Patient Retention and Continuity of Care of an Underserved Oncology Population within a Public Safety-Net Health System

Abstract

Cancer patients in underserved populations are at high risk for patient attrition and treatment delay. Infrequent appointment recording often results in patients who are lost to follow-up. We hypothesized that the utilization of Lean Six Sigma methodologies would increase patient scheduling for radiation oncology appointments thereby increasing patient retention within a large urban safety-net health system. The entire clinic staff collaborated to improve electronic health record (EHR) appointment scheduling using the Lean Six Sigma DMAIC approach (Define, Measure, Analyze, Improve and Control). Appointment data was collected for three months prior to and during the pilot study period from the EHR and the radiation oncology record and verify system. We determined the root causes for delinquent scheduling, including lack of staff availability to schedule patients into two electronic systems and to call no-show patients to reschedule. Interventions included implementation of an electronic order for follow-up scheduling and blocked time for personnel to contact no-show patients and verify scheduling. After the formation of a novel process map, control plan, and Failure Modes Effects Analysis (FMEA), the pilot study commenced for a planned six-month period. We report on the first two months of our pilot study. Follow-up appointment scheduling into the EHR improved from baseline 2% to 98% (p<0.01). No-show appointment rescheduling into the EHR improved from baseline 0% to 64%(p<0.01). A novel electronic scheduling intervention was added after the first month when no-show rescheduling into the EMR was at 43% with subsequent no-show rescheduling after the second month at 87% (p = 0.01). The patient no-show rate declined from 19% for the pre-intervention period to 17% for the first pilot month and to 15% for the second pilot month (p = 0.3). Utilization of the Lean Six Sigma methodology resulted in a significant increase in appointment scheduling within the radiation oncology department. While not yet significant, the no-show rate appears to be trending downward as a result of this scheduling improvement, and we expect the no-show rate to continue to decline as the study matures. These findings suggest that optimized appointment scheduling may improve patient retention and continuity of care in an at-risk population. Future directions include evaluating cancer outcomes and healthcare cost savings as a result of higher patient retention.