The Next Level of Tools and Solutions to Combat Cancellations and No-shows (1)
Having patients not show up or cancel at the last moment is commonplace, but in today’s dental economy we must counter the commonplace with common sense. What follows are more tools and solutions to minimize the lost income and productivity from patients not showing up.
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 and is 100% anonymous (online or practice software responses do not get the attention you would like because patients feel like you will capture their IP address and know who posted it). 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 if you respond quickly to address their grievance. 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 quickly and fix or improve the situation and C/A & NS diminish. (The comment card was included in PART 34 of this series.) Any print shop can take care of it for you. Just check with the local Post Office first to get your Business Reply mail account (the printer will the information).
Let’s spend a little time going through 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 office 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” or loss leader. If it is, you will have all sorts of trouble in filling your schedule and having patients cancel or not show up.
In PART 35 of this series a few weeks back, I included a copy of the Oral Hygiene Dental Fitness Report. We use this report in each of our offices to ensure that the patient understands that this is much more than “just a cleaning”. It creates more value for the hygiene appointment. For the first time your patients will actually understand the level of expertise and the procedures (other than the cleaning) that were performed.
We pre-appoint over 92% of all our patients for recall at the time of treatment and this is done in the hygiene operatory by the hygienist. 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. Who better to engineer the next appointment than the person that worked on the patient today? Our front desk was tasked with taking the money and interacting with patients on the phone and greeting them upon 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 one day in the future. 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 4-10 days to get a new patient in for hygiene, they will go elsewhere.
Granted, they will probably schedule with you, but will not show up. A great question for you to be asking yourself is: If you are prebooking everyone for their recall appointment but only booking any one provider to 70% of the day, what happens to the other 30%? They go in another blank column knowing that when you approach that date 6 months from now, you may need to hire another hygienist if you are inspiring your patients and they all return. Keep in mind that a hygienist can only see about 600 patients in a year if they still see new patients, recall, and do perio.
One more secret on normal recall appointments is when pre-appointing for the next visit in 6 months is to have the patient fill out the recall reminder card (upon receiving it in the mail, 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 noteworthy 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. Electronic recall software was never designed to be a standalone recall/reactivation system, but rather, an adjunct to an already good recall system.
About 30 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 dollars for bleaching felt slighted and were upset. Being the approval addicted over achiever I was, I immediately offered to give them extra bleach syringes every time they came in for a cleaning at no charge and offered all their friends and family the free bleaching that I was advertising. Thus, was born the bleaching or “whitening for life” strategy. It was not planned, but in hindsight it created a system to reinforce the patient maintaining and keeping their 6-month hygiene visit. The other ripple effect of marketing and attracting patients who wanted the free bleaching was that this type of patient wanted all those nasty black mercury fillings replaced and really appreciated cosmetic procedures.
In recent years no fewer than 12 companies have arisen that create a digital follow through for your recall and confirmation systems. Listed below are some of the most prevalent. It is not a replacement for anything we have already discussed but is an adjunct to them. This provides one way to reach out and contact those patients who wish to use digital contact as a way to lower failed appointments by another method. Online communications companies:
Same Day Treatment
This may seem a little counterintuitive while discussing limiting cancellations and no-shows, but offering your patients same day treatment guarantees they show up. Hey, they never left. This works especially well to fill cancellations as well as adding production by doing short productive things like single fillings. If your clinical speed is up to snuff, then fitting in a crown is even better. Note: You only add treatment if the staff says to do so. You should never run over or ever run late. This is a system. You do not operate by the seat of your pants. If the procedure is considered not that big of a deal to the patient, and if they find this service convenient, they will always go for it. Also, a financial agreement must be in place prior to treatment.
How to Fill a Cancellation or No-Show: 5 Strategies
We’ve gotten your failed appointments down to at least 8-9% or less, but we still need to fill the empty spots left by that small percentage of patients that have C/A & NS.
1.The Morning Huddle: Every morning before the day begins you gather the troops for about a 10–15-minute strategy session. Where are any holes, who was not confirmed, who owes us money, what special things do we look for? We are striving for perfectly engineered hygiene and doctors’ schedules. Any holes that we see we all address and find a solution to end the day on goal with everything filled. For example: We have a cancellation on the doctor’s schedule from 1:00-2:00pm today. We look at the hygiene patient before 1:00pm to see if they have any undone work that could be scheduled and if so, they are contacted to extend their appointment on the doctor’s schedule. We look at the hygiene patient coming in just after the 2:00pm time and see if they have any uncompleted treatment and ask if they would like to come in early to take care of it. We see if any emergencies are available to take the 1:00-2:00pm time. We averaged about $2,000-3,000/day of extra treatment just from our emergency patients. (NOTE: You should have one more chair than you typically use to stop facility blockages to production). We look at the doctor’s patient coming in just before 1:00pm and see if they have work that could be extended into the opening. We had glass doors in our sterilization area and would take a dry eraser board pen and write down any changes or needs in the schedule in the sterilization area so that all day long everyone was aware of a problem time that needed to be filled. We were dedicated not to end the day even a dollar short of our goal.
2.The Purge Sheet: Decades ago, we took this purge sheet and used it to purge our entire chart inventory by placing the sheet on a clip board and having every staff person purge two files per day. Every person including the doctor did this. They would pull out the clip board along with the two charts to the right of it and if not current (patient has not been in to see us in the last 12 months), they were placed on the purge sheet so that the front desk could reactive them by phone and/or letter. Now we use an electronic purge audit but still place those patients on the purge sheet for the front desk to put through our reactivation protocol.
3.The Call List: The call list consisted of patients who had scheduled but requested an appointment ASAP or said they were available on short notice to fill a cancellation or no-show. We also used it for single or simple crown seats. We never scheduled single crown seats ahead of time. We found that the patients would always want an appointment to seat their crowns during peak demand times (we wanted to save these times for new patients and large productive cases). Our script for not prescheduling them was to just mention that it would take about 10-14 days for the crown to return from the lab, and that if it was ok with them, we could just give them a call the minute their crown came in and that would surely mean getting them back in quicker. To create a super productive schedule, you must fill at least 60% of it with Substantial Cases (anything at or above the fee of a crown). It is impossible to reach a substantial goal just doing denture adjustments, emergencies, and single fillings. Let me give you an example: If your goal was $6,000 a day in production, and a crown went for about $1,000, then you would need $3,600 or about 3.5 crowns or an equivalent dollar amount procedure (60% of your day in substantial cases). If you had 3-4 crowns on your schedule, it would be a “good” day. Have more, and it will be a great day. The procedures do not have to all be crowns, but the appointment value must equal the crown fee (an appointment for 5 fillings could equal one substantial case). Fall short of the substantial case goal and everyone knows it will be a full court press until we get the right number. No excuses, just getting it done. You should consider the substantial cases the “bricks” that build your production, while the seat crowns, single fillings, adjustments, and other small unproductive cases are the mortar that fills in the rest of the time. You are essentially building a wall of production for your successful schedule. To get the patient to do this we used this script: “Mrs. Jones, it should take about 2 weeks to get your crown back from the lab, but rather than making the appointment today why don’t we give you a call the minute it comes in so that we can get you back as soon as possible”. This makes perfect sense to the patient and sounds like it is designed to benefit her. When you are ready to have her come in and seat the crown, you merely use the dual alternative close to get her to come in during a non-peak demand time around other more productive treatment in the future. It would go something like this: “Mrs. Jones your crown is in. Would you like to come in Monday or Tuesday? (Answer: Tuesday)
Would you like morning or afternoon? (Answer: Afternoon)
Would you like early afternoon or late afternoon? (Answer: Late)
We can see you at 3:15pm. How would that work for you?”
This works incredibly well. Doing it the other way, you make the appointment 2 weeks away and the crown may not be ready, or if it is, you find that during the passage of the 14 days it took to get it back, you needed to schedule a large case at that very time, but because of the conflict you had to put off a substantial case to service the minor appointment. This is not engineering the schedule for maximum productivity. The same strategy works on the hygiene schedule except their substantial cases are new patients and scaling and root planing. While not at the value of a crown, they are the highest dollar production per hour on their schedule. Keep in mind that a hygienist needs about 2 new patients a day to be super productive thus introducing them to the possibility of more scaling and root planing.
4.New Patients: A well run general dental practice should be attracting about 40-60 new patients per doctor each month, with a large number of them being direct referrals (minimum of 50%). Having an ever-increasing number of new patients along with the healthy hygiene that goes along with it, ensures a never-ending source to fill cancellations and no-show. We averaged 200-300 new patients per month for three doctors and 11 hygienists in our two locations that were just 2.5 miles apart on the same street. We could always find a willing patient to come in early or stay a little later to finish up their work and help us maximize our time. This is just one more source to draw on to fill that failed appointment.
5.Emergency Patients: How you handle an emergency patient says a lot about the level of training and ownership your staff has in the practice. 99% of what we do with an emergency patient is handled by a staff person. Someone calls in with a tooth ache. One question is always asked of each caller: “How soon can you be here?” (does not commit the practice to this specific time). We always had one more operatory than we needed each day. We always had the capacity to fit in an emergency or productive surprise. So, the patient arrives and is immediately taken back to our extra room. The assistant takes x-rays, history, finds out what the patient wants, and what their budget and dental IQ are. She basically “triages” the patient. She tells the patient what she sees without actually diagnosing the case. She also tells the patient what I will probably suggest if they want to save the tooth. They briefly discuss finances, and she comes to get me. As we walk down the hallway she might say: “Numb number 19”. I don’t have to ask if we have the time, what we are doing, or if the patient can afford the treatment. My assistant has already done everything. I confirm the diagnosis, and confirm the patient’s wishes, and proceed. Another scenario might be that as we approach the room she says “prescription”. I know the patient can’t afford to fix the tooth, or we do not have the time, and that the future appointment is already booked. I do not start treatment without the staff giving me the go ahead. Doing this would guarantee that we would run behind or create problems in our accounts receivable. The staff runs the schedule and they “own” the process. They understand the business of dentistry and they know how to serve our patients. Let go and let your staff finally grow as a team.
To Confirm or Not: A couple of years ago, I was taken aback by the idiocy of some speakers and consultants who had concluded that we should not confirm our patients’ appointments because, and I quote, “it would make our patients dependent on us to remind them”. I am sitting at the back of the room thinking: “Exactly”! Do not confirm and you can count on them not showing up every time. I want the patients to depend on us. We are consumer driven and the consumer wants and needs to be controlled and guided into the behavior we want. Another way to look at this is that this confirmation time puts you in front of them one more time. It gives you one more encounter to identify any blockages or uncertainty in the patient and then deal with it. We want to take all the blockages off the table so that there is nothing that would prevent the patient from showing up.
Pre-appointment call: I called every new patient 24 hours before their appointment just to ask if I could answer any question that might make their appointment go better for them. They almost fell over with every one of these calls I made. I was remarkable in their eyes because I was a dentist who cared enough to ask.
Urgency: The final puzzle piece is essential to closing the back door on your practice. The ideal dental encounter goes like this. The patient walks into the office to have their teeth cleaned, they are diagnosed and offered same day service, they accept, make payment arrangements and the chair is reclined and the service delivered. No cancellation, it is paid for, no buyer’s remorse, and you have the perfect encounter. There were no delays or handoffs. The patient came in and never left. Any other situation increases the chance of a poor handoff, not getting paid, or the patient not showing up. If you have ever watched a track meet the final competition is always the team relay. Four runners with a starter, 3 handoffs, and the anchor. Everyone knows the race is won or lost on the “handoff”. Fumble the baton, stumble, start too late or too quickly and you lose the race. The world is filled with spectators and 2nd and 3rd place finishers. You need to show-up, start on time, and finish well. Urgency is the glue that holds the entire system together. We use urgency to impress the patient of the importance of follow thru, tie them to each staff member that has interacted with them, and create phantom pressure to complete and pay for treatment. Here is an example of what happens:
I come in to check the hygiene patient. The hygienist takes a moment to let me know what the patient wants (the patient had sensitivity on tooth #19 to pressure and cold. They have an existing large amalgam filling with a cracked mesial buccal cusp that is clearly shown on the intraoral photo on the monitor) and what they need (a crown). I confirm and reinforce the treatment plan in the matter of just a minute or two and turn to the patient and say: “Mrs. Jones, we need to get you in as soon as possible and fix that cracked tooth before it is lost or turns into a root canal or worse. Whatever you do, do not eat anything on that tooth before you have it restored.” I then turn to the hygienist and say: (the hand-off creating urgency) “Sandy, whatever you do, get Mrs. Jones in within the next 24-48 hours, even if you have to get Cathy to move someone.” The patient is listening and hears the urgency and hears that we are going to go out of our way to make sure she is put at the front of the line. We think this is urgent and we are transferring our urgency and enthusiasm to the patient while involving 2 or 3 staff people that she would have to disappoint by not following thru with our suggestions. Sandy escorts Mrs. Jones to the financial secretary or front desk person and once again ties urgency to the follow thru of scheduling, paying, and showing up for this very important procedure. “Cathy, Mrs. Jones has a fractured tooth on #19 and needs to get in as quickly as possible so that this does not turn into a root canal or total loss of the tooth. Dr. Abernathy said to get her in within 24-48 hours even if you have to move someone.” Now Cathy studies the schedule as if this is going to be difficult (we all know we have the next couple of days filled with holes, and we could fit her in at almost any time). She looks up with that caring concerned look and says (Dual Alternative Close): “Mrs. Jones, would you prefer Monday or Tuesday? (Answer: Monday)
Would you like morning or afternoon? (Answer: Morning)
Would you like early morning or late morning? (Answer: Early)
We have 10:00am this coming Monday. How would that work for you?” (DONE!)
Cancellations and No-Shows will always be a challenge and probably the key benchmark separating the good from the great. You and your staff should read this and take the time to meet and discuss it in depth. Role play, rehearse, and script every step of your patient encounters. Add to your tools to move the patient into, through, and out of your practice in such a way as to inspire them. If you are not growing in numbers of new patients, profitability, and lowered overhead you are not inspiring those patients. Remember: Loyal, inspired patients do not cancel or no-show. And great practices do not tolerate Cancelation and No-Show rates above about 8-9%. Take charge of your practice and your future. Do it today!
Michael Abernathy, DDS