Proactive Overbooked Routines Through Empiric Noshow Data (PORTEND)

Proactive Overbooked Routines Through Empiric Noshow Data (PORTEND)

Ped Bunsongsikul MD 11/19/2013

Problem

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

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

Other methods• Calculating Member Historic NoShow Rate For each member

• # of prior PCP appointment No Shows/Total # of prior PCP appointments

• For each given W, that W’s Historic NoShowRate is calculated

• All of the patients prior NoShows / Total # of prior PCP appointments for all the patients

• This number is multiplied by the number of routine appointments to get the AdjustedHistoricNoShowRate for the W

• For each given W, that W’s Historic NoShowRate Sum is calculated

• Sum of the members Historic NoShowRate for that W

• Assuming that the WHistoricNoShowRate predicts the no show rate for each member, the following equation is applied.

• 1 – (1- WHNSR) ^n Where n = number of routine appointments.

• This gives the exponential method.

Cumulative PPV vs Cumulative Addons (6 months West Covina)

Data - 1 Year BPK Family Med

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

6 Month Family Medicine Data

Family Medicine Baldwin Park 1/1/2013 - 6/30/2013Total Ws 13853% of W with NoShow 0.592Total NoShows 12869Pts Scheduled/W 9.7Pts Seen/W 8.8

Threshold value 0.77 Met Threshold Below ThresholdHad No-Show 1805 6395 8200Did not have No-Show 395 5258 5653

2200 11653 13853Sensitivity 0.220PPV (223/241) = 0.820

P-Value (Chi2 with Yates) < 0.0001NoShow Compensation 0.171

Variables

• Threshold• The threshold level can be adjusted up or down to balance PPV vs Sensitivity

• Timing of report• Reports can be run the week prior to allow for scheduling of routine

appointments.• The earlier the report is run:

• There will be fewer Ws that will meet threshold (decrease sensitivity)• there may be an increase in PPV as there will be more time for appointments to be

scheduled.• Increased risk of cancellation which could disrupt the theoretical no-show probability

Other Variables that are not considered• Timing of appointment (AM vs PM) – Not statistically significant• # of supply in the W (I would like to factor it in to help in automation)

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

Original Process•Report run on Thursday•Schedules are adjusted by Thursday Afternoon

Current Process•Report run on Wednesday.•The schedules are adjusted by Thursday afternoon

Template

Rules

• If you have travel time or other held/IW time in the W, you will not get the addon (IMPAAQT, Inbasket, and CSG IW do not count)

PORTEND Started- 9/30WCO and Montebello Actual Data

• Overall 126/159 (79.2%) shifts had a no show• 159 overbooked appointments to compensate for 939 noshows (17%)• Bad Day defined as everyone showing up and 12 patients are seen in

the AM or 11 patients seen in the PM.

PORTEND 9/30/2013 - 11/1/2013 Weekly Total Clinic

Threshhold AddedClinic

CancelW Routines Overbooked

W No Shows

W No Show Rate Pt's Seen/W

Bad Days

Total Noshows

Added Appt/ Total NS Total Ws %W with NS Combine PPV

Pt's Seen/W

MON 09-30 21 17 1 16 15 0.94 9.2 0 92 0.17 101 0.62 8.6WCO 09-30 19 19 0 19 13 0.68 8.6 0 109 0.17 158 0.48 0.8 7.9MON 10-07 17 17 1 16 11 0.69 9.1 1 67 0.24 113 0.45 8.1WCO 10-07 16 14 0 14 13 0.93 9.4 1 97 0.14 138 0.56 0.8 8.5MON 10-14 21 16 1 15 13 0.87 8.5 1 82 0.18 122 0.53 7.7WCO 10-14 20 17 0 17 11 0.65 8.6 0 104 0.16 145 0.51 0.75 8MON 10-21 21 15 1 14 10 0.71 10.1 1 60 0.23 111 0.43 7.4WCO 10-21 23 22 0 22 20 0.91 8.5 1 125 0.18 148 0.58 0.83 7.4MON 10-28 14 10 0 10 8 0.80 10.6 1 88 0.11 104 0.54 7.1WCO 10-28 18 17 1 16 12 0.75 9.6 1 115 0.14 135 0.56 0.77 7.6

Total 190 164 5 159 126 0.79 7 939 0.17 1275

Physician Impact

• Increase in patients seen per half day

• Low probability for a ‘bad day’. (7/159 shifts)

Paneled MDs

Paneled FTEs

Mid-Level FTEs

Avg. Membership per W

Avg. Panel

Size per W

Unassigned Rate

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

% New Member

booked w/in standard

% of MDs Meeting Bonding

Goal

% Able (bonding

rate)

% Able Preventiv

e

% Able Routine

% Able Same Day

Leakage to UCC

Waitlist Volume

> 9 < 7% 30 10 80% 90% 64% 64%100% 85% 85% 40%

Aug-13 18 16.5 1.6 6.12 5.77 6% 5.8% 12.4% 2.8% 12.5% 8.7% 8.98 7.3% 11.0 8.0 75% 39% 98% 28% 58% 87% 76% 32% 13.3% 23

Sep-13 18 16.5 1.6 6.12 5.78 6% 11.0% 12.3% 5.9% 11.0% 5.7% 9.12 10.8% 12.0 9.0 70% 67% 99% 67% 61% 90% 79% 40% 12.8% 17

Oct-13 18 16.5 1.6 6.14 5.79 6% 11.9% 12.4% 5.6% 12.4% 6.0% 8.78 7.2% 10.0 7.0 72% 61% 99% 61% 64% 93% 82% 35% 12.6% 14

TOTAL YTD 8.84 9.8%

Aug-13 8 7.3 0.8 6.69 5.96 10% 8.0% 17.3% 4.5% 10.2% 5.4% 8.41 5.6% 12.0 8.0 77% 29% 95% 13% 56% 82% 71% 36% 9.2% 30

Sep-13 8 7.3 0.8 5.91 5.26 10% 10.0% 20.1% 5.5% 10.7% 5.6% 8.17 15.7% 11.0 8.0 78% 63% 99% 25% 58% 86% 76% 36% 9.3% 19

Oct-13 9 8.8 0.8 6.38 5.67 10% 19.6% 23.2% 15.1% 8.4% 3.5% 8.92 8.0% 12.0 7.0 78% 56% 100% 56% 63% 90% 78% 42% 8.4% 19

TOTAL YTD 8.71 11.8%

Aug-13 15 14.4 1.1 5.80 5.10 11% 14.1% 33.6% 12.5% 7.6% 1.9% 8.24 11.0% 8.0 7.0 73% 80% 99% 60% 65% 89% 80% 43% 8.6% 105

Sep-13 15 14.4 1.1 5.79 5.10 11% 11.1% 23.6% 8.6% 7.8% 3.3% 8.85 8.9% 9.0 7.0 72% 80% 99% 60% 66% 89% 82% 44% 9.0% 110

Oct-13 15 14.4 1.1 5.94 5.25 11% 15.7% 44.1% 16.1% 7.2% 2.9% 8.78 4.1% 7.0 7.0 74% 73% 99% 73% 69% 93% 82% 49% 8.5% 4

TOTAL YTD 8.62 9.1%

Aug-13 16 14.7 2.0 6.46 6 7% 11.0% 14.1% 6.0% 8.6% 3.1% 8.78 5.7% 7.0 6.0 77% 81% 99% 75% 69% 95% 87% 47% 8.9% 21

Sep-13 16 14.7 2.0 6.47 6 7% 12.0% 18.8% 8.1% 8.5% 3.5% 8.71 4.4% 6.0 6.0 81% 94% 98% 94% 69% 94% 87% 49% 8.5% 1

Oct-13 16 14.7 2.0 6.51 6.02 7% 13.4% 17.4% 9.3% 7.7% 3.1% 9.16 8.5% 6.0 5.0 81% 94% 98% 69% 71% 96% 87% 48% 8.7% 1

TOTAL YTD 8.87 8.0%

Aug-13 21 18.0 1.5 6.14 5.67 10% 10.8% 14.8% 5.4% 9.6% 4.1% 9.00 7.4% 7.0 6.0 75% 100% 98% 67% 67% 93% 90% 44% 12.9% 7

Sep-13 21 18.0 1.5 6.09 5.64 9% 15.9% 27.1% 10.2% 8.7% 2.2% 8.96 4.9% 7.0 5.0 81% 95% 99% 81% 70% 91% 90% 50% 13.1% 13

Oct-13 21 18.0 1.5 6.09 5.62 10% 16.1% 26.0% 11.7% 8.4% 3.1% 8.96 6.9% 5.0 4.0 88% 95% 99% 76% 69% 93% 89% 46% 12.5% 23

TOTAL YTD 8.99 8.7%

Aug-13 78 70.9 7.0 6.21 5.69 7% 9.9% 18.5% 6.5% 9.5% 4.4% 8.72 7.6% 9.0 7.0 75% 71% 98% 38% 64% 90% 82% 41% 10.9% 186

Sep-13 78 70.9 7.0 6.08 5.58 7% 12.0% 20.4% 8.0% 9.2% 3.8% 8.85 8.2% 9.0 7.0 76% 82% 99% 71% 66% 90% 83% 45% 10.9% 160

Oct-13 79 72.4 7.0 6.18 5.65 7% 15.4% 24.6% 11.2% 8.9% 3.8% 8.91 6.8% 8.0 6.0 79% 78% 99% 68% 68% 93% 84% 44% 10.5% 61

Region 14.0% 21.0% 7.0% 9.6% 3.0% 8.98 6.2% 8.0 5.0 84% 99% 65% 92% 84% 37% 8.8%

TOTAL YTD 8.84 9.2%

Diamond Bar

Montebello

San Dimas

West Covina

Family Total

Regional Standard

Baldwin Park

Medical Center Goal

17.1%

16.0%

12.0%

20.0%

20.4%

13.9%

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)

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.

SpecialtiesDermatology

Dermatology Baldwin Park 1/1/2013 - 6/30/2013Total Ws 1017% of W with NoShow 0.79Total NoShows 1571Pts Scheduled/W 13.4Pts Seen/W 11.8


241 776 1017Sensitivity 0.277PPV (223/241) = 0.925P-Value (Fisher Exact) < 0.0001NoShow Compensation 0.153



Specialty Cardiology

• Not useful BPK Cardiology

Total Ws 919% of W with NoShow 0.242Total NoShows 278


66 853 919Sensitivity 0.104PPV (335/370) = 0.348P-Value (Fisher Exact) 0.051NoShow Compensation 0.237

SpecialtiesNeurology

Neurology Baldwin Park 1/1/2013 - 6/30/2013Total Ws 899% of W with NoShow 0.484Total NoShows 800





Future Direction

• Improvements• Join the Appointment Supply into the Terradata Query

• 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.

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

Staff

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

Documents

Proactive Overbooked Routines Through Empiric Noshow Data (PORTEND)