BUSI 311 Week 3 Discussion Board Forum 3 Example

Discussion Board Forum 3: Quality Improvement in a Physician Practice

BUSI 311 Introduction to Healthcare Administration, Discussion Board Forum 3

Thread by [Student Name]

The practice, its no-show figures and the classmates are composites; the textbook, Scripture and the peer-reviewed articles cited are real.

In the first quarter of this year, 14% of scheduled visits at our internal medicine practice ended as no-shows. For six physicians, that meant about 25 empty appointment slots a day, revenue we could not recover and, more important, patients with diabetes or heart failure who went months without follow-up. Our only intervention was a single automated text two days before each visit. This week's chapter on quality improvement gave me a structured way to change that.

Buchbinder and Shanks (2017) describe quality improvement as a continuous process of measuring performance, testing changes and building successful changes into routine work, and they present the Plan-Do-Study-Act cycle as a practical method. I used it as follows. In the plan stage, we audited a month of no-shows and found that patients who missed visits were most often those booked more than three weeks ahead and those with a prior missed visit. We set a goal of 10% within three months and agreed to test any change on one physician's schedule before spreading it, which is the heart of the method: small tests, measured honestly.

For the do stage, we chose a change the evidence supports. Robotham et al. (2016) combined 21 randomized trials and reported that text notifications cut the chance of a missed appointment by a quarter, 15% versus 21%, and that multiple notifications worked better than one. Oikonomidi et al. (2023) reviewed interventions that used predictive models to target patients at high risk of missing and found moderate-certainty evidence that targeted phone reminders reduced no-shows substantially. So for one physician's patients, we added a second text the day before the visit and a personal phone call to patients with a prior no-show.

In the study stage, that physician's no-show rate fell from 14% to 9% over six weeks while the others stayed flat. In the act stage, we adopted the change for the whole practice and began a second cycle aimed at patients booked far ahead.

Jesus described a shepherd who searches for a single missing sheep even though ninety-nine remain safe (English Standard Version Bible, 2001/2016, Luke 15:4). A no-show is often that one patient. An empty appointment slot is a quality problem only because a person who needed care is missing from it.

Reply to Brianna

Brianna, you suggested that your clinic simply overbook to make up for no-shows. Overbooking can protect revenue and keep physicians busy, but the evidence for it as a quality strategy is thin. Oikonomidi et al. (2023), in their review of predictive model interventions, found that the effect of model-based overbooking on outcomes was uncertain, whereas targeted reminders had stronger evidence. Overbooking also has costs: when more patients show up than expected, waits grow, physicians rush and patients who did come on time receive worse care. Werner et al. (2023) reviewed 61 studies of behavioral economic approaches to missed appointments and found strong support for reminders by text, phone or mail across many settings, but little testing of other approaches, which suggests that reminders should come first. They are cheap, they rarely harm anyone and they address the most common reason patients miss visits, which is simply forgetting.

I would suggest pairing a small amount of targeted overbooking, only in slots with the highest predicted no-show risk, with better reminders, and measuring wait times as well as no-show rates so you know whether overbooking is harming the patients who do arrive. Proverbs teaches that the plans of the diligent lead to abundance, but everyone who is hasty comes only to poverty (English Standard Version Bible, 2001/2016, Proverbs 21:5). A careful test on a single physician's schedule would show which approach helps your patients most before the whole clinic changes. Do you know your clinic's current no-show rate by appointment type? New-patient visits and long-booked follow-ups often run much higher than urgent visits, and the right strategy may differ for each.

Reply to Terrence

Terrence, you proposed offering free rideshare trips to patients who miss appointments, since many of your clinic's patients do not drive. Transportation is a real barrier for many patients, especially in neighborhoods with limited bus service, but a well-known trial suggests the idea needs careful targeting. Chaiyachati et al. (2018) offered free rideshare transportation to Medicaid patients at two Philadelphia primary care practices and found that only 26% of those reached used it, and the missed appointment rate was essentially unchanged: 36.5% with the offer and 36.7% without. The authors suggested that future programs target patients with the strongest transportation needs. The finding does not mean transportation is unimportant; it means that offering rides to everyone wastes effort on patients whose real barrier lies elsewhere. A clinic with limited money would get more value from finding the minority of patients who truly lack transportation and serving them well. Werner et al. (2023) also found that most evidence supports reminders, which suggests combining any transportation offer with a reminder call that asks directly whether the patient has a way to get there.

Jesus asked the blind man near Jericho, What do you want me to do for you? (English Standard Version Bible, 2001/2016, Luke 18:41). Asking patients what they need, rather than assuming we already know, might reveal that some lack rides while others lack child care or time off work. Could your clinic add a transportation question to its reminder calls and offer rides only to patients who say they need one, then track whether those patients keep their appointments?

References

Buchbinder, S. B., & Shanks, N. H. (2017). Introduction to health care management (3rd ed.). Jones & Bartlett Learning.

Chaiyachati, K. H., Hubbard, R. A., Yeager, A., Mugo, B., Lopez, S., Asch, E., Shi, C., Shea, J. A., Rosin, R., & Grande, D. (2018). Association of rideshare-based transportation services and missed primary care appointments: A clinical trial. JAMA Internal Medicine, 178(3), 383-389. https://doi.org/10.1001/jamainternmed.2017.8336

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Oikonomidi, T., Norman, G., McGarrigle, L., Stokes, J., van der Veer, S. N., & Dowding, D. (2023). Predictive model-based interventions to reduce outpatient no-shows: A rapid systematic review. Journal of the American Medical Informatics Association, 30(3), 559-569. https://doi.org/10.1093/jamia/ocac242

Robotham, D., Satkunanathan, S., Reynolds, J., Stahl, D., & Wykes, T. (2016). Using digital notifications to improve attendance in clinic: Systematic review and meta-analysis. BMJ Open, 6(10), e012116. https://doi.org/10.1136/bmjopen-2016-012116

Werner, K., Alsuhaibani, S. A., Alsukait, R. F., Alshehri, R., Herbst, C. H., Alhajji, M., & Lin, T. K. (2023). Behavioural economic interventions to reduce health care appointment non-attendance: A systematic review and meta-analysis. BMC Health Services Research, 23(1), 1136. https://doi.org/10.1186/s12913-023-10059-9