Study Finds Quality Improvement May Improve Eye Care Appointment Scheduling

Application of quality improvement methodology by a multidisciplinary team could improve the efficiency of outpatient ophthalmology appointment scheduling.

Scheduling of emergency referrals in ophthalmology could be improved through a quality improvement methodology, according to new study findings published in JAMA Ophthalmology.

The aim of this study was to evaluate the time from emergency department (ED) discharge to appointment scheduling following an urgent ophthalmology referral.

Patients receiving care at Stanford Health Care in Palo Alto, California, whose referrals were marked as urgent comprised the study cohort. The mean length mean from ED referral to outpatient appointment was determined by averaging days from referral to scheduling of the appointment in the 6 weeks prior to the start of the interventions (August 9-September 19, 2020).

The study found 5 key drivers of appointment scheduling after referral: a location in the medical record that reliably contains the outpatient appointment recommendation details, a clear point of contact responsible for the process at each step, financial authorization, schedule availability, and patient education and understanding of the plan. Interventions were developed for each key driver, and these were implemented from September 20-October 25, 2020.

In the 6 weeks prior to the interventions, the mean time to make a follow-up appointment was 2.8 days after ED urgent referral placement. In the 5 weeks after implementation (October 26-November 29, 2020), this decreased to 1.3 days (95% CI, 0.20-2.74). The 6-week peri-intervention period had a mean number of days from referral to scheduling of 1.6 (range, 0-6).

Including an outlier patient increased the mean number of days from referral to scheduling to 2.1 (range, 0-14), reducing the decrease compared with baseline to 0.7 days. The mean decrease in scheduling of 1.5 days translates to 642 (95% CI, 86-1173) days of reduced patient wait time.

Feedback to evaluate satisfaction with the process by stakeholders found that it was easier to anticipate and respond to questions about referrals and that message volumes were decreased. Patients who were new found that the consistent source of reference was convenient, and residents reported that the interventions needed minimal additional effort.

There were some limitations to this study. Causal impact of the interventions could not be proven due to lack of a comparison without intervention. Differences in COVID-19 cases during this time also may have affected care seeking behavior of patients, availability of appointments, and the observations of the researchers. Further, the study did not include secondary outcomes, such as mesures of patient and staff satisfaction or clinical outcomes. Data on completion of follow-up appointments and the overarching clinical care goal also were not readily available.

The researchers concluded that their research demonstrated that a reduction in appointment scheduling time could be achieved following application of a quality improvement methodology.

“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,” the authors wrote.


Tan CH, Mickelsen J, Villegas N, et al. Evaluation of interventions targeting follow-up appointment scheduling after emergency department referral to ophthalmology clinics using A3 problem solving. JAMA Ophthalmol. Published online April 21, 2022. doi:10.1001/jamaophthalmol.2022.0889

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