Editor’s note: This article was adapted from a paper submitted toward fulfillment of the requirements of Fellowship in the American College of Medical Practice Executives. Learn more about ACMPE certification: mgma.com/acmpe.
No-shows can affect clinics of any type with a vast array of negative outcomes from high rates. Clinics that serve the underserved are particularly burdened with this issue.1
Many studies have identified characteristics of patients who do not attend their appointment. Highest no-show rates include those of lower socioeconomic status, those with a history of no-showing, those who have no insurance or Medicaid, the length of time from appointment scheduling to appointment, the distance from their home to the facility, those who are young and those suffering from a mental illness or alcohol use disorder.2,3,4 Interestingly, the no-show rate on Mondays tends to be higher than other days of the week.5
High no-show rates negatively impact several areas. First and arguably least important is the financial loss experienced by institutions with high no-show rates. For medical education clinics, however, each patient who chooses not to attend their appointment causes an educational “miss.” Over the course of one’s medical school or residency training, these missed learning opportunities can result in both knowledge and experience deficiencies. The downstream effect for the learners’ future patients could be devastating. Most important, when patients don’t attend their appointment, their health suffers.
To start the process of improving the no-show rate, data was collected for one month by calling patients who did not show up for their appointments to find out why. During the course of the four-week period, there were 90 patients who no-showed.
The primary reason patients did not attend their appointment was that they forgot. Brainstorming on process improvement yielded two key areas on which to focus. First, the current appointment confirmation process was examined. The clinic used an automated appointment confirmation texting service. If patients did not respond, no further attempt at confirmation was made. Schedulers were only calling patients who couldn’t be reached by the texting or calling service (e.g., busy signal, phone didn’t accept text, etc.)
The second area of focus was discovered when examining the clinic’s need for an updated and structured no-show/termination policy.
To resolve these issues, schedulers were provided with an updated and accurate daily report of future scheduled appointments confirmed by a patient via text or telephone. They were then asked to call patients who did not already confirm an appointment to verify if the patient planned to attend. Additionally, staff was asked to generate a weekly report of those who no-showed. They were then asked to send a missed appointment letter for the first and second no-shows and a termination letter for a third no-show in six months.
Three months after implementation of these initiatives, the no-show rate dropped by 3.68 percentage points.
Collaboration with leadership was continuous to consider new ways to reduce no-shows. Roadblocks of time management and staffing were monitored.
Research performed by other clinics on ways to reduce the number of no-shows suggests a variety of methods to improve processes. One group found that a phone call prior to the appointment helped.8 For high-risk patients, a phone call after an initial two texts was beneficial, as well.9 Some practices have implemented a double-booking initiative for high-risk patients. Another practice found that improving patient education as well as asking them to sign an attendance agreement helped.10 Many practices use a punitive approach to reduce no-shows. In this model, patients receive a bill for the appointment in which they schedule but do not attend. Some feel as though this increases the burden on those who are most marginalized.11
No-show rates are a problem for nearly all aspects of healthcare. While it’s particularly pronounced in academic clinics across the country, similar struggles exist in non-academic clinics that serve low-income individuals. By implementing key appointment confirmation processes and reducing the no-show rate, revenue will increase, learners will be educated and, most important, health and outcomes will improve.
doi: 10.1136/bmjopen-2016-014120.
2. Dantas LF, Fleck JL, Cyrino Oliveira FL, Hamacher S. “No-shows in appointment scheduling — a systematic literature review.” Health Policy. 2018 Apr;122(4):412-421.
doi: 10.1016/j.healthpol.2018.02.002.
3. Drewek R, Mirea L, Adelson PD. “Lead time to appointment and no-show rates for new and follow-up patients in an ambulatory clinic.” Health Care Manag (Frederick). 2017 Jan/Mar;36(1):4-9. doi: 10.1097/HCM.0000000000000148.
4. Hwang AS, Atlas SJ, Cronin P, Ashburner JM, Shah SJ, He W, Hong CS. “Appointment ‘no-shows’ are an independent predictor of subsequent quality of care and resource utilization outcomes.” J Gen Intern Med. 2015 Oct;30(10):1426-33.
doi: 10.1007/s11606-015-3252-3.
5. Kheirkhah P, Feng Q, Travis LM, Tavakoli-Tabasi S, Sharafkhaneh A. “Prevalence, predictors and economic consequences of no-shows.” BMC Health Serv Res. 2016 Jan 14;16:13.
doi: 10.1186/s12913-015-1243-z.
6. Lacy N, et al. “Why we don’t come: Patient perceptions on no-shows.” Ann Fam Med. Nov/Dec 2004;2(6):541-545.
doi: 10.1370/afm.123.
7. Williamson.
8. Childers RE, Laird A, Newman L, Keyashian K. “The role of a nurse telephone call to prevent no-shows in endoscopy.” Gastrointest Endosc. 2016 Dec;84(6):1010-1017.e1.
doi: 10.1016/j.gie.2016.05.052.
9. Kaplan-Lewis E, Percac-Lima S. “No-show to primary care appointments: Why patients do not come.” J Prim Care Community Health. 2013 Oct;4(4):251-5. doi: 10.1177/2150131913498513.
10. Eichmiller JR. “Sign on the dotted line: How to drive no-show rates to 1.7%.” MGMA Connection. 2014 Jul;14(6):49-50.
11. Blæhr EE, Kristensen T, Væggemose U, Søgaard R. “The effect of fines on nonattendance in public hospital outpatient clinics: Study protocol for a randomized controlled trial.” Trials. 2016 Jun 13;17(1):288. doi: 10.1186/s13063-016-1420-3.
No-shows can affect clinics of any type with a vast array of negative outcomes from high rates. Clinics that serve the underserved are particularly burdened with this issue.1
Many studies have identified characteristics of patients who do not attend their appointment. Highest no-show rates include those of lower socioeconomic status, those with a history of no-showing, those who have no insurance or Medicaid, the length of time from appointment scheduling to appointment, the distance from their home to the facility, those who are young and those suffering from a mental illness or alcohol use disorder.2,3,4 Interestingly, the no-show rate on Mondays tends to be higher than other days of the week.5
High no-show rates negatively impact several areas. First and arguably least important is the financial loss experienced by institutions with high no-show rates. For medical education clinics, however, each patient who chooses not to attend their appointment causes an educational “miss.” Over the course of one’s medical school or residency training, these missed learning opportunities can result in both knowledge and experience deficiencies. The downstream effect for the learners’ future patients could be devastating. Most important, when patients don’t attend their appointment, their health suffers.
Real-world impacts
An academic internal medicine clinic serving a low-income, urban population was studied in 2018. The no-show rate percentage was in the upper teens and a goal was set to reduce this.To start the process of improving the no-show rate, data was collected for one month by calling patients who did not show up for their appointments to find out why. During the course of the four-week period, there were 90 patients who no-showed.
The primary reason patients did not attend their appointment was that they forgot. Brainstorming on process improvement yielded two key areas on which to focus. First, the current appointment confirmation process was examined. The clinic used an automated appointment confirmation texting service. If patients did not respond, no further attempt at confirmation was made. Schedulers were only calling patients who couldn’t be reached by the texting or calling service (e.g., busy signal, phone didn’t accept text, etc.)
The second area of focus was discovered when examining the clinic’s need for an updated and structured no-show/termination policy.
To resolve these issues, schedulers were provided with an updated and accurate daily report of future scheduled appointments confirmed by a patient via text or telephone. They were then asked to call patients who did not already confirm an appointment to verify if the patient planned to attend. Additionally, staff was asked to generate a weekly report of those who no-showed. They were then asked to send a missed appointment letter for the first and second no-shows and a termination letter for a third no-show in six months.
Three months after implementation of these initiatives, the no-show rate dropped by 3.68 percentage points.
Collaboration with leadership was continuous to consider new ways to reduce no-shows. Roadblocks of time management and staffing were monitored.
Discussion
Research suggests that in addition to the above, a sometimes unheralded reason for a patient no-show is his or her relationship with the provider or the healthcare system. When patients feel disrespected or distrust the scheduling system, they don’t feel obligated to either attend or cancel their appointments.6 Practices should strive to better understand their patients and the reasons they no-show and then endeavor to meet their patients’ needs.7Research performed by other clinics on ways to reduce the number of no-shows suggests a variety of methods to improve processes. One group found that a phone call prior to the appointment helped.8 For high-risk patients, a phone call after an initial two texts was beneficial, as well.9 Some practices have implemented a double-booking initiative for high-risk patients. Another practice found that improving patient education as well as asking them to sign an attendance agreement helped.10 Many practices use a punitive approach to reduce no-shows. In this model, patients receive a bill for the appointment in which they schedule but do not attend. Some feel as though this increases the burden on those who are most marginalized.11
No-show rates are a problem for nearly all aspects of healthcare. While it’s particularly pronounced in academic clinics across the country, similar struggles exist in non-academic clinics that serve low-income individuals. By implementing key appointment confirmation processes and reducing the no-show rate, revenue will increase, learners will be educated and, most important, health and outcomes will improve.
Notes:
1. Williamson AE, Ellis DA, Wilson P, McQueenie R, McConnachie A. “Understanding repeated non-attendance in health services: A pilot analysis of administrative data and full study protocol for a national retrospective cohort.” BMJ Open. 2017 Feb 14;7(2):e014120.doi: 10.1136/bmjopen-2016-014120.
2. Dantas LF, Fleck JL, Cyrino Oliveira FL, Hamacher S. “No-shows in appointment scheduling — a systematic literature review.” Health Policy. 2018 Apr;122(4):412-421.
doi: 10.1016/j.healthpol.2018.02.002.
3. Drewek R, Mirea L, Adelson PD. “Lead time to appointment and no-show rates for new and follow-up patients in an ambulatory clinic.” Health Care Manag (Frederick). 2017 Jan/Mar;36(1):4-9. doi: 10.1097/HCM.0000000000000148.
4. Hwang AS, Atlas SJ, Cronin P, Ashburner JM, Shah SJ, He W, Hong CS. “Appointment ‘no-shows’ are an independent predictor of subsequent quality of care and resource utilization outcomes.” J Gen Intern Med. 2015 Oct;30(10):1426-33.
doi: 10.1007/s11606-015-3252-3.
5. Kheirkhah P, Feng Q, Travis LM, Tavakoli-Tabasi S, Sharafkhaneh A. “Prevalence, predictors and economic consequences of no-shows.” BMC Health Serv Res. 2016 Jan 14;16:13.
doi: 10.1186/s12913-015-1243-z.
6. Lacy N, et al. “Why we don’t come: Patient perceptions on no-shows.” Ann Fam Med. Nov/Dec 2004;2(6):541-545.
doi: 10.1370/afm.123.
7. Williamson.
8. Childers RE, Laird A, Newman L, Keyashian K. “The role of a nurse telephone call to prevent no-shows in endoscopy.” Gastrointest Endosc. 2016 Dec;84(6):1010-1017.e1.
doi: 10.1016/j.gie.2016.05.052.
9. Kaplan-Lewis E, Percac-Lima S. “No-show to primary care appointments: Why patients do not come.” J Prim Care Community Health. 2013 Oct;4(4):251-5. doi: 10.1177/2150131913498513.
10. Eichmiller JR. “Sign on the dotted line: How to drive no-show rates to 1.7%.” MGMA Connection. 2014 Jul;14(6):49-50.
11. Blæhr EE, Kristensen T, Væggemose U, Søgaard R. “The effect of fines on nonattendance in public hospital outpatient clinics: Study protocol for a randomized controlled trial.” Trials. 2016 Jun 13;17(1):288. doi: 10.1186/s13063-016-1420-3.
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