Home Forums Discussions General Discussion Report on DNKA's; reducing no-shows

We are looking at ways to reduce our no-show rate. We would like to begin by quantitatively evaluating the extent of the problem. Any ideas?
We have an appointment type, "dnka", that is used when the patient does not show up. We can just count these, but we are looking for a better way. Does anyone have a way to run a report that would show a particular appointment type?

Hi Jon,

We do something similar. I didn't think to make an appointment type called DNKA but we've been putting DNKA in the appointment comments section when they are no shows. If you click on a patient's name in the main patient list and click the down arrow next to the binoculars and click "Search Appointments" you can see all their past and upcoming appointments. There you can see appointment types & comments.

You still have to know what patient to look for though. I didn't see appointment type as one of the things you can search for in advanced search (in 6.3.3)

We also use the set flags to keep track of how many no shows. I made flag categories for dnka 1 to 6 (used to be 5 but had to increase it...) We send a letter when they no show and a final warning letter at 4 no shows, both of which are letter templates in AC.

Ways to reduce no-shows.....

I struggle with this so much, in part from caring for arthritis patients that tend to be older, disabled, and poor more than the average, and probably more from giving too many exceptions to the rules below.

Better patients come from better practices and often have better insurance, which is the eternal uphill climb of practicing. So you have to eliminate referral sources and insurances that exacerbate your no show rate without hurting your bottom line or reputation. Sometimes it takes switching to another ehr which affects the referral pattern.

Better patients are trained patients. We can try to hold our new patients to a high standard with policy statements and protocols they can expect, and train your established patients to increase their standard of paying their co-pays, showing-up, and paying their remainders?

Better reminders. I think the best system would be texting them 2 days in advance, staff calling your most important appointments such as endoscopies and consults, and an automated system the night before for the rest.

Better consequences for the non-compliant patient to prune the practice and prevent lawsuits. We charge missed consults, but give a free warning for the first established patient no-show with a reminder of the whole policy, and then start escalating the fees for subsequent no-shows. I think the fees help, because it practically prepares them for the fact that after so many no-shows they will be discharged from the practice. If there is no fee, there is no consequence, and they are shocked that you would discharge them. Enjoy the conversations with the patients who can think of an excuse for everything! And be thankful for the patients who leave in a huff, for they will be replaced by a better patient.

And if that doesn't work, you can spend more time on the Amazing Charts forum.

We clearly state our policy in our financial agreement that they sign as a new patient. This says that on a second no-show, there is a 25 dollar fee. All patients are called the day before to confirm their appointment. The first no-show they get a letter explaining the importance of keeping an appointment. I have duplicated this below. At the second they have a similar letter, with a notice about the fee due at their next visit. At the third no-show, they receive a discharge letter. Sometimes exceptions are made for circumstance, but most problem patients will repeat their pattern. Occasionally patients will self-discharge at seeing the 25 dollar fee. By discharge, they have had 3 reminder confirmation calls, three letters in the mail about the problem, and paid the fee at least once. They know it is a problem at this point. One way or another, this problem is quickly solved.

Dear Mr. Bill Gates,

You had an appointment today in my office. You did not show up for this appointment, and did not call to cancel and let us know you were not coming. We make every effort to be clear about your appointment time and we also call our patients the day before to confirm appointments. When you do not show up or cancel, we hold your spot until after the appointment time and another patient loses the opportunity to be seen. You have had 2 "No Show" appointments. There is a nominal $25 dollar fee for this that you will need to pay next visit.

Unfortunately, if this continues we will be unable to continue to provide you with care. We would regret losing you, so please help us continue to provide quality care for our patients by respecting our schedule and at least canceling ahead of time if you cannot make an appointment.

Thank you for trusting us with your medical care.


Sincerely,

Dr. Billy Bob Jones

My patient population is from a mostly indigent ? Medicaid population. No shows and DNKA?s are very common.
I have done everything I could think of to ?solve? the problem.
I have come to realize that for my practice, the no shows and DNKAs are just how it is going to be.

So, I have to redefine the problem.

What bothers me about the DNKA and no shows, is the negative impact on the patients health care, and the negative impact on the management of patient flow and my ability to be productive or not.
For the negative impact on health care, if the missed apt is important, then we will attempt to reach the patient [if we have a good phone number]
For the patient flow problems, what I do is :
When a patient cancels or no shows, I review each one and save it in the messages.
When I look in the messages, I form a gestalt opinion if the patient usually makes appointments, misses a little too much, or misses a lot.
I use the ?FLAG? system.
I have a ?5 minute apt? flag ? and in the apt category have a 5 minute slot with category of visit- poor comp
I also have a ?Walk In? flag For people who earn the Walkin flag [with the category- walkin only] they are only offered the apt first in the am [told the apt is at 9 am] or first in the pm- [told the apt is 1:30 pm]and are placed on the schedule to take up a spot 5 minutes before office hours start. So the schedule might have john with an apt for 8: 55 and the category will be walkin .

I find this way, patients are accommodated in the schedule, but if they miss, oh well, not too painful.
If they all come in [a rare event], then it might be a stressful day.

I do not check insurances until they arrive to the office .

Richard, do you do any patient education like sending letters or calling when they no show? We used to not do that but have just started to send a letter every time. Of course, many of the letters come back with a bad address. But I know that some parents have read the letters - they mentioned it when they call. I'm still not sure it's making a big difference with no shows. (We already call them the day before. Many people will confirm and still not show up anyway.) Our patient population is mostly medicaid also and a good portion have trouble with transportation, frequent phone & address changes and not showing up.

We used to phone a couple days before the appointment.
Patients would like the calls, but there was little impact on the show rate.
I'm wondering if one day, there might be an automated patient reminder that would go out through ac.
Does anyone know if this is in the works - we do have this field for e-mails in the demographics

Another option is to take those you would otherwise discharge - and just not offer them appointments anymore.

Explain that they have been consistently unable to keep appointments, so they will have to wait for an available work-in slot when they want to be seen. Granted, this might involve sitting in the waiting room for a couple hours, but we have to live in a polite society. Even people on Medicaid can be expected to be polite and secure rides ahead of time.