----�-- �
r--
I
CA LIFORNIA STATE UNIVERSITY, NORTHRIDGE
BROKEN A PPOINTMENTS
\\
A thesis submitted in partials atisfaction of the requirements for the
degree of Mas ter of Public Health
by
W aleed Ahmed Alkhateeb
......
·
lI
. I
ll
I
!
i
l
I
June, 1972
I
!
I
J
The thes is of Waleed Ahmed Alkhateeb is approved:
CALIF ORNIA STAT E UNIVERSITY, NORTHRIDGE
June, 1972
I
_j
ii
To my parents, my wife,
Diane, and my daughter
Leila.
I
l
I
I
i
I
I
I
·
iii
'·
. .....
I
-,J
A CK NO W LEDGEMENTS
I wish to acknowledge my indebtedness and express my sincere
thank s to my teachers, my colleagues, and my family for their ,
generous contribution of time, -thought, and tolerance.
My deepest appreciation and gratitude to Dr. Lennin Glass,
and Dr. Allan Steckler for their critical guidance and lavish encour­
agement; to Mrs. Inga Hoffman, for giving me
the chance to do this
study and coordinating my field activities; and to Dr. G. B. Krishna­
m urty for serving as my statisti cal conscience.
A cknowledgement is m ade also to Connie Ferarra PHN, Carmel
Fleck PHN, Margaret Di ck son PHN, Mary Duncan R N, and Mrs.
N atolia Baldi, for their inv aluable assistance and cooperation.
iv
TAB LE OF CONTENTS
PAGE
iii
DEDICA TION
A CKNOW LEDGE ME NTS
LIST OF TAB I.E S
A BSTRACT
.
.
.
..
.
•
.
.
•
.
.
•
.
.
.
.
.
.
.
.
•
.
.
.
.
•
.
.
.
•
.
.
.
.
.
.
.
•
.
.
.
.
.
.
.
.
.
•
.
•
.
•
•
.
.
.
•
.
.
•
•
.
.
.
.
.
•
.
.
.
•
.
•
•
•
.
•
·
•
.
.
•
.
.
•
.
.
.
.
.
.
.
..
.
. ............................
·.
.
iv
vii
ix.
C HAPTER
1.
1
I N TRODUC TION
Statement of the Problem
Limitation of the Study
.
.
.
.
•
.
A s sumptions of the Study
Definition of Terms
•
.
•
.
.
.
.
•
.
.
•
.
.
.
.
.
.
.
.
4.
.
.
.
METHODS . .
.
.
.
II
.
.
.
1111
•
•
.
.
•
·.
.
.
o
•
•
•
•
•
•
•
The Questionnaire
5.
R. E SU LTS·
.
.,
.
o
•
·
Descriptive D ata
·
·
It
•
•
.
��
·
·
•
•
•
·
•
.
.
.
.
.
•
•
.
•
.
.
•
•
.
•
.
.
•
.
.
.
.
•
•
•
•
•
•
•
•
.
.
•
.
•
•
•
.
•
.
.
•
.
.
.
•
•
.
�
.
.
•
.
•
•
.
.
•
.
.
.
•
.
•
.
.
.
.
•
•
.
.
.
•
•
•
•
.
.
.
•
.
.
.
.
•
.
.
.
•
•
.
•
•
.
•
.
.
.
.
•
•
•
•
.
•
•
•
.
•
•
.
.
•
•
.
.
•
•
.
.
.
.
•
•
.
.
.
.
•
.
.
•
•
.
.
•
.
.
.
.
.
.
•
.
.
•
•
.
.
•
•
•
.
.
.
•
.
·
.
.
.
•
..
.
.
.
•
•
•
•
.
0
.
o
e
•
..
.
o
•
•
0
•
.
.
•
.
.
.
.
.
•
.
.
•
.
.
•
.
.
•
Ill
•
.
.
·
·
•
•
•
•
•
•
•• •
•
. . . .
.
·
•
·
•
.
·
.
•
•
·
•
·
•
·
•
•
•
•
..
.
.
..
.
.
.
.
•
•
��
•
.
.
•
•
•
. .
.
.
•
.
.
.
.
•
.
.
•
.
.
•
.
.
•
.
.
•
•
Ill
.
.
.
.
•
•
.
•
•
.
.
3,
3
4
6
17
17
17
•
•
2
19
•
.
.
•
•
.
•
.
.
.
•
.
.
.
•
•
.
.
.
•
•
•
•
•
•
•
Oil
.
..
.
.
.
.
.
.
.
22
24
28
I
I
I
I
I
I
I
I
I
I
I
l
ll
I
I
l
l
II
I
'
.
·
"
•
.
.
The Proposed Appointment System
The Study
.
.
.
.
•
.
•
•
F amily Planning Program
The Clinic
.
.
.
BACKGROUND OF THE STUDY
.
•
.
•
3.
.
.
•
•
LITERA TURE R EVIEW
.
•
.
2.
The Setting
.
.
.
.
.
..
.
.
.
.
·
·
·
·
·
·
·
·
·
•
•
•
•
•
•
•
•
•
.
·
•
.
.
.
.
.
.
.
.
·
·
·
·
·
·
·
·
•
•
•
•
•
•
•
•
.
•
•
.
.
·
·
•
•
28
32
32
!
I
!
l
!
I
I
Socio-Economi c Data
v
•
•
.
•
•
.
.
•
.
.
.
•
•
.
•
.
•
•
.
.
•
•
•
.
32
I
i
l
J
·--�
'
TAB LE OF CONTENTS
(cont)
PAGE
....
37
Patient Satisfaction With C lini c Staff . . . . . . . .
39
.. ... . ..... .. . ..
42
.... .. ... ... .. ... ..
46
Patient Satisfaction V!ith C lini c Services
.
.
Clinic Operation Data
Analyti c D ata.
6.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
•
.
.
•
.
DISCUSSION AND SUMMARY . . . . ... . . . . . . . . . . . . . .
.
53
Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
53
Re commendations Related to Study Design . . . . . . . . .
54
Re commendations Based on Findings
54
.
Summary
.
.
.
.
.
.
BIBLIOGRA PHY
A PPENDICES
A.
.
.
.
.
•
.
.
.
The Questionnaire
.
.
•
.
.
.
.
.
.
.
.
.
.
.
lit
.
.
•
•
.
.
.
•
.
.
.
•
.
.
•
•
.
.
.
•
.
.
.
•
.
.
.
•
.
.
.
•
.
.
.
•
.
.
.
•
.
.
.
•
.
.
.
•
.
.
.
.
•
.
.
.
•
.
.
.
.
•
.
.
.
.
•
.
.
.
.
•
.
.
.
.
•
.
.
.
•
•
.
.
.
.
.
.
.
.
.
.
.
•
.
.
.
56
.,
59
... ....
.
ID
.
•
.
•
.
•
•
•
•
63
•
� ...
63
.
1.
English Form
64
2.
Spanish Form
68
B. Hollingshead
73
Scale of Social C lass Index
I
I
I
!
!
J
vi
•,
. �··
LIST OF TAB LE S
Page
· Title
% Broken Appointments as a Fun ction of Clinic
Encounters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
Appointments Kept at Family Planning Clini c by
Number of Reminders sent to Patients . . . . . . . . . .
12
Family Planning Clini c Attendance Records During
the P eriod June 1, 1971, to February 1, 1972. ...
23
4.
Age of Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
33
5.
Marital Status of Respondents . . . . . . . . . . . . . . . . . . .
34
6.
Ethni c Background of Respondents . . . . . . . . . . . . . . . .
34
7.
Educational Background of Respondents . . . . . . . . .
35
8.
Number of Children of Respondents . . . . . . . . . . . . .
35
9.
Family Income of Respondents . . . . . . . . . . . . . . . .
36
10.
Social Cla s s Index of Respondents . . . . . . . . . . . . . .
.
37
11.
Patient Satisfaction With Clini c Services . . . . . . . . .
38
12.
Patient Satisfaction with Clini cal Staff. ... . . .. . .
13.
Sour ce of Referral of Respondents . . . . . . . . . . . . . . . .
43
14.
Number of Clini c Encounter by Respondents . . . . . .
43
15.
Mean s of Transportation of Respondents . . . . . . . . . .
16.
First Appointment Waiting Time
17.
Birth Control Method Chosen by Respondents
18.
Patient Satisfaction with Clini c Appointments . . . . .
19.
Preference For Proposed Appointment System and
Ethni c Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.
2.
3.
II
.
.
.
vii
_
.
.
.
.
40
44
44
•
.
.
.
.
.
.
45
47
48
I
I
I
I
LI ST OF TAB LES
(Cont)
Title
20.
21.
22.
Preference For Proposed Appointment System and
M ethod of Making Appointments. . . . .. . . . . . . . . . . . . .
�
49
Preference F or Proposed Appointment System and
Length of Waiting Time F or First Appointment . . . .
50
Length of Waiting Time for First Appointment and
W hether Patients Minded Waiting.. .. . . . . . . . . . . . . .
51
viii
• .
ABSTRA C T
BROKEN
APPOINTMENTS
by
Ahmed
Waleed
Master
of
Public
June
1972
Alkhateeb
I
Health
Review of appointment re cords at the family planning clinic
of the West Health. Center,
I
Los Angeles County Health Department,
show ed that 4 7% of the appointments were not kept.
To deal with
this high rate of brok en appointments, overbooking of patients was
practic ed.
l
I
. I
The problem wa s not solved.
This further demonstrated
the concept that the availability and accessibility of clinical facilities
and services does not mean that they are always acceptable to patients
or will be used by them.
modification
Achievement of a cceptability may require
of services to meet patient needs rather than personnel
.
I
I·
!
I
I
I
I
demands.
I
I
Il
!
l
A system wa s proposed to reduce the waiting time for an appoint-!
m ent which in turn might result in reducing the rate of broken
appointments.
The proposed system utilized the advantages of both
L__i��������nd _�2p oi�en!_�yst� m_s�·-----------------ix
!
I
l
J
,1
--·----·--------------------·---·-----···----·-··-------�
A study was carried out, using clini c patients as subjects, that
investigated the acceptability of the proposed system by the patients.
Too, the study was concerned with determining the variables that
might have affe cted the b roken appointment rate.
· The majority of patients in this study indi cated their preferen ce
for the proposed system over the existing one.
Acceptance of the
new system depended on the length of waiting time for an appointment,
ie. signifi cantly more people a ccepted the proposed system if the
waiting time for an appointment had exceeded four week s.
The sample population in t his study indicated that they were
satisfied with the service s they were receiving at the clini c, and that
a "Good" staff-patient relationship exi sted at the clini c.
i
I
l
I, .
No other
variable s seemed to affect patients' decision about the
proposed system.
This lead the investigator to con clude that waiting
time for an appointment is highly related to broken appointment s at
this clinic, and. adoption of the proposed system might drasti cally
reduce the broken appointment rate.
!
I
L
____
X
1
r-----------·---- ·-·-----
'
CHA P TER I
I N TR ODUCTION
(. Broken appointments hav e always been a source of concern to
a variety of agenci es and organizations which operate under an appointi\
ment system. ) Administrators of out-pati ent clinics are pa rti cularly
concerned because a high rate of broken appointments reflects unfavorably upon the effi ciency, pro cedures, s ervi ces or personnel of the
clini c.
(_�
certain per centage of broken appointments is anticipated and
generally creates· no problem, but a high rate of broken appointments
can disrupt the effi ci ency of operation and create a wasteful expenditure
of funds.
)
Various reasons have been advanced by administrators as to
possible causes of broken appointments.
Among these rea sons are
such matters as transportation problems, marginal motivation of the
patient, previous unhappy clini cal experience, socioeconomical status of
th e pati ent, mi sunderstandi�g of the date of the appointment, indifferent
treatment by the pa ramedical staff and the long waiting time for an
appointment.
1
2
considerable a.v.. nount of time being spent in the booking of patients
and pulling of re cords.
Too, if all patients for whom appointments
are made appear at the clinic, the result i s one of overcrowding,
impatient consumers and a frustrated, overworked staff.
Unfortun-
ately, if the clinic administrator does not overbook appointments,
the high rate of broken appointments will result in a clini c that
maintains a w hole complement of medical and supportive staff prepared to give patient care to non-existant patients.
Thi s too is a
frustrating a s well as costly situation.
·
W hat i s needed i s a plan that will reduce the problems of
broken appointments so that clinics may be more efficiently run and
the patients better served.
I
Statement of the Problem
I
This study wa s concerned with developing a system that
-I
would reduce broken appointments in a family planning clinic in the
I
West District of the Los Angeles County Health Department.
'I
!
I
aims of the study were primarily :
I.
·j
i
I
1
I
The
to determine the acceptability of the model by the clinic
patients,
·
2.
to make appropriate recommendations on the basis of
the re search findings.
L......- --------
�-·---------------·-···--·----"·
-------------
3
l---------
1I
---------------------------------------1
Limitation of the Study
The study was limited to those patient s attending the family
planning clinic of the West Di stri ct of the Los Angeles County Health
Department.
Therefore the results of the study cannot be extrapolated
to patients attending other clinics. )
A s sumption s of the Study
Every area of s cience i s based upon a set of assumptions or
p ostulates.
Justification of this study wa s based upon two basic
a s sumptions borrowed from p sychology.
I
!
I
I
I
I
'
!
i
!
!
I
I
Most clinical psychologist s
a ssume all behavior i s ordered (41 : 32-64 }.
The principle of ordered behavior is sometimes described as
"psychic determini sm".
Determini sm is the belief that all events in
nature are causally related.
Applied to human beings, determini sm
mean s that all the component s of behavior have their suffi cient causes.
Ba sically all behavior, despite it s complexity, ha s its determinant s
(44 : 172).
From the dynamic school of p sychoi ogy the second assumption
I
states that all behavior i s purposeful.
I
behavior is goal-seeking for sati sfaction of some need, want or desire.
I
i
l
I
I
I
i'
Characteri sti c of purposeful
Purposeful behavior is motivated behavior (3 : 4 66).
1
:!
'"---------------------------------------------···----�----·-----------··--·-·-'
4
�--------------
-----.--------�-------�-------------------------------····---·--
If on e a ccepts these assumpti ons, then it is possible to state
!
I
that the breaking of an appointment is purposeful and r elated to a
,
variety of determina.'l. ts.
�
Definition of Terms:
i
I
1
k/:Appointments:
i
I
I
I
I
I
I
j
\/
Appointment Cancelled:
Birth Control Method:
-
v/Brok en Appointment:
Family Planning:
.j
-'�
l
An entry in the patien£ s chart indicating that
the pati ent failed to notify the clini c of h er
A_ ction by persons to plan for and hav e the
number of children they want wh en they want
I
I
'
Any method that postpones or prevents a
inability to k eep an appointment.
I
I
An entry in the clinic tracer book indi cating
pregnancy.
I
I
clini c.
ability to k eep an appointment.
- i
j
specified time and place with a particular
that the patient notifi ed the clini c of her in-
II_ -
I
A mutual arrangement for a meeting at a
them; in cluding the appropriate education
to enabl e per son s to carry out such action.
M edically Indigent Patient:
Any patient who is unable to afford family
planning s ervices.
kWalk-in Patient:
Patients who are seen without an appointment.
'---·-----------·---------------------------
�--------�---�---�---·--��·-·-------·:;
5
�_.,/R eferral:
I
:
---
�--/ -------------
-----------------------------------·--------------------------------------·-------------------·--··---·--------------�
The act of identifying a person's need for a
particular service and directing him to the
appropriate service agency.
VVhen the need
is for family plalli"'ling services,
above,-
as defined
the referring agent ensures that the
appointment is properly made and follow-up if
the initial appointment is missed or broken.
Cli,."lic Session:
A
three hour family planning clinic session,
during which a physician is present for two
hours.
i
l
!
! '·"'·Patient's Chart:
I
I
i
I
!
I
i
l
.!
l
The supporting staff is present for
the whole three hour period.
A
document containing information about the
patient,
his medical problems,
progress.
treatment and
CHAPTER 2
L ITERATURE REVIEW
In
the early 1 950's hospital authorities in England and Wales
were requested by the M inister of Health to
review the workings of
outpatient departments fpr the purpose of removing all reasonable
causes of complaint.
The Minister asked that special attention be paid
to appointment systems,
punctuality of staff,
and reception of patients.
In this study,
brief mention was made of patients who failed to keep
appointments.
The hospital authorities speculated that the chief reason
was probably that during the interval after making the appointment,
the
patient improved and decided it was not worthwhile to come back.
Another reason put forth was that instructions regarding the appointment
were not made sufficiently clear.
In
�
i
.
I
1
'
another factor considered
an intensive report prepared by the Nuffield Provincial
Hospital Trust,
clinics
Finally,
brief mention was made of the
necessity in certain
to take into account
a certain percentage of outpatients, who without
notifying the hospital, failed to keep the appoint­
ment arranged for them. If there were many,
!
L.
�-�-.---·----�·-·--�·�------·----�----·-----�--�----��-� �·--------·�--·�-�·---·�---���-u---••••--·-·-�--••,•••-�-·
-
6
•.
.�-
7
then no appointment system could be expected
to work very satisfactorily. If there were few,
not more than 10% , then at the cost of only a
slight loss in efficiency, the number could be
offset by increasing the number of patients
called to attend each session, and by decreasing
the appointment interval by a percentage equal to the
defaulting rate ( in this instance 10% ( 35 : 47) .
In
a study of reasons for broken appointments in Los Angeles
County Health Department Family Planning Clinic, Miyoaka ( 34 : 6)
found that 2 4%
of the clinic patients broke their appointments because
of fear of not knowing what to expect, 17%
if' .,
!
\
confusion regarding the appointment,
did not return because of
and 16%
failed their appointment
because the appointment waiting time was beyond four weeks.
found that at times,
patients were booked twice due to the variety of
appointment and scheduling procedures,
appointments,
She also
e.g. patients made their own
'health department staff also made an appointment for
the same patient,
and the hospital staff also made bookings for
appointments.
Miyoaki ( 34 : 4) suggested that since the booking system involved
more than one person and various disciplines within the agency,
disciplinary communications were needed.
inter-
Her recommendations
included :
1.
Feasibility of having only one method of booking,
booking to be arranged by patient herself.
i.e.
8
l
-
2.
Identlficatlon of Spanish-speaking patients
an�-�=elopm:::
o f means to deal with their problems and fears.
3.
1
i
Some instructions r egarding can celling appointments if the
1
pati ent is not able to k eep the booking.
4.
Extensiv e follow-up to find the underlying reasons of those
pati ents who break an appointment.
In the evaluation of a primary care clini c of a local health
d epartment in Los Angeles County, Zukin, Gurfield and Klein found that
brok en appointments averaged 20% of all scheduled appointments.
The
data from this study i n�i cated an inverse relationship between the
IJ
I
,....-- -
I
I
frequen cy of clinic us e and broken appointments ( Table 1) .
The highestj
'--oportion of scheduled broken appointments occurred with patients who
I
;;
had one .en counter and the per centage of broken appointments decreased
as the number of encounters increased (45 : 18 ).
TA B LE
l
[
i
1
I
BROKEN A PP OINTMENTS A S A FU NCTIO N OF C LINIC ENCOU NTER S
En counters
Per Patient
I
I
I
1
2
.3
'•
4
5
6-8
Scheduled
Appointments
275
329
217
202
93
57
P er cent
Broken
23. 6
22. 8
22. 1
14. 3
11 . 8
10. 5
____ __,_,__�______ , __
'
'
i
!
I
_]
9
20% of the patients broke their appointments.
These patients seemed
to give evidence of social disorganization.
their appointments, it wa s found. that 38% forgot or were indifferent
ing (no baby sitter, an illness or no tran sportation ) ( 1: 127).
Hansen, in studying w ell baby clini cs, noted that completion
of the baby's immunization s, unfavorable weather and being seen by
many different physician s w er e fa ctors associated with broken appointm ents (23 : 417).
Oleni cki found that ra ce, age, cost and nationality background
was si gnifi cant in the appointment attendance of an adult clinic population (36: 183).
Mac Donald, Hagberg and Grossman n oted that the presence of
. communication pr:oblems between patients and staff enabled them to
predict poor cooperation in a program of outpatient care following
ho spitalization for rheumatic fever.
Interestingly, ther e seemed to be
no correlation with medical fa ctors such as seriousn ess of the disease
(32 : _456).
Curry found a dramatic improvement in tuberculosis clini c
n
....
'
'
10
-----
--�-------
!
r-.--- ·· ---�-�----------�----,l
attendance as a result of decentralizing s ervices into neighborhoods
·�
·I
w here large numbers of patients liv ed.
!
Having a dedicated staff in-
terested in the ..pati ents as sick human beings also helped the attendance
I
improv ement.
mi ssed a p revious appointment, .reduced the annual mis sed vi sits from
It was
repeatedly demonstrated during this study that there were some thing s
I
which w ere far more important to patients than attending clinics.
.
!
!
I
i
patterns of individuals and groups (11: 877).
Brigg s and Mud reported· that telephone contact before the first
appointment redu ced the number of unkept appointments.
Their results
might be conside red equivocal because they put " responsibility broken
!
fir st appointment" and " kept first appointment" in a single categ ory
I
.I
1
j
I
social, cultural and emotional fa ctors whi ch gov erned the behavioral
I
I
The
a c ceptance of medi cal ca re and s ervices was influenced by economi c,
I
I
Nurses' home visits to patients who w ere ill, or w ho had
50% to 3. 7 %, among people of a low soci o-economic lev el.
I
!
( 5: 18).
Kidd and Euphxat found that one way of reducing the number of
.
unkept o r broken appointments was to educate the referral agents so
that they could· communi cate with those they refer in ways that would
help low er anxi eties about the first appointment and help allay the
un-
ea siness about dis cussing problems with a "strang er" (27 : 394).
•,
-.·
-
11
I
------------------------------------.......................�----------�,
High broken appointment rates have been found to occur in every
i
medi cal field and could be viewed a s one of the major aspects of
medi cal noncompliance.
ed from 15% to 93 %.
Davis r eported that noncompliance rates rang - i
He found that at least a third of the patients
failed to comply with their doclx>r' s orders (14: 4).
In a recent study designed to explain why people who have been
I
I
II
i
detected to have abnormally high intraocular pressures, failed to keep
diagnostic appointm ents, Glogow reported that there were two categori e s of appointment breakers.
The first was comprised of pati ents
w ho failed their appointment at the center where the study wa s conducted, but w ho sought diagnosti c care at other approved eye care
s ources.
i
I
I
i
He cla ssifi ed these people as " compliers" since they followed i
instructions i n s eeking care.
The s econd group w ere called the "non-
compli ers" since they w ere pati ents who broke their appointments and
did not seek any follow-up care at any other sour ce.
l
The behavioral
di agnosis mad e on the noncompliers suggested that th ere w ere two
reasons related to their actions.
1.
These rea sons were:
their mental health, e. g. 3 mental confus cion, alcoholism,
extreme agitation and nervousnef?s, and
2.
elements of fea r and denial that existed within them
(20:203).
Hatcher and Tiller found that there was v,ery littl e response to
_________________ ____
I
i
j
12
�
�� ;�em�
itia
:�=��o � :i::�n= �t :
ders sent to wom
family plannirg clinic.
Of these,
ke t
ir ap
Ninety-seven women were seen in the clinic.
fifty-eight came at their appointment time.
The remaining
thirty-nine came to the clinic after follow-up reminders by post card,
telephone or home visit.
As indicated in Table 2,
twenty-five of the
thirty-nine women who responded
to the follow-up reminders had to be
reminded three or more times.
Of the thirty-nine women,
responded to
(18%)
only seven
the initial post card (24 : 1217 ).
TABLE 2
APPOINTMENTS KEPT AT FAMILY PlANNING CLINIC BY NUMBER
OF REMINDERS SENT TO PATIENTS
I
II
�
- -�--
�
Number of
Reminders
Number of
Kept Appts
0
58
1
7
2
7
3
17
4
7
5
1
Total :
I
I
I
I
'
'·
97
;
lI
i
- ·
-
-
-
- -·
-
-
: : : :: :����: �: : � ��� :� �� ::�::�=���� �
To h l
olve
pr
vol ed in
ch
li
in the outpatient clinic of Children's Hospital Med ical Center in
Boston,
a computer system was devised that has saved time and money for
I
I
the patients and hospital both ( 10:5 5 ) .
With its great speed, the computer keeps up to date
all the data a clerk needs for scheduling. The CRT
( Cathode-ray tube) units make this information
immediately available throughout the clinic building.
At the end of each day, the computer is put to work
on several housekeeping chores using the high-speed
printer and magnetic tapes. First it makes a print­
out of an alphabetical master log listing all patients
who have appointments on the next day. The list is
given to the clerk at the main reception desk on the
street floor.
Second, for each clinic operating the
next day, the computer makes a printout that con­
tains each patients name in his proper appointment
slot and any information that may be pertinent for
the doctor or nurse. Third, a list of appointments
two days in advance is prepared for use by medical
records department in pulling records. The records
then are shipped by conveyor belt to the proper floor.
When the patient arrives at the clinic on the appointed
day, the clerk at the main reception desk checks off
his name against the master log and sends him to
the proper floor. "
In
their eval.uation of the Louisiana Family Planning Program,
Beadsley et al found that the major source of patient referrals was
the postpartum referral system.
Program,
Established and maintained by the
this system accounted for 61%
during the two years of the study.
of the total patient load
They suggested that in addition
to adequate sources of referral it should be noted that.· a large scale
-----·--------�-��.J
>
•.
--
---- - - -
14
------ -···---------·---·----�-----·----------··--·-·--·--·---------·-···-·----·- ,
�------
appointment
and follow-up system was necessary to
of participation.
offered
l
It is noteworthy that 72%
insure high levels
I
I
of all women who were
appointments to the program eventually kept their bookings.
j
I
This data substantiates the strong motivation in this study group towards
l!
participation in the family planning program (2: 1812).
G ould,
Storr!')
and Rich reported that the lowest broken appoint-
ment rate was evidenced
1I
I
i
the postpartum,
in the antepartum phase of patient care.
family planning and child health phases,
In
the rate was
approximately double that which occurred during the antepartum period.
This leads to the conclusion that the patients cared' for in this project
exemplify the traditional attunement to seek care for illness or catastrophe as in this case with pregnancy.
However,
l
they were not inclined i
to seek preventive medical services such as postpartum,
tual,
interconcep-
family planning and child health services despite their availability
I
I
!
l
i
(22 : 1851 ).
Unless individuals are. informed of contraceptive methodology,
II
I
I
l
l
I
l
I
·I
1...
will not be able to
plan their families effectively.
they
Organized family
planning programs have the responsibility to provide adequate information and counseling to the individuals to whom they provide contraceptive services. Hellman suggested that beyond the educational activities
diTectly supporting the delivery of. family planning services,
need to
there is a
develop and make readily available information about population
j
:--·-�-�---�-.-----------�····-!
·-·------�-
15
;:
- -------·-·--------------·-----�·--·-·--···-·-···-----------·1
growth.
Among the goals of� such a program might be the following:
1.
Increase public awareness of the facts about population
.'
:,_
growth and their implications for the individual and
l
society to encourage educated decision-making.
2.
Increase public awa�eness of the determinants and impli-
Increase availability
lI
!
cations of different family growth patterns.
3.
i
I
I
Il
l
of population education curriculum
!
in school systems.
4.
Increase awareness of community leaders of the problems
of population growth and benefits of family planning.
5.
Increase availability to the general public of information
about the methods and benefits of family planning ( 2 5: 35 ).
A critical question facing health practitioners is whether broken
appointments can be red uced by· improving health education programs.
G logow showed that what is important in reducing broken appointments
is not what the patient is instructed
or taught,
in which the information is conveyed.
but rather the manner
Results of this study suggested
i
\l
\!
,,
\i
II
\l
l
!
'
that the client needs to feel that the staff of the m_edical facility is
concerned
The study also suggested that in-depth
education of the patient is needed.
I
I
I
with his welfare.
personal interest and " tender,
be induced
L
____
Once the patient experiences
loving care"
from clinic
staff,
he will
to be available for additional education (21 : 441).
'
----· -·---·---��---�----�- ---�----�-�----�···---··"
16
[I :::::::�: :::�:n:�:�:i:::::�:::��: �:;::�::::�
e ul
j
I
I
I
I
I
----,
n
number of unwanted pregnancies the clinic's program has prevented.
These "
non-events"
are difficult to measure however,
measures are often taken as proxies.
" efficiency"
and other ,
The most immediate measure of
is the number of patients seen per clinic session.
A clinic
that provides services to larger number of patients is more productive .
This measure,
however,
is only indicative of the quantity
rather than
the quality of care provided.
If
broken appointments can be reduced,
patients seen in a clinic can be increased.
then the number of
Thus,
the efficiency of the
clinic can be increased with resulting benefits passed on to the patient.
---
j
""'--------·---·-·--·-·····-···-- ··--·-!
·
----------·
'··
_ .....
l
--------------------------,-·�-��---�--�-,
I
Il
CHAPTER 3
BACKG ROUND OF THE STUDY
The Setting
This study was conducted at the West District Health Center of
the Los Angeles County Health Department.
The West District Health
Center serves an area of 1 , 727 square miles which includes a population of over a half a million people.
at Venice and Culver City,
of Beverly Hills,
Along with two--sub -centers ::
the Health Center serves the communities
Bel Air, Malibu-Palisades, Mar Vista,
Palms,
Santa Monica and the Sawtelle Veteran Hospital.
i
:;
,
i
I
I
I
II
II
.
The District Health Officer,
who is a physician,
has immediate
responsibility for the administration of all public health services performed In
the Health District.
The remainder of the district staff
consists of an Assistant District Health Officer,
nurses,
tionists,
public health social workers,
sanitarians,
physician-clinicians,
health educators,
public· health investigators,
dentists,
registrars,
nutri-
clerks,
community aides and other personnel needed to provide public health
services to the people of the District ( 94
: 3) .
·
Family Planning Program
Family planning programs fall within the framework of the Health
Department's Bureau of Maternal and Child Health. The services in-
L------·-·-------
----- ------�------
-
17
!
!
------- ---------· --���----��-�·-··p-·----------·-'
·
18
·
�--------·--------·-·--·----··-----·---· -·--------------·-��--··.. -···---·--
1
I
I
elude the providing of various birth control methods,
counseling and
referral for therapeutic abortion and male and female sterilization,
!
1
and
assistance in infertility problems ( 9: 29) .
!
E ligibility requirements for the family planning services which
are offered by the County Health Department are of a social and
financial nature;
Social: The following conditions are sufficient for the giving of
contraceptive information and services:
1.
any patient 21 years of age and older
2.
any patient under 21 years of age if she meets any
one of the following conditions.
.
b.
previously pregnant
c.
signed consent by parents
d.
fifteen years of age or older and living away
e.
an emancipated minor)
a female who is sexually active and who,
the opinion of a physician,
in
would run the risk
of an unwanted illegitimate pregnancy.
Financial:
!"
married
from home (
I
i
a.
.
I
Although the main objective of: the program is to pro-
vide family planning services to medically indigent patients,
there is no
financial screening or means test at this time.
I
l
��-·
_.;.•-
'
.
.
'•"
·
--
19
I�::�:
-
!
ents
-=� re�� : ed �:�-bot� ��::���e �nd ��tu�� �at�:��- ;��it�
-
-
-
-
-
-
-
--
-
ing the West District clinics ( 31: 12)
1
1:
I
i
i
The Clinic
i
i
Two different family plann�ng clinics are held at the West District !
Health Center.
I
I
II
I·
I
One is operated by the Health Center staff every first
and third Tuesday of the month between 5 . 00 and 8 . 00 P. M.
fourth Tuesday between 1. 00 and 4. 00 P.M.
This study was
conducted in conjunction with the clinic run by the Health Center staff.
The service d elivery system of the County Health Department
C linic is as follows:
II
1.
l
2.
The Staff:
The staff consists of a physician, a clinic
nurs e, two public health nurses and a Spanish-
I
I
The other
The referrals to either
clinic are handled by the Health Center Registrar.
i
I
i
clinic is operated by the UCLA Medical Center staff every second and
!
I!
I
··
speaking volunteer.
Registration:
!
Patients are registered in advance and their
names are entered on a clinic "tracer" .
Patients' charts are ·pulled out and the clinic
I
I
has them available at the start of the session.
i
I
If the patient is new to the health center,
I
l
a
chart is made in advance and a permanent
1-�·-...-..-�.�........----�--.,..--------
•.-
_.;>·
--
-----�-----------�w-�-·---·-•••••-----··��--·-•'""'�•·-•!
20
·
------------------- --------------------------- ------------···---------
r ecord number is as signed.
3.
Interview:
The nurses record the medical history and socio-
,
I
economic background of the patient.
4.
Education: · A nurse who is trained in family planning dis cus ses
the services -of the clinic, with emphasis on the
v ariety of contraceptive methods available and the
effectivenes s , contraindications . and side effects of
these methods.
A variety of audio-visual aid s are
often employed to aid in the education .
These
include flip charts , anatomy models, films and
s lides .
5.
Medical Examination: This step is handled by the physician with
a nurse assisting.
Some education is almost always
included at this point, though the largest part has
already been given by the nurse before the examination.
6.
Method Selection:
A "pap" smear is obtained at this time.
Based on the patient's preferences and the
advice of the physician, the patient chooses a birth
I
control method , receives instructions on its use and
obtains supplies.
I
L---·------
-
-
----
Methods available include:
a.
Pill
b.
IUD (1!trauterine D evice)
c.
-
----
F o am
-
·-------
---
-------·-·--·-··-
------------·--- -··---··
·
........
·-·· -·--·-····-·
····-'
21
r-------�--�--------�---
d.
7.
Diaphragm
Revis it Appointment:
The patient is usually given an appointment
for a routine return visit which varies from s ix
weeks to one year depending on the method of contraception chosen by the patient.
Because of the high rate of broken appointments that the clinic is
The clinic
experiencing, overbooking of appointments is practiced.
staff can handle approximately twenty patients per session.
The wait-
ing time for a first appointment is about four to six weeks.
I
l
i
!
I
I
I
I
I
i
I
l
i
I.
i
i
l-----·-------�---------------------------·----·---------·--·-··---·-······..·
'·
--
·
l
f-------------·---------�-·��·---�--�-��----------�---�-�-&-�-�--�------�
CHAPTER 4
M ETHODS
This investigator was assigned to do field training in health
education at the West District Health Center of the Los Angeles County
Health Department.
The family planning clinic was selected for the
1,'
l
I
I
I
i
!
;
I
following reason_s:
1.
The d istrict health educator, and the other administrative
1
staff of the family planning clinic, were concerned with
the high rate of broken appointments at the clinic.
A survey of clinic attendance records from June 1, 19 71
2.
through F ebruary 1 , 1972, indicated a high enough percentage ( 47%) of broken appointments to merit serious
consideration ( See Table3) .
The staff of the clinic was interested in finding a solution
3.
to the broken appointment problem.
It seemed most practical to do this study where this in-
4.
vestigator was doing his training since personal contacts
'
had been established and maximum cooperation by the
clinic staff had been as sured.
A proj e ct was proposed to find some of the reasons behind the
high rate of b roken appointments .
It was found later that a similar
s tudy had been done at two other L. A. County Health Districts(34) .
'
i
l
�--·-----��--------·-------·---·-�-��---�--�-------------·--�------�-�-�-���--�--------�·j
22
23
�----·---�-------·-----------· ···---· ··-···--····----------- ·-·-··-�------·--··---- ----- ··-··-····-····--··· ----
I
UB�
II
I
3
F AM I LY PlANNING C LINIC A TTENDANCE RE CORDS DURING THE
PERIOD June 1, 1 9 71 TO F EBRUARY 1, 1 9 72
Date
·I
·
--· ·--·
-,
No . of Ap:ets
Scheduled
No . of AJ2];2ts
KeJ2t
No. of Aa�ts
Broken
2-1-72
44
18
26
1 - 18 - 72
51
15
36
1-4- 72
43
14
29
12-28 -71
44
26
18
1 2 -7- 71
35
20
15
1 1-16-71
41
22
19
1 1 -2- 71
42
20
22
1 0 -19-71
43
18
25
1 0 -5- 71
43
20
23
9 - 21 - 71
36
24
12
9 - 7- 71
41
27
14
8 - 17- 71
46
30
16
8 -3 -71
33
24
9
7-20 - 71
54
33
21
7-6- 71
42
22.
20
6-15- 71
35
18
17
6 - 1-71
44
24
20
TOTAL
71 7
Average Appts Booked
3 75
42. 1 7
=
Average Appts K ept
Average Appts B roken
Average % Broken Appts
=
=
=
22. 0 5
2 0 . 11
47%
342
I
I
j
.
24
--��-�--�----�----�---·-.---��M�.-�--------�-�---------�-_.�y·--��------���·-·-·�----�-,�·'""' "---�---�-'<••-·•-·---··••••-•••••-·-------�--
•
;
The findings of that study, and findings from other related studies
�
reviewed by this investigator, indicated that there was a strong relation
ship between the waiting
broken appointments.
time for an appointment and the rate of
When this relationship was dis cussed with the
various people at the clinic, - the investigator was asked to find out a
way to deal with the problem.
A system for booking appointments was
propo sed and a study was conducted to evaluate the acceptability of such j
a sys tem by clinic patients.
The Proposed Appointment System
1.
Referral
Referral agencies should be instructed
not to make any bookings for patients
but rather to emphasiz e to the patient
that it is her responsibility to contact
the health center for details of the service
offered .
However the referral agency can
explain to the patient that the clinic
operates under two systems, walk-in for
edu cation and appointment for medical
examination.
I
!
I
"
i
2.
The F irst Visit When the patient contacts. the health cente:�;
the clerk should explain that an appoint-
!
L
ment is not neces sary for the first visit.
·�-·��--------�---·��v-�------·----------·-·-·----�-�----·--·---··�---··-·-•-·-----·��---�·----·--•·-�•·-·--·-··------�-··••
25
Dur ing this initial visit a trained nurse
should tell the patient abouth birth control
methods available.
Contraceptive foam
can be provided as a temporary method
of birth control until a more perm anent
method is selected at a subs equent visit.
Then the patient can register for an
appointment to see the doctor for a
med ical examination during which her
preferred birth control method is deter­
mined.
3.
The Appointment:
Booking the appointment can be handled
by a nurs e, a clerk or a trained volun­
teer.
Whoever is handling the booking
should ask the patient which method she
is going to choose and the time of her
menstrual cycle ( so that the appo intment
time will not conflict) .
The appointment ·Sheet should have "return''
patients already booked.
There should be
no more than twenty-five patients booked
at any time.
26
Extensive follow-up should be an integral
part of any health delivery system.
In
this situation, where public health nurses
are available, follow-up visits shoul9 be
carried out for both patients who already
are in the program and those who have
broken their appointm ents.
Reminders
should be sent to patients before their
s cheduled visit.
Phone calls and field
follow-up for those patients who break
appointm ents should be part of this
proposed system.
1·
The proposed system has two basic assumptions:
L
The family planning service delivery system has two
maj or
and separate components;
!
a.
edu cation and
!
b.
medical examination
;
I
'i
I
2.
Patient motivation i s highest at the time the patient is
initially
seeking family planning services.
This motivat-
ion is time dependent, ie.) there is an inverse relationship
I
I
!
i
between level of motivation and waiting time, the longer
the waiting time, the less motivated the patient becomes
in keeping the appointment.
27
The proposed system utilizes the advantages of both the appointment and walk-in systems.
1.
These include:·
Advantages of the appointment system are:
a.
Number of patients is predetermined, thus staffing
is predictable.
b.
Some patient education is pos sible over the phone
while the appointment is being made.
c.
Patients who like their activities planned m ay
respond best to the appointment system while
putting off the visit if they were to use the walkin system.
2.
Advantages of the walk-in system are:
a.
The patient's needs are served immediately.
b.
Patients may be served whose motivation might
other-wise be lost due to waiting for an appointment.
c.
Informality may attract certain patients.
The use of this proposed system has certain advantageous factors:
I
II
I
a.
A lthough broken appointments are anticipated, this will
not affect the clinic efficiency because there will always
be patients available to be substituted for those who have
broken the ir appointments.
b.
T ime is s aved in processing patient charts and records.
------- ----
l_,
1
I
J
28
I
-I
I
There will be only twenty to twenty-five bookings each
s es sion rather than forty to fifty.
Follow-ups will be e asier beacuse of the small number of
c.
patients booked at each session.
The only disadvantage to the proposed system is that the patient
is required to m ake two visits.
This disadvantage may not be serious
since some of the patients already make two visits in the existing
system.
I
·
F ollowing the development of the proposed system, a study was
conducted to determine if the system was acceptable to clinic patients.
I
The Study
A sample of forty female patients was selected from the clinic.
These subj ects were selected from four clinic sessions scheduled
1·I
between M ar ch 27, 1 9 72 and May 2. 1972.
The Questionnaire
!
A questionnaire was devised to elicit responses about the proposed appointment system ( See Appendix A) .
After constructing the questionnaire, s ix pre-test interviews
were conducted among clinic patients.
As a result of the. pre-test
interviews , some questions were rephrased and the order of present-
I
l
L- ----------··
·
,,.
.-
29
r
I
I
I
l
I
ation was altered.
The questionnaire which was used to collect the data in the study
The information obtained was classified
contained twenty-seven items.
into two categories:
1.
socio-economic or census-type and
2.
information pertaining to the subject matter of the investigation.
The so cio-economic data included age, marital status, ethnic background, level of education, number of children, family income, and
employment.
The remainder of the questionnaire sought to gather
both objective information and subje ctive opinions related to the study.
I
I
I
!
I
I
I
An attempt was made to present the various items in a logical
progres sion within a framework of interest to the patient.
One point
of agreement among most survey experts is that the opening question
s hould be easily answered (40
:
573).
If the initial questions create a
feeling of anxiety, hostility or ignorance in the respondent, she may
I
give biased replies throughout the questionnaire.
l
s impler or more neutral items early in the questionnaire was designed
'
I
I
I
I
I
I
!
Placement of the
to give the _patient a feeling of confidence and responsibility.
It has been recommended that questions to which a respondent
m ay be sensitive o r which require a great deal of thought should be
placed in the middle o r towards the end of the questionnaire.
L--------------�--
These
30
�
-------------·-------------·�-------------- -------·----·--·-·------------···!
I
I
questions should never be placed at the very end because they may
leave the respondent with misgiving about the purpose of the questionnaire , the investigators and the study in general.
As this was an exploratory study and involved a relatively small
s ample, s everal open- ended questions were included.
These questions,
by not sugges ting responses, allowed the subj ect to respond in terms
o f her own fram e of reference.
The freedom to respond forced the
subj ect to answer in terms of those factors that were relevant to her.
Thus the open-ended question provide an indicator of the factors
I
· II
I
I
I
whi ch
were prominent in the thinking of the individual about a given issue
(4 0: 2 57) .
In the questionnaire, various forms of questions were utilized.
Thes e included the di chotomous form (yes -: no) , the open-ended form and
the three point s caled form .
. I
I
I
I
The scaled questions were established
expression of an open-ended response.
to obtain a quantitative
A patient was asked to rate
II .
advisable that relevant questions with fixed- alternatives responses be
I
included.
I
I
I
I
I
j
s omething as "Goo d ", "Average" or " Poor".
Selltiz et al have stated
-
that the inability to probe in the open-ended questionnaire makes it
When thes e s tructured questions were used, the patient was
afforded the opportunity to elaborate o r clarify the answers.
_______
I
31
·r----�------------------------------------------- -------------------------- ------
1!
I
II
!
I
i
The questionnaire was self-administered.
The investigator was
pres ent at , all times while respondents were answering the questions
and helped explain any ambiguities.
If the subj ect was a return
patient to the clinic, she was administered the questionnaire at the
beginning of the clinic s ession.
First vis-it patients were asked to
respond to the questionnaire after they had been seen by the doctor.
This was essential because part of the questionnaire dealt with patient
s atisfaction of the clinic operation.
The questionnaire was translated into Spanish to minimize the
language b arrier for Spanish- speaking subj ects.
A copy of the quest-
ionnaire used in this study has been included in Appendix A.
i
i
! .
l
I!
L�-------------------------------------------------------------------
---------- - - -- :
'·
_ .,.,_
I
CHAPTER 5
RESU LTS
Data were collected from a sample composed of 40 females
representative of the family planning clinic population of the West
District Health Center, Los Angeles, County Health Department.
These patients were studied as to their feelings about a newly proposed appointment system and the current operation of the family
I
I
planning clinic.
Data were analyzed in two ways.
frequency tabulation of responses were obtained.
in the questionnaire
i
First, descriptive data and
Second, item 15
I
was selected as the dependent variable and chi-
square analysis was performed.
This had the effect of dichotomizing
the respondents into two groups:
those that accepted the proposed
i
l
I
I
I
II
appointment system and those that did not accept the proposed
system.
A.
DESCRIPTIVE DATA
Socio-E conomic Data
l
l
!
j
are considered in this section.
I
I
I
ber of children, family income, and social class of the respondents
l
I
ll
Age, marital status, ethnic background, level of education, num-
Eighty two percent of the patients in the sample were thirty
year s old or younger, ( T able 4) .
.
The youngest respondent was eight-
k-----·---
32
I
1
!
I
J
33
r
'
I
. teen years old, and the oldest respondent was forty one years old.
The mean age for the sample was twenty six.
1
TABLE
AGE
Age
OF
4
R ESPOND ENTS
F requency
Percent
1 8-20
5
1 2. 5
2 1-25
15
3 7. 5
26-3 0
13
3 2. 5
3 1 -3 5
4
10
Over 3 5
3
7. 5
TOTA L
40
1 00
Seventy two percent of the respondents were either married or
had been previously married.
Twenty seven percent of the s ample
were single, and none were widowed, ( Table 5) .
F ifty five percent of the patients were white and forty five
percent represented a variety of minority groups.
Of the two respond-
ents who answered "Other" one was from Cuba and the other respondent was from South America, ( Table 6) .
I
I
L_.
_
_
_
34
--------···----··--··--------------------------------- -·----------· -···--·····---.
TAB LE 5
MARITA L STATUS OF R ESPOND ENTS
Percent
M arital Status
F requency
Single
11
27 . 5
M arried
26
65
Divo r ced
2
5
Separated
1
2. 5
40
100
W idowed
TOTA L
TA BLE 6
ETHNIC BACKGROUND OF R ESPOND ENTS
Ethnic Background
F requency
Percent
White
22
55
Black
4
10
Oriental
6
15
M exican-American
6
15
Other
2
5
TOTA L
40
100
·---------------------
35
Indeed, at least fifty percent had some college or technical s chool
j
TABLE 7
I
I
I
EDU CA TIONA L BA CKGROUND OF R ESPOND ENTS
Percent
F requency
Education
i
I
Less than high s chool
6
15
High school graduate
14
35
Some college or technical s chool
13
3 2. 5
College graduate
5
1 2. 5
Post graduate
2
5
100
40
T OTA L
F ifty s even percent of the respondents had one or no children
None of the patients had more than four children, ( Table 8 ) .
TABLE 8
NUMBER OF CHilDREN OF R ESPOND ENTS
Number of children
F requency
Percent
None
14
35
1
9
22. 5
2
4
10
3
8
20
4
5
12. 5
40
100
M ore than 4
TOTAL
F o rty s even percent of the patients had incomes below $5, 000 ,
i
L
( Table 9}.
This was expected because the County Clinic is suppos ed
..·-··---------·-------------------�----------·--·--···------··- -- ---------- - - - ··---· --·
-
36
g ive
��
�--t�
:1,
I
I
j
1
l
,I
I
I
I
rv ices to
--��:��-w��---::·-- --·-··-·1
;�:
:;-;
:
;�:
�
�:li
��;
:� ;:�
ent
-
financial s creening, s ome financially
ab l e women were also found in
this sample.
TA BLE 9
FAMILY INCOME OF RESPOND ENTS
F amily Income
F requency
Less than $3 , 00 0
5
1 2. 5
14
35
$ 6 . 999
12
30
$7 ' 000 - $9 , 999
7
$3 . 000
$5 . o o o
_
_
$4. 999
Over $ 1 0, 0 00
2
TOTA L
40
Percent
17. 5
5
100
The social class of the respondents was determined by using the
Ho llingshead Scale of So cial Index ( see Appendix B) .
F o rty two percent of the s ample were designated as classes 2
and 3 , which are considered the white collar workers, and fifty seven
percent were designated as classes four and five which are considered
the blue collar workers ( Table 10).
I
I
ll
___
'
--------· ----- ···---····--··----'
.
37
TABLE 1 0
SOCIA L C LA SS INDEX OF RE SPONDENTS
-1
!
·
s o cial C la s s
Pe r cent
F re quency
____________________________
________________________________ __
I
C lass 1
C las s 2
4
10
C lass 3
13
32. 5
C las s 4
14
35.
Class 5
9
22. 5
TOTA L
40
100
Patient Satisfaction With Clinic Services
Many studies have shown that satisfaction with medical care
might have some connection with broken appointments , ( 5 , 1 7, 21 , 3 2) .
A series of ques t ions which attempted to measure the patient's
degree of satisfaction was included in this study ( Table 11) .
Ninety seven percent of the patients stated that the educational
session about birth control was helpful; and the instructions regarding l
the use of the birtl). control method they cho se were easy for them to
understand.
Mo st of the patients commented that they were getting
"Excellent" information about birth control methods and their proper
�----- ----
'·
. ......
l
j
I
I
J
r-·----·---�--:---·---------·- --------·---�-----------·-------------------------·-·--·------------- ----------··--·--------------·---------------------·--··--··-·---------- ·
TAB IJ E 11
PATIENT SATISFA CTION WITH C LINIC SERVIC ES
IT :EM
I
2.
3
.
4.
NO
YES
%
1.
!
( N)
AL
'T'O'T'
TA
TO
% < N)
%
( N)
Did you think the educational sess ion about birth
contro l method s was helpful ?
9 7. 5
39
2. 5
1
lDO
40
Are the instructions regarding the us e of the birth
control method you cho se easy for you to understand ?
9 7. 5
39
2. 5
1
100
40
Are you getting the kind of service you expected to
get at the clinic?
92 . 5
37
7. 5
3 10 0
40
31
22. 5
9
40
Do you feel you are getting personal attention in this
clinic ?
77
. 5
100
I
I
I
� -
TOTA L
91
36
9
10 0
--------- -----
40
- -�-�
-�
-Q':l
39
r-----------------·--------�---·.
I
I
. i
use.
··- --·-------·---·----------------- - --·-·· ----·- · ·-·-····-··-···· --···· - · · ·-. -·•· -· ·--·
Only one patient thought otherwise in both cases.
She stated
" I know more about birth control than the nurses could ever tell me ".
Ninety two percent of the s ample thought they were getting the
kind of service they expected to get at the clinic.
responded negatively to the question
than I expected" .
One patient
but commented " It' s better
Few patients stated that they did not know what to
expect when they first came to the clinic, however they indicated that
I.
I
they were well s atisfied with the services they had received.
i
Seventy seven percent of the s ample stated that they were getting
personal attention at the clinic.
Among the patients ' comments who
responded negatively to this question were, "You can never get personal attention in a county clinic," or " With all the people they see in
one ses sion, the staff have no time to give personal attention to anyone".
Patient Satisfaction With Clinic Staff
The staff-patient r elationship was investigated from the patients '
point of view.
The staff included the doctor, the nurses, and the
r eceptionist, ·( Table 1 2) .
The patient's feeling about the medical and
paramedical personnel with whom they had contacts, has been mentioned frequently by administrators as a factor in clinic attendance,
( 5 , 1 7 , 21 , 3 2
).
.
'
-----··�---------·-···-----·----------··--·----- ··1
TABLE 12
PATIENT SATISFAC TIO N WITH C LINIC STAF F
\
IT EM .
;------��--
I
\
I
1.
I
I
�!
Would you say the servi ce at the clinic that
are getting is :
Poor
Average
Good
%
( N)
%
75
30
22. 5
8
% ( N)
( N)
Total
%
( N)
100
40
1 00
40
10 0
4 0
100
40
you
2 .
How does the do ctor treat you ?
80
32
20
8
3.
How do the nurses treat you?
85
34
15
6
4.
How d o the receptioni sts treat you ?
80
32
20
8
2. 5
-
1
1 0 0 40
1
TO TA L
3 2 19
7 1
80
--�-�----_,
H'>0
41
�-------------------------------------------------- ---------------·------- ------·----------- -----,
I
- I
Seventy five percent of the patients rated the clinic services as
" Good".
One patient rated the service as " Poor", because the doctor
attended to another patient before attending to her.
E ighty per cent of the sample rated the do ctor as "Good".
of the patients commented that the doctor was "F r iendly".
Many
" Good"
treatment was an elus ive combination of friendliness , gentle handling,
sympathy, and honest interest in the patient.
" Average" tre atment was described as " Polite , nice, o r
pleasant", but the word " fr iendly " was absent from the description.
E ighty five percent of the patients described the nurses
treatment as " Good".
They felt that the nurses were friendly,
pleas·ant, cheerful, and helpful.
Some of the patients rated their
treatment on a comparative basis, recalling experiences in other
county clinics which were less than "Good".
Patients who rated nurses' treatment as " Average" had no complaints.
They merely s aw the nurse as someone who was polite and
directed them to an examining room.
Most of the patients identified the receptionist as the appointment
clerk.
E ighty per cent of the respondents rated the receptionist as
"Good".
'·
.
.-
42
None of the patients rated any of the staff as "Poor " .
This in
itself was an indication of a good staff-patient relationship, and could
be excluded as a factor of broken appointments in this study.
Clinic Operation Data
I
1
i
l
.i
This section contains data about patients source of referral,
number of clinic encounters , transportaion, appointm ent making, and
patients choice of
F ifty
birth control
methods .
percent o f the patients were referred to th e clinic by
" word of mouth ", either by a r elative or by a friend .
percent were referred by county agencies .
Forty
The patients who responded
" Other" , wer e referr ed to the clinic by their private physicians ,
( T able 13) .
F o rty five percent of the s ample were first time patients, and
fifty five percent were returns , ( Table 14) .
Seventy percent of the patients , cam e to the clinic in privately
operated automobiles.
I.
This indicated one
of two things:
The patients were living in areas which were far away
from the clinic.
2.
rr:he patients , as the case is in Los Angeles, depend
heavily on their cars as means of transportation, ( Table
43
TAB LE 13
SOURCE OF REF ERRA L OF RESPONDENTS
Source
F requency
4
Re lative
Percentage
10
F riend
16
40
Public health nurse
10
25
Other county clinics
4
10
Department of social services
2
Other
4
TOTA L
40
5
10
100
TAB LE 14
NUMBER OF C LINIC E NCOUNTER BY RESPOND ENTS
. j
L-------------------
-----·------�--�---------·-------.-------------------�··- J
44'
TAB LE 15
MEANS OF TRANSPORTATION O F RESPOND ENTS
M eans
F requency
Percent
25
62. 5
Auto (others)
7
1 7. 5
Public transportation
6
15
Walking
2
5
TOTAL
40
Auto (self)
100
F o rty five percent of the respondents had to wait over four
weeks for their appointments, (Table 1 6) .
Other studies, ( 5 , 28 ,
34)
have shown that broken appointments are highly related to the waiting
time.
Thus, encountering a high percentage of patients who had to
wait a long time for an appointment was an indication of a highly
motivated population in this study.
TAB LE 1 6
F IRST A PPOINTME NT WAITING TIME
Waiting time
Frequency
Per centage
Less than 2 weeks
11
27. 5
2-4 weeks
11
27. 5
4- 6 weeks
14
35
over 6 weeks
TOTAL
·
'---�-------
4
40
10
100
45
The majority of the patients chose the pill as a method of birth
control, ( Table 17) .
TAB LE 17
BIRTH CONTRO L ME THOD C HOSE N
M ethod
BY
F requency
RE SPO}..lD ENTS
Percent
Pills
26
65
I. U. D.
10
25
Diaphragm
4
10
40
100
Other
TOTA L
Patients satisfaction with clinic appointments was investigated
in this study, ( Table 18) .
Ninety five percent of the patients thought that the clinic time
was convenient for them.
Sixty three percent thought that waiting
time for an appointment was too long.
As many patients stated that
waiting tim e at the clinic was too long as those who stated that wait­
ing time at . the clinic was short.
Some patients stated that "Two
hour s " waiting time was a long wait.
Sixty five percent of the patients stated that they would like the
clinic to send them a reminder of their appointment time.
The rest
.4: 6
of the patient s, although they thought this might help them remember
their appointment, stated that the y did not care for the clinic to do
that.
Most of them did not want anyone to know about their part-
icipation in a family planning clinic.
When asked to choose between the existing appo intment and
s cheduling system and the proposed appointment booking system, s ixty
eight percent of the patients preferred the proposed sys tem over the
existing system.
Since the proposed system dealt mainly with reduc-
ing the waiting time for an appointment, this finding strongly supported :
the findings that patients were asked to wait a long time for an
appointment.
The las t ques tion that was included in the questionnaire, asked
the respondents what things they would like to see changed at the
clinic.
The comments to this question were ·.consistent.
The indi-
cation was that more than one doct or was needed at the clinic.
B. A NA LYTIC DATA
Chi square analysis was performed with the proposed system
The other variables in the questionnaire
as the dependent variable.
were used as independent variables.
i
i
1
were s ignificant at the 0 . 0 5
None of the chi-squares obtained
significance level except for the
following:
-------------�--------- ---�------···--�--- ------..... ..... .. ..... .....,
L---------- ------------
'·
.-
-:--·--···---·- -·-·- -.-·- "'�···--····--·- ··-·----·-..-·�·-----------..--.-·�---···
-.·-.- - ···"�-·-·-·----�·-· -··""····- · ··" '·- ··--·-··-�- ·--- -·-·--··--·- - �----· ---·-- ·-·
TABLE 18
PATIENTS SATISFACTIO N WITH CLINIC APPOINTMENTS
ITEM
Yes
%
( N)
No
To:tal
% ( N)
% ( N)
2
40
1.
Is the clinic time convenient for you ?
9 5
38
2.
Did you mind waiting that long ?
3 7. 5
1 5
3 .
Did you have to wait a long time for your turn
at the clinic?
5 7. 5
23
42. 5
1 7
100 40
Would you like the clinic to send you a reminder
before your next appointment?
65
2 6
3 5.
14
1 00 40
64
2 5
3 6
1 5
4.
TO TA L
····-"· -----···-·-- ---------· ----.-�
5
62 . 5 2 5
..
10 0
1 0 0 40
100 4 0
--------·-��-----·------·-·· " .
- « - ·�-·-- - - ·-��---c.--·---.---�-�--�""'
>P>-.
">!
48
1.
Var iable number 3 in the questionnaire, which seeked
the ethnic background of the respondents, was collapsed into two
categories, white and minorities.
Chi-square analysis against the
two categories of the proposed system (Table 19 ) yielded a chi square
of 3. 4
7.
This was not s ignificant at the 0. 05 level ,
3. 84 is s ig-
The investigator
nificant at that level with one degree of freedom.
felt that this value should be reported as it tended towards s ignificance�
.1
TAB LE 19
PREFERENCE F OR PROPOSE D APPOINTMENT SYSTEM AND
ETH NIC BACKGROUND
PROPOSED
SYSTEM
White
%
30
NO T
AC C E PT
( c)
d . f.
2.
Total
�N)
(15 )
(b)
%
6 7. 5
{N)
( 2 7)
.
'
I
(d)
2 5
( 10)
55
( 22 )
=
3 7. 5
( 12 )
( a)
X 2
%
{N)
ACCE PT
TO TA L
Minorities
3. 7
4
7. 5
*
( 3)
32 . 5
( 13)
45
( 18 )
100
40
p
0 . 08
1
=
Another variable which yielded a chi- square value tending
towards s ignificance, was variable number 2 5 .
This variable d ivided
the sample into patients who preferred making appointments themselves, and those who preferred the clinic to do it for them, (Table 20) . !
I
*
x
2
2
=
(a
n (ad - b e)
+ 0. 5
+ b) " ( c + d) ( a + c) ( b
'·
+
d)
----·---·------�-----�.��1
. ......
'··
.-
49
TABLE
20
PREFERENCE F OR PROPOSED APPOINT ME NT SYSTEM AND METHOD
APPOINTME NTS
OF MAKI NG
MAKING OF APPOINTMENTS
Self
C linic
Total
ACCEPT
%
30
NOT
ACCEPT
( N)
( 12)
%
37. 5
( N)
( 15)
25
(10) . 7 . 5
(3)
55
( 22)
%
67. 5
( N)
(27)
PROPOSED
SYSTEM
TOTA L
2
x
=
d. f
p
3 . 74
45
( 18)
32. 5
(13 )
100
40
. 08
=
i
3.
The only variable that yielded a significant chi-square
value when compared with the proposed appointment
variable number 1 2 .
system was
After it was collapsed , this variable d ivided
the respondents into a group of patients who waited less than four
weeks for their fir st appointment, and another group who waited
over four weeks for their first appointment.
was 3 5 . 93 , ( Table 21) .
The chi-square value
This indicated that the two variables, the
proposed system and waiting time, were not independent of each other.
As a result, the null hypothes is " There is no relationship between
waiting time for an appointment and acceptance of the proposed
'·
.
.-
...
.
-
i
i
.,
'
50
appo intment system" , was rej e cted.
In other words, the findings
supported the research hypothesis that acceptance of the proposed
system by patients was related to the length of waiting time for an
appointment.
I
TAB LE 2 1
PREFERE NC E F OR PROPOSED APPOINTME NT SYSTEM AND LENGTI{
i
O F WAITING TIME F OR THE F IRST APPOINTME NT
WAITING TIME
OVER
LESS THA N
TOTAL
4 WEEKS
4 WEEKS
%
AC C E PT
PROPOSED
SYSTEM
%
( N)
%
(N)
( 7)
50
(20)
67. 5
(27)
27 . 5
( 11)
5
(2)
32. 5
(13 )
45
( 18 )
55
(22)
100
(40)
17. 5
NO T
ACCEPT
TO TA L
x2
d . f.
(N)
p
3 5 . 93
=
0 . 0 01
1
To s how the direction of relationship of waiting time to acceptance of the model, a "t" test was performed on the proportions of the
s ample accepting the proposed system who waited less than four weeks,
against the proportion of the sample accepting the proposed system who
waited ove r four weeks.
The test yielded a "t" value of 4 . 13.
This
was found to be highly s ignificant at the 0 . 0 0 5 level and indicated that
s ignificantly more patients who waited over four weeks accepted the
proposed appo intment system than patients who waited less than four
weeks.
'·
·
_ ..,_
51
A chi-square analysis of variable number 13 , which classified
respondents into a group who minded waiting for an appointment and
those who did not mind waiting, against var iable number 12, length
of waiting time, yielded a chi- square value of 6. 51.
This was
s ignificant at the 0 . 0 5 s ignificance level, ( Table 22).
TABLE
22
LENGTH O F WAITING TIME FOR F ffiST APPOINTMENT AND
WHETHER PA TIE NTS MINDED WAITING
WAITING TIME
LE SS THAN
4 WEEKS
%
%
{N)
10
MINDED
TOTA L
OVER
4 WE EKS
(4 )
27. 5
{N)
%
( 11)
37. 5
DID NO T
MIND
42 . 5
( 1 7)
20
(8 )
62. 5
TOTA L
52. 5
( 21)
47. 5
(19)
100
2
X
d. f.
p
6 . 51
=
=
{N)
(15)
( 2 5)
(40)
0 . 01
1
A "t" test between the proportion of s ubj e cts in the "Minded"
group ;yielded a "t" value of 2. 8 5
*.
This was s ignific ant at the
0 . 05 level and ind icated that s ignificantly more patients who waited
over four weeks minded waiting for their appointments than patients
who had to wait les s than four weeks.
'·
.-
52
*
t
V
=
P1
P l
p 2
( 1 - Pl )
n 1
+
P2
( 1 - P2 )
nz
53
C HAPTER
6
DISCUSSIO N & SUMMARY
Discuss ion
The data analys is led to the following conclusions:
1.
The population of this study was found to b e a represent­
ative s ample of clinic patients.
2.
The patients interviewed were satisfied with the clinic
services.
As a result this :factor could be excluded from
the reasons for broken apointments at this clinic.
3.
There was a good patient- staff relationship in this clinic,
and this factor also could be excluded from the reasons
for broken appointments .
4.
A high percentage of the sample in this study
(45%)
had
to wait more than four weeks for the ir first appointment.
If one accepts the as sumption that broken appointments
could be related to waiting time , then this factor could
be considered a major reason for broken appo intments . in
this cl inic.
5.
A high percentage of the patients
(68 %)
preferred the
proposed appointment system over the existing one.
This
was also found to be sig-n ificantly related to waiting time.
6.
Many patients stated that they had to wait a long time for
their turn at the clinic.
Most of the patients related their
54
waiting time at the clinic to the fact that there was only
one physician attending all
the patients .
As a result of the findings of this study the following recommend_:
ations seem to be appropriate:
Re commendations Related To Study Design
1.
The study, to be more comprehensive; should have in­
cluded patients who broke their appointments.
This
would have made it possible to compare two different
population groups on the variables under investigation.
2.
F uture studies should include a quest ion to find how far
patients live from the clinic.
Since this variable was
not included in this study, it was not possible to identify
whether the patients were from the area
that the clinic
is supposed to serve or not and whether this might be
related to broken appointments.
Re commendations Based On F ind ings
1.
It i s s trongly recommended that the proposed appointment
s ystem be adopted.
of the system
Since there was a high . acceptability
among patients , a pilot program · co uld
result in showing that adoption of the new system might
55
reduce the rate of broken appointments at the clinic.
2.
The data showed that s ixty five percent of the patients
s tated that they would l ike the clinic to send them
reminders before their appointments, and thirty five
percent did not want the clinic to send them reminders.
Therefore, a question regarding reminders should be
included in the forms filled out by patients when they
firs t attend the clinic.
The health center registrar
s hould then send reminders to those patients who respond
pos itively to the question.
3.
Many patients thought that they had to wait a long time
for their turn at the clinic because of staff shortage.
Clinic staffing patterns could be related to broken appoint­
ments .
F ormulas exist to assist administrators in
determining
an
appropriate staffing pattern. Dean ( 1 5: 3 5) ,
suggested that the administrators could calculate the
following factors as they apply to their programs:
A.
Determine the number of "weighed" patients seen
per hour.
a.
number of first admissions seen per:hour.
b.
number of medical revis its per .hour times
0 . 77
c.
number of non-medical revisits per hour
. '
56
times 0 . 3 6
d.
add a , b , and c to get actual "weighed"
patients per hour
B.
Determine the number of patients that could have
been seen per hour with present staff.
number of physicians in attendance per hour
a.
times 0 . 606
b.
number of nurse s in attendance per hour
times 1 . 284
c.
number of non-profess ionals in attendance
per hour times 1 . 022
d.
add a, b, and c to get possible "weighed"
patients per hour.
If the poss ible number of
"weighed" patients is larger than the
number of actual "weighed" patients served, the clinic can be con­
s idered to be overs taffed.
If the actual is larger than the poss ible,
the clinic is probably understaffed.
Summary
A high rate of broken appointments was noticed
of the family pla:i:ming
clinic
by the staff
at the West Health Center of the Los
Angeles County Health Department.
The rate calculated for seventeen
clinic sessions s cheduled between June , 1 9 7 1 , and F ebruary, 1972,
57
was found to be
47%.
T o deal with the broken appointment problem
over booking of patients was practiced.
This, did not solve the
problem but r esulted in more work for the clinic staff and the
health center personnel in the preparation
of charts and medical
records for non existing patients.
The investigator proposed a system to deal with the broken
appointment problem.
The proposal utilized the advantages of both
the walk-in and appointment systems.
The basic assumption for
the proposal was the two different operations take place in family
planning clinics.
The first operation is concerned with an education - :
al session about birth control . methods and their proper use.
The
second operation is concerned with medical examinations and dispen­
sation of the des ired method to the patient.
The proposal tried to
separate the t\vo functions from each other.
A study was carried out to find whether the proposed system
was acceptable to clinic patients. and to find factors that could have ·
resulted in the high r ate of broken appointments.
The result indicated that the majority of the patients were
s atisfied with the clinic services.
was very good.
The patient -staff relationship
The only variable that affected patients acceptability ,
of the proposal was waiting time for an appointment.
The results
58
indicated that significantly more patients accepted the proposed
system if waiting time for an appointment exceeded four weeks.
The
main advantage of the proposal system would be reduced waiting time,
and having family planning services available to the patient at the
time the patient is highly moti.vated towards seeking such services.
'•
.
.-
BID LIOGRAPHY
1.
Alpert, J. J. "Broken Appointments, " Pediatrics. 34: 127, July, 1 964. ·
2.
Beasley, J. D. et al. "Evaluation of National Health Programs:
Louisiana Family Planning, " A. J. P. H. . , 61: 1812, September,
19 71 .
3.
Berlin, D. A. "Evaluation of a Mental Health Information and
Referral Service, " Community Mental Health Journal.
144: 54,
1
April, 1 9 70 .
4.
Boring, E . C . A History of Experimental Psychology. 2nd ed.
New York: Appelton-Century�Crofts, 1950 , pg. 466.
5.
Briggs, E. H. and Mudd, E. H. "An Exploration of Methods to Reduce
Broken F irst Appointments, " F amily Coordinator. 17-18 ,
January, 1 968 .
6.
Cardew, B . "An Appointment System Service for General Practi­
tioners: Its Growth and Present Usage, " Brit, Med. J. .
4: 542, December , 1967.
7.
Carne, S. "An Appointment System in a Practice with Immigrant
Patients, " Brit. Med. J 4: 544, December , 19 67.
•
•
8.
Chan , S. "Keepjng Appointments, " New Eng. J
February, 1969.
9.
County of Los Angeles Health Department. History and Functions .
Julyl 19 70.
•
.
Med
•
•
280-448 ,
10. Cronkhite, L. W. "Computer Brings Order to Clinic Scheduling
·
System, " Hospitals. 43: 55, April, 1969.
11. Curry, F. J. "A New Approach for Improving Attendance at Tuber­
culosis Clinics, " A. J. P. H 58: 8 77 , May, 1968.
•
•
12. Curry F. J. "Neighborhood Clinics for More Effective Outpatient
Treatment of Tuberculosis, " New Eng. J. Med. 279 : 1262,
De cember, 1968 .
1 3 . : Dale, A. C. " Appointment System, " The Hospital, London. 47: 5 69 ,
August, 1951.
14. Davis, M. s. !'The state of the Art: The Issue, " paper presented at
.
\
60
the Second Invitational Conference, Health Education in the
Hospital, University of Chicago, illinois, October, 19 69.
15. Dean, C. R. "Staffing Patterns and Clinic Efficiency, " Family
Planning Perspectives. 2: 3 5 , October, 1970.
1 6 . Densen et al. "Primary Medical Care for an Urban Population: A
Survey of Present and Potential Utilization, " J. Med. Educ.
43: 1244, December, 1968.
1 7 . Elling, R. , Whittemore, R. , and Green, M. "Patient Participation
in a Pediatric Program, " J. Health and Human Behavior,
1 : 183, 1960.
1 8 . Fink, D. �· " The Management Specialist in Effective Pediatric
Ambulatory Care, " A. J. P. H. 59 : 527, March, 1969.
19. Fink. D. et al. "Effective Patient Care in the Pediatric Ambulatory
Setting: A Study of the Acute Care Clinics, " Pediatrics.
43 :9 27, June, 1969 .
20
;\i
•
.
Glogow, E . "Why People Fail Appointments, " The Sight-Saving Review.
Winter, 1970-19 71.
21 . ) Glogow , E. "Effects of Health Education Methods on Appointment
Breaking, " Public Health Rep. 8 5:441 , May, 1970.
22. Gold, E. M. , Stone, M. L. and Rich. H. "Total Maternal and Infant
Care: An Evaluation, 11 A. J. P. H. 59 : 1851 , October, 1969 .
23
·
Hansen, A. C. "Broken Appointments in a Child Health Conference, "
Nurses Outlook. 1:417, 1953.
24. Hatcher, R. A. and Tiller, M. J. "Acceleration of a Public Health
Department Family Planning Program: Referral from Well
Baby C linics in Muscogee County, Georgia, " A. J. P. H
59 :1217, July, 1 969 .
•
•
25. Hellman, L. M. "A F ive 'Year Plan for Population Research and
F amily Planning Services: Overview, " Family Planning
Perspectives. 2: 3 5 , October, 1971 .
26. Hoffmann, P. B. and Rockart, J. F. "Implications of the No-Show
Rate for S cheduling OPD Appointments, " Hosp. Prog. 5 0: 3 5,
·
61
August, 1969 .
27. Kidd, A. H. and E uphrat, J. L. "Why Prospective Outpatients F ail To
M ake or Keep Appointments, " J. Clinical Psych 27:394,
July; 19 71.
•
--
•
)
28-� /kilder, J. "Appo intments and Schedules or Scheduling Methods, "
Hospitals. 44:99, November, 1970.
29 . Leverett, D. IL "The Operation of a Community Dental Clinic in a
Health Center: · An Evaluation, " J. P. H. Dent
31: 27 , Winter,
1971.
•
•
30. Levitt, H. N. "Introducing an Appointment System in a Single-Handed
Practice, " Practitioner, 6: 1 5, March, 1968.
3 1 . Los Angeles Regional F am ily Planning Council, Directory. Los
Angeles , C alifornia, March, 1971.
32. MacDonald, M. E. , Hagberry, A. M. and Grossman, B. J. "Social
F actors in Relation to Participation in Follow-up Care of
Rheumatic Fever, " J. Pediatrics. 62:456, 1963 .
33
• .
Mitchell, M. B. and Gautreau, F . "Appointment Scheduling, "
Hospitals. 44: 58 , June, 19 7 0.
34 . Miyoaka, A. "Exploration on the Problem of Broken Appointments ­
Family Planning, " Unpublished study presented to the County
of Los Angeles Health Department , Bureau of Maternal and
Child Health, November, 1971 .
3 5 . Nuffield Provincial Hospitals Trust. Studies in the Function and
Design of Hospitals. London: Oxford University Press, 1956
pg. 4 7.
/
'\)
3 6 . }Z>lencki, M. " Appointment- Breaking in a General Medical Clinic, "
Cornell Comprehensive Care and Teaching Program. Research
Memorandum No. 5, Series C, 1959 .
3 7> .
Plant, T . F . "Keeping Appointments, " New Eng. J. Med
F ebruary, 1969.
38 .
Raynes , A. E. ·· and Warren, G. "Some Distinguishing Features of
Patients F ailing to Attend a Psychiatric Clinic Mter Referra�"
Am. J. Orthopsychiatry. 41: 581, July, 1971.
'·
.-
'·
. .......
•
•
280: 448 ,
62
3 9 . Reynolds, J. "Delivering Family Planning Services: Autonomous vs
Integrated Clinics, " Family Planning Perspectives. 2: 15 ,
January, 1970.
40
•
.
Selltiz , C . et al. Research Methods in Social Relations. San
F rancisco: Holt, Rinehart and Winston, 1967.
41. Shaffer, G. W. and Lazorus, R. S. Fundamental Concepts in Clinical
Psychology. New York: M cGraw-Hill, 1952, pp 32-64.
42. Vlasak, G. J. "A Few Characteristics of Patients in Urban Tuber­
culosis Clinics, " Public Health Rep
84: 159, February 1969 .
•
•
43 . Westheimer, R K. et al. "Use of Paraprofessionals to Motivate
Women to Return for Post Partum Checkups, " Public Health
Rep. 8 5: 625, July, 1970.
•
.
44. Woodworth, R. S. ·Contemporary Schools of Psychology
Ronald Press Company, 1948 p. 172.
•
New York:
45. Zukin, P. , Gurfield, R. M. and Klein, B. W. "Evaluation of a
Primary C are Clinic in a Local Health Department, 1 1
Unpublished study, January, 1972.
APPENDIX
A
QUESTIONNAIRE
63
'•
.-
1.
English Form
This is a study which will help the family planning clinic staff to improve
their s ervices .
Please read the questions carefully .
Circle the answer
that you feel applies in your cas e .
1.
Age:
2 . Marital Status :
3.
1.
Single
2.
Married
4.
Separated
5.
Widowed
White
2.
Black
4.
5.
3.
Oriental
Mexican-American
5.
Other
2.
High School
Highest level completed in school:
1.
Less than high school
3.
Some college o r technical school
4.
College graduate
5
.
.
Post graduate
Number of children:
1.
6.
Divorced
Ethnic Background:
1.
4.
3.
None
2.
1
4.
3
5.
4
6.
More than 4 children
3.
2
What i s your family incom e ?
1.
Less than $ 3 , 0 0 0
2 . $ 3 , 0 0 0 - $4 , 999
3.
$ 5 , 0 0 0 - $ 6 , 999
4.
5.
Over $10 , 0 0 0
7.
What is the occupation of the head of household ?
8.
How did you hear about this family planning clinic ?
------
1.
Relative
3.
Public Health Nurse
5.
Department of Social Services
2.
64 .
$ 7 ' 0 00 - $ 9 , 999
Friend
4.
Other county
clinics
65
9.
10.
11.
How long have you been coming to this family planning clinic ?
1.
F irst time
2.
Six months or less
3.
One year
4.
Two years
5.
More than two years
How d o you get to the clinic?
Auto ( self)
3.
Public transportation
Yes
COMMENT
Walking
4.
2.
No
-------
How long d id you have to wait for your first appointment?
1.
Less than two weeks
3 . --4-6 weeks
·
13 .
Auto (other)
Is the clinic time convenient for you ?
1.
12.
2.
1.
2.
2-4 weeks
4.
a ver 6 weeks
Did you mind waiting that long?
1.
2.
Yes
COMMENT
No
___;______
_
_
_
_
_
14.
Did you have to wait a long time for your turn at the clinic?
1.
COMMENT
15.
Yes
2.
No
------
Since the clinic can not give you an appointment to see the
doctor right away, which of the following would you prefer to do ?
1.
Come to the clinic at the earliest time for information, and
foam as a temporary birth control method. . Then make an
.
•
. .......
66
appointment to see the doctor later ?
2.
Make one appointment ( as it is now) and wait to receive
information and see the doctor at the same time ?
1 6.
17.
Which birth control method did you choose ?
1.
Pills
2. I. D. D.
3.
Diaphragm
4.
Other
Did you think the educational s ession about birth control methods
is helpful?
1.
COMMENT
18.
Yes
2.
No
-----
Are the instructions regarding the use of th e birth control
method you chose easy for you to understand ?
1.
Yes
2.
No
COMMENT
_
_
_
_
_
_
_
_
_
_
_
_
_
_
19 .
Are you getting the kind of service you expected to get at
the clinic?
1.
C OMMENT
20 .
2.
No
--------�-
Would you say the service you are receiving in this clinic is:
1.
21.
Yes
Good
2.
Average
3.
Do you feel you are getting personal attention in this clinic?
1.
C OMMENT
Yes
2.
No
-------
'·
.-
Poor
67
22.
How does the doctor treat you ?
1. .
23 .
Good
2.
Average
3.
2.
Average
Good
3.
Yourself
2.
Poor
The Clinic staff
Would you like the clinic to send you a reminder before your
next appointment?
1.
Yes
COMMENT
27.
Poor
Whom do you prefer to make your clinic appointments ?
1.
26 .
3 . Poor
How do the receptionists treat you?
1.
25.
2. Average
How do the nurses treat you ?
1.
24.
Good
2.
No
------
What would you liked changed at the clinic?
COMMENT
•.-
. .. ·
-------
68
Spanish Form
2.
/
Este es un estudio que nos ayudara a mejorar el servicio de la
cl (nica de planeamiento familiar.
cuidadosam ente.
Por favor lea las preguntas
C ircule la respuesta que aplique en su caso.
1.
Edad :
2.
Condicion matrimonial :
-----,..
Es de famila:
3.
1 . Soltera
2. Casada
3.
Divorciada
4.
5.
Vivda
1.
Blanca
Separada
2. Negra
3 . Mexicana-Americana
4 . Oriental
5 . Otro
Hasta que ali.otermino en la es cuela:
4.
1.
Ntfmero de Jlijos
5.
/.
No termine secundaria
2.
Un poco de universidadoo cole�rio
tecmco
3.
Termine' secundaria
4.
Termine la univers idad
5.
Estudios post-graduados
1.
Ninguno
5. 4
6.
.
2. 1
6.
C ualito ganan usted y su marido por ano:
1.
M enos de $3 , 000
2.
$ 3 , 000 - $ 5 , 000
3. 2
/
4.
3
Mas de 4 hijos
69
3.
$ 5, 000 - $7, 000
4.
$ 7 , 000 - $10 , 000
5.
Mas de $ 1 0 , 000
/
7.
E n que' trabaj a l a persona que sostienne l a familia ?
8.
;
Como se entero de esta clmica?
,
-----
,
1.
Pariente
3.
Enfermera del Condado
4.
Otras cU n icas del Condado
5.
Dej:>artmento de services sociales
(welfare, Medi- Cal)
2. Amiga
6. Otro
9.
Cu�ta tiempo que Usted Viene a esta cl (nica de planam iento
familiar?
1.
5.
10.
11.
Primera vez
2.
Seis Meses omenos '
4.
Dos Aiio s
,
Mas d e Dos a nos
c O'mo viene a l a cl inica?
1.
Carro (propio)
3.
Transportaci<fn publica ( camion, taxi, ect.)!
4.
Caminando
2.
Carro ( otro)
I
La hora d e cliii i ca e s conveniente para
1.
Si
2.
No
I
'--------=--=---_j
COME�E
�.
.
-
'·
.
-
70
12. cutnto tiempo tuvo que esperar para su primera cita?
1.
Menos d e 2 semanas
2.
2-4 semanas
3.
4-6 semanas
4
13 .
•
,
Mas de 6 semanas
/
Le mo lesto esperar tanto tiempo ?
1.
COMENTE
14 .
.
2. No
Si
------
Tuvo que e sperar mucho tiempo en la cH nica para que la
atiendan ?
I.
COME NTE
15.
Si
2.
No
__;_____
_
_
_
_
Como l a cl ih ica no puede darle una cita para que vta al doctor
immediatamente.
1.
e rial de las sigientes cosas p�eferir fu hacer.
Venga a la cl(nica e n seguida para informaciOn. y espuma
como mttodo temporario de cuidarse; y tomar una cita
·
/
para ver al doctor otro dta.
2.
Haga una cita ( como se hace ahora) y tenga que espera,
recibiendo informacidn y viendo al doctor al mismo
tiempo.
1 6.
..
. 1?
"' 1 metod o de contro 1 escogw
C ua
1.
2. Diafragma
Pas tillas
3 . Aparato intrauterino (espiral o coil)
'·
. .....
71
4. Otro
17.
Pienz a que l a clase que le dieron a cerca d e los diferentes
m etodos para cuidarse l e ayudo?
COMENTE
18.
.
2 . No
1 . Si
.
-------
/
Coinprendio facilmente las instrucciones quel d ieron para
. /
explicarle como usar el metodo que escogw.
1.
Si
COMENTE
19 .
2. No
-------
/
Esta recibiendo la clase de servicios que esperaba recibir en
la cH nica?
1.
Si
COMENTE
20.
2. No
-------
Dir(a usted que los servivos que esta recibiendo en esta cl (nca
son:
1.
21.
/
Buenos
2 . Regulares
3 . Pobres
/
�
Sien.te que esta recibiendo aten cion personal en esta clmica?
.
1.
Si
2. No
COMENTE
-------
22.
c o'mo la trat6 el doctor ?
B.1en
/
2.
Regularmente
3. Mal
c o'mo la trat6 la enfermera ?
2.
Regularmente
3 . Mal
1.
23 .
1
•,
.-
•
B.1en
/
72
24 .
/
/
Como la trato la recepionista?
2. Regularmente
25.
3. Mal
,
Quien prefiere que haga sus citas ?
1 . Usted misma
2.
26.
La questr� . que la cHn ica mande su cita por corr eiro a 1 casa?
1.
CO ME NTE
27.
Las personas en la cl (nica
2.
Si
No
------
Qu t cos as le q_ustar fa que cambien e n esta clill ica ?
COME NTE
'·
_ ;.....
------
'•'
.-
...
.
�
..
APPENDIX
B
HOLLINGSHEAD . SCALE
/
,
73
HO LLINGSHEAD SCA LE
*
The Hollingshead Social Class Index or Index of Social Position
is a two factor index based on the sum of the weights given to each
category within the education scale and occupational scale.
Educational Scale Weighted Scores
&
8.
Professional training
College graduate
1 2 . Some college
1 6 . High s chool graduate and business school
20 . Some high s chool (1 0-1 1 years)
24 . Approx. grade school 7-9 years)
�
Under 7 years of school
1:..
Higher executives , proprietors of large concerns and major
Occupational Scale Weighted Scores
*
professionals.
Hollingshead, A. B. Two Factor Index of Social Position.
Station, New Haven, Conn. , 1965.
Yale
Hollingshead, A. B. , and Reddick, F. Social Class and Mental
Illness. John Wiley and Sons, New York,
1 958, pp. 398-407.
74
75
14.
Business managers , proprietors of medium bus inesses, and
lessor profes sionals.
21.
Administrative personnel, small independent businessmen, and
minor professionals .
28.
Clerical and sales workers, technicians, and owners of little
businesses.
3 5.
Skilled manual employees
42.
Machine operators and semi-skilled employees
49.
Unskilled employees
Index of So cial Pos ition Weighted Scores
:
11-17
Class 1, upper clas s
18 -27
Class 2, upper middle class
28 -43
Class 3 , middle clas s
44-60
Class 4, lower middle class
61-77
Class 5, lower class