Patient Flow and Control of the Appointment Book



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Dental Appointments: Schedule

Source: IHS Dental Clinical Efficiency Manual

Available online at: home.dentist.ihs.gov

Patient Flow and Control of the Appointment Book

1. Appointment Scheduling


Examine the appointment book to determine how far in advance the book is filled for each provider. Most IHS programs find that as this time period increases, the broken appointment rate increases. Also, if the appointment is booked too far ahead, there may be insufficient lead time to allow for the scheduling of meetings and other events. As a result, patients must be rescheduled, which is inconvenient for patients and staff.

Recommendation: The appointment book should be filled no more than three weeks in advance.

Remedies: If the book is filled more than three weeks ahead and the situation is not due to a temporary problem that will resolve itself, consider adopting a call-in system or waiting list system to regain control of the appointment book, especially if the broken appointment rate is relatively high. (See Attachment II, "Controlling an Overloaded Appointment Book"). Stress the importance of obtaining approval from the service unit director/program director and the tribal health committee/tribal council before instituting either of these policies. If feasible, patient surveys or focus groups should be conducted to determine what type of appointment system the patient population prefers. At the very least, patients should be informed that a change in policy is coming.


2. Routine Exam Appointments


Ask members of the dental staff who schedule appointments (e.g., receptionist or dental assistant) how an eligible patient goes about getting an appointment for a routine dental exam. Determine whether everyone who asks for an appointment gets an appointment or whether a call-in system or waiting list system is used to maintain control of the appointment book. Also determine whether various staff members are consistent in their answers re: how to get an appointment and that the answers agree with protocols listed in the policies and procedures manual.

Recommendation: Scheduling for routine exams should be consistent among staff and agree with written appointment policies.

3. Series of Appointments for Patients


Ask the appointment scheduler(s) whether a series of appointments is given to patients for routine treatment. Programs sometimes give patients a series of appointments because the appointment book is filled far in advance, and they don't want the patients to wait a month or more between appointments. Obviously, giving a series of appointments when the appointment book is already scheduled too far ahead only compounds the problem and is not recommended.

Recommendation: A series of appointments should not be used for routine treatment, especially if the appointment book is filled more than three weeks in advance.

4. Time Allotted for Procedures


Determine how the staff allocates the amount of time on the schedule for each procedure. Determine whether the amount of time allotted for each type of procedure seems realistic, i.e., scheduled treatment time is likely to match actual treatment time. Also determine whether the same amount of time is scheduled for each patient, regardless of the procedure to be performed, for example, all patients are given a one-hour appointment.

Recommendation: The amount of time scheduled for each patient varies with the procedures to be performed and is realistic for those procedures.

5. Mix of Services for Double-booking of Patients


Examine the appointment book to determine the mix of services that are scheduled together when patients are double-booked (given appointments during the same time period) for a provider using two or more operatories. Procedures which are not dentist-intensive, such as exams, prophys, and sealants are very well suited for double-booking. For example, exam patients scheduled together provide for excellent flexibility. If both patients keep their appointments, then each receives an exam. If only one of the patients shows up, that patient can be given an exam plus additional services, such as a prophy, sealants, or restorative treatment. Dentist-intensive procedures that require significant blocks of time with little opportunity for the dentist to leave the chair, e.g., long surgical procedures and prosthetics, can also be double-booked, but consideration should be given to scheduling services that are not dentist-intensive in adjacent operatories.

Recommendation: Patients who are double-booked should be scheduled so that the procedures they require complement each other. This means that if both patients keep their appointments, patient flow is not severely disrupted, and if only one patient shows up the staff are kept busy.

6. Short-Notice Patient Call List


Determine whether a short-notice call list is maintained and how often it is actually used. A short-notice list can be useful for filling in canceled or broken appointments. If a call-in system is in place, it also serves to "give something" to the patient who calls in too late to get an appointment for the next scheduling period. For the short-notice list to work, however, it must be used and updated routinely.

Recommendation: A short-notice call list should be in place and should be used routinely when a broken or canceled appointment will result in down-time.

7. Patient Waiting Lists for Certain Services


Determine which services have waiting lists by asking the dental staff. Also, determine whether the waiting lists are used, i.e., determine how many names actually come off the list and whether they come off in an equitable way (usually the first people to get on the list should be the first people off the list).

Recommendation: If waiting lists are used for certain specialty services, patients should actually come off the list and should receive appointments in an equitable way.

8. Quadrant Dentistry


This includes multiple quadrant dentistry, when treatment needs are minimal. Determine whether quadrant dentistry is being practiced by reviewing dental charts. Also use the BMR data to observe local trends in the average number of visits per patient. The IHS has always recommended quadrant dentistry as an efficient way to do restorative treatment, as opposed to filling "one tooth at a time." Operatory setup and cleanup time, greeting and dismissing the patient, and waiting for anesthesia are sometimes more time-consuming than actual procedure time, so it is important to complete as much treatment as is feasible during each appointment. Even though third party reimbursements might be geared to "dental visits," regardless of how much treatment is provided at each visit, the demand for care at most locations will dictate that quadrant dentistry be provided. The practice of four-handed dentistry can also enhance the efficiency of delivering care. However, caution should be exercised to avoid the “trap” of practicing four-handed dentistry when the auxiliary’s time is better utilized at another operatory. Refer to the section on the use of dental auxiliaries for more information.

Recommendation: Quadrant dentistry (or multiple quadrant dentistry, when appropriate) is routinely used to provide restorative treatment.

9. Treatment Plans Completed


Determine whether treatment plans are being completed in an appropriate number of appointments by reviewing dental charts selected at random. Use the DDS software Quality Assurance options (PADA or SCOM) to select records of completed patients (those having 9990 code reported in their record). The BMR may also be used to observe recent trends in the total number of patients completed and the average number of visits per patient at the facility.

Recommendation: Treatment plans should be completed in as few appointments as is feasible.

D. Emergency Patient Flow

1. Emergency Exam Appointments


Ask members of the dental staff who schedule appointments (e.g., receptionist or dental assistant) how an eligible patient goes about getting an appointment for emergency treatment. Can the patient drop in anytime, or is there a specific emergency time set aside? Is the patient supposed to call the clinic before coming in for an emergency? Then determine whether various staff members are consistent in their answers re: how to get an emergency appointment and that the answers agree with protocols listed in the policies and procedures manual.

Recommendation: Knowledge of protocols for emergency treatment should be consistent among staff and agree with written appointment policies.

2. Walk-in Patients per Day and Broken Appointments per Walk-in Patient


Determine the average number of walk-in (unscheduled) patients per day. The data elements are a count of emergency visits (0140 or 9170) per day the clinic was open for care. Use the BMR data (emergency visits, broken appointments.) to determine trends for at least the past 5 quarters. It is also wise to examine the appointment book for the past several months to count the number of walk-in patients per day and the number of days the clinic was open. This method not only provides a reasonably accurate measure of the average number of walk-ins, but the "usual range" can also be determined (e.g., an average of 3 emergencies per day, with a usual range of 0 to 5 emergencies per day). It is a good idea to involve one or more clinic staff members in the process. The audit goes faster and the local staff learns how to calculate this ratio and perhaps will also learn why it is important to determine the ratio periodically.

Note: The BMR workload data count emergency visits based upon the use of the 0140 Emergency Exam and/or the 9170 Emergency Encounter codes for a visit. This compensates for the variability in the use of these codes among local programs. The number of days the clinic is open can be estimated from the count of Dentist-days in the quarterly BMR. At one-dentist stations the count will equal the number of days the clinic saw patients. In multi-dentist facilities the Dentist-days count does not provide a good estimate of the number of days the clinic provided care during the time period being used for evaluation. However, it can be assumed that multi-dentist clinics will be open every day, except under unusual circumstances.

The number of walk-ins per day provides information that will enable the reviewer to determine whether a special time should be set aside in the schedule for emergency (walk-in) patients. Following are two ways in which this information can be applied:

Option a. Some reviewers look at the average number of emergencies per day and the usual range and divide these numbers by the number of dentists available to see emergency patients (e.g., 5 emergencies per day, with a range of 0 to 8, and a staff of two dentists = 2.5 emergencies per day per dentist, with a range of 0 to 4 emergencies per day).

If the average number of emergencies per day per dentist is three or less, then a special emergency time is probably not necessary. Other variables may also influence the decision to have or not have a special emergency time in the schedule. For example, if the usual range is very wide (which can lead to days when the dentists are overwhelmed with emergencies), if the broken appointment rate is very low (which allows little time to squeeze in the emergency patients), or if the broken appointment rate is very high (which allows plenty of time to see emergency patients).



Option b. Other reviewers prefer to weigh the broken appointment rate against the walk-in rate to determine whether a dedicated emergency time is necessary. The ratio 9130/0140 per day or 9130/9170 per day is used, depending on how walk-ins are designated in the program. As in the determination of walk-ins per day, finding the number of days must currently be accomplished using estimates of the number of days the clinic was open for services during the time period being evaluated.

If the ratio of broken appointments to walk-ins per day is one or more, broken appointments exceed walk-ins, and adequate time should exist during the day to see walk-ins without setting aside a special emergency time or emergency team. If the ratio is less than one, then a dedicated emergency time is probably necessary. The amount of time to set aside for emergencies can also be estimated by looking at the BA/walk-in ratio, e.g., a ratio of .4 BAs per walk-in will require that more time be set aside for emergency treatment than a ratio of .8 BAs per walk-in.



Recommendation: Whether or not a special emergency time should be set aside in the schedule should be determined by one of the two methods listed above and applied accordingly.

3. Resources for Specific Emergency Time


If a specific emergency time is being set aside in the schedule, the following two indicators can be used to determine the amount of resources that are being dedicated for emergency treatment:

Percent Clinic Hours Designated Walk-In (special emergency time) =


Walk-In Hours / Total Clinic Hours

Percent Provider Time Designated Walk-In (special emergency time) =


Provider Walk-In Hours/Total Provider Hours

From a review of the appointment book (one to three months) determine the actual number of clinic hours and provider hours that are dedicated to treating emergency patients and divide these numbers by the total number of hours that are available for dental treatment. Then determine whether the amount of resources in clinic hours or provider hours is reasonable for the emergency load of the clinic.



Recommendation: If the number of clinic walk-in hours or provider walk-in hours is greater than can be justified by the emergency patient load, then the number of hours dedicated to the treatment of emergency patients should be reduced or eliminated.

4. Routine Exam Appointments for Emergency Patients


Through discussion with the dental staff, determine how an emergency patient obtains a regular exam appointment. For example, is the patient asked to call back for an appointment, or is the patient given an appointment as he/she leaves the clinic?

Although the following is anecdotal information only, many IHS-funded dental programs have reported that approximately two-thirds of the emergency patients who are given appointments at the end of their emergency visit will fail the follow-up appointment. If emergency patients are asked to call back for an appointment (or are placed on a waiting list, if the clinic has a waiting list appointment system), then the broken appointment rate for patients who respond is typically far less than two out of three.



The reason is that many emergency patients are episodic care users who do not often return for scheduled appointments. This group of patients must not be ignored, however. Emergency patients should be informed that they require an exam and additional treatment and then given the opportunity to access the clinic by calling in or going on the waiting list like all other patients who are seeking an appointment. Episodic users can also be given the option of getting on the short-notice call list or, if they have no phone and/or transportation problems, could be given the opportunity to wait in the clinic until there is a broken appointment.

Recommendation: Emergency patients should be asked to call back for a routine appointment or be placed on a waiting list, rather than giving those patients an appointment at the end of their emergency visit.

Note: The follow-up appointment for an emergency patient who has not had a recent complete dental exam should be for an exam, not for root canal treatment or other procedures that fall into high levels of care. Even though the patient might have had a root canal access preparation during the emergency visit, it is important to do an exam next so that an appropriate treatment plan can be developed.


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