HLTH 6882 Week 11 Final Improvement Proposal Paper Example

Improvement Proposal: Recovering Lost Specialist Visits at Prairie Bend Community Hospital Through a Booking Window and Short-Notice List

Student Name

Walden University

HLTH 6882: Improving Healthcare Performance Through Social Entrepreneurship

Instructor Name

Month Day, Year

Improvement Proposal: Recovering Lost Specialist Visits at Prairie Bend Community Hospital Through a Booking Window and Short-Notice List

Executive Summary

One booked specialist slot in four at Prairie Bend's visiting specialist clinic ends without a completed visit, about 40 lost visits a month, and two-thirds of those losses come from visits booked six or more weeks ahead. We propose replacing the current practice of booking every referral on arrival with a three-week booking window, a short-notice list for late cancellations and one-week reminders, run by an outreach coordinator function carved from existing scheduler hours. On illustrative figures, the change costs about $24,000 a year and $3,000 to start, and returns about $29,000 in recovered visit revenue and $36,000 in a planned orthopedic session day that would no longer be needed. We ask the chief executive and the finance committee to approve a one-quarter pilot on orthopedic sessions and, if it meets its predictions, adoption across all specialties.

How Large Is the Problem

Prairie Bend Community Hospital, a composite rural hospital, holds critical access status, a designation that limits it to 25 inpatient beds and a short average stay (42 C.F.R. § 485.620) and makes it depend on visiting specialists for cardiology, orthopedics and urology. Across the past year the visiting clinic completed 1,440 of its 1,920 booked visits, a kept rate of 75%. Lost slots are no-shows plus cancellations inside the final two business days that nobody refills. The clinic's own best three months averaged 89%, which supports a target of 90%. All figures in this proposal are illustrative; full tables appear in the appendices of the earlier analyses.

Why It Happens

Slots booked 43 or more days ahead were lost at a rate of 37%, against 10% for slots booked within three weeks. Tracing the cause in the clinic's records led to an unwritten rule of booking each referral the moment it arrives; the nearest sessions fill up, pushing later referrals six weeks or more out, by which time many patients forget the date or have been seen elsewhere. Transport was tested as an explanation and rejected; lost rates barely changed with distance. Published reviews rank long lead time high among predictors of missed visits (Dantas et al., 2018), and the clinic's data shows it at a striking scale.

What Peers Do

Cedar Ford Memorial Hospital, a composite peer in the same state network, keeps about 88% of booked specialist slots after reconciling definitions. It opens slots only three weeks before each session, keeps a short-notice list that refills about half of late cancellations and sends text reminders a week ahead. The window and the list address the cause found at Prairie Bend directly and could transfer with little change.

What Would Change

Referrals that are not urgent will wait on a holding list; slots will open three weeks before each session; patients able to come at short notice will form a list called after late cancellations; and a one-week reminder will be sent by text, or by call where a patient has no mobile phone. Urgent referrals will be booked at once. The scheduler will work about ten hours a week as outreach coordinator, stopping registration coverage on session days, rebooking calls after no-shows and mailed reminder letters; a float clerk will cover registration on the four session days. The county aging offices will be asked to accept short-notice ride requests, reaching past resources the hospital holds, in the sense Dees gave social entrepreneurship (Dees, 2007). Advanced access work supports redesigning how capacity is booked before adding more of it (Murray & Berwick, 2003).

How It Would Be Tested

The pilot will run on orthopedic sessions for three consecutive session days. Its predictions, written before it starts, are that the kept share for orthopedics will rise from 71% to between 80% and 88%, that 35% to 60% of late cancellations will be refilled and that coordinator work will take 8 to 12 hours a week. These are predictions, not results. The design follows the plan-do-study-act method, including the features a systematic review found most often skipped: stated predictions, a small-scale test and frequent data over time (Taylor et al., 2014). The pilot will stop if an urgent referral waits on the holding list, if any session day falls below 65% or if the specialist group reports disruption.

What It Costs and Returns

Recurring costs are about $14,560 a year in coordinator hours and $9,216 in float clerk coverage; start-up costs are about $3,060 for reminder setup and training. Returns are about $28,800 a year if half of lost slots are refilled, valued at a stand-in $120 net per visit for the finance office to correct, because critical access hospitals are paid for outpatient services on a cost basis (42 C.F.R. § 413.70), and $36,000 in a second orthopedic session day already in next year's budget. The coordinator hours come from tasks the change replaces and from registration coverage the float clerk takes over. Should recovery reach only one lost slot in four while the second orthopedic day is still bought, spending would exceed returns by roughly $9,000 a year; the case therefore depends on whether recovered orthopedic slots shorten the waiting list.

How Anyone Will Know

The outcome measure is the kept rate, defined exactly as in the gap analysis. Process measures track short-notice offers within one business day, reminder reach and median days from referral to visit. Balancing measures track registration wait times on session days and sessions running past their contracted end. Each appears on a run chart centered on the 71.5% baseline median, and improvement is declared only when at least six points in a row sit above that line (Perla et al., 2011).

Keeping the Change Alive

Many improvements fade once their champion moves on. Reviewing 125 sustainability studies, Wiltsey Stirman and colleagues reported that rigorous assessment of whether programs lasted was rare, and they listed organizational context, capacity and processes among the forces shaping whether programs survive (Wiltsey Stirman et al., 2012). This proposal therefore names three safeguards that do not depend on any one person. The outreach coordinator function will be written into the scheduler's job description, with its hours protected, so it survives a change of scheduler. The three-week booking window and the urgent-referral exception will be written into the outpatient services policy manual, so the rule is no longer unwritten. And the quality committee will review the kept rate every month, so that a slide back toward the old practice is visible within a month.

Decision Requested

We ask the chief executive and the finance committee to approve the one-quarter orthopedic pilot now, with its staffing and template changes, and to agree that adoption across all specialties will be decided on the pilot's results against its written predictions. If approved, the pilot can start with the next orthopedic session confirmed under the specialist contract's 60-day notice.

References

Condition of participation: Number of beds and length of stay, 42 C.F.R. § 485.620 (2024).

Dantas, L. F., Fleck, J. L., Cyrino Oliveira, F. L., & Hamacher, S. (2018). No-shows in appointment scheduling: A systematic literature review. Health Policy, 122(4), 412-421. https://doi.org/10.1016/j.healthpol.2018.02.002

Dees, J. G. (2007). Taking social entrepreneurship seriously. Society, 44(3), 24-31. https://doi.org/10.1007/BF02819936

Murray, M., & Berwick, D. M. (2003). Advanced access: Reducing waiting and delays in primary care. JAMA, 289(8), 1035-1040. https://doi.org/10.1001/jama.289.8.1035

Payment for services of a CAH, 42 C.F.R. § 413.70 (2024).

Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality & Safety, 20(1), 46-51. https://doi.org/10.1136/bmjqs.2009.037895

Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety, 23(4), 290-298. https://doi.org/10.1136/bmjqs-2013-001862

Wiltsey Stirman, S., Kimberly, J., Cook, N., Calloway, A., Castro, F., & Charns, M. (2012). The sustainability of new programs and innovations: A review of the empirical literature and recommendations for future research. Implementation Science, 7, Article 17. https://doi.org/10.1186/1748-5908-7-17