When Patients Don't Show Up

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April 2002

By James E. Glinn, Sr, PT

Using the cancellation and no-show rate as an important quality control indicator in your private practice.

A basic tenet in marketing strategies for outpatient rehabilitation services is that the most important customers are past and current patients, clients, and referral sources of a given organization.

Most of us involved in the oversight and delivery of outpatient rehab services become very concerned when patients fail to show up for their scheduled therapy appointments, yet in today's fast-paced American business environment, it is not surprising that patients' priorities may occasionally preclude their attendance for a scheduled therapy visit. It is arguable, however, that if patients truly respect the relationship with their therapist, they will do one of three things :

1. Make every effort to keep their scheduled appointments.
2. Call to cancel and reschedule an appointment if they choose not to attend.
3. Be apologetic to front office staff and therapists for missing an appointment without calling, cancelling, or rescheduling. We should then view the rates of no-shows and cancellations as being significantly different. While both adversely impact staff productivity, costs, and revenues, it is the no-show rate that should really raise red flags.

From my own experience working with 200 outpatient physical therapy practices, quite often practices that describe their businesses as "struggling" or "worse off than last year" have average weekly no-show rates that exceed cancellation rates.

In order to determine where your practice stands in regard to no-shows and cancellations, important data should be tracked:
1. The average total weekly no-show/cancellation rate
2. The average weekly cancellation rate
3. The average weekly no-show rate
4. The average weekly percentage of number 1 that reschedule the missed appointment and attend the rescheduled appointment during the week in question.

Why are the above numbers important (aside from apparent lost revenues)? The fact is that they are indications of several important staff considerations: front office staff abilities and attitudes; treatment staff abilities and attitudes; teamwork between office and treatment staff; and team building on the part of clinic managers and owners.

In short, if you are the manager or owner of an outpatient clinic, unacceptable cancellation/no-show rates are the fault of yourself or of an administration who shackles you from making the necessary changes to improve this aspect of quality.

Quality Control Checklist
Put simply, there are only three major drivers of success in outpatient therapy clinics: ability of staff, access to service, and atmosphere of the clinic.

Your job as owner or manager is to foster an environment that provides the above "triple ‘A" experience" to your patients, clients, and referral sources. Which of the above is most important? They are all equal in value (perhaps the busy clinic down the street with the poorly trained clinical staff is offering a portion of the above that your less busy clinic is not). If any of the above areas are weak, cancellation/no-show rates will increase.

Using a SWOT (strengths, weaknesses, opportunities, threats) analysis to assess how your clinic addresses ability, access, and atmosphere is beneficial. You and your staff must work on and improve weaknesses in any areas of the "three A's."

Management must cultivate the following in their practice culture: cancellations/no-shows are everyone's responsibility, everyone in the organization should take missed appointments personally, and they should create a cancellation/no-show policy. Consider cultivating the following among pertinent staff:

Patient services representatives (otherwise known as receptionists) must be customer focused and highly valued for their ability to create a great first impression.
Treating staff must be customer focused and adept in their treatment skills and client/patient communication.
Billing and collections staff need to be customer focused, competent in their use of pertinent technology and courteous, yet firm in collecting accounts receivables.
Housekeeping staff must also be customer focused and excellent at maintaining a hygienic and esthetically appealing atmosphere and positive interaction with patients.
To effectively address a cancellation/no-show problem, you need to get the facts:
Begin with tracking the most prevalent days of missed appointments. Mondays and Fridays are common and should not necessarily raise a red flag. However, days when a particular office staff or clinical staff member is working or not is a problem.
Measure cancellations vs no-shows. No-shows are real negatives and indicate a lack of value of your service on the part of the customer, and core management/staff problems.
Track weekly average cancellation/no-show rates and establish an acceptable rate. Do not include patients who reschedule and keep a missed appointment during the same week in this number. An acceptable initial rate should be in the area of 10%, but clinics that really address these issues have dropped the weekly average down to as low as 4%.
React quickly in assessing the reasons for a seemingly unexpected significant increase in both rates. Determine what has changed recently in your practice. Have you hired a new staff member or let someone go?
Ask your patients for additional pertinent information at their first visit, ie, cell phone numbers and email addresses.
Create a flexible but not well-publicized appointment system with a "come right on in, we can see you now" policy.
Remind all new patients with a phone call within 24 hours of their scheduled appointment.
Create a missed patient contact system. Call the patient within 15 minutes following a missed appointment and use the following flow chart. If the patient answers the phone, remind her of the appointment and ask if she would like to come in now or reschedule. If there is no answer, leave a message, then call the patient's cell phone, leaving a message if there is no answer. If an email address is known, send an email. If no direct contact is made and the patient misses the visit, call to remind him of his next appointment. Call to reschedule at least five times before discharging a patient and have the treating therapist make at least two of the five phone calls.
Avoid the Monday, Wednesday, Friday treatment mentality. A missed Monday appointment should be rescheduled for Tuesday and so on. Always give 3-day-per week patients the option of scheduling their third weekly visit on a Thursday or Friday.
Workers' compensation patients can be encouraged to keep appointments if they understand that missed appointments will be reported to both their physicians and case managers.

Encouraging Staff Buy-In
Customer focus requires the development of a staff and management team who place their profession high on life's priorities list. Indeed, cultivating the priority paradigm that rehabilitation services are at least number three on the priority lists of staff and management is an important team-building consideration.

Here are some considerations regarding staff buy-in:
1. Minimize the impact on the organization of employees who place their profession low on their priority list (educate, terminate, or decrease hours worked).
2. Establish standards for an acceptable cancellation/no-show rate.
3. Reward staff for cancellation/no-show rates falling below the set percentage (rewards may be a pat on the back, dinner for two, gift certificates, money, increased continuing education opportunities).

What is an ideal goal to strive for? In a well-run customer-focused practice, average weekly no-show rates should drop to as low as 5% to 7%. Generally speaking, practices that reach that rate have incentivized staff with financial rewards.

By investigating and addressing your practice's no-show and cancellation rate, staff accountability and revenue should be on the rise. ®

James E. Glinn, Sr, PT, is CEO of FutureRehab, a health care consulting firm specializing in practice development in Bakersfield, Calif. He may be reached at jamesglinn@futurerehab.com or via the Web: www.futurerehab.com.

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April 2002