Background: Patient “no-shows” cause significant concern for healthcare organizations as it affects continuity of care provided to the patient, quality of care, waiting times for new patients, and wastes clinic resources. This project aimed to reduce the rate of no-shows in a general pediatric clinic to less than 10% to be consistent with the international benchmark range of 5%–10% of primary care clinics. Materials and Methods: A multidisciplinary team was formed to address the rate of no-shows using a quality improvement–driven approach in August 2017. Retrospective data analysis showed that 33% of patients who were referred to the general pediatric clinic at King Abdullah Specialist Children Hospital did not show up for their appointments in March 2017. Results: The impact of reengineering the patients' appointment communication process led to a noticeable reduction in the rate of no-shows in the general pediatric clinic, reaching 14% in 1 month (November to December 2017) compared with the baseline of 33%. Data analysis for the post-intervention period showed a progressive decline in the no-show rate, reaching below 10% in the general pediatric clinic, indicating a big shift in the rate of no-shows among the patients attending the general pediatric clinic. Conclusion: Reengineering the communication process and increasing awareness to update contact information are effective strategies for improving communication with patients and reducing the rate of no-shows for scheduled appointments. The next step is to share project findings with healthcare workers and leaders to sustain the improvement.
Healthcare institutions usually provide scheduled appointments for follow-up in outpatients. Yet, data analysis for the outpatient clinic showed a noticeable high number of no-shows among outpatient clinics at King Abdullah Specialist Children Hospital (KASCH). We analyzed retrospective data and found that 663 (33%) of 2002 patients who were referred to the general pediatric clinic did not show up for their appointments, as shown in Figure 1, wasting time and resources as well as increasing waiting time for other patients who were in most need for such care.
Patients who do not keep their scheduled doctor appointments represent a significant loss for healthcare providers and affect the continuity of care.[1,2] Available research showed that a reminder e-mail message can decrease the rate of no-shows; in addition, understanding the characteristics of patients who miss their appointments could help formulate interventions to reduce no-show rates. For example, patients with chronic medical conditions need a regular follow-up visit to control their disease, in case a patient missed his or her appointment. Therefore, the medical condition of the patients with chronic diseases might turn worse and they might end up visiting the emergency department. Moreover, it can increase unplanned hospital admissions and mortality among uncontrolled chronic conditions.[3–5] In 2016, Stephenson indicated that text messaging is an effective strategy for reminding patients and reducing no-show rates. Thus, this quality improvement (QI) project aimed to reduce the no-show rate in the general pediatric clinic to less than 10% within 1 year to meet the international benchmark for no-shows, which ranges between 5% and 10% in primary care clinics.
Materials and Methods
Measurement and assessment
The initial data collection started at outpatient clinics at KASCH by measuring the rate of no-shows as the number of patients who did not attend their appointments, as shown in Figure 1. The baseline data showed that the highest number of no-show patients for their scheduled appointments in the general pediatric clinic reached 33% (662/2002). Then, the QI team at KASCH decided to conduct a rapid survey among patients attending the general pediatric clinic as a starting point to understand why some patients did not show up for their appointments. The results of the survey showed that there are several reasons for no-show, some are related to patients and staff (42%) and others are systems-related factors (58%), as shown in Figure 2. The highest percentage (29%) of patients reported that they did not receive an appointment text message (SMS) on their phone at the time of scheduling and no reminder SMS either afterward. On the basis of data findings, the QI team concluded that the current status of the patient communication process is not effective. Therefore, the communication process was mapped out and reengineered to address the reason for no-shows in the general pediatric clinic at KASCH in August 2017.
A multidisciplinary QI team was formed consisting of a team leader, physicians, clinic nurse, patient information services, data analyst, information technologist, and patient relations specialist. The QI team members started analyzing the causes of the problem using different quality tools including survey, brainstorming, and a cause-and-effect diagram. The team found that the communication process with patients seems to be the main reason for no-show because of couple of reasons including lack of updating the contact number and verification of the reminder SMS [Figure 2]. The following interventions were tested for addressing these reasons for patient no-shows: (1) reengineering the process of patient communication regarding their follow-up appointments and (2) updating patient contact numbers on the same day of clinic visit. The intervention began in November 2017. Data were analyzed using Microsoft Excel 2010 (Excel Version 2.0 -QI-CHARTS Software (Scoville Associates).
Three Plan–Do–Study–Act (PDSA) cycles were used to test the proposed interventions related to no-shows.
PDSA Cycle 1: The first PDSA cycle was related to the patient survey. We asked the patients if they received the confirmation SMS for their follow-up appointments. The prediction was that the patients would give feedback about receiving the SMS about their scheduled appointment. We conducted a rapid survey of 344 patients attending the general pediatric clinic. The QI team found reasons for no-shows related to system factors (56%) and human and environmental factors (42%), as shown in Figures 2 and 3, respectively. We chose to focus on the system-related factors, revealing that 29% of patients reported they did not receive the SMS about their follow-up appointments, concluding that the communication with patients seems to be the main reason for the no-show. Then, the QI team moved to the next PDSA cycle to reengineer the communication process and update patient contact number.
PDSA Cycle 2: The result from the first PDSA cycle survey confirmed the main reason for no-show was related to patient communication factors. We started our intervention in reengineering the communication process by updating the patient contact number and confirming the SMS was delivered on the same day of clinic visit. The prediction was that patients would receive the SMS to confirm the next follow-up appointment. The registration office sent the SMS to patients, but the results showed that still there were some patients who did not receive the SMS because their contact number was not updated through the registration office, resulting in action to conduct an awareness campaign among patients about the importance of updating their contact number to get follow-up appointment reminders.
PDSA Cycle 3: The third PDSA cycle focused entirely on increasing awareness among patients attending the general pediatric clinic about the importance of updating their contact numbers at the registration office on the same day of the clinic visit. Part of the awareness campaign was engaging healthcare providers, including physicians, to talk to their patients about updating their contact number when scheduling an appointment for the next visit. The prediction was that patients will take the issue seriously and update their contact number at the registration office on the same day of the clinic visit.
The rapid patient survey about the causes of no-shows revealed that 29% of contributing factors were related to the process of appointment communication with patients, including that their contact numbers were not updated, resulting in a situation where patients were not answering the calls and reminder texts were not delivered. Reengineering the patients' appointment communication process led to a noticeable reduction in the no-show rate in the general pediatric clinic of less than 14% in 1 month (November to December 2017) compared with the baseline of 33%, as shown on the control chart [Figure 4]. Further, data analysis for the post-intervention period (January 2018) showed a progressive decline in the no-show rate, reaching below 10% in the general pediatric clinic [Figure 4], indicating that the project led to a big shift in the rate of no-shows among the patients attending pediatric outpatient clinic and progressing well toward meeting the international benchmark (5%–10%).
Surveying patients about their experience was crucial in making the changes for this QI process-driven project. Conducting the awareness campaign among patients about updating their contact numbers was also important, but most important was engaging the healthcare providers and physicians during the process of addressing the reasons for no-shows. We did not address factors related to physician behavior, such as requesting unnecessary appointments, which might be among the reasons that patients do not show up. Also, the results of the project cannot be generalizable to other outpatient clinics except those who share the same reasons for no-show. Outpatient clinic managers as well as healthcare providers who have the same problem of no-show among their patients may benefit from our results by testing the project ideas in their context.
This QI project aimed to reduce the no-show rate in the general pediatric clinic to less than 10% to be consistent with the international benchmark of 5%–10% no-show rate among primary clinics. This project focused on implementing a sustainable solution by reengineering the patients' appointment communication process. The newly designed system sends text messages to patients to confirm and remind them about their next appointment. This was an effective strategy to reduce the rate of no-shows for scheduled appointments from 33% to below 10% in the general pediatric clinic, which was the project target and within the international benchmark.
We thank Dr. Fahad Al Hemoudi, Mr. Abdullah Al Zahrani, Ms. Hadeel Al Deraihem, Ms. Rasha Al Ahmari, Ms. Hawazen Al Otaibi, Ms. Huda Al Ghamdi, Dr. Jubran Al Qanatish, Dr. Hesham Al Maimouni, Mr. Mohammed Al Harbi, Mr. Mazyad Al Motairi, Ms. Basma Hameden, Mr. Micahel Redmond, Mr. Abdullah Al Shammery, Mr. Nasser Al Mahaimeed, and Mr. Bandar Al Breaky for participating and sharing their knowledge to achieve the project target.
Financial support and sponsorship
The authors disclosed no funding related to this article.
Conflicts of interest
The authors disclosed no conflicts of interest related to this article.
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