There is nothing worse than having a perfect day scheduled at 8:00am and by 9:00am, 20% of the day has cancelled. What’s even worse is that cancellations and no-shows seem to affect the most productive procedures (Crown and bridge for the doctor and soft tissue appointments for hygiene). Therefore, the 20% cancellation rate may mean an eighty percent reduction in production. It is never just a 20% reduction in production. Cancellations and no-shows are much like a chronic infection that never goes away. It keeps an otherwise good practice from becoming a great one. It is the difference in a profitable practice and a very marginal one. Take this system and do not wait to share it with the rest of the staff. Remember: There is no learning without application. It is not enough to just share this information with the office. It has to be tracked, measured, and there must be consequences for your staff not following it to the letter. They are either doing the system and getting results, or falling back on what they have always done, and failing to meet goal. There are two types of staff: Good staff that need some more training or poor staff that need their future freed up. You will never go any further in your practice than the staff member with the least commitment to your vision and goals. It is the weakest link. It is no longer good enough to have good staff. You must move to the level of excellent staff: The right people in the right seat on the right bus. Do not delay. Make the hard decisions you know you need to make and reap the rewards of a new level of profitability and production. (Coaching Clients: Refer to our philosophy and systems of the Purpose Driven, Doctor Led, and Staff Owned Practice Model)
Expectations versus Reality
Cancellations and No-Shows (C/A & NS) are a fact of life. They will always exist. Statistically, 20% of your patients will try to cancel or no-show. Zero percent C/A & NS is not a reasonable goal. We should shoot for an 8-9% number and of those, I would shoot for a 95% filled or replaced goal. In other words, they will still try to cancel but someone has the responsibility to replace almost every one of them. You can ill afford the ripple effect of the loss of even one patient. Below you will find a chart of “One More per Day”, or if you would like, “One Less per Day”.
ONE MORE PER DAY
|Procedure||Fees||# Days||ADDED $$|
ONE LESS PER DAY
|Procedure||Fees||# Days||ADDED $$|
There are seven procedures listed. Four of these are performed by a hygienist and three by the dentist. These procedures, if added each day to an existing schedule, would create the production of the average dental practice. That’s right: Just add these seven procedures each day and you have added the production of another entire dental practice to your schedule, and it is virtually all profit. For example: Assume a dental practice is open 200 days/year. Add one more crown per day at $1000/crown, and you have added $200,000. The opposite is true also. Let one person who is scheduled for a crown cancel each day and you have lost $200,000 for the year. Every day it is “game on” all day long. Each member of the staff and the doctor must be dedicated to making every day the best it can be. There is no margin for error. No “do over’s”. No way to go back and redo that day or make it better. Far too many offices operate under the misconception that they can make up for today next week or next month. We all have the same amount of time. Great practices take advantage of the time they have.
Why do patients fail to keep their appointments?
According to the ADA, patients listed time, money and fear as the main concerns they had at the dental office. I would agree but would add a couple more areas in order to eliminate failed appointments.
- Time. “Consumerism” is the new buzz word in business today. For dentistry this means we are a small consumer driven business. Patients frequent our business and buy based on emotional decisions and not logical ones. The best clinical dentist does not necessarily have the best practice. You will be judged on your people skills more than your clinical ones. Patients vote with their feet. So, if you are constantly seeing the back of your client’s heads, you are doing something wrong. Convenience is a huge draw for most patients. When do patients want to come in? Usually from 7am-9am and 3-6 pm, and on Saturdays. We call these peak demand times. Times when our patients want to come in areConsumer hours. When are most dental offices open? MondayThursday from 9-5: Where did this come from? Probably from the 1950’s when there wasn’t a dentist on every corner. These are not Consumer hours. Are there any doubts about why patients cancel and no show in an office with standard hours? Time is important and you need to respect what your patients ask for. Be there when your patients want to come in, and your productivity goes up and C/A & NS go away. We were always open 6 days each week and this translated into an average of 10-15 new patients a week just because we were there for them on Fridays and Saturdays and our competition wasn’t. Another area of concern will be new patients who call in and are forced into taking a time that is either too far off, or during an inconvenient time of the day knowing they never planned to keep the appointment, or use some lame excuse or saying they will call back, or need to check with their spouse. I might add one more thing about time, and even money. There is a double standard in dentistry. We moan and complain when our patients don’t show up or are late, yet we never are on time. Because of my obsession with time, I can say I never ran late, never ran into lunch or past closing time. That was only for 31 years, so maybe I will slip one day but I doubt it. By constantly running late, you are marketing your practice. You are telling the consumer (You remember: That’s the guy who pays your overhead) that you do not respect their time and that you are more important than they are. Not a great message to give your clients. Is it any wonder why you do not get the number of direct referrals you think you should? As long as I am wound up, there is a double standard on money. You doctors can’t afford the dentistry you present. You fail to pay your bills on time, yet get upset when patients find it difficult to afford your case presentations. Our Summit clients are required to pay us by credit card kept on account because we know that they fail to pay their own bills in a timely fashion. Even with that safeguard we routinely find that their credit cards are denied (over the limit). Isn’t it about time for all of us to walk the walk?
- Fear: In today’s market place you must be “Painless”. Every patient should be offered nitrous oxide, premeds, post op analgesics, antiinflammatory injections, head phones, oral and IV sedation, Intraflow syringe, x tips, septicaine, Dexamethasone, Stabident, (If you don’t know what I am talking about, start looking on Google or call me) DVD/video and a caring and concerned staff that understands their role: serve the patient. Guess who gets to vote on whether you are painless? One guess, and it doesn’t include you or your staff. That’s right. Only the patient gets to decide if you removed their fear and were painless. You can’t afford to pay for the type of marketing that tells everyone that you are painless and it costs nothing. Hurt one patient and everyone in town will know about it.
- Money: We have got to figure out a way to help our patients afford the kind of dentistry they need. You have to show concern about making dentistry fit into your patient’s budgets. (Coaching Clients: Be sure and go back and reread our module on 100% case acceptance.) If you want the dentistry more than the patient, then you have crossed the line. You cannot appear needy or too assertive in pushing treatment. Always happily give them what they want and tell them what they need. Do this, and fit it into their budget and you will have a patient for life. Most of you use Care Credit. While it is a good company, it does not have the highest acceptance rate of all the healthcare finance companies out there. You need to add layers of companies to direct your patients to. One is not enough. You can even use a couple of companies to get a single case financed by having each company cover a portion of the cost. If you do not fit the cost of treatment into your patients budget, they will always cancel and no show. It is always about money. Think of it this way. You have a system to finance their treatment, but with money or any other blockage that we are discussing, you are also reading the patient. You are looking at body language and what is not being said. The job of the financial secretary is to identify any hesitance on the part of the patient that might prevent them from keeping their commitment to the office. If you do sense this, then go back, ask a question and probe deeper and identify where you lost the patient.Here are a few other companies to try:
- Wells Fargo – http://financial.wellsfargo.com/retailservices/wfha_dental.html
- Chase Health Advance – http://www.chasehealthadvance.com/patient-financing/procedures/dental.asp
- Citi Health – https://www.citicards.com/cards/portal/healthcard/nsc/content.do?screenID=5005
- Enhance Patient Finance – www.enhancepatientfinance.com
- Health One – www.healthone-financial.com/HomePage.php
- Lack of Trust. This is huge. If you are not willing to find a way for them to fit the cost of dentistry into their budget, be there when they want and need to come in, and show compassion and caring, then you become the donor practice for your area. The donor practice is the one that continues to quietly drive off patients for lack of consumerism while blaming it on the economy, poor demographics, and lack of dental IQ of the patient. I have said many times that the best referral source I had was the two dentists down the street that unknowingly sent me patients because they failed to inspire them. Trust occurs when we master serving (not service). The lion’s share of this falls to the staff. From the first phone contact thru the final payment, your staff represents the practice. They control your future success. We need to understand what each patient is worth to us. Divide the number of new patients you have into the production per month. This number is the amount of production per new patient (not on each new patient). In an average dental practice in the U.S. it is about $1,000. In a well run general practice it will get to about $2,500. Anything over this will put you in the boutique style of practice and will usually be with older doctors who see only adult patients with a high percentage of crown and bridge. Add to this the lifetime value of a patient and you need to see each new patient as a $5,000 – 10,000 dollar bill. While I know that money is not the point, it is a measure of the service you provide your patients. Another way to look at it is tomeasure the number of new patients who are directly referred to you by existing patients. If it is not at least 40% direct referrals you are not inspiring your patients. Loyal patients do not cancel. Think of it this way. If you are not currently growing, you are not inspiring your patients. Your systems will ultimately determine the range of patients you will be able to inspire. It is impossible to get better at giving patients what they don’t want. Learn to create trust and you will inspire your patients, direct referrals and new patients will increase, and cancelations will disappear.
Each of you needs to go back and read or listen to our program on “How Patients Judge a Dentist”. This one topic can forever change your outlook on how you practice dentistry. We have had clients completely turn around their overhead, production, and new patient numbers. This is the cornerstone for every system we have developed over the last 20 years. Get this right and you will not be able see all the patients that will want to come in. If you are not a current client, give us a call to purchase a CD that fully explains these concepts. You cannot afford to start another year without implementing these strategies.
Hopefully, we have spent enough time so that you understand why cancellations and no-shows occur. Let us now spend the time to help you minimize its impact on your day.
We see hundreds of offices a year and talk to even more doctors. In a small percentage of cases we find that in some offices technology is holding them back. I don’t care what type of software you use, but it has to let you schedule in 10 minute increments (15 minute scheduling is one of the worst blockages of a profitable dental practice). Going from a 15 to a 10 minute schedule will make you about 30% more profitable (Be sure and go back and listen to your audio recordings, consult with your coach, and reread our module on scheduling). We have to engineer our schedules to make our days more productive. It costs nothing while giving you the biggest bang for the buck as far as improvements go. Let me just use one example: In a normal hygiene schedule you frequently see one patient every hour or about 8 per day. Have a 20% cancellation rate and you are down to only 6 patients that day. Go to a 10 minute schedule and give them about 50 minutes to do a 6 month recall instead of 60, and you now have an extra 80 minutes a day to schedule a couple of more patients. Now if we still had a 20% cancellation rate (Goal is less than 10 with 95% of them being filled) you still have 8 patients to work on and have had less impact on your productive day. 2 patients more a day during an entire year (200 days) means at least an extra $20,000-30,000 more per year per hygienist. The smart doctors are always looking at the numbers. Eliminate a majority of C/A & NS and we add another $30,000 in hygiene or a total of $60,000/year/hygienist. Imagine what you could do on the doctor’s schedule!
Cancellation and No-Show Fixes:
- Scheduling above goal. The secret of super productive practices is to always schedule 15% more production than your goal. Fall a little short and you still have a super productive day. Start hitting the goal on a routine basis. Then you raise it 5-10% and tie a reward or bonus to it. (Coaching Clients: Reread the module and listen to audio on profit sharing and bonuses to inspire your staff)
- We make cancelling too easy. Over and over, time after time while visiting an office the same scenario occurs. I can only hear one side of the conversation, but it goes something like this: “Hello, Dr.____________ office, this is Cathy, I can help you. Oh really. Yes. I understand. Well let us know when you would like to come in. Thanks.” You know what has just happened. Someone has called to cancel with some minor excuse, and your front desk person did not make it a big deal, failed to try and get the patient to keep the appointment, did not reschedule, and worst of all left it to the patient to call back. No effort, no consequences, no production. This is serious, and it goes on all day long. Start recording your calls and see how long it takes to retrain, redo your job description, or free up someone’s future. Remember: Get the right person in the right seat on your bus. You will be appalled at what goes on all day while you slave back in your operatory. The phone is the most important piece of technology in the entire office. The person using this technology has to be one of the best people in the entire office. If she doesn’t come across as being competent, caring, compassionate, and consumer oriented, you won’t even get the opportunity to mess up the relationship, because the patient will either not schedule or schedule with no intention of showing up. If you think all the money you spend on marketing is not working, you may be wrong. You could be getting hundreds of people to call, but no one makes an appointment because of how they were handled on the phone. It is called the “threshold test”. What are you doing to make it difficult to get into your office? What barriers have you intentionally or unintentionally erected? Poor hours, no outside financing, never cleaning teeth on the first appointment, not being insurance friendly…….. Nothing is a sacred cow. Relook at everything you are doing and why. Make it easy to get an appointment. If the answer to any question the patient asks is anything other than “YES”, I am going to want to know why. Always measure what you want done. It is called the “Hawthorne Effect”: What gets measured, gets done. In fact, every position needs to be measured by a graph, and used to manage the office by the numbers. So how do we make it a big deal? It should go something like this: “Hello, this is Dr._______________ office. This is Cathy. I can help you”. (Listen to their story, and remember, the person who asks the questions controls the conversation). “Mrs. Jones, we scheduled this appointment for 3 hours specifically for you. We confirmed the time and appointment yesterday by phone”(It is not confirmed unless you talk to the person scheduled. Leaving a message is not a confirmation. The most important phone number to have is the cell phone number.)“Dr.____________ has two assistants set aside to help him in this procedure, and has a helicopter (just kidding) from the lab coming to pick up your case.” Close with: “How may we help you keep this appointment?” (Then don’t say a word. Wait for the response. Keep waiting. Do not talk. Not yet. A little longer. The first person to speak looses). This gets a lot of them. Let’s say they still insist they cannot come in today despite your best efforts. The next script goes something like this: “Mrs. Jones, if you will hold on a moment I will pull your records and get Dr.___________ on the phone. He will want to discuss this with you personally” (If a hygiene appointment, get the hygienist). All of a sudden they start backstroking. They thought they could just call and leave a message, or beg off with someone that they had no relationship with. The minute the Doctor or Hygienist is involved, things change. I do this myself, and train every office we work with to do this. Will I come to the phone? Absolutely. We are about to have a “come to Jesus” talk. I can have this talk because I know we have eliminated the problems with money (we will give them what they want with multiple financial options at no interest for a year or two), fear (most of my patients didn’t even know they were there), and time (we are open 6 days a week, and I am always on time). There are no double standards in our office. We walk the walk. The nice thing is that I often don’t even have to make it to the phone before the patient changes her mind and comes in a little late, modifies the treatment, gets picked up by us, or actually tells us the truth as to why she was trying to not come in. Usually the reason revolves around money, fear, time, or trust. It can even be as easy as wanting to go with someone to shop or eat. You must have a skilled person orchestrating this encounter and it must be done in a scripted, methodical method to get consistent results. We define case acceptance as patients showing up on time, paying for treatment, and referring everyone they know. There is no plan B. We want 100% “case acceptance”. Let’s say even after talking to me she cannot make it. I never reschedule immediately. I do not want to look needy and in most cases I will try and have her prepay the entire treatment and not give her one of our peak demand times. I explain that if we make this appointment, it needs to be at a time that even if they are dying I would still need a week’s notice.
Using the phone well is a trainable skill that will get you consistent results. This is the order of a normal call:
- Prioritize each call. We always use the last number on our string of office lines for marketing pieces. If that number rings, it is a new patient. You cannot be doing 3 things and pick up this call. We even place mirrors behind the phone so it would remind our staff to smile. Do not put people on hold!
- Introduce yourself to the caller.
- Answer common questions the caller may have.
- Take control of the call by asking a question and begin the close. The goal of any call is to make an appointment that the patient will keep.
- Utilize a dual alternative close to limit the options for the patient to make the appointment. “Mrs. Jones, would you like to come in Monday or Tuesday” Answer: Tuesday. Would you like morning or afternoon? Answer: Morning. Would you like early or late? Answer: Early. We have an appointment for 9:30am. How would that work? Answer: Great.” You will notice that there is no wrong answer and each answer moves the patient down a path that limits their options and moves them closer to making the appointment. Do not minimize the brilliance of the dual-alternative close. It has been around for over a century, and it works every time.
- Wrap up the call by getting the name, confirmation numbers, and anything else you need.
I have said many times that the most important piece of technology in your entire office is the PHONE. Along with this is the assumption that the most important staff person is the one who picks it up when it rings. The problem is that the person who answers the phone may not be the person who has the most training, or the one you would most like to handle the first encounter with the patient. Phone training has to be intentional and planned with a result in mind. The result you always look for is a “scheduled patient”. Anything else is unacceptable. Fail to measure this with a graph, (calls vs. scheduled patients) and you will not get the result you want. Prioritize your time and understand that there are no cell phones used by the staff, and especially the doctor, during business hours. Phone time is a personal intrusion on a job you and your staff are being paid to do. Misuse of the phone is often the number one reason for running late or off schedule. I was listening to several staff complain about how their doctor was always on the phone. When they asked me what I would do, I asked why he got on the phone in the first place and was told: All of his friends, stockbroker, builder, wife …. would call and he would drop everything and go back to his office and start a conversation. I asked how he knew they called, and they said they would go tell him. Is it just me, or is this dumb? My answer was: “Don’t tell him. Just tell the caller that he is with a patient and have them leave a message. Then hide it until lunch time (or the end of the day) and then give them to him.” You would have thought I taught a cave man how to build a fire. They were dumb founded by my brilliance. Our office manual states that there were no, none, nada, zilch, ain’t no way, absolutely no personal phone calls during business hours. I never broke the rule and I held my staff to the same standard. A major part of leadership has always been leading by example. Doctor, you are not the exception. If someone calls wanting to speak to the doctor or any staff member and states it is “an emergency”, simply verify that 911 has already been called. If not, it isn’t an emergency! Take a message.
While we are talking about the phone as the most important piece of technology in the office, we need to address its care and feeding. If we look at a traditional office you will find that the phone is left unanswered for more hours than it is answered. We typically work 32 hours per week, but the phone should be answered 24 hours a day, 365 days a year. An answering service or answering machine will not cut it. The goal is to havea live person who has the power, training, and authority to handle any situation the caller may have. This is the plan. I pay my staff to carry an office cell phone that has all calls forwarded to it any time we are not in the office. The staff person has printed off the hygiene/doctor schedule for the next couple of days so that emergencies can be routed or scheduled, cancellations can be discouraged, and if they occur, the schedule can be modified that very minute. The pay was minimal to do this, but the kicker was that for every patient she scheduled for treatment she was paid a bonus of about $15-20/patient. This could result in 4-5 new patients scheduled a weekend and an extra $100 for the person who carried the phone. With this, we have added another layer of certainty that when we show up on Monday morning the schedule is full and productive.
Just a few more phone pearls:
- Use the phone number that is the last one in rotation for all marketing. Do not use the number listed in the phone book. In this way, when you see the last line ringing, you know it is a new patient. If you are hurried or trying to juggle 4-5 things at a one time, don’t pick it up. You have to be mentally in the game when you talk to new patients. I would rather they have to call back than to get someone who comes off as uncaring, not compassionate, non-listener who puts them on hold. This is a horrible first impression that will never be overcome. Bad first impressions assure you of a lot of C/A & NS.
- Always give patients a way to reach you after hours. If you really don’t want them to call, always take the time to give them your business card and then take the time to write down your personal cell number. Perceived personal access will prevent them from calling. They will guard the number with their life and never use it, but you can bet they will tell everyone they know about you.
- Pre-Op phone calls. A couple of years before I sold my original practice, I began secretly doing something that transformed my productivity and almost eliminated all cancellations and no-shows with new patients. I worked with a couple of younger partners that were better looking and better with people than I was and were both sneaking up on my production level. I guess I was proud enough to not want them out produce me, so I secretly started looking at the next day and making a copy of the schedule with the names and phone numbers of all of the new patients that were coming in. We usually averaged 10 a day. I would just call and say: “Hello, this is Dr. Abernathy and I was just calling to see if you had any questions or if I could do anything to make your visit tomorrow go more smoothly”. Once again, it was like I taught a cave man to make fire. They were so pleasantly surprised that I had personally called they were completely taken aback. The result was that the next day, while 6 hygienists and 3 doctors in two locations were working, the hygiene light that indicated they were ready for a check comeson. This signals that one of us needed to check hygiene. I couldn’t do it all, and as the better looking, younger, better people skilled dentists rushed in to make a great first impression, they were met with a surprise. As they introduced themselves the patient would turn and say: “I was hoping to see Dr. Abernathy”. Even if I was not in the office that day, many patients would allow the young doctors to check them, and then still make an appointment for treatment with me. Imagine. A simple phone call that makes an average patient act like they already knew me or were referred to our office by a trusted friend. The effect: Less reluctance, more case acceptance, and a happy, referring, lifelong client who never fails to show up.
- Since Monday is consistently the worst day for C/A & NS, stop scheduling patients with a history of missing appointments on Mondays. Simple. Only schedule your most reliable and consistent patients on Monday. It will be a much more pleasant day.
The Comment Card
Let’s add one more level of certainty that will insure fewer C/A & NS. The comment card is given to every patient that comes through our office. With this we are able to solicit feedback from each patient. The card has a prepaid business reply stamp that guarantees that it will be returned to the office if mailed. Statistically 92% of patients who have a less than perfect experience in your office will say nothing — and never return. Give them the opportunity to vent and over 90% will return. This is a great investment and is used to modify every system in our office. I always assumed that if there was a bad comment about one of our staff, or some procedure, that there were at least 100 more patients who did not bother to mention it, but were certainly not happy with us, and would not return or favor us with a referral. Get a poor report card, and you better take it seriously. Act upon it, and fix or improve the situation and C/A & NS diminish. The comment card is included as a separate attachment (.pdf file). Any printshop can take care of it for you. Just check with the local Post Office first to get your Business Reply mail account.
Let’s spend a little time going thru the special requirements of hygiene and how we can minimize C/A & NS there. In our practice, the hygiene department produced one third of the total production per month. That was around $200,000 per month. It was not a loss leader for our practice. We engineered our hygiene department to be the entry point for a majority of our patients. It was super important to get this right. Hygiene cannot be thought of as “just a cleaning”. If it is, you will have all sorts of trouble in filling your schedule and having patients cancel or not show up. A second attachment (.pdf file) with this document is a form called the Oral Hygiene Dental Fitness Report that we use in each of our offices to insure that the patient understands that this is much more than “just a cleaning”. It creates more value for the hygiene appointment. This form was given to me by a hygiene consultant (Annette Ashley Linder) many years ago and works great. It is not kept in any chart (we are chartless), but is given to the patient to take home. For the first time your patients will actually understand the level of expertise and the procedures (other than thecleaning) that were performed.
Like most of you, we pre-appoint 92% of all of our patients for recall at the time of treatment and this is done in the operatory. Technology allows us to schedule from the operatory by the one person who could best assess the true amount of time needed to treat the patient on the next appointment. Our front desk was tasked with taking the money and interacting with patients on the phone and greeting them at their arrival. Everything else was performed chairside. While we pre-appoint over 90% of our patients for recall, we only pre-book about 70% of any day. Keeping any one day with about 30% openings allows us to have peak demand time for our new patients in the future. Completely pre-booking any day in the future creates blockages to processing new patients. If it takes you more than 3-5 days to get a new patient in for hygiene, they will go elsewhere. They will probably schedule with you, but will not show up.
One more secret on normal recall appointments is to pre-appoint in 6 months is to have the patient fill out the recall reminder card (they will recognize their own handwriting and will actually read it), and most important, have your hygienist write a personal message to the patient about something they discussed that day. The patient receives the card a couple of weeks before the appointment. The patient reads it because she recognizes her own handwriting, and sees the personal note and is taken aback by the fact that the hygienist could remember what they talked about 6 months ago. Very impressive and note worthy by the patient creating a bond to the office and makes it unlikely that she will fail to show up. We still call a couple of days ahead of the appointment to confirm that the patient will show up, but the system works incredibly well to help insure a consistent follow thru.
About 10-12 years ago, we started marketing free bleaching for new patients who paid our regular fee for a cleaning, exam, x-rays, and consultation. As a result of this, the patients who last week paid hundreds of dol