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. 2022 Apr 21;140(6):561–567. doi: 10.1001/jamaophthalmol.2022.0889

Evaluation of Interventions Targeting Follow-up Appointment Scheduling After Emergency Department Referral to Ophthalmology Clinics Using A3 Problem Solving

Charissa H Tan 1,2, Jake Mickelsen 3, Natacha Villegas 2, Mariya Levina 2, Andrea Shows 2, Kathryne Oruna 4, Benjamin Erickson 2, Heather E Moss 2,5,✉
PMCID: PMC9026243  PMID: 35446350

Key Points

Question

Can implementing targeted interventions improve follow-up appointment scheduling after emergency department urgent referral to outpatient ophthalmology clinics?

Findings

In this quality improvement study, targeted interventions were associated with a significant reduction in mean time to schedule an outpatient ophthalmology appointment following emergency department urgent referral.

Meaning

These findings suggest efficiency of outpatient ophthalmology appointment scheduling for emergency department urgent referrals may be improved by using a structured quality improvement methodology implemented by a multidisciplinary team representing key stakeholders in the process.

This quality improvement study examines factors associated with time until appointment scheduling following emergency department (ED) referral for urgent outpatient ophthalmology services.

Abstract

Importance

Many patients seen for eye-related issues in the emergency department do not receive recommended follow-up care. Prior evidence supports that scheduling appointments is a barrier to accomplishing the transition to outpatient ophthalmology care.

Objective

To evaluate time until appointment scheduling following emergency department discharge with urgent outpatient ophthalmology referral.

Design, Setting, and Participants

The A3 problem solving process was implemented by a multidisciplinary team as part of a structured quality improvement program with the goal of reducing the mean time between urgent referral placement in the emergency department and outpatient ophthalmology appointment scheduling. The study was conducted at Stanford Health Care, an academic medical center in Palo Alto, California, affiliated with Stanford University School of Medicine. Using medical center administrative records, all patients discharged from the adult emergency department with an urgent outpatient referral to the Stanford Department of Ophthalmology from August 9 to September 19, 2020 (baseline; n = 43), and from October 26 to November 29, 2020 (after implementation of all interventions; n = 21), were included.

Interventions

Interventions developed to target the workflow of the ophthalmology resident, emergency department, ophthalmology clinic, and health system schedulers to address key drivers of the referral-scheduling process included medical record documentation guidelines, identification of responsible parties, preidentified appointment slots, patient education materials, and education of stakeholders, and were implemented by October 25, 2020.

Main Outcomes and Measures

Mean time between urgent referral placement (ie, emergency department discharge) and appointment scheduling with outpatient ophthalmology at baseline vs postintervention.

Results

At baseline, appointments were scheduled a mean (range) 2.8 (0-7) days after referral placement. In the 5 weeks following implementation of interventions, the mean (range) decreased to 1.3 (0-4) days, a difference of 1.5 days (95% CI, 0.20-2.74; P = .02). This corresponds to 642 (95% CI, 86-1173) days of reduced patient wait time annually. In addition, there was less variability in the number of days between referral and appointment scheduling after intervention compared with baseline.

Conclusions and Relevance

The results suggest improvement in efficiency of outpatient ophthalmology appointment scheduling of urgent emergency department referrals could be achieved through application of a quality improvement methodology by a multidisciplinary team representing key stakeholders in the process.

Introduction

Of the 2 million ophthalmology-related emergency department (ED) encounters that occur annually in the US, 44.3% to 76.6% are for nonemergent conditions that require follow-up at an outpatient eye clinic.1,2,3 Follow-up is important for treatment continuation,4 correction of misdiagnosis,5,6 avoiding return ED visits,7 and transition to long-term ophthalmic care. However, literature has reported that 25.2% to 39.0% of patients seen for eye-related issues in the ED do not receive recommended follow-up care.2,8 Chen et al2 examined completion of recommended outpatient follow-up after general eye-related ED visits and identified younger age, having Medicaid or being uninsured, increased length of time between ED visit and follow-up appointment, nonurgent condition, and a best-corrected visual acuity of 20/40 or better as factors associated with being lost to follow-up. These findings align with the broader literature on outpatient clinic follow-up after ED visits in which studies have observed age, sex, insurance status, and financial concerns to be associated with the likelihood of patients keeping follow-up appointments.9,10,11,12,13,14 Insurance status has been associated with not only whether patients receive follow-up care but also the timeliness of follow-up appointments.12 Because a greater length of time between ED visit and clinic appointment is associated with a lower rate of follow-up, timeliness is an important consideration in ensuring patients obtain recommended follow-up appointments.2,10

There are many reported clinician and health system activities that can improve follow-up after ED evaluation.15 Creation of an appointment prior to ED release,9,11,16,17,18,19,20 telephone reminders,18,21,22,23 engagement with specialty clinicians at ED point of care,10,24 written instructions,25,26 and greater referral accessibility27 are associated with increased follow-up rates. In addition, multiple studies have shown that reducing or eliminating barriers to care (eg, transportation, childcare, and cost) is associated with increases in the rate of successful follow-up.10,27 For example, Messina et al10 made the process for obtaining specialty care follow-up after ED visit easier for patients through real-time appointment scheduling, ED clinician determination of urgency, input from specialists, electronic medical record documentation of referral, and waiver of payment at specialty appointments. While these interventions improved both the number of appointments scheduled and the number of appointments kept across the board, 98% of ophthalmology patients kept their appointment once it was scheduled—a higher likelihood than any other specialty that was studied by 8.58-fold. This demonstrates that a higher rate of follow-up completion can be obtained and that system characteristics may influence completion of follow-up more than individual patient characteristics.

Our ophthalmology practice is part of a large academic medical center and as such receives many urgent and nonurgent outpatient referrals from the ED. While management, physicians, and staff are aligned regarding the importance of providing outpatient ophthalmic care in a timely manner, parallel and inconsistent lines of communication, limitations in schedule availability, and delays in insurance approvals necessitate increasing amounts of staff time to establish outpatient appointments following ED visits. This results in the frustration of patients and staff and may adversely impact patient access and outcomes. Accordingly, we selected ED to outpatient ophthalmology patient transitions for focused attention as a quality improvement project, which was implemented using the A3 problem solving process taught by the Stanford Quality Improvement Realizing Improvement Through Team Empowerment course.28

A3 has been a useful tool for health care organizations seeking to improve service quality.29,30,31 The A3 approach to problem solving was initially one of the Lean Six Sigma strategies of quality improvement developed by the Toyota Motor Company. It uses the principles of the plan-do-study-act cycle to solve problems in a systematic, step-by-step manner. The objective of this project was to provide data to support ways of potentially improving efficiency in appointment scheduling following ED discharge with an urgent outpatient ophthalmology referral.

Methods

Setting and Team

The study was conducted at Stanford Health Care, an academic medical center in Palo Alto, California, affiliated with Stanford University School of Medicine. The population of interest consisted of patients seen in the adult ED, which is a level 1 trauma center, discharged with an urgent outpatient referral to the Stanford Department of Ophthalmology. The data used in this study were previously collected for health care operations purposes and were provided in a deidentified manner such that the identity of participants could not be determined directly or indirectly. Therefore, the current study was exempt from institutional review board approval and informed consent. The study was conducted according to the Standards for Quality Improvement Reporting Excellence (SQUIRE) reporting guideline.32

A multidisciplinary 6-member team consisting of a medical ophthalmology attending physician, surgical ophthalmology attending physician, ophthalmology resident physician, patient scheduling lead for ophthalmology, head ophthalmology clinic nurse, and assistant ophthalmology clinic manager led the project. An emergency medicine attending physician served as a consultant, and a quality improvement coach provided support regarding application of quality improvement methods.

Baseline and Target State Identification

The process map for outpatient ophthalmology appointment scheduling following an ED visit is shown in Figure 1. The ED clinician generates a referral as part of the discharge order, often on the recommendation of the ophthalmology resident. Once financial coverage is confirmed, the referral details are used to identify an appointment in the schedule, which is offered to the patient.

Figure 1. Target Process for Scheduling of Outpatient Ophthalmology Appointments Following Emergency Department (ED) Referral.

Figure 1.

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The solid line indicates the entire process; the dashed line, the focus of this project; the yellow shading, the project end points.

All team members contributed their perspective to generate a map of the baseline process in the clinical practice setting, including lines of communication and sources of frustration (Figure 2). The team believed the process between referral placement and appointment scheduling was contributing the most to both staff frustration and delays in scheduling. Thus, the time for this to occur was selected as the project outcome. The workflow of this process is independent from the requested follow-up interval, making it uniform and comparable across patients. Additionally, it is part of the workflow for all new ophthalmology outpatient referrals so improved efficiency could be expected to benefit patients beyond those who were the focus of this effort. Prior evidence supports that scheduling the appointment is a critical barrier in ophthalmology patient follow-up.10

Figure 2. Baseline Expanded Process Map for Scheduling Ophthalmology Outpatient Appointments Following Emergency Department (ED) Referrals Capturing Communications Between Stakeholders.

Figure 2.

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Dark gray shading represents stakeholders leading this project; yellow shading, the project end points. Solid black lines show routine routed written communication; solid green lines, routine verbal communication; dashed gray lines, passive written communication; dashed black lines, as-needed communication.

EMR indicates electronic medical record.

The population of interest was narrowed to those whose referrals were marked urgent for the purposes of outcome assessment. This population was selected to focus on patients for whom there is a potential improved medical outcome to be gained from successful transition to the outpatient setting and for whom reducing the lag in appointment scheduling is likely to be most impactful.

A cornerstone of quality improvement is measuring the current state and establishing a target state. A process mean from ED referral to outpatient appointment scheduling was determined by averaging the number of days from referral to appointment scheduling across urgent ophthalmology referrals from the ED in the 6 weeks preceding the start of the interventions (August 9 to September 19, 2020). The team developed a specific, measurable, attainable, relevant, and time-based goal of reducing the mean time between referral placement (ie, ED discharge) and appointment scheduling with outpatient ophthalmology to less than 2 days.

Analysis

Several areas for improvement were identified using swim lane and fishbone diagrams. A swim lane diagram provides clarity and accountability by delineating the responsibility associated with each role in a process. It also highlights handoffs between individuals or groups. The findings demonstrated considerable inconsistencies, duplication, and complexity in workflow. A fishbone diagram helps to visualize associations and was used to identify and classify the barriers preventing each involved party from making an appointment (Figure 3).

Figure 3. Factors Contributing to Lack of Timely Appointment Scheduling.

Figure 3.

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ED indicates emergency department.

Identification of Key Drivers

Key drivers are processes that must happen consistently or structures that must be in place for the goal to be met. Based on the streamlined process map (Figure 1) and fishbone diagram (Figure 3), we identified 5 key drivers: (1) common reference for desired outcome—meaning a location in the medical record that reliably contains the outpatient appointment recommendation details so all involved parties know where to consult when coordinating the appointment (internal communication), (2) passing of responsibility—meaning a clear point of contact responsible for the process at each step, (3) financial authorization in a timely manner, (4) schedule availability, and (5) patient education and understanding of the plan (external communication).

Development of Interventions

Interventions were developed to target the workflow of the ophthalmology resident, ED, ophthalmology clinic, and health system to facilitate each key driver.

  1. Common reference for desired outcome: a standardized ED consultation recommendation template was developed for inclusion by ophthalmology residents in their consultation notes for each patient. Details included ophthalmology clinicians involved in the patient’s care, recommended follow-up interval, subspecialty follow-up to be scheduled, degree of urgency, and insurance coverage. All stakeholders who might seek this information were alerted to its expected presence in the ophthalmology consultation note.

  2. Passing of responsibility: the ophthalmology clinic nurses agreed to be the central point of contact to receive notifications about overnight ED patients needing urgent follow-up, to field phone calls from patients about their ED follow-up, and to address questions from the scheduling coordinators about referral orders. Ophthalmology residents included the nurses in any communications about ED patients.

  3. Financial authorization in a timely manner: for patients whose insurance was not contracted with our health system or for whom a delay in approval was anticipated, a financial override policy based on diagnosis and urgency of follow-up was developed. Such an override policy required approval by ambulatory services at the medical center and was unable to be implemented during the initial phase of this project.

  4. Schedule availability: an agreement was reached with clinic management to reserve daily appointment slots in an urgent care clinic for possible ED follow-up. This reduced the need to create overbooking slots, in turn reducing exchanges between staff and schedulers.

  5. Patient education: a template was created so patients would receive consistent messaging regarding their follow-up recommendations in their ED discharge instructions. In the note, the patient was informed of the time frame for follow-up as well as clinic and scheduler contact information. In the case that their insurance was not contracted with the institution, they were advised of this potential barrier and advised to seek the advice of their primary care physician or insurance provider for assistance in coordinating care. Templated ED discharge instructions required programming the ED electronic medical record system and were beyond the scope of the initial implementation. However, the ophthalmology residents verbally informed patients and provided the information to the ED clinicians.

Sustain Plan

A plan was developed and implemented to ensure the successful interventions would continue. The interventions targeted were creating a standard ED consultation recommendation note, delegating a clinic point of contact for referrals, and reserving appointment slots for ED follow-up patients. For the ED consultation recommendation note, the standard template was included in the annual resident orientation and in the resident handbook. It was also included in quarterly patient transition reviews and notes were open to audit and feedback. The other interventions were maintained by the clinic staff, including making sure schedulers were aware of the appointments available for follow-up. A semiannual audit was conducted to ensure sufficient appointments were available.

Assessment

The postintervention process mean for time from ED urgent referral to outpatient appointment scheduling was calculated by averaging the number of days from referral to scheduling appointment across urgent ophthalmology referrals from the ED for 5 weeks following full implementation of interventions (October 26 to November 29, 2020). This timing was determined by the time of intervention implementation and business analytics resources allocated to the project. To allow for direct comparison with the 6-week duration baseline process mean, a 6-week peri-intervention process mean was calculated by including 1 additional week when most interventions were implemented. Time for appointment scheduling was compared between baseline and postintervention referrals using 2-sided t test for independent samples. Significance was set at P ≤ .05.

Results

Baseline Assessment

For the 6-week period from August 9 to September 19, 2020, outpatient ophthalmology appointments were made a mean of 2.8 days after ED urgent referral placement. Variation in appointment scheduling time ranged from 0 to 7 days.

Interventions

Ophthalmology resident and clinic-based interventions were implemented from September 20 to October 25, 2020. Patient education and financial override policies required health system-level interventions that were beyond the timeline of this project and are being pursued separately. Following implementation of interventions, qualitative informal feedback was sought to evaluate satisfaction with the process by stakeholders not on the project team. Ophthalmology outpatient clinic staff reported that it was easier to anticipate and respond to questions about referrals and that message volumes were decreased. New patient schedulers stated that having a consistent source of reference when creating appointments was convenient and that message volumes were decreased. Residents reported that the interventions required minimal additional effort.

Follow-up Assessment

In the 5 weeks following implementation, from October 26 through November 29, 2020, the mean number of days from referral to scheduling decreased to 1.3 days (decrease of 1.5 days; 95% CI, 0.20-2.74; P = .02, t test for independent samples) (Figure 4). Variation was 0 to 4 days, a decrease of 3 days. The 6-week peri-intervention period that included 1 week of transition had a mean (range) number of days from referral to scheduling of 1.6 (0-6), reflecting a decrease of 1.2 days compared with baseline. Extending this to include patient 58 (an outlier) increased the mean (range) number of days from referral to scheduling to 2.1 (0-14), reducing the decrease compared with baseline to 0.7 days. Considering that there were 428 annual urgent referrals from the ED to outpatient ophthalmology for fiscal year 2020, the mean decrease in scheduling of 1.5 days translates to 642 (95% CI, 86-1173) days of reduced patient wait time.

Figure 4. Time From Emergency Department Urgent Referral to Scheduling Ophthalmology Outpatient Appointment.

Figure 4.

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Each data point represents a single patient. Patients 1 through 43 were referred during the 6 weeks prior to implementation of any intervention and patients 61 through 82 were referred during the 5 weeks following implementation of all interventions. Patients 44 through 60 were referred during the time of intervention implementation.

Discussion

In this quality improvement study, the A3 problem solving process was implemented as part of a structured quality improvement program to evaluate changes in the mean time between urgent referral placement in the ED and appointment scheduling for outpatient ophthalmology appointments at an academic medical center preintervention and postintervention. We identified schedule availability, insurance approval, and effective communication handoff as barriers to an efficient process at our institution. Implementing interventions that targeted these key drivers was associated with a reduction in scheduling time. Subjective impressions from stakeholders were positive. Our project achieved its target goal despite all proposed interventions having not yet been implemented, which demonstrates that strategically targeting factors that prevent a system from running efficiently can lead to positive outcomes even if not all factors are addressed. This illustrates an important concept in the A3 process: the effectiveness of the solution depends on both the quality of solution as well as its adoption by those involved in the process. Because our interventions were applicable to the existing system, stakeholders were able to adapt to the new process more easily. Although we present this as a targeted project, quality improvement is an ongoing effort requiring regular reevaluation. As of February 2022, these interventions had been sustained for 1.5 years.

Although the analysis and interventions were focused locally, they address a common problem, given that more than one-fourth of patients who are referred to an outpatient ophthalmologist by the ED are not seen,2,8 with timeliness of creating the follow-up appointment being an important contributing factor.2,10 Our interventions target this and other factors that have been shown to be associated with increased patient follow-up rates. There are other potential interventions that were precluded by resource availability. For example, ensuring the patient has an appointment scheduled prior to ED discharge would require near real time availability of outpatient schedulers, which is inconsistent with current asynchronous business hours workflow. Similarly, authorization to waive charges for outpatient care would require institutional-level policy changes. Other medical centers have addressed the challenge of timely outpatient services by offering same-day appointment slots at their ophthalmology clinics.33,34 While this reduces the need for urgent follow-up from the ED, it does not eliminate it because some eye care emergencies occur outside of clinic operating hours and patients may not be aware of what requires immediate attention and what can wait for same day outpatient care.1,3,35

Limitations

A limitation of this project is that causal impact of the interventions cannot be proven owing to lack of a comparison without intervention. The performance period was during the COVID-19 public health emergency and although the institutional regulations, outpatient volumes, and government restrictions were similar during the baseline and postintervention periods, differences in COVID-19 cases during this time may have impacted care seeking behavior of patients, availability of appointments, and our observations.

In line with the A3 method, the primary outcome was a process outcome, which was the direct target of interventions. The project did not include secondary outcomes, such as (ideally validated) measures of patient and staff satisfaction. Neither did it assess clinical outcomes. Data on timely completion of follow-up appointments after referral, the overarching clinical care goal under which this project operated, are not readily available because patients seek care at multiple institutions following ED visits. While continued practice of interventions more than 1 year after the project ended has been confirmed, lack of business analytics resources precludes assessing if the reduction in scheduling time has persisted.

Conclusions

The findings show a reduction in outpatient ophthalmology appointment scheduling time for urgent ED referrals following application of a quality improvement methodology by a multidisciplinary team representing key stakeholders in the process. While our chosen interventions were customized for our institution, this study serves as an example of how targeted intervention may move the needle on a complex process with the goal of improving patient care, staff satisfaction, and efficiency.

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