Taking the Bite Out of Patients Not Showing Up
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 their 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 sort of office 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 or less (15-minute or even 30-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 20% more profitable. 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 give just one example: In a normal hygiene schedule you frequently see one patient every hour or about 8 per day if they are all recall appointments. 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 minutes, 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 8% with 95% of them being filled) you still have 8 patients to work on and have had less impact on your productive day. Two patients more a day during an entire year (200 work days) means at least an extra $20,000 to $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! NOTE: Go from 60 minutes for the average office recall appointment and go to 50 minutes, increase the hygiene production 31% if you can get them in with no cancellation or no-show.
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.
- 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 to 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 away 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, and on and on. 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 or the number they can be reached the day before the appointment.) “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 morning or late morning? 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 are always looking 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, etc., would call the practice 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, along with his cell phone until lunch time (or the end of the day) and then give them to him.” You would have thought I had 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, isn’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 have a 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, or a 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 17 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 start a 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 comes on. 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 37% still made 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.
- Shooting yourself in the foot. 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.
Next week, we take a dive into a deep toolbox of systems and tips on further ways to minimize the cost of cancellations and no-shows while introducing the concept of “attrition”.
Michael Abernathy, DDS