Reducing delays in oncology clinic appointment scheduling for inpatients: A quality improvement project at a Veterans Affairs medical center.
Authors: Simmons Kristen , Sada Yvonne H , Song Michael Meansup , Iqbal Cyrus Ahmad , Siddiqui Maria , Abdur-Raheem Emily , Bylov Timur , Sabichi Anita Lyn , Vaclavik Lindsay , Horstman Molly 
Published: October 2023

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Background: Oncology follow-up after hospital admission is an important transition of care. Patients with cancer discharged from the hospital often have high acuity needs such as new diagnosis follow-up or evaluation for resumption of therapy. We developed a multi-level intervention to improve post-discharge oncology appointment scheduling at the Michael E. DeBakey VA Medical Center in Houston, TX. Our goal was that by May 1, 2023, we would decrease the average monthly time from inpatient oncology RTC ordering to appointment scheduling from 3.4 days to 1 day. Methods: A process map identified inefficiencies in the existing oncology clinic scheduling process for inpatients. Quantitative data on timing of appointment scheduling was gathered from the electronic health record system from November 2022 through April 2023 and analyzed using Microsoft PowerBI and Excel. Based on this data and input from stakeholders, we designed the following interventions: 1) redesigning the “return to clinic” (RTC) appointment request order in December 2022; 2) educating oncology providers in February 2023 about how to write RTC orders to accurately reflect appointment urgency; 3) changing the triage process used by scheduling staff to prioritize post-admission oncology follow-up in April 2023. Improvements were measured using annotated statistical process control charts. Results: At baseline in November 2022, there were 22 completed RTC orders to oncology clinics for inpatients. These appointments requested an outpatient oncology visit for a mean time of 24.7 days in the future. On average, the RTC orders were placed 2.3 days prior to discharge and appointments were scheduled 3.4 days after the order was placed. Only 48% of inpatients with oncology clinic appointments requested had appointment scheduled prior to discharge. During the intervention period from December 2022 through April 2023, there were 130 completed RTC orders for inpatients to oncology clinics, with an average of 26 completed per month. The outcome measure of mean monthly time from RTC order placement to appointment scheduling was reduced from the baseline of 3.4 days in November 2022 to 2.3 days in April 2023 after interventions. There were no significant changes in the process measures of proportion of RTC orders completed correctly or proportion of inpatients with oncology clinic appointment scheduled at time of discharge. Conclusions: Redesigning the RTC order and educating ordering providers and schedulers on the appropriate use of the RTC order features decreased the time for oncology clinic appointment scheduling for inpatients. Additional reduction in scheduling time may be seen with a triaging process for return to clinic orders that prioritizes inpatients and improving communication with inpatients about available appointment times.