Planning clinics

This may not apply to every doctor but the statistical lesson is an interesting one.

Many folk in specialties set up subspecialist clinics to deal with particular conditions. Thus in rheumatology you can find early rheumatoid arthritis clinics, lupus clinics, combined clinics with orthopaedic surgeons or paediatricians etc.

There is a nice Powerpoint presentation which proves that this should be avoided if you wish to be efficient (1). Subdividing your work will increase your waiting lists and you will end up with some underbooked clinics. This is queue theory at work.

Do not be afraid to overbook clinics. There has been repeated blathering about the problem of patients who fail to attend their outpatient appointments. The Department of Health wants us all to stop patients not attending, because it is wasting the NHS £700m per annum. Actually a “Did Not Attend”, or DNA for short, costs nothing (2). People overbook their clinics to compensate for DNAs, just like the airlines do; what’s good enough for EasyJet is good enough for me. If everybody does turn up you have a hell of a clinic but it doesn’t happen often, and a no-show saves a lot of investigation, and no-one is actually charged for them (it would be different if they were).

Anyway – why do patients DNA? I audited this about 15 years ago and doubt much has changed. Many never got the appointment in the first place (sent to the wrong address, postal failure etc). Some cancel, but this does not get through to the clinic. A tiny number forget. Many have some other pressing commitment, such as a family funeral, a relative in hospital somewhere else, a childcare problem. Or the car broke down. I fell these are all quite reasonable excuses. Given the overbooking bit there is no need to spend vast sums on armies of clerks who are going to chase the patients up the day before, whether by phone, email or text message.

However there is a curious DNA issue which I call the endless loop syndrome. Let’s suppose a patient cancels and the clinic doesn’t know. What happens next is as follows:

• Let’s say the patient rings to cancel the day before the appointment (January 30th), and is rebooked for 5th March
• The patient doesn’t appear in clinic, so the clinician completes a DNA form, which generates another appointment booking. However this takes a day to process, and is for 12th March
• Patient receives the letter confirming their own rebooking
• Two days later they receive a second letter generated through the DNA, for 12th March. The letter says “Due to unforeseen circumstances your appointment with Dr Bamji has been changed to the 12th March”
• The patient thinks this change refers to the appointment they made for the 5th, but this remains on the system
• On 5th March the patient doesn’t appear in clinic, so the clinician completes a DNA form, which generates another appointment booking. However this takes a day to process, and is for 27th April
• The letter confirming this is received by the patient on the 11th March, and they assume it refers to the appointment the following day, so they don’t turn up
• On 12th March the patient doesn’t appear in clinic, so the clinician completes a DNA form, which generates another appointment booking. However this takes a day to process, and is for 9th May

And so on.

Moral: If a patient fails to attend make sure that there is not some later extant appointment. Eventually they will complain at being continually postponed and wonder what they have done to offend you.

References

1. See http://www.steyn.org.uk for some demand management presentations, including queue theory
2. Letter in “The Times” from Yours faithfully, 18th December 2010

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s