How Does Your Clinic Handle No-Shows?

[Lane Therrell FNP, MSN, RN, NP]

Do you make reminder calls before the appointment? Do you have a cancellation policy? If so, do you enforce it? Beyond any administrative policies your clinic may or may not have in place, do you routinely make it your business to find out why your patients aren’t showing up for appointments?

Despite the high estimated cost of no-shows, many clinics do not follow up adequately with patients who fail to keep appointments. Busy clinics may make reminder phone calls before appointments, or send letters after a certain number of missed appointments. Some may even discharge the patient after a certain number of no-shows, a policy that is more of a lose-lose than a win-win, in my opinion. And of course, clinicians themselves may secretly breathe a sigh of relief when a patient fails to show up for a scheduled appointment (Woohoo! Extra time to chart!).

Asking is Patient-Centered

The point is that much of the clinical mindset and the academic research on patient no-shows is decidedly NOT patient-centered. And yet it should be. Ultimately, the resolution to no-shows requires a different action by the patient. But when was the last time you actually asked a patient to tell you, in their own words, in a face-to-face conversation, why they didn’t come to the appointment? You’ll never know the truth unless you ask.

Academic literature abounds with statistics and estimates on how costly no-shows are to the clinic, hospital, or medical system. Some papers even frame no-shows as a detriment to patient safety, citing delayed testing and missed screenings as factors that negatively impact human health. And yet, if we used our no-show data to start conversations with patients, we might uncover useful information that could help us deliver care that is truly patient centered.

What Patients Say

My own thinking on this topic began to expand when I started making it a point to ask my patients why they didn’t show up. I learned a lot about my patients’ home and life situations that kept them from keeping their appointments on time, or at all. These same circumstances were contributing to their health outcomes. And ultimately increasing the cost of care.

Here are some reasons my patients have offered for not keeping their scheduled appointments. No doubt these statements will trigger some memories for you about patients you’ve seen.

• “I couldn’t get my dad down the stairs, out of the house, and into the car to bring him in.”
• “I couldn’t get a babysitter.”
• “I forgot.”
• “I got drunk and couldn’t drive myself in.”
• “I started feeling better, so I didn’t think I needed to come.”
• “I really hate coming here.”
• “My time is too important to waste hanging out in the waiting room with a bunch of sick people.”
• “I wasn’t feeling bad, so I didn’t think it was important.”
• “I know the clinic’s busy, so I didn’t call ‘cause I didn’t want to be a bother.”
• “I couldn’t get a ride.”
• “I didn’t have enough money for a bus ticket.”
• “I was afraid to hear the news you were going to give me.”
• “I didn’t know you wanted me to let you know I wasn’t coming.”
• “I had to pick up my kids from school, I left my phone at home, and then we got stuck in traffic.”

These statements roughly echo the findings of a small study that revealed 3 main reasons patients don’t keep appointments: 1) emotions; 2) a perception of being disrespected by the healthcare system; 3) a failure to understand the appointment scheduling process. This particular study didn’t pick up on transportation and mobility issues, or chronic stress and time management, which have been recurring themes for my patients at the various clinics I’ve worked at over the years.

Improving the Quality of Care

All of these reasons, no matter how they are categorized, represent deeply significant life and health problems for patients. Some are more easily resolvable than others. But they all provide us with information we can use to provide better quality care. All we have to do is take the time to ask, listen, and dig a little deeper.

Whatever the reasons our patients offer, the process of making and keeping healthcare appointments for healthcare involves multiple factors. No-shows should be examined closely from the patient’s perspective. If we can’t see the problem from the patient’s perspective, we can’t hope to help people access the care they need.

It’s not our job to resolve every individual’s personal problems, but by asking our patients directly why they fail to keep their appointments, we get to know our patients better. This insight can become part of bigger solutions over time. Meanwhile, this simple act of communication is one way we can build trust and rapport, and keep our care truly patient-centered.

We need to know why our patients aren’t keeping their appointments. The information helps shape the care we deliver. And it affects the health outcomes our patients can expect to achieve. By asking the right questions, we’re improving the quality of care.

Questions for Discussion

1. How does your clinic handle no-shows?
2. Is the system your clinic is using effective?
3. Do you ask your patients why they don’t keep appointments?
4. What are some of the reasons you’ve heard from patients about why they failed to keep an appointment?

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Sources and Resources

No-shows in appointment scheduling – a systematic literature review

Prevalence, predictors and economic consequences of no-shows

Why We Don’t Come: Patient Perceptions on No-Shows

[caliotter3]

When my dentist office billed me for a no-show for the second time when no appointment existed for the second time, that action contributed to me finding a new dentist.

[Lane Therrell FNP, MSN, RN, NP]

8 minutes ago, caliotter3 said:

When my dentist office billed me for a no-show for the second time when no appointment existed for the second time, that action contributed to me finding a new dentist.

This is a great example of how a failure to be patient-centered is bad for business ... and by extension, bad for health. Your comment is also an excellent reminder of why we need to preserve the freedom to choose our providers, and vote with our feet when they don't meet our needs.

[caliotter3]

There was at least one other good reason for me to change, but adding insult to injury to my wallet did the trick. I was paying out of pocket and could not afford the high fees to begin with, so another $50 twice just to pad the account was the straw for this camel's back.

[TriciaJ, RN]

On 7/4/2019 at 9:23 AM, caliotter3 said:

There was at least one other good reason for me to change, but adding insult to injury to my wallet did the trick. I was paying out of pocket and could not afford the high fees to begin with, so another $50 twice just to pad the account was the straw for this camel's back.

Wait, you didn't actually pay them, did you? I hope you disputed this. Is it possible they had another patient by the same name and were too sloppy to check additional identifiers?

[caliotter3]

I vaguely remember calling and arguing with them the first time. When it happened the second time, I never bothered with them, just did not pay it, and went to a new provider. It was a matter of inattentive front desk personnel. For all I know, they may have been told to pad accounts. There was some kind of controversy over partner providers leaving the practice. Who knows?

[Lane Therrell FNP, MSN, RN, NP]

11 minutes ago, caliotter3 said:

I vaguely remember calling and arguing with them the first time. When it happened the second time, I never bothered with them, just did not pay it, and went to a new provider. It was a matter of inattentive front desk personnel. For all I know, they may have been told to pad accounts. There was some kind of controversy over partner providers leaving the practice. Who knows?

You did the right thing. And I certainly hope your new dental provider is more attentive to detail and proper billing.

[Redhead,RN, BSN]

We are an urban FQHC so the vast majority of our patients are underserved and transient. We found we had a very high no show rate in the mornings, so we turned all of our morning time slots into walk in only for all providers. It was initially hard for the providers and staff, but we've been doing it for over a year and it seems we've all adjusted and it is better for our patients.

[Lane Therrell FNP, MSN, RN, NP]

59 minutes ago, Redhead,RN said:

We are an urban FQHC so the vast majority of our patients are underserved and transient. We found we had a very high no show rate in the mornings, so we turned all of our morning time slots into walk in only for all providers. It was initially hard for the providers and staff, but we've been doing it for over a year and it seems we've all adjusted and it is better for our patients.

This is a great innovative solution, based on the needs of your local patient population. Hats off to your FQHC for being flexible and willing to at least try it out. I once worked at a community clinic that set up "night clinic" hours to accommodate the needs of working families, and it was very effective. We can definitely use more of these types of solutions.

[Oldmahubbard]

When I had a private psych practice with a physician, the no show rate in the morning was probably triple that of the afternoon. Food for thought.

[debirn918]

My husband had an appointment with his provider a week or 2 ago. By the time we found the office, in a new building just across from the prior building, we were just going to make it on time. Then when we were directed to the correct floor, there was no true indication of how to check in. Stepped off the elevator and there were 2 desks in front of us and then at the other end of the floor was another area with 2 desks, I think only one was actually open for check in. We waited to be checked in and by the time we made it to the desk we were 5 minutes late. The receptionist told us we would probably have to reschedule. Luckily he was able to still get in, but due to an insurance change it took another 15 minutes or so for me to provide the information, while he started his appointment. So, just to let people know, it is sometimes multiple issues that result in a late or no show instance. (We live in the country and even out here, we have our roads blocked for 10 to 15 minutes in order to allow a long train to pass. In fact this happened the day after this appointment.)

[Jory, MSN, APRN, CNM]

Our clinic gives a 48 hour notice...we started doing this for several reasons vs the 24 hour notice we used to have:

1. We have a list of patients on a waiting list that would like to be seen earlier, this gives one business day to move them to that slot.

2. People have more time to re-arrange their schedule if they forgot about the appointment.

If you miss one appointment, we don't care. It happens, but you get a letter.

If you miss two appointments, we send a second letter.

If you miss three appointments....we don't dismiss from the practice, but you have to pay $150 up front to schedule all future appointments. If you miss, we keep it, if you show up it's credited toward your visit or if your insurance covers it, we refunded it back.

Because we are an OB/GYN practice, all sterilization reversal consults require $150 up front.