A project at Seattle Children’s to address missed appointments at its ambulatory clinics shifted to reducing disparities that impede access to care.
The challenge
The missed appointment rate across all Seattle Children’s ambulatory services was 8.8%, higher than the hospital’s internal benchmark of 7.5%. A cross-functional team tasked to investigate the problem started with a pulmonary specialty clinic with an overall missed appointment rate of 11.2%.
However, the data suggested patients from underrepresented groups missed appointments at higher rates. For example, patients who identify as Black or African American missed appointments in the pulmonary clinic at a rate of 19.4% and those who spoke Spanish missed 12.8% of appointments.
“The early data showed significant disparities, which changed the course of the project. We wanted to narrow that gap, and that really changed the work for us,” said Tia Rooney, director of ambulatory operations.
The process
The multidisciplinary team included practice and program leaders, schedulers, data analysts, and patients’ family members and guardians who offered insights into why appointments are missed. The team experimented with solutions. Personalized text messages and reminder calls did not offer statistically significant changes. The team next attempted to pinpoint patients with a high likelihood of missing appointments. Daniel Harton, Seattle Children’s lead data analyst, looked at five years’ worth of missed and completed appointment data to create a model that predicted a patient’s probability of missing an appointment with 89% accuracy. More than 20 features were included in the predictive analysis, including:
- Day and time of the appointment.
- Number of days between appointment scheduling and the date of the appointment.
- Type of appointment.
- Patient use of MyChart.
- History of completed and missed appointments.
- Type of insurance.
Demographic information such as race, ethnicity, and language data, were not included in the predictive model.
The solution
Knowing which patients were most likely to miss an appointment allowed the team to develop an intervention. Patients at 40% or higher risk of missing an appointment were called by a scheduler a few days prior to the appointment. During the Predictive Missed Appointment Call (PMAC), the scheduler used a specific script to identify ways to help the patient complete the appointment.
“We tried various scripting and specific words,” Rooney said. “It seems very simplistic but the number of iterations we went through regarding the language used was critical to success.”
At first, the scheduler asked the patient’s parent or guardian if there were any “barriers” that would prevent the patient from coming to the appointment. Eventually, the team landed on “Can I provide you any accommodations?” Rooney said that question prompted family members or guardians to identify specific needs.
The PMAC scheduler was equipped with a menu of hospital- and community-based services to offer patients. For instance, Seattle Children’s helped families find short-term childcare for siblings during the pandemic when visitor restrictions were in place. Transportation to appointments and negotiating insurance preauthorizations and other challenges were other common requests.
“The goal is to help patients receive the care they need to improve outcomes. Anything we can do to help reduce a disparity works toward that goal,” Rooney said.
The missed appointment rate at the pulmonology clinic decreased from 11.2% overall to 7% after PMAC calls started. The missed appointment rate among patients who identify as Black or African American and Spanish language speakers also decreased to 12.7% and 8.5%, respectively. The initiative has been expanded to other specialty clinics and a community health center.
- A dermatology clinic reduced its rate from 16.5% to 13.3%.
- A neurology clinic reduced its rate from 12% to 9.7%.
- A community health clinic reduced its rate from 26.7% to 18.7%.
Rooney said the project has shown positive results, but there’s still work to do. “It has reduced missed appointments across the board, but we still have a huge opportunity with other patient populations,” she said.
Lessons learned
- Include a representative from your organization’s diversity, equity, and inclusion staff on the team.
- Conduct “warm handoffs” by connecting the patient’s family member directly to the service provider instead of asking the family member to contact the provider directly.
- Mark requested accommodations in the patient’s electronic record so services can be organized before future appointments.
- Expand accommodations and services to account for different geographic communities or patient populations.
Rooney and Harton’s presentation, “An Equitable Approach to Reduce Missed Appointments,” was a session at Children's Hospital Association's 2024 Transforming Quality Conference.
