1. Carol Drucker, MD Margaret Bell, MPH
Improving Access to Dermatology Appointments in the Cancer Prevention Center
Carol Drucker, MD
Margaret Bell, MPH

2. Before the change….

3. Problems Identified: Time to first open appointment: 142 days
Patients with urgent problems were dealt with one by one, interrupting scheduler, nurse and doctor to look for a non-existent place in the schedule to put them.
Urgent problems were on an appointment "wait list." for 79 days
Clinics ran late routinely
No lunch for the doctors, overtime for the nurses, and dissatisfaction and stress for all.
Over 200 "missed appointment reschedules" were backlogged.
Temporary hold placed on “new” patients
Increased liability
Lost revenue opportunities
High patient dissatisfaction
High provider and staff dissatisfaction.

4. Improving Access to Dermatology Appointments in the Cancer Prevention Center
AIM:
To decrease wait time for urgent appointments in Dermatology Cancer Prevention Center by 10% from July 2007 to December 2007

5. Fishbone Analysis

6. Potential Changes/Interventions
Develop a process working in patients with urgent problems
Develop a process of differentiating appointment types
Revamp the missed appointment process

7. Develop a process for working in patients with urgent problems
Restrict appointment in cancellation slots to a designated PSC
Develop a wait list with sufficient info to know who should be worked in
Develop a system of prioritizing of the patients with urgent problems on the urgent list
Develop tools for PSC/RN’s

8. Patient Prioritizing Method

9. New Prioritization Process
Patients prioritized to high/low risk by RN/MD
Form developed to communicate risk to PSC
Appointments types changed to accommodate risk

10. List of High Risk Factors
Excessive sun exposure and/or sunburns
History of actinic keratoses
History of basal cell skin cancer
History of squamous cell skin cancer
Having over moles
History of dysplastic (atypical) moles
History of melanoma
Family History of melanoma
Other

11. Current Missed Appointments Process
Current process :
Annual low risk screenings given same weight as high risk
Three phone calls to patient missing appointment by RN
PSC reschedules appointment up to 3 times
Business Center verifies insurance each visit
All patients given 15 minute appointment

12. Hi-Ho! Hi-Ho Off to work we go
Televox
A patient call reminder system helped identify last minute appointment slots.
“HOLES”
Hi-Ho! Hi-Ho Off to work we go

13. Missed Appt Process for RN

14. MA Process Long Term

15. Derm Appointment Types

16. PSC Communication Tool

17. New Process Instead of 3 calls and 3 reschedules:
Low Risk: Only letter without reschedule
High Risk: Letter reminder at risk with factors identified
Undiagnosed: Individually follow up by MD or RN.

18. Reduced annual low risk savings by 23.9%
Appointment Type
Reduced annual low risk savings by 23.9%

19. Final Results Improved by 91.14%
AIM: To decrease wait time for urgent appointments in Dermatology Cancer Prevention Center by 10% from July 2007 to December 2007.
RESULTS:
Improved by 91.14%
Access less than 48 hours for urgent patients
Urgent wait list gone

20. Why go through the effort?
Aim: Improve access for urgent appts.: 91.1% improvement
Decrease in missed appts.: Televox process ROR 1925%
More appointments available
Predictable days
Transferable
Reduction of risk
liability savings: $40,000 -$240,000
Missed appts. Dropped 9.49%
*751 Additional new patients /year
*40 Additional F/U patients /year
*939 Additional CPC patients appts/year
Standardization of practice and decrease in variation
Use of forms to achieve standardization
Wait list for urgent appointments gone
*PAS time saved for financial clearance
*RN time saved for documentation and calling
*PSC time saved for scheduling appts.
Additional Derm. Procedures/year
Additional Colonoscopies/ year
Staff more content, get lunch breaks, less interruptions, able to start new day without bringing backlog of work with them
Practice changes started with one MD moved to all MD’s
Urgent patients seen in less than 48 hours
6 % newly diagnosed cancer patients referred to other centers for cancer treatment

21. Gross Annualized Revenue
Volume Annualized
Service
Annualized Gross Revenue
751
New Patients (PRS, Tech)
$262,099 40
Follow up patients (PRS, Tech)
$ 11,480
939
Other screening (PRS, Tech)
$271,859
1502
Dermatology procedures (PRS, Tech without pathology)
$887,667 59
Colonoscopies (Downstream revenue)
$222,843 48
Newly Diagnosed Cancers:
Breast, Colon, Melanoma*
(Downstream revenue)
$4,275,006
Personnel Time Savings (RN, PSC, PAS)
$ 17,647
Total New Income
$5,948,601
*Based on a rate of 6% although average cancer diagnosis in center is 14.4% (to be conservative with projections as percentage of patients
treated here is not known). In addition, lowest institutional estimates for cancer diagnosis treatment cost were utilized as patients are generally
diagnosed at an earlier stage (a mix of 50% breast in situ, 45% simple melanoma and 5% colon.
** Based on 2 biopsies per patient. Generally new patients average 3-4 or higher. Does not include photography charges, extensive procedures or
Cryosurgery.
*** EIW was data source and institutional charge master was source for charge estimates.

23. Sustaining the Gain James - Rebviltlraq Projects Found Crumbling
“What ultimately makes any project sustainable is local ownership from the beginning in designing the project, establishing the priorities.”
James
- Rebviltlraq Projects
Found Crumbling
NY Times. Sun 29 Apr07