Diving into Bumps

By Chris Profeta, MPH

The Bump Rate

The bump rate is an access metric used to measure internally-driven appointment cancellations and, by proxy, disruptions to care caused by the health system. bump is defined as a patient appointment that was cancelled by an internal stakeholder – the physician or provider for example. The reasons for the bump may vary but the key factor is the appointment change is instigated by the system, not the patient. The rate is derived by dividing the volume of bumps into all scheduled appointments across a designated period of time. 

The average bump rate in 2021 for PAC members was 6.2%, with our cohort of children’s hospitals averaging 5.7%. 

Bumps can be a massive dissatisfier to the patient. Patients and families need to plan for childcare and transportation or arrange work schedules to attend a physician’s visit. The closer the bump is to the appointment date, the greater the negative impact on the patient. 

Defining the Metric

The bump rate can be a highly actionable and informative data point if clearly defined and measured. However, accurately calculating the bump rate can be challenging. There is a large spectrum of cancellation reasons directed by internal stakeholders; the metric’s educational value will swing based on which are included. The human element involved in distinguishing a bump from other types of appointment cancellations adds additional room for inaccuracy. 

For example, is a cancellation due to the appointment being deemed not clinically necessary an event that ought to be included in the metric?  That could be viewed as a “provider-driven cancellation” and is certainly an interesting data point (especially if the cancellation is not refilled), but it is not necessarily helpful if trying to learn about provider clinic closure statistics or disruptions to care. Similarly, how should a team member classify the moving of a patient off a sick provider’s schedule onto a partner provider’s schedule for the same day/same time? For even more complexity, how about for the same day but different time? And, what if the patient is moved because the physician is attending an EHR training class required by the health system – or attending to another patient in an unforeseen emergency in the operating room? 

If the metric does not have clear intention driving the inputs, the fidelity of the metric diminishes. More importantly, the lack of meaning makes the metric unactionable. It is crucial to clearly define what events qualify as a bump and effectively train team members on these criteria. Preferably, cancellation categories will be defined so that deeper insights can be gleaned when performing more robust analyses. 

Unpacking the challenges helps you as a leader to determine how best to collect data about the metric – and actions that you can take to improve operations.  

Keep in mind that more cancellation categories available for a staff member to select increases the chances of mislabeled events, especially for positions that have high turnover. Finding a balance between specificity and accuracy is difficult, yet vital. 

Analyzing the Rate

Comparing the bump rate to past performance or against a target rate to measure the effectiveness of policies or behavior is only the tip of the iceberg. Once the definition of a bump is clearly defined and different types of cancellations are bucketed into categories, it becomes possible to learn more about what types of bumps are occurring and what happens to patients after the bumped appointment. 

Avoidable and Unavoidable Bumps

Some bumps are unavoidable, such as a provider who is ill and must cancel clinic. Other bumps, such as provider trainings, vacations, or conferences, are often known well in advance and could be avoided with strong practice policies. Looking inside the different cancelation categories can help focus interventions. 

Access Impact of Bumps

In and of itself, the bump creates a challenge for the patient as a singular event, but the bigger picture is perhaps even more important. What happens to the patient after they are bumped? How many days is the patient’s care been delayed; does it present a safety problem or is the timing irrelevant? Does the patient return or does the patient find care elsewhere? Is there a different outcome for new versus established patients? Does the time horizon of the bump impact the outcome? Broader still, how does bumping one patient impact appointment availability for other patients? These are important access questions that can be explored with the bump data and ensuing discourse. 

Calculating the number of days between the bumped appointment and the rescheduled appointment can be an informative metric. Compare, too, how many of the bumped patients do not arrive for another appointment with that provider, clinic, or health system. These analyses provide estimates for (1) how well the clinic recovers from bumps, (2) the patient attrition level, (3) the market alternatives available to the patient in terms of appointment access – or the appointment lag elasticity of demand, and (4) how many additional appointment slots are being occupied by patients who were bumped beyond the original appointment.

The insight can be used to estimate the impact of bumped appointments on total appointment lag for all patients in the clinic. As one patient’s schedule is rearranged, future appointments for all patients – the overall capacity -- are impacted. 

Clinical Impact of Bumps

Established patients are typically followed at certain time intervals. Based on the diagnosis, missing the determined window of care can impact micro-level issues such as prescription refills or therapy orders (which may be timed) – or perhaps even clinical outcomes. Pairing reports about these elements of the patient’s care with bumps can lead to meaningful insight and interventions. 

Impact on Clinic Staff

A high bump rate doesn’t just impact the patients. Bumping and rescheduling patients requires valuable administrative resources, can place undue burden on partner providers, and often disrupts clinic flow – especially when unplanned overbooks are used as a last resort. 

Calculating the time and resources spent bumping and rescheduling patients can help drive staffing decisions and workflow optimization.

Actions to Take

Deciding what interventions to pilot is highly specific to the challenges at the provider or clinic level, staffing resources, and overall goals. One approach is to focus on reducing avoidable bumps and minimizing the impact of unavoidable bumps.

Reducing Avoidable Bumps

Requiring providers to submit out-of-clinic requests 30- or 60-days prior can help reduce the impact of avoidable bumps. Assessing meetings, trainings, etc., that are concurrent with clinical obligations is a must. Paying careful attention to schedules set up for learners, trainees, and new providers is critical, as these are often the sources of problems. Educating all internal stakeholders on the downstream effects of bumping patients can help gain buy-in and improve adherence to the policy.

Minimizing the Impact of Unavoidable Bumps

Having policies in place to open “make-up” clinics within days or weeks of the bump or establishing care teams to offer an appointment with a different provider that is familiar with the patient’s care plan are ways to reduce the impact of unavoidable bumps on the patient. Creating an “on-call” position for the clinic may be of benefit. Challenge the team to consider other ways to address bumps by baking backup strategies into the fabric of the clinics’ operations. 

Health systems that commit to reducing avoidable bumps and minimizing the impact of unavoidable bumps gain an important competitive advantage in the market and take a leap toward truly patient-centric care.

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