Proactive Overbooked

Routines Through Empiric Noshow Data (PORTEND)

Ped Bunsongsikul MD 1/24/2014

Problem

• Patient No-shows impair our ability to provide excellent access

• 59% of any given Family Medicine W will have a no-show. (based on historical data)

Potential Solutions

• Automatic Overbooking to compensate for anticipated No shows

• Change provider mindset to the thought that no-shows are undesirable.

Overbooking Intelligently

• Development of a method to calculate a number that is assigned to every W. This number is based on the historic no-show pattern for the members scheduled. (Done through a Terradata Query)

• That number correlates to the probability that there will be a no-show for that W. If the number reaches a threshold, there is an 80% chance that there will be a no-show for the W.

• For these Ws, one of the existing routine appointments is converted to an Overbook. This frees up a routine slot that can be booked by the call center as a routine.

Calculation of the PORTEND output

APPT_TIME APPT_MADE_DATE apptnoshow apptcomplete totalapptpcpnoshowrate = apptnoshow/totalappt

10/24/2013 8:30 9/25/2013 0 4 4 0.0010/24/2013 8:50 10/21/2013 0 9 9 0.0010/24/2013 9:30 10/21/2013 0 8 8 0.0010/24/2013 9:50 10/16/2013 4 4 8 0.5010/24/2013 10:10 10/20/2013 0 12 12 0.0010/24/2013 10:30 10/17/2013 1 14 15 0.0710/24/2013 11:10 10/22/2013 7 18 25 0.2810/24/2013 11:30 10/21/2013 6 24 30 0.20

18 93 111 1.05

Threshhold : Sum of pcpnoshowrate => 0.77Exclusion: if sum of apptnoshow < 4Exclusion: if sum of total appt < 6

*The Terradata Query is found in the Notes of this slide

Data - 1 Year BPK Family Med

July 2013-June 2014 Baldwin Park Family Medicine Physician Providers (23,564 Ws)

6 Month Family Medicine Data

Prospective Predictions – Dry Run8/26-9/27 Baldwin Park Family Med

Added Appointments by Clinic Adds

Week of DMB SDM WCO MON BPKDepartment

Total

W Clinic

Cancel

Overbooked W with

NoshowsMeasured

PPVTotal

Noshows

Appts Added/Total

NSTotal Shifts

Estimated Overbook%

Overfilled Ws (11 pts were

seen)8/26/2013 4 24 42 21 25 116 5 86 0.775 467 0.184 530 20.9% 6 Friday Report9/2/2013 8 12 27 18 26 91 5 72 0.837 403 0.179 451 19.1% 5 Friday Report9/9/2013 16 13 31 25 46 131 6 99 0.792 529 0.187 607 20.6% 8 Friday Report

9/16/2013 13 17 25 15 46 116 2 92 0.807 516 0.178 595 19.2% 8 Thursday Report9/23/2013 5 9 16 26 30 86 5 64 0.790 448 0.143 564 14.4% 5 Thursday Report

540 23 413 0.799 2363 0.175 2747 18.8% 32 Thursday Report

Procedures

Current Process•Report run on Wednesday.•The schedules are adjusted that same day

•The latest booked routine slot is converted to an overbook.•The original overbook slot is converted to an unblocked routine slot. The slot in the same period becomes an unblocked routine slot as well. Net effect is 2 additional routine slot available for the call center to book. -2 potential same day appointments. The overbook slot is “pre-booked”.

TemplateAM Existing Template AM Changes

8:30 Slot 1 8:30 Slot 18:50 Slot 2 8:50 Slot 29:10 Slot 3 Slot 4 9:10 Slot 3 Slot 49:30 Slot 5 9:30 Slot 59:50 Slot 6 9:50 Slot 6

10:10 Slot 7 10:10 Slot 710:30 Slot 8 10:30 Slot 810:50 Slot 9 (SD) Overbook Slot 10:50 Slot 9 (Routine) Slot 1211:10 Slot 10 11:10 Slot 1011:30 Slot 11 11:30 Slot 11

PM PM Changes1:30 Slot 1 1:30 Slot 11:50 Slot 2 Slot 3 1:50 Slot 2 Slot 32:10 Slot 4 2:10 Slot 42:30 Slot 5 2:30 Slot 52:50 Slot 6 2:50 Slot 63:10 Slot 7 3:10 Slot 73:30 Slot 8 (SD) Overbook Slot 3:30 Slot 8 (Routine) Slot 113:50 Slot 9 3:50 Slot 94:10 Slot 10 4:10 Slot 104:30 Doctor Time 4:30 Doctor Time

The latest booked routine slot is converted to an overbook.

The original overbook slot is converted to an unblocked routine slot. The slot in the same period becomes an unblocked routine slot as well. Net effect is 2 additional routine slot available for the call center to book. Minus 2 potential same day appointments. The overbook slot is “pre-booked”.

Additional Exclusion Rules

• If you have travel time or other held/IW time in the W, you will not get the addon (At discretion of the scheduler)

• Need at least 9 appointments available in the supply.

It takes about 2 hours for the schedulers to make the changes each week.

Implementation Timeline

• 8/26/2013-9/27/2013 Dry Run. 540 appointments added. 79.9% of the identified shifts actually had a no-show.

• 9/30/2013 West Covina and Montebello went live• 10/30/2013 San Dimas went live• 12/4/2013 Baldwin Park, Diamond Bar went live

PORTEND Summary

• 9/30/2013-12/27/2013• 522 Ws were adjusted with an Overbooked Routine• 19 Ws Clinic Canceled (Leaving 503 W affected)• 416 of 503 Ws had at least one noshow (82.7%)• 266 Ws had more routines booked than supply

• (Actual routine appointments created)

PORTEND Summary ContinuedDefined by Supply•33 ‘Bad days’ out of 503 Ws 6.6%

• Where pts seen is greater than supply• Compare to 592 ‘bad days’ out of 6656 Ws without adds = 8.9%

Selection bias is present because, as the PORTEND Ws are more likely to have no-shows.

PORTEND Summary Continued• 4766 total Provider Ws for the clinics affected• 503 of 4766 Ws were affected (10.6%)• 503 of 3976 No shows compensated for (12.7%)• 266 of 3976 True compensation (6.7%)• Sensitivity = 416/2665 Ws with a NS = 15.6%• Actual W No Show Rate = 2665/4766 = 55.9%

MeasuresASQ Trends as MOBs went live on PORTEND

MOB PORTEND START ASQ - Oct 2013 ASQ - Nov 2013 ASQ - Dec 2013 ASQ - Jan 2014 ASQ - Feb 2014West Covina October 2013 8.96 9.09 9.26 9.2 9.11Montebello October 2013 8.78 8.63 9.15 9.35 9.01San Dimas November 2013 9.16 8.76 8.96 9.12 9.33Baldwin Park December 2013 8.78 8.95 8.96 8.84 9.18Diamond Bar December 2013 8.92 8.96 8.73 8.62 9.08

MOB Live on PORTENDASQ affected by PORTEND (ASQ score typically lags 2 months)

Measures

• Time to 3rd available appointment• Fam Med Dept: % of MD’s with Next 3rd Available < 14 days• 78% (Oct) -> 84% (Nov) -> 90% (Dec)

• Booking Utilization (booked/supply)• 101.7% (Portend) vs 93.9% (Unadjusted)

• Actual Supply Utilization (pt’s seen/supply) – (selection bias)• 86.4% (Portend) vs 83.8% (unadjusted)

• Net Loss• Fam Med Dept: 15.4% (Oct) -> 15.2% (Nov) -> 13.4% (Dec)

Measures

Downside•Providers might need to see more patients•Decrease supply of Same Day appointments

Paneled MDs

MD/DO % Appt Loss

Mid-Level % Appt Loss

% Un Booked

% No Show

% of Overbook

Appts

ASQ Appt

Access

ASQ Contact>1 forAppt.

ADW Preventa

tive

ADW Routine

Routine %

Booked W/in

standard

% of MDs w/ N3AA <

14

> 9 < 7% 30 10 80%

Oct-13 18 11.9% 12.4% 5.6% 12.4% 6.0% 8.78 7.2% 10.0 7.0 72% 61%

Nov-13 18 10.5% 7.1% 4.9% 12.0% 6.7% 8.95 6.1% 10.0 7.0 75% 61%

Dec-13 18 11.0% 10.1% 5.5% 12.9% 7.3% 8.96 6.3% 10.0 7.0 75% 78%

YTD 8.86 9.1%

Oct-13 9 19.6% 23.2% 15.1% 8.4% 3.5% 8.92 8.0% 12.0 7.0 78% 56%

Nov-13 9 20.4% 20.5% 15.1% 9.1% 3.6% 8.96 9.1% 11.0 6.0 83% 67%

Dec-13 9 16.7% 15.8% 11.4% 10.0% 5.0% 8.73 2.8% 11.0 7.0 80% 67%

YTD 8.74 10.5%

Oct-13 15 15.7% 44.1% 16.1% 7.2% 2.9% 8.78 4.1% 7.0 7.0 74% 73%

Nov-13 15 17.0% 38.4% 15.3% 7.9% 2.5% 8.63 14.3% 7.0 6.0 80% 87%

Dec-13 15 16.6% 24.5% 11.5% 9.1% 3.4% 9.15 5.8% 8.0 6.0 79% 93%

YTD 8.72 9.2%

Diamond Bar (Dec)

Montebello (Oct)

Adult Primary Care Access Scorecard

Regional Standard

Baldwin Park (Dec)

Medical Center Goal

11.1%

16.4%

17.2%

Paneled MDs

MD/DO % Appt Loss

Mid-Level % Appt Loss

% Un Booked

% No Show

% of Overbook

Appts

ASQ Appt

Access

ASQ Contact>1 forAppt.

ADW Preventa

tive

ADW Routine

Routine %

Booked W/in

standard

% of MDs w/ N3AA <

14

> 9 < 7% 30 10 80%

Oct-13 16 13.4% 17.4% 9.3% 7.7% 3.1% 9.16 8.5% 6.0 5.0 81% 94%

Nov-13 16 12.9% 21.5% 8.8% 8.0% 2.7% 8.76 3.5% 6.0 5.0 83% 94%

Dec-13 16 8.2% 11.2% 4.9% 8.9% 5.3% 8.96 4.0% 7.0 5.0 86% 100%

YTD 8.87 7.3%

Oct-13 21 16.1% 26.0% 11.7% 8.4% 3.1% 8.96 6.9% 5.0 4.0 88% 95%

Nov-13 21 15.4% 20.9% 9.6% 9.2% 3.0% 9.09 10.2% 5.0 5.0 85% 100%

Dec-13 20 14.7% 19.7% 8.8% 9.6% 3.4% 9.26 6.0% 7.0 5.0 83% 100%

YTD 9.02 8.6%

Oct-13 79 15.4% 24.6% 11.2% 8.9% 3.8% 8.91 6.8% 8.0 6.0 79% 78%

Nov-13 79 15.2% 21.7% 10.3% 9.2% 3.7% 8.88 8.6% 7.0 6.0 81% 84%

Dec-13 78 13.4% 16.2% 8.2% 10.1% 4.8% 9.04 5.2% 8.0 6.0 81% 90%

Region 14.0% 20.0% 8.0% 10.1% 3.0% 9.04 6.6% 8.0 5.0 86%

YTD 8.86 8.8%

San Dimas (Nov)

West Covina

(Oct)

Family Total

Adult Primary Care Access Scorecard

Regional Standard

Medical Center Goal

15.0%

13.0%

8.5%

Limitation

• This method identifies the shifts that are likely to have a no-show. However, it does not identify which patient will no-show.

Comments

BPK Same day appointment protocol includes a Round Robin. This ensures adequate same day access.

IMPAAQT is also being done in the BPK Family Medicine (Montebello and West Covina). Currently on hold due to the flu season.

Conclusion

• It is possible to predict which shifts have a high likelihood of having a no-show.

• By overbooking these shifts, it is possible to partially compensate for the anticipated no-shows with only a small chance of overscheduling the providers.

• There may be a better overbooking process to minimize the work required by the schedulers. (Takes 1-2 hours a week to make changes to 70-100 schedules)

Future Directions• Expand to other primary care departments (internal medicine)

• Improvements• Join the Appointment Supply into the Terradata Query (done)• Increase frequency of the runs (will increase sensitivity)

• Automation• The PORTEND output number is calculated automatically for each W• For any W that reaches the threshold, the overbook slot becomes

bookable by the call center for routine appointments.• Would need a proper schedule template. Planning for July 2014.

• To place an overbook slot on an unblocked slot.

• Factors• The Call Center software has been delayed until April 2014.

• Preparing a report to present to Region and perhaps publish in the Permanente Journal.

Staff

• Local Physician Lead: Ped Bunsongsikul, MD• Local Support Staff: Alma Gallardo, Lisa Ordaz• Schedulers: Gina Gallego, Iverica McDonough