Problem Identification
No show is the act of patients failing to make an appearance for a scheduled appointment without informing their healthcare practitioner in advance. Patients’ failure in showing up for their CT scan appointments is a recurrent problem in medical facilities all over the world. While there are different factors involved, no show indicates population health disparity which remains a priority in global health. Missed appointments not only impact patients’ health outcomes but also have financial consequences on the involved medical facility, depending on remittance sources and mode of care delivery.
Moreover, they elicit a discrepancy between supply and the anticipated demand for CT scan services, thus equally impacting medical system performances and service quality. Studies have revealed several reasons patients fail to turn up for CT scan appointments. They include family and work commitments, forgetting, transportation problems, hospitalization, long waiting periods, and financial difficulties (Bedford, Weintraub, and Dow, 2020). However, forgetting appointments is one of the major causes of no-shows that can be curtailed considerably through the implementation of effective strategies.
Medical facilities also play a role in patients’ missing appointments. For instance, they may give patients long waiting periods between the booking date and the actual appointment date, which further increases the likelihood of non-attendance among patients. Days of the week also matter when scheduling appointments (Bedford, Weintraub, and Dow, 2020). Patients have an issue with work-life harmony due to the daily demands that they face each day. For instance, parents must provide basic needs for their families and may take up two or three jobs a day, which can be exhausting. Most healthcare providers are usually available during the first few days of the week and hence, they schedule most appointments with patients within that period. However, weekdays are also work days for most people and a patient would rather go to work than go for an appointment and risk getting fired from their job.
Though missing appointments is common among patients, it negatively affects their health and well-being. A patient’s health status may worsen due to an undiagnosed underlying condition. For instance, if a patient is experiencing chronic headaches but fails to show up for CT scan appointments, they may not know the cause of those headaches. A problem like an infection in the brain that can be treated may further lead to a stroke, brain damage, or in other cases, death of a patient if not diagnosed early enough. Patients with kidney problems, lung diseases, and bone disorders require CT scans from time to time since they are identified as chronic conditions. Failing to turn up for these scans may lead to further complications and the worsening of underlying conditions which reduce the quality of patients’ lives (Briatore et al., 2020).
Healthcare costs are also likely to increase when patients miss their appointments frequently since it maximizes the consequences of a disease. Therefore, reminding patients of the importance of attending scheduled appointments in advance may increase their likelihood of showing up and one major way of doing this involves phone calls and text messaging services.
Problem Analysis
Most patients set to attend CT scans do not show up for various reasons but forgetfulness and the presumption that the issue was resolved and some of the leading causes. There is a need to identify a root cause(s) to create a solution and improve health outcomes related to imaging appointments. In this section, the 5 whys method of root cause analysis shown in Figure 1 is utilized and a single line of evidence is identified to reach the root cause. Research has shown that a myriad of factors affects CT scan appointment attendance, including cultural factors, gender, age, socioeconomic status, and co-morbidities (Rosenbaum et al., 2018). While there are patient and institutional-related reasons for missing CT scan appointments, this paper focuses on the causes given by patients to create a patient-centered solution and implementation.
Most of the reviewed materials point to forgetfulness as the main explanation patients provide for missing CT scan appointments. The 5 whys method analyzes this simple yet complex problem to identify a root cause. Briatore et al. (2019) found that 44% of the patients who missed appointments cited forgetting about it while (Bedford, Weintraub, and Dow, 2020) identified this reason as the second most prevalent at 38%. Other researchers, such as Marbouh et al. (2020), Wilson and Winnard (2022), and Roseland et al. (2021), do not give specific percentages but identify forgetfulness as one of the leading reasons given by patients who missed their scan appointments. Through a review of extensive data, Shahab and Meili (2019) established that forgetfulness was the most frequent cause of no-shows among radiology patients. Following the high occurrence of forgetfulness as the explanation for missing scan appointments, this root cause analysis focuses on it over other reasons given by patients.
Firstly, the first why seeks to identify the cause of a health care problem or concern. The problem identified is the failure of patients to show up for their scheduled CT scans. This affects the radiology department’s efficiency and workflow, hospital healthcare costs, patients’ health outcomes, and the relationship between patients, hospital personnel, and the healthcare system. When patients fail to attend scans, it means others miss the opportunity to get services, delaying their screening and treatment and creating capacity problems at CT clinics. In addition, there is wasted resource allocation, contributing to high costs and decreased efficiency in the CT clinics. The nonattendance of CT scan appointments has negative effects on patient’s health outcomes as it could increase the chances of mortality or morbidity. Therefore, patients failing to attend CT scan appointments is a major health problem for radiology and imaging departments.
The second why investigate the reason most patients give for failing to show up on their appointment day. In this case, forgetfulness is the major reason the CT scan patients will give. However, forgetfulness is a complex factor as there are various underlying causes linked to it. While patients may not give a direct transparent reason, forgetfulness could be related to an unwillingness to attend the scan session due to cultural factors or an inability to show up due to transportation difficulties, weather conditions, health status, and competing events. Nevertheless, it is important to seek further clarification to identify a root cause.
The next and third why directed to patients points to the lack of reminders, especially when the booking and appointment date are far apart. Most patients lack modern reminders to help them plan and attend their CT scan appointments. Additionally, traditional reminders such as physically recording the appointment dates in their diaries and notebooks proved ineffective. Live staff phone calls are also considered a traditional reminder approach and are prone to failure if the callers are busy and overwhelmed by work, causing them to forget and not make the call at all or call too late for the patient to get ready. An investigation into failing or lack of reminders is necessary for the root cause analysis.
The fourth why investigates why reminders were not set or why they failed. The indication points to CT scans not being perceived as necessary in the treatment plan by most patients. In addition, patients who felt that their health condition had improved also did not pay keen attention to appointment reminders. Finally, the last why identifies why patients forgot to set reminders as inadequate communication from the clinic staff and insufficient knowledge of the need for the scan in their treatment journey. There is a need to find a solution that enhances reminders and communication between the patient and the CT scan clinic.
Solutions
To solve the identified problem, there is a need for implementing effective strategies that focus on patient’s social determinants regarding their ability to show up for appointments. Using phone calls and text messaging is a good and practical strategy (Liu et al., 2017). With people using their phones as a major form of communication, this approach can significantly improve non-attendance rates of CT scan appointments in medical facilities.
For instance, healthcare providers could designate a few staff members to make calls and send messages to patients in advance. This way, they can confirm their attendance and make time in case they had forgotten or taken on other priorities during their time of appointment. Though automated calls are a cost-effective way of reminding patients about their appointments, studies have shown that calls from medical staff members are a more effective approach (Mikhaeil et al. 2019). Therefore, a combination of these two may be even more effective than using only automated calls.
Due to the nature of the equipment used in CT scanning, most healthcare facilities cannot afford them. For this reason, patients flock to the few facilities that have these machines, and thus, limited slots are allocated on a first-come basis. No-shows result in lost opportunities for patients to obtain the healthcare services they need. However, if a patient confirms the inability to show up before the scheduled time, the gap can be filled by another patient on the wait list who may be available on short notice Mander et al. (2018). Additionally, sending a simple text message can go a long way in solving patient scheduling conflicts and miscommunications that may have occurred when arranging face-to-face appointments (Liu et al., 2017). It is important to customize the content of text messages such that they meet the needs of patients. This may involve giving patients clear information on how to prepare, what to bring, and including the scheduled appointment time so that they can prepare in advance for the whole process.
It is worth noting that phone calls and text messaging may not be the most effective method for a certain group of patients. While some may not be comfortable with this method, others lack access to mobile phones. Therefore, healthcare providers should be mindful of such limitations and offer other ways of reminding patients about their CT scan appointments. For instance, postcards and emails can be an alternative to calls and text messages Mikhaeil et al. (2019).
Emails favor patients who possess smartphones and are always checking their emails. A brief email can serve as a good reminder for patients who easily forget due to tight business schedules. It can be sent automatically and include a link for the receiver to either confirm or cancel their appointments. Postcards can be sent through the mail since they are more of a traditional method that favors those who lack mobile phones. Information sent on postcards should include essential information about the appointment such as the date, location, time, and how to reschedule or cancel in case of unavailability. With all these strategies in place, medical facilities can minimize losing income and maximize service quality.
Implementation
The recommended solution for improving CT scan appointment attendance is a combination of text messages and automated calls before the visit day and a follow-up live call after a missed appointment. Automated messages and calls are recommended before the appointment date to encourage the patient to show up for the CT scan (Aljuaid et al., 2022). However, if the patient fails to come, a staff member will call to reschedule the appointment. The purpose of this intervention plan is twofold: to reduce no-show cases in the CT scan clinics and reduce the time between a missed visit and the rescheduled appointment.
Automated text messaging (ATMe) is the primary connection between the patient scheduled for a CT scan and the radiology clinic. While hospitals are required by law to acquire consent from customers before they can send marketing and billing messages, appointment reminder messages are not regulated (Aljuaid et al., 2022). The communication channel begins immediately after a customer completes the appointment booking process at the hospital.
Therefore, it requires a link to the radiology department’s electronic health records (EHR) system. The first step of the patient is to register at the EHR point of entry for the radiology department. A staff then helps the patient with appointment booking and communicates the need for the specifically scheduled scan. The EHR system’s button that completes the booking process should be set to trigger the ATMe system to accomplish two actions: record the details of the booking for future messaging and send a booking confirmation message to the customer. The instant message received by the patient establishes the communication between the CT clinic and the patient, strengthening future messages.
It is preferable to send the ATMe two days before the appointment date as it enables the patient to make any preparations for the hospital visit. The contents, style, tone, and timing of the message are important in ensuring the effectiveness of the system. The contents should include a personalized salutation, time, date, and location or address of the appointment. These details are automatically filled in from the EHR system. An example message should be brief and precise, such as, ‘Dear Ms. XXX, this is a reminder for your appointment scheduled for Thursday 23/03/2023 at 374 Hospital Road, Philadelphia, PA 99999.’
Furthermore, the message contents may also include a reminder to bring essential documents like their form of payment, insurance cards, and other paperwork. The style and tone of the message should be professional yet with a personal touch to avoid the feel of the machine-generated text. In addition, the best time is between 6 pm and 7 pm when most people are off work and before they go to bed. At this point, the ATMe might also inquire about the patient’s possibility of attending the appointment by replying a yes, no, or not sure to the text. If the patient replies with an express no, the clinic can schedule another patient for that slot and skip the automated call reminder, going direct to the live rescheduling call. However, if the patient’s response is yes or not sure, or no response at all, the system schedules an automated call.
The automated call (AT) is a machine-programmed call that carries similar contents as the ATMe but will be made one day before the appointment day. A live call takes approximately eight minutes per patient, which is highly time-consuming for a busy healthcare clinic (Aljuaid et al., 2022). Therefore, an AC will save time and finances for the radiology department. The AC system is the same as the ATMe system but it relays the message in the form of a voice call. It should feature a warm voice that is as close as possible to a human one. An AC should also monitor the line to determine if it was answered, unanswered, sent to voicemail, or rejected. Depending on the outcome, it should take preset action or deliver the intended message. When the call is answered, the system should deliver the message and prompt the customer to reply with the options like ATMe.
If the call is unanswered or the user is busy, the system should call again after a few minutes. When the call is sent to voicemail, the system should leave a voice message reminding the customer of the appointment and provide the clinic’s number for a callback. If a call is rejected, the system should immediately trigger an ATMe reminder. Even after setting up reminders via ATMe and AC, patients might miss CT scan appointments due to the other causes discussed earlier. After a missed appointment or if a patient’s response to the ATMe or AC is a ‘No,’ the system schedules a live call within 48 hours and sends the request to the call center immediately.
Live calls will be triggered from the automated system when a patient responds with a ‘No’ or from the EHR system 24 hours after an appointment is missed. A staff member from the call center will call the patient and request to reschedule the appointment to another day. This call aims to ensure that customers have an opportunity to raise any concerns they might have and seek explanation and additional information as necessary. The live call mainly seeks to eliminate the lack of knowledge and inadequate communication root cause by giving patients and staff another opportunity for clarifications.
During the call, the caller will introduce themselves and respectfully ask the customer for their time. The caller will proceed to give the details of the missed appointment and ask the patient if they remember it. Depending on the response, the caller should guide the customer by explaining why such a CT scan is critical in their treatment plan. Additionally, the patient should have time to give as many reasons as they feel are necessary to ensure complete understanding of the circumstances. Once the caller has reminded and convinced the patient that the scan is important, they will ask whether to reschedule.
Most patients who have gained a fresh understanding of their situation and the need for a CT scan will agree to rescheduling. In addition, the time between reschedules completed over live phone calls are expected to be lower than where patients take the initiative to rebook an appointment. Aljuaid et al. (2022) established that rescheduling over the phone and within a short time of missed appointment reduced the period between missed visit and rescheduled date from 30.7 to 12.1 weeks in two years. Therefore, the strategy to combine these methods and reschedule missed appointments is backed by scientific research.
A key decision in the implementation of this strategy is to choose between off-the-shelf or custom made software for the automated calls and texting systems. Examples of off-the-shelf platforms that are currently used in healthcare include GReminders and ReminderCall. GReminders is created to work with Google and it extracts information from Google calendar and sends a text to the patient with details of the appointment. It also asks the patient to respond with a Yes or No to cancel or keep the appointment. ReminderCall offers both automated calls and texts, and personalizes the caller ID to match the hospital details. It also works with the existing EHR system as intended in this implementation plan. Alternatively, the hospital can develop its automated reminder software in-house using their existing computing personnel or by contracting a third party. Regardless of the method used, the software must be compatible with existing systems at the center and perform all the functions and actions outlined in the implementation plan.
References List
Aljuaid, M.A. et al. (2022) ‘Does the combination of phone, email, and text-based reminders improve no-show rates for patients in breast imaging?’, Current Problems in Diagnostic Radiology. 52(2), pp.125-129. Web.
Bedford, L.K., Weintraub, C., and Dow, A.W. (2020) ‘Into the storm: A mixed methods evaluation of reasons for non-attendance of appointments in the free clinic setting’. Comprehensive Clinical Medicine, 2, pp. 2271-2277. Web.
Briatore, A. et al. (2020) ‘Causes of appointment attendance, nonattendance, and cancellation in outpatient consultations at a university hospital’, The International Journal of Health Planning and Management, 35(1), pp. 207-220. Web.
Liu, C. et al. (2017) ‘Text message reminders reduce outpatient radiology no-shows but do not improve arrival punctuality’, Journal of the American College of Radiology, 14(8), pp. 1049-1054.
Mander, G.T. et al. (2018) ‘Factors associated with appointment non‐attendance at a medical imaging department in regional Australia: A retrospective cohort analysis’, Journal of Medical Radiation Sciences, 65(3), pp. 192-199. Web.
Marbouh, D. et al. (2020) ‘Evaluating the impact of patient no-shows on service quality’, Risk Management and Healthcare Policy, 13, p. 509. Web.
Mikhaeil, J.S. et al. (2019) ‘Attend: A two-pronged trial to eliminate no-shows in diagnostic imaging at a community-based hospital’, Journal of Medical Imaging and Radiation Sciences, 50(1), pp. 36-42. Web.
Roseland, M.E. et al. (2022) ‘Targeting missed care opportunities using modern communication methods: A quality improvement initiative to improve access to CT and MRI appointments’, Academic Radiology, 29(3), pp. 395-401. Web.
Rosenbaum, J.I. et al. (2018) ‘Understanding why patient’s no-show: Observations of 2.9 million outpatient imaging visits over 16 years’, Journal of the American College of Radiology, 15(7), pp. 944-950.
Wilson, R. and Winnard, Y. (2022) ‘Causes, impacts and possible mitigation of non-attendance of appointments within the National Health Service: A literature review’, Journal of Health Organization and Management, 36(7). Web.