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Chapter V: Results
The objective of this quality improvement project was to decrease the number of
missed appointments and increase telehealth utilization at a family medical clinic by
implementing evidence-based interventions. This section highlights the project's outcomes,
which were evaluated through data analysis of pre-and post-intervention metrics, including
the total number of missed scheduled appointments, usage of telehealth services, and post-
implementation staff satisfaction survey. These factors were employed to assess and
determine the project's success.
Sample Description
During the 12-week quality improvement project conducted from April to June 2023,
a total of 1,821 patients had scheduled appointments with healthcare providers at the clinic.
To ensure the selection of a focused and relevant sample, specific inclusion criteria were
applied. Participants were required to be over 18 years old, identify as male or female, speak
English, and have an existing care relationship with the clinic. As a result of applying these
criteria, 721 patients were excluded from the study. The reasons for exclusion included being
17 years old and younger, non-English speaking individuals, or not currently enrolled in the
clinic. Consequently, a total of 1,100 patients were carefully chosen and included as
participants in the project.
Missed Scheduled Appointments Impact
During the 12-week quality improvement project, a range of integrated interventions
was implemented, incorporating live phone-call reminders, SMS messaging reminders, and
telehealth services. These interventions successfully yielded a notable 6.12% reduction in the
missed appointment rate, effectively achieving the project's primary objective of improving
patient attendance. To assess the overall percentage of missed appointments, the number of
2
unattended appointments was divided by the total number of patients scheduled at the clinic,
as outlined in Table 1. The results underscore the effectiveness of the integrated interventions
in enhancing patient attendance and demonstrate their vital role in optimizing healthcare
delivery.
Table 1:
Total Percentage of Missed Scheduled Appointments from January to June 2023
23-Jan
23-Feb
23-Mar
23-Apr
23-May
23-Jun
Scheduled Appointments
411
432
389
384
373
403
Missed Appointments
103
101
94
87
64
58
% Missed Appointments
25.06%
23.38%
24.16%
22.66%
17.16%
14.39%
Figure 1 presents a bar graph illustrating the changes in missed appointment rates
before and after the implementation of evidence-based interventions. Prior to the
intervention, the rate of missed appointments was 24.19% between January and March 2023.
However, following the implementation of the intervention, the missed appointment rate
decreased to 18.07% from April to June 2023. This graph clearly demonstrates the significant
reduction in missed appointments resulting from the intervention, indicating its effectiveness
in improving patient attendance.
Figure 1:
Percentage of Missed Scheduled Appointment Pre-and-Post Implementation
3
Pretest Mean
Post-test Mean
0%
5%
10%
15%
20%
25%
30%
24.19%
18.07%
A paired sample t-test was conducted to compare the means of missed appointment
rates before and after the intervention. The analysis was performed on a sample size of 1100
participants. The mean missed appointment rate in the pretest was determined to be 0.3197,
whereas, in the post-test, it decreased to 0.1930. The obtained p-value was exceptionally low,
indicating a value of 0.0000. This extremely small p-value provides robust evidence against
the null hypothesis, signifying that the observed difference in missed appointment rates
between the pretest and post-test is statistically significant.
Table 2:
Paired Sample T-test for Means
t-Test: Paired Two Sample
for Means
Missed Appointments
Pretest(%)
Missed Appointments
Post-test(%)
Mean
0.3197
0.1930
Variance
0.0102
0.0024
Observations
1100
1100
Pearson Correlation
-0.0168
Hypothesized Mean
Difference
0
df
1099
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t Stat
37.2481
P(T<=t) one-tail
2.3259E-197
t Critical one-tail
1.646241309
P(T<=t) two-tail
4.6518E-197
t Critical two-tail
1.962124896
Over the course of 12 weeks, a consistent decrease in missed appointments was
observed as illustrated in Figure 2. The project began with a missed appointment rate of
25.06% in the first month, which served as the baseline. As time progressed, the rate of
missed appointments gradually declined. By May 2023, the rate had dropped to 17.16%,
signifying a substantial improvement compared to the initial baseline. The persistent
reduction in missed appointment rates throughout the project highlights the lasting impact of
the intervention in minimizing missed scheduled appointments.
Figure 2:
Trend of Missed Appointments from January to June 2023
23-Jan
23-Feb
23-Mar
23-Apr
23-May
23-Jun
0
20
40
60
80
100
120
Utilization of Telehealth Services
The utilization of telehealth services was assessed by analyzing electronic health
records (EHR) over a 12-week period, both before and after the implementation of the
project. Table 2 provides valuable insights into the utilization trends during this period.
5
Initially, it was observed that 7.06% of the participants were utilizing telehealth services from
January to March 2023. However, with the introduction of the intervention, there was a
remarkable shift in the adoption of telehealth. In the subsequent post-test from April to June
2023, the utilization rate significantly increased to 12.24% of the participants actively
utilizing the available telehealth service (see Figure 3).
To determine the overall percentage of telehealth service utilization, the total
percentage from the pre-and post-implementation phases was calculated and divided by three,
representing the three months of the study period. This assessment provides a comprehensive
understanding of the utilization patterns and highlights a significant improvement in the
utilization of telehealth services following the implementation of the project.
Table 2:
Total Percentage of Telehealth Utilization from January to June 2023
23-Jan
23-Feb
23-Mar
23-Apr
23-May
23-Jun
Scheduled Appointments
411
432
389
384
373
403
Telehealth Utilization
73
77
83
107
130
167
%Telehealth
6.64%
7.00%
7.55%
9.73%
11.82%
15.18%
Figure 3:
Percentage of Telehealth Utilization Pre-and-Post Implementation
Pretest Mean
Post-test Mean
0%
2%
4%
6%
8%
10%
12%
14%
%Telehealth
6
Staff Satisfaction Survey
The quality improvement project successfully achieved its objective of enhancing
staff satisfaction within the designated 12-week timeframe. All seven staff members
completed the post-implementation surveys distributed via Survey Monkey and returned
them on time. The average score on the Likert scale was 3.5 points, indicating a satisfactory
level of staff satisfaction. Analysis of the post-test results revealed that four staff members
reported strong satisfaction, two reported somewhat satisfied, and one expressed a neutral
response. Notably, no instances of strong dissatisfaction were reported among the surveyed
staff members. Figure 4 visually presents the average responses from the post-
implementation questionnaires, providing further evidence to support the accomplishment of
our stated objective. However, it is important to acknowledge that one participant did not
respond to one of the questions in the post-implementation questionnaire.
Figure 4: Staff Satisfaction Survey Post-Implementation
Str
ongly
satis
fed
Somewha
t satisfed
Neithe
r
di
ssa
tisf
ed
nor satisfed
Somewhat dissatisfed
Str
ongly
dissatis
fed
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Satisfaction
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Chapter VI: Discussion
Evaluation of Processes and/or Outcomes
The quality improvement project aimed to achieve three objectives within a twelve-
week period. The first objective was to reduce the rate of missed appointments by 2%.
Impressively, the project exceeded this target, achieving a 6.12% reduction in missed
appointments. The rate of missed appointments decreased from 24.19% to 18.07%, indicating
a significant improvement in patient attendance. To evaluate the effectiveness of the
interventions, a paired sample t-test was conducted on a sample size of 1100 participants. The
results of this statistical analysis showed a statistically significant decrease in the mean
missed appointment rate, from 0.3197 in the pretest to 0.1930 in the post-test. This outcome
emphasizes the effectiveness of the implemented strategies in improving patient attendance
and reducing the burden of missed appointments in the clinic.
The second objective was to increase the utilization of telehealth services offered by
the family medical clinic by 3% within the 12-week timeframe. The project successfully
achieved this goal, with the rate of telehealth service utilization increasing from 7.06% in the
pretest to 12.24% in the post-test. The successful increase in telehealth service utilization not
only demonstrates the project's effectiveness but also reflects the clinic's adaptability to the
evolving landscape of healthcare delivery.
Lastly, the project aimed to enhance staff satisfaction with the newly implemented
appointment reminder process. The target was to achieve an average of 3.5 on the Likert scale
within the 12-week period, which was measured through a customized post-satisfaction
survey. The project successfully achieved this objective, with staff satisfaction significantly
reaching an average score of 3.5 on the Likert scale. All seven staff members participated in
the post-implementation surveys, with four reporting strong satisfaction, two reporting
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somewhat satisfied, and one expressing a neutral response. Importantly, no reports of strong
dissatisfaction were received from the surveyed staff members. This outcome highlights the
project's positive impact on staff satisfaction and the overall work environment within the
clinic
.
The quality improvement project effectively addressed its three main objectives,
resulting in reduced missed appointments, increased utilization of telehealth services, and
enhanced staff satisfaction with the new appointment reminder process. The positive
outcomes of this project demonstrate its significant impact on improving patient attendance,
aligning with the current trend of telehealth adoption, and promoting staff satisfaction within
the family medical clinic. These achievements not only contribute to the patient’s relationship
with the clinic, the clinic's overall efficiency, and effectiveness but also serve as a testament
to the value of quality improvement initiatives in healthcare settings.
Analysis of the Implementation Process
The initial step of the process centered around effective communication strategies to
inform both patients and staff about the project. Proactive measures were taken by the clinic
to inform patients during the scheduling process, and email communication was conducted to
ensure all staff members were aware of the changes and understood the project's goals and
objectives. This initial step laid the groundwork for engagement and participation,
significantly reducing resistance to change and increasing the likelihood of successful
adoption. As the implementation progressed, the clinic made necessary modifications to the
appointment reminder process based on feedback from staff and patients. The timing of
phone calls and SMS reminders was adjusted to optimize patient response rates. Additionally,
when the clinic manager conducted follow-up phone calls to patients who missed their
appointments, inquiries regarding the reason for the missed appointment were asked. These
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modifications were implemented to enhance the intervention's effectiveness and address any
identified challenges.
Throughout this step, several important lessons were learned. The clinic recognized
the importance of clear and concise communication, emphasizing the use of simple language
and avoiding medical jargon in patient communication. Staff members were provided with
ample opportunities to seek clarification and ask questions, ensuring their understanding and
buy-in. Furthermore, the clinic prioritized promptly and transparently addressing staff
concerns to maintain their engagement and cooperation.
The most crucial success achieved during the implementation was the establishment
of a strong foundation for the quality improvement project. Effective communication of the
project's objectives and goals fostered ownership and engagement among staff members. This
led to staff embracing the project, complying with its requirements, and actively contributing
to its success. Furthermore, informed patients, resulting from the communication efforts,
demonstrated improved adherence to appointments and utilization of telehealth services,
which positively impacted patient outcomes and satisfaction. To facilitate effective
communication, personalized approaches such as phone calls and SMS reminders were
employed, resulting in a reduction in missed appointments. The promotion of telehealth
services also played a vital role in adapting to technological advancements in healthcare
delivery. Emphasizing the benefits and convenience of telehealth helped patients recognize its
value and encouraged their participation. Another valuable lesson learned during the
implementation was the importance of continuous monitoring and feedback from staff
members. By implementing a post-implementation survey questionnaire, staff satisfaction
levels were assessed, providing valuable insights for adjustments and improvements in the
intervention process. Establishing regular communication channels and feedback loops
proved essential in addressing challenges and ensuring ongoing staff engagement.
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The implementation process was not without its challenges. Difficulties in
implementation included the initial adjustment period for staff members to familiarize
themselves with the new intervention process. It required coordination among various roles,
which may have caused some initial challenges and delays. However, with ongoing training
and support, these difficulties were overcome, and the intervention became an integral part of
the clinic's workflow.
Analysis of Limitations
While the project aimed to decrease the incidence of missed scheduled appointments
and improve telehealth services, there were a few limitations and deviations from the original
project plan that could have affected the effectiveness of the intervention. One limitation was
the small sample size. The project involved 1100 participants, which may not fully represent
the diverse population attending the clinic. A larger sample size would have provided more
robust data and increased the generalizability of the findings. Additionally, the project was
conducted in a single clinic, which limits the generalizability of the results to other healthcare
settings.
Furthermore, the project did not address the potential impact of socioeconomic factors
on missed appointments. Financial constraints, transportation issues, or other social
determinants of health could have influenced appointment attendance rates. Future research
should consider incorporating these factors to gain a more comprehensive understanding of
missed appointments.
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Implications for Practice Change
Practice
The results of the project demonstrated a positive impact on missed appointments and
telehealth utilization. The sustained decrease in missed appointments and the adoption of
telehealth services indicate the potential for sustainability of the intervention. The clinic
should continue to implement and monitor the standardized appointment process to ensure
ongoing improvements in patient engagement and satisfaction.
To enhance future performance, modifications could be made to the intervention. This
may include refining the appointment reminder process, incorporating patient preferences for
communication (e.g., email, text message, phone call), and exploring additional strategies to
overcome barriers to appointment attendance, such as providing transportation assistance for
patients in need.
While the project was conducted in a specific clinic, the findings can be generalized
to similar primary care settings. Other clinics and health centers can learn from this project
and implement similar interventions to improve no-show rates and telehealth utilization.
However, it is important to consider the unique characteristics of each healthcare setting and
adapt the intervention accordingly.
Future Research
Future research could explore interdisciplinary collaboration between healthcare
providers, researchers, and technology experts. Collaborative efforts can lead to innovative
solutions for improving appointment attendance and telehealth utilization, such as developing
personalized mobile applications or utilizing artificial intelligence for predictive modeling of
missed appointments.
Some potential research questions for future investigation include: What are the long-
term effects of the intervention on patient outcomes, such as healthcare utilization, disease
12
management, and patient satisfaction? How do socioeconomic factors impact appointment
attendance and telehealth utilization, and how can interventions be tailored to address these
factors? And what are the cost implications of implementing and sustaining the intervention,
and how do they compare to the potential cost savings from reduced missed appointments?
The findings of the project will be disseminated within the clinic and organization to
inform other healthcare providers and administrators about successful interventions. This will
be done through presentations, staff meetings, and sharing of project reports. Dissemination
will also extend beyond the clinic to the broader healthcare community, such as presenting at
conferences, publishing in journals, and engaging in knowledge exchange with other
healthcare organizations.
Nursing
The project has significant implications for nursing practice. Nurses play a crucial
role in the delivery of care and patient education. By actively participating in the
implementation of standardized appointment processes and telehealth interventions, nurses
can contribute to improving patient outcomes and reducing missed appointments. The project
highlights the importance of effective communication, patient engagement, and the utilization
of technology in nursing practice. Advanced Practice Nurses (APNs) can play a leadership
role in implementing and sustaining the changes proposed in the project. They can provide
guidance and support to other nursing staff, ensuring adherence to standardized appointment
processes and effectively utilizing telehealth services. APNs can also contribute to the
development of protocols, guidelines, and educational resources that promote best practices
in appointment management and telehealth utilization. In nursing education, incorporating
training on appointment management, patient engagement strategies, and telehealth
technologies can better prepare future nurses to address the challenges associated with missed
appointments and the evolving healthcare landscape.
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Health Policy
The project highlights the importance of policies and regulations that support
telehealth utilization and patient engagement. Policy issues may include reimbursement
policies for telehealth services, regulations on patient communication and consent, and
guidelines for electronic health record systems that facilitate appointment reminders and
tracking. The project's success can also inform policy development or reform at various
levels. At the unit level, policies can be established to standardize appointment reminders and
incorporate telehealth services into routine care. At the system level, policies can address
reimbursement for telehealth visits and facilitate interoperability of electronic health record
systems. Locally, regionally, and nationally, policymakers can collaborate with healthcare
providers to develop guidelines and regulations that promote telehealth utilization and patient
engagement, ensuring equitable access to care and efficient healthcare delivery.
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Chapter VII: Conclusion
Value and Impact (Usefulness) of the Project to Health Care and Practice
This quality improvement project has demonstrated significant value and impact on
healthcare and practice. By implementing an integrated intervention to standardize the
appointment process, the project aimed to reduce the number of missed appointments,
increase telehealth services utilization, and enhance staff satisfaction with appointment
reminders. The project has successfully met its objectives and delivered positive outcomes.
The missed appointment rate significantly decreased by 6%, indicating improved patient
commitment and engagement. The statistical analysis using a paired sample t-test confirmed
the statistical significance of this decrease in missed appointment rates. Moreover, the
utilization of telehealth services showed a substantial rise, with a 5% increase post-
implementation of the intervention. This increase reflects the success of the strategies
implemented to enhance telehealth services.
The project also addressed staff satisfaction, with an average of 3.5 on the Likert scale
post-implementation. The number of staff members reporting strong satisfaction was many,
while those reporting somewhat satisfaction were very few. Notably, there were no staff
members reporting strong dissatisfaction. These findings indicate that the integrated
intervention positively influenced staff satisfaction with the appointment reminders process.
Met DNP Essentials
Some DNP Essentials were met by the implementation and completion of the project.
First, the project addressed Essential IV: Clinical Scholarship and analytical methods for
evidence-based practice. By conducting a comprehensive analysis of participant
demographics, statistical analysis of attendance rates pre and post-implementation, and
qualitative analysis of the participant opinion survey, the project demonstrated a strong focus
15
on evidence-based practice and the use of analytical methods to drive decision-making and
improve patient outcomes. In addition, the project fulfilled Essential VIII: advanced nursing
practice. By implementing an integrated intervention that incorporated text messaging,
telephone appointment reminders, and telehealth services, the project exemplified the
advanced nursing practice in promoting patient engagement and improving healthcare
delivery. The increase in telehealth utilization and the good staff satisfaction scores further
highlight the project's alignment with Essential VIII.
Plan for Dissemination
The findings of the project will be disseminated within the clinic and organization to
inform other healthcare providers and administrators about successful interventions. These
findings will be presented through poster and podium presentations, presentations to the
organization, and submission for publication. These channels will allow the project findings
to reach a wider audience, both within the organization and at local, regional, and national
conferences. By sharing the project results, other clinics and health centers can benefit from
the insights and strategies employed in improving appointment and telehealth services.
Attainment of Personal and Professional Goals
The project facilitated the achievement of personal and professional goals for the
DNP student and the project team. The DNP student gained valuable experience in leading a
quality improvement project, applying evidence-based strategies, and collaborating with
interdisciplinary team members. The student developed skills in project management, data
analysis, and communication, which are essential for future leadership roles in healthcare.
The project team members, including medical assistants, front desk staff, and the clinic
manager, also actively participated in the project, contributing to its success and achieving the
shared goal of improving appointment attendance and patient satisfaction. The project
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provided a platform for professional growth, enhancing their understanding of quality
improvement processes and promoting a culture of continuous learning within the
organization.
In conclusion, this quality improvement project achieved its goals of reducing missed
scheduled appointments, increasing telehealth services utilization, and enhancing staff
satisfaction. The project has significant value and impact on healthcare and practice, aligning
with various DNP Essentials. The dissemination plan will ensure the project's findings reach
a broader audience and that the attainment of personal and professional goals has been
accomplished. Overall, this project serves as an exemplar for improving appointment
processes and telehealth services within the primary care setting, with the potential for
broader implementation across the healthcare industry.