Dr. Dowling is president of Dowling Medical Director Services, a private health care consulting firm specializing in quality improvement, clinical informatics, and health care policy affecting specialty care. He is the former medical director of a large,
Written policies should address scheduling guidelines and appointment cancellations, advises Robert A. Dowling, MD.
Among the top allegations against physicians resulting in payment in the National Practitioner Data Bank, failure to diagnose, delay in diagnosis, and failure to monitor rank first, third, and seventh, respectively. (Also see my recent article, “HHS program collects data on malpractice, adverse actions,” July 2019, page 21). Losing patients to follow-up can result in these allegations and create risk to the patients and the practice. In this article, I will discuss how seemingly mundane practice operations can contribute to or help mitigate risk in this area.
Also by Dr. Dowling: How to improve patients’ access to their health information
Urologists face a work force shortage and are among the busiest surgical specialists in the U.S. (bit.ly/AUA18census), resulting in pressure to see more patients per unit of time. More patient appointments also mean more pressure on the staff scheduling return visits and those answering phones, as well as more opportunities for costly reschedules, no-shows, and cancellations. A busy practice has many potential points of failure in this area, which are magnified when the occasional patient “falls through the cracks.” Every urology practice should have in place written policies to minimize these points of failure, cross-train on those policies, and constantly reinforce adherence to them.
What to include in scheduling guidelines
The first set of policies should address scheduling guidelines for your practice and providers. Common points of failure in the urology practice are elective surgical appointments, postoperative appointments, emergency encounters, and even routine follow-up appointments.
Elective surgeries typically require the coordination of several schedules (patient, provider, and facility), insurance verification, and more than one phone call. Your policy should make sure there is no opportunity to “lose” these patients and track where they are in the process.
One helpful practice is to create a resource in your practice management (PM) scheduling software called “Surgery scheduling,” and schedule an “appointment” for the patient on that schedule. Then, the staff working the steps in the process can work their “appointments” every day from that schedule and track the status. Once the surgery date has been determined, the patient should be scheduled in your PM system just like an office appointment.
Avoid having redundant schedule platforms or booking surgery appointments on software that was not designed for privacy, tracking, reporting, and compliance (Outlook, Google calendar, etc.). Best practice is to schedule the future postoperative appointment at the same time the surgery is scheduled to minimize the chance a surgical patient will not get an appointment; this is also a common courtesy to the patient and a reminder that they need postoperative care and follow-up.
The patient with the chronic indwelling ureteral stent requiring periodic exchange deserves special mention. Many of these patients and their providers see no benefit in an office appointment between exchanges and simply schedule periodic elective surgeries to change the stent. These patients are particularly vulnerable to complications, and your practice should never rely solely on the patient to “call us to schedule in 4 months.” Create a placeholder appointment in the PM system that reminds the scheduler when it is time to reschedule.
Patients that are seen first in an acute setting-hospital or emergency room-are also vulnerable to being lost: They are not preregistered in the practice systems, often have multiple providers, may not hear or comprehend the rationale for following up, and in some cases may seek to avoid accountability for expensive hospital bills.
The best practice to ensure these patients follow up is to submit charges daily and use the first charges as a prompt to attempt to contact the patient by phone as soon as possible, even if they are still in the hospital. Be sure your physicians and staff understand financial policies and the responsibility of the practice, if any, to continue to follow the patient after their acute episode (patients with indwelling stents, for example).
Finally, don’t forget the routine process that happens at your checkout desk-scheduling routine appointments. Many patients will resist making an appointment at checkout for a variety of reasons, and some may even refuse (see below). This is particularly common for an annual or semiannual appointment months in the future. In this case, it is best to make a “placeholder appointment” that can then be moved, if necessary, when the patient calls back with a firm date and time. Your policy should ensure that no patient whom the provider intended to continue to follow is ever missing from your future appointments schedule.
While some practices use “recalls” to cut down on no-shows (bit.ly/practicerecalls), this creates another resource-intensive workflow and an inability to easily mine data on “future appointments.” I recommend keeping it simple-every active patient should have a future appointment.
Next: Addressing missed appointments, cancellationsAddressing missed appointments, cancellations
Now that your practice has established a standard scheduling policy that addresses all of the common scenarios, you need a companion policy that addresses the common issues of refusal to schedule an appointment, missed appointments, cancellations, and reschedules. That policy should address how, when, and how often to attempt to contact the patient; how and when to notify the provider; and how the outcome is documented in the medical record. While some circumstances are more serious than others (eg, the patient with testis cancer who misses his surveillance appointment), the process will usually involve non-clinical staff and is best kept simple without exceptions or discretion.
For example, your policy might state that patients who miss an appointment are first contacted by phone; if this is unsuccessful, a written letter is generated; if this attempt doesn’t generate an appointment within 2 weeks, a certified letter is routed to the physician for signature-who is the best decision maker regarding whether to send the letter. Another decision is whether to terminate the physician/patient relationship and can be addressed at the final point in your policy.
Whether you decide to have one step or five steps, your policy should ensure that the provider is aware of every patient who permanently drops off the schedule and is given an opportunity to contact the patient and/or create the appropriate documentation in the medical record. Cancellations usually come in the form of a phone call, and the policy will need to address what your staff says to the patient and the workflow for communicating the outcome to the provider.
Your policy for rescheduling may require more parameters; for example, rescheduling office visits versus procedures, rescheduling within a certain time frame, or rescheduling new versus established patients. Again, you will need to strike a balance between one-size-fits-all (safest) and creating different rules for different situations (riskier).
Bottom line: Urologists are at risk of malpractice allegations not only for their actions, but sometimes for their inactions. The physician/patient relationship creates some accountability for both parties, but the information imbalance means that the physician bears the greater responsibility for taking reasonable steps for continuity of care. Be sure your practice has written policies that address the common reasons patients may be lost to follow-up, and that you follow those policies.