Sustainable Interventions to Reduce Patient Missed Appointments at a Large Inner-City Pediatric Clinic

Purpose: Pediatric no-show and canceled clinic appointments (missed appointments) are a chronic problem impacting patient outcomes and clinics' financial well-being. From a patient perspective, the limited number of pediatric specialists means that patients may need to wait months before the next appointment. From the clinic's perspective, missed appointments generate non-value added (NVA) activities and costs, lost revenue, and disruptions in care.

During phase I of the quality improvement project, a nurse-led project team calculated a 16% missed appointment rate at a large pediatric inner-city clinic that serves a high-risk disadvantaged population. The missed appointment rate meant that too many pediatric patients missed patient care, and the clinic suffered financial losses. The annual revenue loss from the missed appointments was over $160,000, and the NVA costs were $56,000. Phase I deliverables included identifying the significant patient factors associated with missed appointments and developing a prediction model to predict the impact of the factors on missed appointments. This abstract focuses on the outcomes of the second phase of the project. Phase II's purpose was to develop and implement sustainable interventions to reduce the number of missed appointments.

Methods: The project team implemented interventions aimed at two significant patient factors associated with missed appointments: 1) patients forgetting about appointments and 2) high risk for missed appointment visit types. The first intervention was a patient reminder system. Designated staff placed a targeted reminder call to the patient one day before the appointment. The second intervention moved the PVC13 vaccine and the Hib vaccine from the "12-month well-baby visit" to the "15-month well-baby visit." Historically, the 12-month visit had a low missed appointment rate while the 15-month visit had a high missed appointment rate. The intervention's goal was to create a sense of importance in patients' families' minds for the 15-month visit. The team executed a 16-week pilot program for the interventions.

Results: Over the 16-week pilot program, the missed appointment rate dropped from 16% to 14% (p=.006), the no-show rate dropped from 9.5% to 8% (p=.000), and the "15-month well baby visit" missed appointment rate dropped from 34% to 27% (p=.034). The results saved the clinic approximately 30 minutes per day in NVA activity time. The project team collaborated with leadership to 1) ensure the interventions became policy and 2) create a quality initiative to transform other high-risk visit types into low-risk visit types.

Conclusion: A nurse-led project team successfully developed and implemented two interventions that reduced the missed appointment rate in a large pediatric inner-city clinic. The results improved overall care for a high-risk disadvantaged population while improving the financial condition of the clinic. This project’s success demonstrates the importance of having nurses in quality improvement leadership roles to improve patient care.