O2047: Improving Outpatient Follow-up Appointment Scheduling for Pediatric Palliative Care Patients

Purpose/Objectives: Purpose/Objective
Pediatric palliative care (PPC) plays a critical role in maintaining quality of life, providing symptom control, and facilitating goal-concordant care for children with serious illness and their families. Longitudinal continuity of care is a domain of high quality PPC. Yet, little is known about the frequency of PPC outpatient (OP) encounters and those who are lost to follow-up. A system to ensure reliable, timely, consistent follow-up visits is required to provide compassionate continuity of care for PPC patients and families.

Design/Methods: Design/Methods
Using Quality Improvement (QI), a PPC team at a quaternary care pediatric hospital interrogated their established outpatient (OP) PPC encounter documentation and scheduling processes to improve rate of timely OP follow-up. The aim was to increase the percent of timely scheduled OP follow-up appointments (defined as within 14 days after current OP encounter) from approximately 40% to 70% in 6 months. The outcome measure was the percent encounters with timely scheduled follow-up appointments. The process measure was the percent of encounters with appropriate follow-up documentation (defined as a specific timeframe) in OP encounter notes. A key driver diagram was developed and included consistent documentation, clear communication, standardized scheduling process. Interventions included team meeting to communicate follow-up needs, development of universal documentation within electronic medical record (EMR), and real-time personal feedback on follow-up documentation rate. The complex scheduling process required extensive time for evaluation of available interventions within EMR, our institutional scheduling processes, and collaborative work with subspecialties.

Results: Results
Baseline data were collected via manual chart review and 547 outpatient encounters were evaluated. Demographic data collected included diagnostic group of which oncology, perinatal, medically complex, and neuromuscular disorder patients were the top four groups. The outcome measure, percent of encounters with timely scheduled OP follow-up appointments, remained at nearly 40% (Figure 1). Special cause variation was observed in the percent encounters with appropriate follow-up documentation (process measure) with an increase from 76% to 85% (Figure 2).

Conclusion/Discussion: Discussion
Continuity of care is a domain of quality PPC. QI methodology was applied to improve OP follow-up scheduling and thus continuity of care by a PPC team. Although documentation of follow-up needs has improved, our rate of timely follow-up scheduling still has room for improvement. Our largest challenge involves the complex process of scheduling appointments that involved human diligence and hard work which leads to high variability and low reliability. Future interventions will focus on creating a highly reliable system for outpatient follow up, to improve PPC patient care.