Problem Statement: During the fiscal year 2018, our medical clinic experienced an average no-show rate of 6.2%, resulting in the loss of 1,212 appointments or a monthly average of 186 appointments, and $499,344 in lost revenue (cost per no-show $421). This trend is increasing, and if not reversed, could result in a projected loss of 1600+ appointments and lost revenue of more than $650,000 over the next 12-month period. The accountability of no-shows by supervisors is unchecked or limited. Goal Statement / Proposed Outcomes: 1st Marine Logistics Group subordinate commands will decrease appointment no-shows from 6.2% to <5% at our medical clinic by August 2019. Outcomes include an increased awareness by executives on the cost of appointment no-shows by 1st MLG patients, increased communication between patients and their supervisor, marked reduction of appointment no-shows by 1st MLG patients, increase in DEERS demographics information accuracy, and increased accuracy of point of contact information for local area executives. Our team will implement controls or enforce controls already in place (i.e. no-show list to commands) to ensure continuity of outcomes.

1. 1ST MED BN, 1ST MLG
Lean/Six Sigma – Green Belt Project
Start Date: 10 Sep 2018
Reduction of No-Show Rate at 22 Area
Marine Centered Medical Home Clinic
1st Medical Battalion, 1st Marine Logistics Group
Project Belt: LCDR John W. McAfee, Operations Officer
Champion: CDR Dean Goad, Executive Officer
Process Owner: LCDR Nick Saltzman, MCMH OIC
Command Belt: LT Curtis Popp, Surg Co B Commander
Black Belt Mentor: Mr. Michael Teegardin
PIO# - 25751

2. 1ST MED BN, 1ST MLG
Project Charter
Problem / Opportunity Statement: Goal Statement / Proposed Outcomes:
During FY 2018, 22 ABMC experienced a monthly no-show rate of
9% from 1st MLG subordinate commands. In addition, failed
appointments decrease overall access to care for patients requiring
immediate care.
22 ABMC will decrease the monthly No-Show rate from 9% to 5%
no later than 1 Apr 2019.
Expected Benefits:
Metric Baseline
Improvement
Goal
MISSION (Readiness) - Increased access to care through greater
appointment availability
MISSION (Health) - Increase in overall patient population health
through better appointment availability for patients with immediate
health care needs
Primary Metric 9% 5%
Secondary Metric
Tollgate Planned End Date Actual End Date Primary Metric:
Define 22-Oct-18 15 Nov 2018 Monthly appointment no-show rate
Measure 26-Nov-18 16 Dec 2018
Analyze 1-Apr-19 27 Feb 2019 Secondary Metric:
Improve 15-Apr-19 25 Apr 2019
Control N/A 25 June 2019

3. 1ST MED BN, 1ST MLG
Project Team
Member Role Member Role
HM3 Mark Shiraki HM3 Dustin Hubbart
Project Lead
Project
Champion
Command
Black Belt
Black Belt
Mentor
Financial
Analyst/SME
Process
Owner
LCDR John
McAfee
CDR Dean Goad LT Curtis Popp
Mr. Shawn
Dewey
N/A
LCDR Nick
Saltzman

4. 1ST MED BN, 1ST MLG
Existing Solutions

5. 1ST MED BN, 1ST MLG
SIPOC
In Scope: 22 Area MCMH Patient Scheduling and Processing
Out of Scope: Non-22 Area MCMH Patient Scheduling and Processing
Suppliers
• Patients
• Clinical appointment
staff
• BUMED
• Providers/HMs
• MCMH
• Command/unit
• NHCP (referrals to
specialty care)
Inputs
• DHA Access to Care
Standards
• Rx for vaccine, RIG
• MCMH SOPs
• Self-referral
• PHAs/Physicals
• TRICARE Patient
Portal (Self)
• Patient counseling
• Provider/appt
availability
Process Outputs
• Scheduling of
appointment
• No-Show Rate Metrics
(AHLTA/CHCS)
• SharePoint Dashboard
• Patient presents for
scheduled appt
• Reminder printed
upon req
• Automated appt
reminder
Customers
• Patients
• Clinical appointment
staff
• BUMED
• Providers/HMs
• MCMH
• Command/unit
VOC22 ABMC will decrease the monthly No-Show rate
from XX% to XX% no later than 1 Apr 2019.
Patient
schedules
appointment
Patient
encounter
closed
Provider
completes
appt
Appt Booked
in CHCS by
patient or
clerk
Patient
Arrives for
Appt
F/u apt
booked if
required

6. 1ST MED BN, 1ST MLG
Voice of the Customer
 Internal Customers
 Clinical Appointment Staff
• Appointment availability to provide to patients. Direct correlation to no-shows and
appointment availability.
 BUMED [DBC and Healthcare Business Office, NHCP]
• Medical readiness metrics displayed in TRICARE Operations Center (TOC) are adversely
affected by No-Shows. Goal to reduce No-Show Rate below 5%.
 Providers
• Medical readiness is adversely effected by no-shows. “A no-show buys me more time to
complete other administrative work.”
 MCMH
• Adversely effects third next available appointment, clinic staffing is misaligned to
compensate for no-show, lost “revenue,” and cost of emergency room visit by those unable
to access MCMH appointments.
 External Customers
 Patient
• Access to care is limited (appointments are only available outside of DHA’s Access to Care
Standard), and “Gunny wouldn’t let me leave the shop on time for my appointment.”
 Parent Command
• “I don’t want my Marine away from the shop for too long.”

7. 1ST MED BN, 1ST MLG
General
Hard to measure
Specific
Easy to measure
Patient Attends
Appointment
Work Schedule
Memory
Transportation
RVU
Leadership is aware of Appointment
Appointments during off hours
contact to make all appointments
Set reminders
Vehicle in proper working order
Lock on a ride
Increase revenue from attended Appt’sFinancial gain
Effect Drivers CTQs
Critical to Quality

8. 1ST MED BN, 1ST MLG
Data Collection Plan
Metric
Data
Type
Operational Definition
Sampling
Notes
Source &
Location
Collection
Method
Who Will
Collect
22 Area
MCMH No
Show Days
Discrete
No-Show rate = Total # of
patients who do not show up
for their appointment divided
by (total booked – canceled
appointments).
Population
measured
over 1
calendar year
CHCS
Database
Extraction
Process
Owner
No Show
Summary
by Clinic
Discrete
No show rate for clinic, by
team (blue/green), from 1 Jan
2018 to 31 Dec 2018
Population
measured
over 1
calendar year
CHCS
Database
Extraction
Process
Owner
Primary 22 Area MCMH No Show Days
Secondary No Show Summary by Clinic
Tertiary
How will data be used? How will data be displayed? What is the plan for starting data collection?
To identify problem areas within the
22 Area MCMH appointment
scheduling process
Displayed in working log and
portrayed on control charts
Process owner will run no-show reports in CHCS to
capture raw data for further analysis

9. 1ST MED BN, 1ST MLG
Team Month
Total
(minus
canx)
No
Shows
%No
Shows
Monthly
DEFECT?
Monthly
DEFECT
Rate
BLUETEAM January 842 51 5.71% 1
BLUETEAM February 692 64 8.47% 1
BLUETEAM March 964 65 6.32% 1
BLUETEAM April 786 42 5.07% 0
BLUETEAM May 869 46 5.03% 0
BLUETEAM June 954 51 5.07% 0
BLUETEAM July 794 39 4.68% 0
BLUETEAM August 951 58 5.75% 1
BLUETEAM September 680 32 4.49% 0
BLUETEAM October 696 34 4.66% 0
BLUETEAM November 567 45 7.35% 1
BLUETEAM December 767 41 5.07% 0
GREEN TEAM January 1,038 85 7.57% 1
GREEN TEAM February 844 63 6.95% 1
GREEN TEAM March 1,045 97 8.49% 1
GREEN TEAM April 864 65 7.00% 1
GREEN TEAM May 549 40 6.79% 1
GREEN TEAM June 601 49 7.54% 1
GREEN TEAM July 482 43 8.19% 1
GREEN TEAM August 671 42 5.89% 1
GREEN TEAM September 632 41 6.09% 1
GREEN TEAM October 660 37 5.31% 1
GREEN TEAM November 965 50 4.93% 0
GREEN TEAM December 479 32 6.26% 1
41.67%
91.67%
BLUE TEAM % No-Show
Average – 5.94%
GREEN TEAM % No-Show
Average – 7.29%
Data Collection Plan

10. 1ST MED BN, 1ST MLG
Capability Report
(Blue Team)

11. 1ST MED BN, 1ST MLG
Capability Summary Report
(Blue Team)

12. 1ST MED BN, 1ST MLG
Capability Report
(Green Team)

13. 1ST MED BN, 1ST MLG
Illustrations

14. 1ST MED BN, 1ST MLG
# OBSERVATION
AREA/ACTIVITY
OBSERVED
FINDINGS/DATA COLLECTED OR
REVIEWED/CONCERNS
FOR FURTHER ANALYSIS
1 Patient asked to verify DEERS data. Front desk of clinic
Data was verified by the front desk clerk as inaccurate. Provided
instructions to update contact information.
2
Patient was provided multiple appointment times the following
business day.
Front desk of clinic
Access did not appear to be an issue in this instance as multiple providers
and multiple time slots were available during this particular period.
3 Patient did not receive an appointment reminder. Patient
No text, e-mail, or phone call was received by the patient to remind them
of their appointment the following day.
4
Patient was not reprimanded by parent command for missing a
medical appointment.
Patient
No letter was received from MHS, BUMED, Navy Medicine West, or the
MCMH that the patient missed their medical appointment.
5
6
7
8
9
10
GEMBA

15. 1ST MED BN, 1ST MLG
Current Process Map
Start
Eligible Pt Requests
Appt
Is DEERScontact
infocurrent?
Pt Directedto
Update DEERS
Appt Booked
Is Appt within
24 hrs?
Patient No-
Shows?
Appt Kept End
Appt ReminderSent
Appt Documented
as No-Showat End
of Day
No
Yes
No
Yes
Yes
No

16. 1ST MED BN, 1ST MLG
Root Cause Analysis
Excessive No-Show Rates
Tricare On-line – phone #s in DEERS are often incorrect
DEERS database not accurate/current
Scrubbing and Copy Forward of Appointments
NOT followed at all times
Patients forget appointment
Patients unsure of how to update information in DEERS
CHCS NOT updated with current info
Weather conditions prevent patients from reaching clinic
Insufficient CHCS print out of following day s appt Missing/Insufficient CHCS print
out of following day s appt
DEERS check for patients are
NOT consistently performed

17. 1ST MED BN, 1ST MLG
Prioritize Root Cause
1) Phone number in DEERS is incorrect or missing
2) Missing/Insufficient CHCS print-out of following days appointments
3) Lack of standardization

18. 1ST MED BN, 1ST MLG
“DOWNTIME”
Rating NVA Examples of each type of WASTE
1 of 4 Defects
Human factor (i.e. patient just forgets appt); Front desk provides information to patient on
how to update DEERS
4 of 4 Overproduction Patient redirected to appropriate PCM
Waiting
3 of 4 Non-utilized Talent Currently, staff not calling following day’s appointments
Transportation
2 of 4 Inventory Appointments too far in the future, therefore patient forgets
Motion
Excess
Processing
Eight Wastes (MUDA)

19. 1ST MED BN, 1ST MLG
Documentation of Improvements and
Changes
• Metrics report provided to supported commands (CLB-15, 1st Med Bn, 1st Supply
Bn, CLR-15, LSSS, MAG-39) to spur competition
• Letter to supported command with Enclosure with list of Marines/Sailors that
missed appointments for the week, with recommended consequences
• Implementation of Audiocare (includes text message appointment reminder)
• Campaign to update DEERS demographic information during command indoc,
during appointment check in, and posters around MCMH
• Posters in each treatment room to convey to Marines/Sailors the true cost of no-
show for appointment
• Front desk or care team to call next day appointments

20. 1ST MED BN, 1ST MLG
Problem
Identified
Action Needed
Created
Date
Completed
Date
Improvement
Metrics
Person
Responsible
What is the waste? How
is the waste Eliminated?
Monthly No-Show
metrics pulled and
provided to MSE
commanders
Develop system to
pull metrics on
monthly basis
26 Apr 2019 15 May 19 No-Show Rate ?? HM3 Shiraki
Previous 3 months of no-
show data included in data
pull to identify trends with
repeat offenders
Memo to send to
MSE commanders
with their unit’s No-
Shows
Create memo to send
to MSE commanders
26 Apr 2019 15 May 19 No-Show Rate ?? LCDR Saltzman
Memo is in existence;
requires adherence/usage
Audiocare system
not functioning
properly
Contact NHCP POC
to ensure contract is
active for patients
paneled to clinic
26 Apr 2019 15 May 19 No-Show Rate ?? HM3 Hubbartt
NHCP confirms that the
Audiocare contract is
intact and the technology
is functioning properly
Patients unaware
of requirement or
benefit of updating
contact info on
DEERS
Develop campaign to
educate patients to
update their info
26 Apr 2019 No-Show Rate ??
LCDR Saltzman,
LT Popp, HM3
Hubbartt
Patients unaware
of Cost associated
with Appt No-Show
Develop campaign to
educate patients
26 Apr 19 15 May 19 No-Show Rate ?? LCDR McAfee
Posters received from
NHCP to hang in exam
rooms
Patients don’t
receive reminder
phone calls the day
prior to their appt
Develop procedure for
front desk staff to call
the following day’s
patients to remind
them
26 Apr 19 No-Show Rate ?? LCDR Saltzman
Implementation Plan

21. 1ST MED BN, 1ST MLG
Future State Map
Start
Eligible Pt Requests
Appt
Is DEERScontact
info current?
Pt Directed to
Update DEERS
Appt Booked
Is Appt within
24 hrs?
Patient No-
Shows?
Appt Kept End
Appt Reminder Sent
Front DeskCalls
Next Days Appt s
Pt Arrives Late
Appt Documented
as No-Showat End
of Day
No
Yes
No
Yes
Yes
No
No
Yes

22. 1ST MED BN, 1ST MLG
Control Plan
CONTROL PLAN
Department Name: ABMC
Process Name: No-Show Elimination
1 2 3 4 5 6 7 8 9 10 11 12
Name of
Measure
Measure Definition Measure Calculation Data
Source
Goal Measure
Frequency
Sample Size When to
Act/Trigger
Who Decides to
Act
Who
Acts
Reaction to Out of
Control
Display Method
No-Show
Percentage
Percentage of
appointments
where a patient
didn’t show up.
Complete or
Incomplete
(Patient
Encounters)
Data
pulled
from
CHCS/
AHLTA
Below 10% Monthly N/A When
percentage
increases
above 10%
Process
Owner
LPO Reinforce policy
and
professionally
educate staff.
Graph
Kept
Percentage
Percentage of
appointments
where patients
showed up.
Complete or
Incomplete
(Patient
Encounters)
Data
pulled
from
CHCS/
AHLTA
Above 90%
Kept
Monthly N/A When
percentage
falls below
90%
Process
Owner
LPO Reinforce policy
and
professionally
educate staff.
Graph

23. 1ST MED BN, 1ST MLG
Post-Improvement Graphical Analysis
04/201903/201902/201901/201912/2018
0.10
0.09
0.08
0.07
0.06
0.05
MM/YY
Proportion
_
P=0.07322
UCL=0.09371
LCL=0.05273
Sigma Z = 0.995202
Tests are performed with unequal sample sizes.
22 Area Clinic - Family Medicine No Show Percentage Improvement
• Improvements resulted in decreasing no-
show rate from 9%, down to 5.2% in April.

24. 1ST MED BN, 1ST MLG
Results Impact
Decreased percentage of No-Show Patients
Health benefits from patients attending
appointments
Improved staff utilization
Improved perception of LSS methodology and PI
effectiveness
Navy Medicine Goals
• Readiness
• Health
• Partnerships
Command Focus Areas
• Safe, Quality Healthcare
• Patient Experience
• Commitment to Staff
Mission Benefit Types
• Productivity Improvement
• Energy/Environmental
• Operational
• Personnel-Related
Financial Benefit Types
• Cost Savings
• Cost Avoidance
Project Benefits