1. Proactive Overbooked Routines Through Empiric Noshow Data (PORTEND) Ped Bunsongsikul MD 1/24/2014

2. Problem Patient No-shows impair our ability to provide excellent access 59% of any given Family Medicine W will have a no- show. (based on historical data)

3. Potential Solutions Automatic Overbooking to compensate for anticipated No shows Change provider mindset to the thought that no-shows are undesirable.

4. 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.

5. Calculation of the PORTEND output *The Terradata Query is found in the Notes of this slide

6. Data - 1 Year BPK Family Med July 2013-June 2014 Baldwin Park Family Medicine Physician Providers (23,564 Ws)

7. 6 Month Family Medicine Data

8. Prospective Predictions – Dry Run 8/26-9/27 Baldwin Park Family Med

9. Procedures Current Process Report run on Wednesday. The schedules are adjusted that same day The latest booked routine slot is converted to an overbook. The original overbook slot is converted to an unblocked routine slot. The slot in the same period becomes an unblocked routine slot as well. Net effect is 2 additional routine slot available for the call center to book. -2 potential same day appointments. The overbook slot is “pre-booked”.

10. Template The latest booked routine slot is converted to an overbook. The original overbook slot is converted to an unblocked routine slot. The slot in the same period becomes an unblocked routine slot as well. Net effect is 2 additional routine slot available for the call center to book. Minus 2 potential same day appointments. The overbook slot is “pre-booked”.

11. Additional Exclusion Rules If you have travel time or other held/IW time in the W, you will not get the addon (At discretion of the scheduler) Need at least 9 appointments available in the supply. It takes about 2 hours for the schedulers to make the changes each week.

12. Implementation Timeline 8/26/2013-9/27/2013 Dry Run. 540 appointments added. 79.9% of the identified shifts actually had a no- show. 9/30/2013 West Covina and Montebello went live 10/30/2013 San Dimas went live 12/4/2013 Baldwin Park, Diamond Bar went live

13. PORTEND Summary 9/30/2013-12/27/2013 522 Ws were adjusted with an Overbooked Routine 19 Ws Clinic Canceled (Leaving 503 W affected) 416 of 503 Ws had at least one noshow (82.7%) 266 Ws had more routines booked than supply (Actual routine appointments created)

14. PORTEND Summary Continued Defined by Supply 33 ‘Bad days’ out of 503 Ws 6.6% Where pts seen is greater than supply Compare to 592 ‘bad days’ out of 6656 Ws without adds = 8.9% Selection bias is present because, as the PORTEND Ws are more likely to have no-shows.

15. PORTEND Summary Continued 4766 total Provider Ws for the clinics affected 503 of 4766 Ws were affected (10.6%) 503 of 3976 No shows compensated for (12.7%) 266 of 3976 True compensation (6.7%) Sensitivity = 416/2665 Ws with a NS = 15.6% Actual W No Show Rate = 2665/4766 = 55.9%

16. Measures

17. Time to 3rd available appointment Fam Med Dept: % of MD’s with Next 3rd Available < 14 days 78% (Oct) -> 84% (Nov) -> 90% (Dec) Booking Utilization (booked/supply) 101.7% (Portend) vs 93.9% (Unadjusted) Actual Supply Utilization (pt’s seen/supply) – (selection bias) 86.4% (Portend) vs 83.8% (unadjusted) Net Loss Fam Med Dept: 15.4% (Oct) -> 15.2% (Nov) -> 13.4% (Dec)

18. Measures Downside Providers might need to see more patients Decrease supply of Same Day appointments

21. Limitation This method identifies the shifts that are likely to have a no-show. However, it does not identify which patient will no-show.

22. 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). Currently on hold due to the flu season.

23. 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. There may be a better overbooking process to minimize the work required by the schedulers. (Takes 1-2 hours a week to make changes to 70-100 schedules)

24. Future Directions Expand to other primary care departments (internal medicine) Improvements Join the Appointment Supply into the Terradata Query (done) Increase frequency of the runs (will increase sensitivity) 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. Planning for July 2014. To place an overbook slot on an unblocked slot. Factors The Call Center software has been delayed until April 2014. Preparing a report to present to Region and perhaps publish in the Permanente Journal.

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