We can improve quality and provide patient-centered care by following up with no-shows. Do you have a no-show policy? Upgrade your efforts by being willing to ask patients about their individual circumstances.
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
How does your clinic handle no-shows?
Is the system your clinic is using effective?
Do you ask your patients why they don’t keep appointments?
What are some of the reasons you’ve heard from patients about why they failed to keep an appointment?
... 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.)
I live in the country, too, and often find myself caught behind slow-moving farm equipment on winding roads with little opportunity to pass. Ideally, a good clinic attendance policy will account for this kind of thing. Meanwhile, I'm glad you and your husband finally found the right place and he was able to be seen. Whew! What a hassle.
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.
I like your clinic's rationale for its 48-hour notice. That is helpful for those on the waiting list as well as for the originally scheduled patient. I'm wondering if a 72-hour notice or longer might be even better? I suppose it may depend on how far in advance appointments are scheduled.
Lane Therrell FNP, MSN, RN, NP
18 Articles; 192 Posts
I live in the country, too, and often find myself caught behind slow-moving farm equipment on winding roads with little opportunity to pass. Ideally, a good clinic attendance policy will account for this kind of thing. Meanwhile, I'm glad you and your husband finally found the right place and he was able to be seen. Whew! What a hassle.