Closer look reveals true reason for no-shows
Physicians must lead way to improvement
When Hennepin County Medical Center - a large public teaching institution in Minneapolis - took a hard look at its high no-show rate for outpatient clinic appointments, it made a startling discovery: There appeared to be little the hospital could do about the primary causes of the problem, says Michele Young, senior office services supervisor for ambulatory services.
However, the extensive investigation of the no-show issue led to some solid recommendations for improving customer service and shot down a number of pet theories on why patients failed to show up for appointments, she says.
In July 1995, the formation of a team to study the high appointment fail rate was prompted by requests from physicians in two of the hospital's specialty clinics, ENT and dermatology, Young says. Concentrating initially on those clinics, which had fail rates of 42.1% (dermatology) and 35.2% (ENT), the team created a mission statement and objective and constructed flowcharts and tree diagrams to identify the effects of the no-shows.
The effects on the institution include these:
o lost revenue;
o staff under- or overutilization;
o fewer patients available for teaching purposes;
o increased clinic overhead for follow-up on failed patients.
The effects on the overall patient population include these:
o decreased availability of appointments;
o unpredictable wait times;
o negative public relations (due to wait times).
The effects on the patients who fail to show up include these:
o possible worsening of their medical condition;
o increased emergency department and hospital usage;
o suboptimal treatment of chronic conditions.
The unpredictable wait times, Young points out, were due to the staff's attempts to compensate for the no-shows by overbooking and providing more appointment slots. "So if, instead of the usual 30% or 40% fail rate, it's suddenly only 15%, you can't accommodate the patients," she says.
The team found that four groups of patients failed to show up in greater proportions, Young says. They included intake patients (neither employed nor insured), patients on Medicaid, members of a certain managed care plan, and the self-pay population (uninsured but employed).
One of the institution's pet theories was that the people failing to show up were those given follow-up appointments after being discharged from the hospital, she says. Instead, the team discovered the no-shows were primarily patients who made their own appointments at the clinic and those who made repeat clinic visits.
Another disproved hypothesis was that with a large indigent population, patients without telephones were failing more often. But the team found only 10% of the patient population didn't have phones. Subsets of patients were responsible for repetitive fails, she points out. For example, 14 dermatology patients accounted for 400 failed appointments, and 68 ENT patients were no-shows on five or more appointments over a six-month period. The team also discovered patients ages 45 and younger failed more often than their older counterparts.
Patients got telephone calls
With these data in hand, the team was ready to find out why people don't show up for their appointments. It received approval from hospital administration to conduct a patient telephone survey. At this point, administration asked the team to extend its study to include the majority of the hospital's on-site clinics, both primary care and specialty, as well as one off-site clinic, the Family Medical Center.
In preparing for the survey, the team removed repeat appointments from the call list to ensure patients were not called more than once, and it made sure patients were called within one week of the failed appointment, Young says.
After going through the bid process, the hospital selected C.J. Olson Market Research Inc. of Minneapolis to conduct the survey. Between February and April of last year, 1,152 telephone interviews were completed. The University of Minnesota Language Center assisted in 49 non-English-speaking interviews. Letters were sent to patients without phones, asking them to call for an interview and offering $10 if they did. Fourteen of those responded.
The interviewees first were asked if they knew they had an appointment on the day in question. If they said "no," the interview was discontinued, Young says. That was true in only 4% of cases.
The most important thing the team did through its survey, she says, was to disprove the pet theories about why patients didn't make their appointments. "The team started out with about 40 theories and disproved 11 right off the bat."
The main reasons patients gave for failing to show up were personal and emergency conflicts, forgetting about the appointment, and transportation issues. The transportation issues, she notes, had nothing to do with parking problems, which shot down another pet theory.
The team also identified a number of concerns related to the appointment-making process, including variation in practice and in compliance with established practice, Young says. At some clinics, for example, it was the practice of clerks to check for any pre-existing appointments when scheduling a new one, and at others, it was not, she explains. Even where it was the practice, staff were not always consistent.
The team's recommendations regarding these and other issues "were things that may improve clinic operations or customer satisfaction, but we found there was not a lot we could do to significantly impact the fail rate," she notes.
Some patients indicated they didn't always feel they had a good choice of time or day in making an appointment. Many perceived, based on how the scheduler sounded, that the first time and date suggested was their only option, Young says. The survey also revealed some problems with discordant appointment slips. For example, the slip says "Wednesday, May 12," but May 12 is a Tuesday.
In some cases, providers told patients an upcoming appointment wasn't necessary. In others, patients said they weren't going to keep a scheduled appointment, but the information sometimes wasn't communicated to the clerk doing the scheduling, the team found. Patients also indicated they wanted a central appointment "cancellation line" to call, complaining that the hospital's main lines frequently were busy.
"Our hope is to tighten our own internal processes and to act on some of these recommendations," Young says.
During its investigation, she says, the team discovered how often the institution schedules "marginal appointments," which are arranged "just to get something in the system." This might involve, for example, a rash that could clear up, making the appointment ultimately unnecessary.
There was some indication, Young points out, that physicians schedule marginal appointments because they like to have a few "light" cases to break up their workday. After hearing the team's presentation, one physician said he scheduled such appointments more often than he realized. Residents at the teaching institution sometimes schedule an appointment when a regular staff physician wouldn't, which led to higher amounts of marginal appointments, Young says.
The team became aware of a program at Contra Costa Health Centers in Martinez, CA, in which the ambulatory care system stopped making any follow-up appointments and decreased its fail rate by 50%. As part of its "Patients' Choice" program, highlighted in the winter 1997 issue of Ambulatory Outreach magazine, Contra Costa changed its family practice profile from one with 89% pre-booked and 11% same/next day appointments to a profile with 40% pre-booked and 60% same/next day appointments.
Patients are given written instructions on how to call and make a same/next day appointment, and there are a few pre-booked appointments available for particularly vulnerable patients the provider is concerned about, the article points out.
One of the differences between that health care organization and her own, Young says, is that all personnel at Contra Costa - including physicians - work under the same administrative umbrella, and one of the physicians leads the redesign effort. Another unusual factor is that Contra Costa's physicians belong to a union.
"Our clinics report up [through the hospital's chain of command], but our physicians are privately owned, so the institution doesn't have a lot of control over them," she says.
The team is hopeful, Young says, because the physician who is the medical director of quality management is interested in the Contra Costa proposal. This two-part remedy - short-notice clinics and the elimination of marginal appointments - would significantly improve the appointment fail rate, team members believe.
"If physicians choose to jump on this," she says, "it's the one thing that could work."
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