Reducing the No-Show Rate in Immunization Clinics at a Local Health Department: Lessons Learned

Summary

Impact Statement:

This 10-county District health department improved the processes of immunization clinic scheduling, preparation and follow-up and reduced the number of “no shows” , leading to greater efficiency and capacity. The improved process and staff training were then standardized across the 10 counties.

Summary:

The overall no-show rate for immunization clinics at District Health Department (DHD) #10 was too high, leading to inefficiencies in clinic effectiveness. A quality improvement (QI) process was used to study the issue, collect data, determine possible solutions, test the solutions, implement strategies, and continue to monitor the no-show rate. The fishbone technique helped the team understand more about why clients did not keep appointments. The IS map illustrated the scheduling process for immunizations and highlighted the differences among the 10 counties. Techniques were tested to improve the no-show rate, including the use of incentives, collecting best methods to contact clients, and making reminder calls. No-show data were collected before, during, and after the QI project. Findings led to a standardization of the immunization clinic process and staff training across all 10 counties.

Organization that conducted the QI initiative:

District Health Department #10

Citation:

Oleniczak, S. Public Health Quality Improvement Exchange. Reducing the No-Show Rate in Immunization Clinics at a Local Health Department: Lessons Learned. Thu, 12/27/2012 - 15:17. Available at https://phqix.org/content/reducing-no-show-rate-immunization-clinics-local-health-department-lessons-learned. Accessed May 28, 2023.

Background and Aim

Planning and Execution Details

QI Implementation:

(See attached storyboard) Immunization clinics were experiencing significant appointment no-shows, thus providing an opportunity for improvement in customer service for both internal and external clients. The QI team developed a flow chart of the clinic appointment scheduling process and clinic preparation. It was determined early that there were many versions of the scheduling process across the 10 counties and that process assumptions made by administration were not necessarily accurate in all the counties. This led to the need to gather local data on the process to compare to the assumed process. Each county was asked to develop a process map on its clinic flow from scheduling to clinic day to dealing with no-shows. The 10 process maps were compared to the administration assumed process map. Possible reasons for no-shows were outlined using a fishbone diagram, and the five whys were used to narrow the focus in determining intervention possibilities. It was determined that baseline no-show data from the previous year were needed. These data were collected from all 10 counties and presented in a graph to illustrate the total number of appointments, the number of no-shows, and the percentage of no-shows by county. Graphs were also developed to illustrate the time during the day and season when no-shows occurred. Review of the 10 county process maps led to a revised “best practice” process map, and clerical and nursing staff were trained. Four pilot initiatives were chosen and implemented in five different counties: client incentives for keeping appointment; send reminder postcard a week ahead; call clients 48–72 hours before the appointment with documentation of call and when; and collection of best method to contact client and utilization of reminder system based on client preference. Ongoing data collections on no-show rates were collected quarterly and reviewed. Steps Taken: • Collected baseline of no-show rates for all 10 counties for the previous year. • Developed assumed process/flow chart of immunization clinics. • Presented the flow chart to clerical staff and then to nurses for input by county. • Conducted interviews of staff in the immunization clinic to gain information on factors that influence the no-show rate—including nurses and clerical support staff. • Nurses collected information from clients who did not keep their appointment as to the reasons. • Analyzed no-show data and the scheduling and reporting process. • In five counties, one of four interventions was tested for 3 months to improve the no-show rate: send reminder postcards; call clients 48–72 hours before the appointment; ask client for prefered method to contact; provide incentives for keeping appointments. • Collected quarterly no-show rates and reviewed the interventions for a positive impact.

Focus activities

Immunization:

Adult Immunizations- administration of vaccine to population

Administration:

Customer Service/satisfaction

Organizational effectiveness

QI Methods:

PDCA/PDSA Cycle (Plan, Do, Check/Study, Act)

QI Tools:

Initiative Dates:

4/1/09 to 9/30/10

Initiative Duration:

Between 12-18 months

Methods of evaluation:

In five counties, one of four interventions was tested for 3 months to improve the no-show rate: • Send reminder postcards. • Call clients 48–72 hours before the appointment. • Ask about the best method to contact clients. • Provide incentives for keeping appointments.

Supplemental Materials:

Storyboard

Supplemental Files:

Attachment	Size
MLC3 StoryBoard final DHD10 April 15 2010 updated.pdf	196.85 KB

Results

Measurable QI Outcomes:

Our project did not lead to measurable outcomes as it was determined early that all 10 counties used different forms for scheduling and different processes for client reminders, thus making standardization of data collection extremely difficult and the ability to show improvements nearly impossible. In addition, during the intervention stage of the QI project, H1N1 as a public health emergency hit and created a confounding variable both in our QI team being able to meet regularly and, more importantly, in any hope of a true implementation of our pilot interventions. Clinic staff were extremely busy, and H1N1 often took priority over maintaining the interventions and data collection. Several of our team meetings and teleconferences had to be cancelled. In general, the data collected were not reliable. Interventions were not implemented with any fidelity.

Other QI Outcomes:

One outcome that was immediately realized was the need for a standardized process for scheduling because all 10 counties used different forms for scheduling, thus making standardization of data collection extremely difficult—ultimately, this led to immunization scheduling going to an electronic process. Moving to an electronic process also addressed the standardization of collecting a no-show rate.

Lessons Learned, Observations and Insights:

The process of collecting data, scheduling, check-in, and follow-up differed among counties and this affected the no-show rates and the accuracy of the data collected. Also, the impact of H1N1 as a public health emergency was a confounding variable during the QI process. Several team meetings had to be cancelled, clinics were busier, additional staff were pulled in to assist and may not have been familiar with the processes, the interventions were not always conducted, and staff responsibilities changed. (See the attached storyboard for lessons learned and the complete project.) In summary, while the QI project did not produce documentable numbers for improvements, it was a learning opportunity for team members, who then took the process back to share with the broader agency and implemented training and QI projects within their divisions.

Future Plans:

• Immunization scheduling has moved to an electronic scheduling system to assure continuity across the district and standardize the process. • All counties will make reminder calls one business day before the appointment. • Clients will be asked for the best way to contact them (phone, text, e-mail, etc.) and will be documented in the agencies' electronic medical record/scheduling system. • No-show data will continue to be collected and reviewed. • If the no-show rate increases, a PDSA cycle will be initiated to look for improvement opportunities.

Reducing the No-Show Rate in Immunization Clinics at a Local Health Department: Lessons Learned

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

Comments

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Reducing the No-Show Rate in Immunization Clinics at a Local Health Department: Lessons Learned

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

Comments

QI Spotlight