mission, to provide sustainable and focused care to ENT patients, in that it promotes quality in care delivery through the reduction of no-shows. The contact person for the project is Dr. Heather Weinrich, and he would be instrumental in accessing key information about the facility, its operations and the challenges it faces.
Problem Statement
The efforts of the UIC Department of Otolaryngology to provide sustainable and effective ENT care are currently constrained because of two key issues. One of them is patient no-shows, which refers to when a patient who has booked an appointment with a specialist fails to honor it without giving any explanation or notice. No-shows at the hospital have multiple downstream effects. For example, unused appointment slots result in decreased access to care by other patients, other effects include lost revenue for the clinic and increased tendency of the facility to overbook as a way of compensating for no-shows and subsequent increase in waiting times and physician burn-out when too many patients to handle visit. Currently, the prevalence of no-show at the department stands at 30%. An assessment of the status of no-shows at the clinic as well as the possible solutions to the issue is required in order to improve the utilization of ENT at the UIC department of otolaryngology in the context of the current patient population and resource constraints at the facility.
The second constraint that the hospital faces is of patients cancelling appointments. Cancellation in this regard involves a patient notifying doctors of his or her inability to attend not more than 96 hours prior to the appointment time. At the time of cancellation, the hospital system is in no position to reschedule appointments or book in another patient. As such, the booked time remains unused, the hospital and the physician lose revenue thus the otolaryngology department is utilized poorly. Additionally, the underutilized time is allocated to another service. Currently, the rate of cancellation at the department is higher for tonsillectomies compared to other conditions handled by the department. The cancellations may be related to failure to obtain insurance clearance beforehand. In this case therefore, the objective of the present paper may be to find solutions to the high rates of cancellations at ENT.
The proposed solutions show that the project team understands various issues around the challenges at the organization. The hospital staff currently has no clear understanding of the actual levels of cancellation and no-shows that happen at the facility because of 2 two reasons. The first is the absence of emphasis on knowing the prevalence of no-shows and cancellations at the hospital. The staff mostly report on the prevalence of no-shows based on approximations of the two issues. Secondly, the system used by the hospital to make appointments is ineffective in that it does not flag no-shows making it difficult to follow them. This inability to flag no-shows is a challenge to doctors since it makes it hard for them to follow through to avoid rebooking patients who have shown tendencies for repeat no-shows.
The project team intends to first conduct an analysis that would reveal the actual rate of no-shows at the facility and subsequently conduct a data analysis and a CBA for ENT. The data on the no-shows and cancellation rates and the reasons behind them will help the team to propose approaches to solving the two problems. The MOU between the hospital and the project team indicates that the objectives of the project team are to analyze the data available on the no-show and cancellation rates at the hospital and explore the best practices to managing patient scheduling. They would also be required to provide guidance on how to reduce the no-shows and cancellations at the facility.
List of Abbreviations/Acronyms
The following list of abbreviations should be considered relevant for this project.
ENT – Ear, nose, and throat.
Research/Literature Review
Patient No-shows: An Overview
Patient no-shows are a common phenomenon in many healthcare facilities. Gajwani (2014) posits that no-shows are more common in healthcare facilities/departments dealing with psychiatry cases. Particularly, psychiatric clinicians struggle with the mentioned matter in many healthcare facilities, even among non-psychiatry related departments. Samuels et al. (2015) report the high prevalence rates of no-shows in pediatric healthcare facilities. Similarly, advanced sleep medical services also experience high rates of no-shows and cancellations. Shryock (2018) avers that in a general outpatient setting, the no-show rates amount to 23- 34% of the total bookings. Mohamed et al. (2016) also noted that no-show rates for PDSAs amounted to approximately 49% of the total bookings at a Qatar hospital in October 2013. Mohamed further states that no-shows in hospitals result in long waiting time for patients, as well as wastage of clinic resources and is a significant concern for healthcare providers. The total cost implications of no-shows in the country go to millions each year as described by Mohamed et al. (2016). Various reasons have been mentioned for patient no-shows and suggestions have been made for the improvement of the no-show outcomes in healthcare facilities.
Most of the articles reviewed attributed no-shows to various causes in healthcare practice. For example, Gajwani (2014) indicates that no-shows can be as a result of lack of communication with patients, transportation problems to the hospital, conflicts with other plans and feeling better. Other explanations for no-shows are mentioned by Samuels et al. (2015) include lack of approval from the insurance company, other personal reasons and failure to get time off work. Anxiety about medical procedures and forgetting appointments are also mentioned extensively as some of the reasons behind no-shows. Mohamed et al. (2016) also mentioned lack of urgency as a cause of no-show in a pediatric healthcare setting. Each of these reasons implies that different approaches can be used to reduce no-shows. No particular strategy may be applicable for all healthcare facilities so it is the responsibility of the healthcare service providers to understand the reason behind high no-shows and cancellations and put in place a strategy that can help to handle that particular reason.
Reducing No-shows
For most healthcare facilities, reducing no-shows comes at an extra cost to medical practice. For instance, Gajwani (2014) points out that some of the practices used in psychiatric healthcare facilities to reduce no-shows include changing policies and procedures to be more patient centric, reducing waiting times for patients by identifying areas in which patients were taking longer times than expected, increasing patients’ education about the implications of non-adherence to medication and need for follow-up, and collaboration with the teams to support patient care. Shryock (2018) proposes better ways for managing patient scheduling to reduce losses resulting from no-shows. These include prioritizing complex patient visits, managing call interruptions, creating a triage chart for patients, and working towards open access to information. Each of these approaches works only when used in combination with others.
Methods
The project team used a mixed research methodology in which information was obtained from healthcare practitioners, particularly physicians, surgeons and ENT specialists to fulfill the objectives of the project. The data collected was quantitative as it included the number of no-shows recorded by specific practitioners over the first five months of 2019. This data was required to help develop an understanding of the actual prevalence rates for no-shows and cancellations at the UIC Department of otolaryngology. The data was collected through a questionnaire, in which the practitioners had to fill in the numbers in the form of a table.
Findings
The collected data showed that the average no-show rates at the facility stands at 27.7%. This is contrary to the initial estimates that indicated an average of 31% no-shows. The table below shows a summary of the numbers of patient no-shows over several months as reported by the different practitioners.
| January | February | March | April | May | June | FYTD Total | |
| Joe | 50 | 68 | 81 | 67 | 94 | 360 | |
| Sims | 53 | 70 | 84 | 78 | 54 | 339 | |
| WENIG | 18 | 25 | 42 | 35 | 33 | 153 | |
| Rubenfeld | 51 | 79 | 78 | 21 | 81 | 310 | |
| Fellows | 23 | 18 | 11 | 25 | 23 | 100 | |
| Dixon | 90 | 111 | 82 | 134 | 111 | 528 | |
| Reed | 43 | 54 | 46 | 37 | 24 | 204 | |
| Allergy | 0 | ||||||
| Scheeler | 192 | 172 | 202 | 197 | 190 | 953 | |
| Albian | 150 | 193 | 256 | 267 | 185 | 1051 | |
| Achim | 51 | 43 | 64 | 44 | 47 | 249 | |
| Total FY19 | 993 | 1098 | 1185 | 1267 | 1207 | 4247 | |
| Total no shows number | 295 | 295 | 269 | 400 | 334 | ||
| no shows rates | 29.708% | 26.867% | 22.70% | 31.571% | 27.672% |
Table 1: No-shows from January to June for each Practitioner
This data indicates that the no-show rates at the UIC Department of Otolaryngology are lower compared to those presented in other studies. There is evidence of no-show rates as high as 49%, with the more generally reported being around 30-34%. It is also evident that some of the doctors, particularly Scheeler and Albian, have higher no-show rates compared to other practitioners because of the variation in no-show prevalence by the department/nature of illness. There are departments such as psychiatry, in which patients do not consider their conditions urgent anymore as well as those in which patients feel anxious about the medical procedures to be implemented. While this data shows the probable discrepancies between departments in terms of no-show prevalence, it cannot be used as a conclusive evidence of no-show prevalence across departments.
Results/Recommendations
The results obtained led the team came up with various suggestions that can be used to address the problem of no-shows and cancellations at the department. The first option is for the hospital to charge a mandatory appointment fee that is refundable upon utilization of the slot. Pursuing this option would result in increased motivation to attend hospital appointments and reduce financial losses for the hospital in case patients fail to attend scheduled appointments. Secondly, the facility could engage in awareness creation activities. They could aim at informing patients of the need for follow-up and the implications of failing to attend follow-up meetings. Additionally, the hospital could opt to improve its appointment system to ensure that it is capable of flagging no-shows and reporting on the same.
The team recommends a combination approach to problem solving. Improving the system will offer a more real time representation of the status of no-shows at the hospital and improve the management of patients who have proven to be perennial no-shows. This can be combined with the payment requirement as a strategy to reduce no shows. While educating patients is beneficial to the reduction of no-shows, it does not attain significant results due to the never-ending need to educate new patients and to refresh existing ones. The final recommendation therefore, is that the client should focus on understanding the scope of the problem before making efforts to solve it. The improved system will help significantly with this.
Conclusion
No-shows and cancellations are common in any given healthcare facility. However, understanding their causes and the potential implications can help healthcare facilities to develop strategies for reducing no shows and to implement those strategies. Accordingly, various studies in the past have shown that hospitals experience patient no-shows as a result of forgotten appointments, transport problems, anxiety about medical procedures, and feelings of reduced urgency among others. In the current project, the objective was to conduct a data analysis at the UIC Department of otolaryngology, establish the prevalence rates for no-shows and cancellations, and provide the proposals for managing the same. The gathered data confirmed that no-shows occur at higher rates in some departments than in others. On the other hand, the results showed that the no-show rates are actually lower than initially estimated. The project team recommends the use of a combination of methods beginning with system updates for the appointment system and following up with exacting payment during appointments. Requiring patients to make refundable payments when making appointments can be a motivating factor to adherence to those appointments.
References
Gajwani, P. (2014). Can what we learned about reducing no-shows in our clinic work for you? Current Psychiatry, 13(9), 1-6.
Mohamed, K., Mustafa, A., Tahtamouni, S., Taha, E. & Hassan, R. (2016). A quality improvement project to reduce the ‘no-show’ rate in a pediatric neurology clinic. BMJ Quality Improvement Reports, 5.
Samuels, R.C., Ward, V.L., Melvin, P., Match-Greenberg, M., Wenren, L.M., Yi, J. et al. (2015). Missed appointments: Factors contributing to high no-show rates in an urban pediatrics primary care clinic. Clinical Pediatrics, 1-7.
Shryock, T. (2018, March 25). How to reduce patient no-shows. Medical Economics Blog.