No-shows, cancellations demand look at facility, staff, and access

The problem isn’t always with the patient, clinics find

When patients don’t show up for their appointments, the natural first step for many practices is to penalize the patient. But the problem might not lie with the patient, and if it doesn’t, charging the patient a missed-appointment fee or kicking him or her off the patient roster won’t improve the clinic’s no-show and cancellation rate.

"First of all, you can’t relate the no-show rate to the [quality of] the practice," says James E. Glinn Sr., PT, a practicing therapist whose consulting firm, FutureRehab LLC of Bakersfield, CA, specializes in practice development and has extensively studied no-show and cancellation rates. "I’ve seen practices with great therapists with terrible no-show rates, and practices that I would say are only moderate with very low no-show and cancellation rates."

Glinn started asking his focus groups and seminar participants what the three primary factors were that drive patients to their practices, and the top three boiled down to what he now calls the Triple A’s: ability of the staff, access for the patient, and atmosphere of the clinic.

When he tried to get the therapists and managers he worked with to name one of the three that was most important, they couldn’t. Excellent therapy, for example, could be undermined by lack of convenience or an unwelcoming atmosphere.

"And I think then I realized how mediocre therapists could excel in their practice, by allowing patients to come in when they wanted and having a friendly, warm atmosphere," Glinn says.

But when does the no-show and cancellation rate signal a problem? Glinn says he has found that if a clinic’s rate of nonarrivals borders on or exceeds 10%, it’s time to take a hard look at what is causing patients to not come in. Cancellation and no-show rates can’t be eliminated entirely, of course, but Glinn says they can be addressed successfully, and the two types of nonarrivals should be examined independently.

There are four sets of data that practices should look at to determine how they are faring in terms of no-shows and cancellations:

  • average weekly combined no-show and cancellation rate;
  • average weekly no-show rate;
  • average weekly cancellation rate;
  • average weekly percentage of no-shows and cancellations who reschedule and then arrive for the rescheduled appointments.

He says a struggling practice typically will have a no-show rate that is higher than its cancellation rate. "It’s one thing to call and cancel because the patient can’t make it in," he says. "It’s another to not respect the practice enough to even call."

Glinn says when practices first start tracking their no-shows and cancellations, they might find them to be in the 14% to 16% range. As soon as they start offering incentives to the front-desk and therapy staff, that figure is likely to drop quickly. "The internal marketing [of a practice] is real important; and if that’s not there, if your staff aren’t motivated, your arrival rates aren’t going to improve," he points out.

As far as which one of the Triple A’s a practice should examine if it wants to lower its cancellation and no-show rates, Glinn says it depends on the practice.

"With a large rehab center, if staff aren’t motivated, then the problem is the atmosphere and access; they’re more interested in their own schedules than in the patients’ schedules," he says. "Private practices generally beat up on the larger continuums by accommodating patients and being more friendly, because there’s more incentive for smaller practices to see those patients."

A practice that aggressively tracks its no-shows and cancellations and then addresses the internal problems that contribute to the high rates can see its weekly average fall to as low as 3% to 4%, Glinn explains.

He commonly hears that practices blame poor patient arrival rates on cultural or societal causes, but he doesn’t agree with that view. "You’ll hear in rural areas, patients won’t come in on Fridays, or in some urban areas, they won’t come in the morning," Glinn notes. "That’s nonsense. It’s an internal problem, not a patient problem."

Motivating the staff is key to improving patient arrival rates, but Glinn says money isn’t always the answer. Examining how much voice staff members have in the practice or in scheduling might be one tool, he says. Because patients have more choice now than they did several years ago, drawing on staff input to develop creative ways to make a practice more accessible, able, and attractive to the patient can result in improvements, Glinn adds.

Staff should be educated about what are acceptable rates for cancellations and no-shows. Rewards for rates falling below a set percentage can be as simple as recognition for a job well done to gifts or cash bonuses.

Staff members who have a negative impact on the practice because they lack the desire to make their jobs a priority should be addressed with training or, if that does not correct the problem, reduced hours or termination.

Note whether no-shows and cancellations took an upturn upon the hiring or firing of a particular staff member, or if rates rise or fall on days that specific front-desk staff members or therapists are present or absent. These indicators can signal areas for improvement in troublesome employees or for recognizing staff members who encourage patient arrivals.

It’s always good practice for therapists to foster a sense of partnership with their patients, emphasizing the importance of adhering to a physical therapy schedule and the role of the patient as an equal in the relationship, Glinn points out. Success or failure in this effort can be evident in an individual clinician’s patient arrival rates.

What you can do

When faced with a no-show and cancellation rate problem, there are basic steps practices can follow:

  • Call the patient once or twice before the appointment as a reminder.
  • Call patients who miss appointments to let them know they’ve missed.
  • Have the therapist call the patient personally to discuss concerns over the effects of missing therapy.
  • Penalize the patient with a charge for a no-show.

"At first, practices I work with immediately want to penalize the patient," Glinn says. "But if you look at the three A’s, you can show them a weak area [in their practice], and they can usually see that the problem is internal."

But practices often will penalize the patient anyway, he says. "The problem with that is that it makes patients and referral sources mad," Glinn notes. "I think a better approach is to let the patient know that [the option to charge them a fee] is there, but that you’re going to forgive it. You build good will with the public and your patients."

In the case of workers’ compensation patients, a reminder that missed appointments are reported to the patients’ physicians and their case managers can be an encouragement to meet appointments.

Glinn reminds practices that he consults with that their patients are their No. 1 referral source. "Of course, there’s the fact that people have less time for physical therapy," he adds. "Everyone’s multitasking. Do you want to make them mad by charging them for forgetting?"

In addition, there are some limitations on imposing fees for no-shows. Insurers will not pay fees for missed appointments, so the practice is forced to collect directly from the patient, which, in some cases, may be difficult. Some insurance contracts specifically prohibit charging no-show fees. Finally, Medicaid forbids clinicians from charging its patients for missed appointments.

Glinn offers some suggestions for what to say to patients who miss appointments. He suggests calling the patient within 15 minutes of the missed appointment, and if he or she answers the phone, asking if the patient would like to come in at that time. If there is no answer, phone messages should be left at any phone numbers in the patient’s record (home, cell, work), and if the patient’s e-mail address is known, an e-mail should be sent.

Glinn says the patient should be called at least five times to reschedule before he or she is discharged as a patient, and the patient’s therapist should personally make some of the calls.

Sandra Lloyd, outpatient clinic manager for The Institute for Rehabilitation and Research (TIRR) in Houston, says the patient-practitioner relationship is a critical factor in whether a patient is likely to keep his or her appointments. "There are some [therapists] who patients would not dare miss appointments with," she says.

TIRR uses a two-call reminder process prior to appointments, and Lloyd says her clinics have seen positive results because it gives patients additional notice and reminders that they have appointments coming up. "It’s important because so many physical therapy patients rely on others for their transportation," she points out. "Transportation is absolutely key to getting them in for their appointments."

Another step TIRR took was to put some staff on flex time so that they could work in the evenings, to call patients’ homes at a time when they could speak with the caregiver or parent of the patient rather than just the patient. This gives one more opportunity to work out any scheduling or transportation problems prior to the actual day of the appointment.

In areas where patient populations include those who don’t speak English fluently, leaving phone messages in English won’t help much. Some centers have found that hiring bilingual staff or employing part-time staff fluent in their region’s prevalent second language to make reminder calls has significantly improved no-show rates among those patients.

Large centers with hundreds of reminder calls to make each week often rely on telephony systems to automatically dial and leave recorded messages for patients with upcoming appointments. While detractors say the recorded calls are too impersonal, advocates of the systems have reported significant increases in their patient arrival rates.

Information on telephony systems may be obtained from several companies, including TeleVox (; iVoice (; PhoneTree (; and JulySoft (

Need more information?

James E. Glinn Sr., PT, CEO, FutureRehab LLC, 5629 W. Hillsdale Ave., Visalia, CA 93721. Phone (559) 733-2478. E-mail:

Sandra Lloyd, Outpatient Clinic Manager, The Institute for Rehabilitation and Research, 5100 Travis St., Houston, TX 77002. Phone: (713) 797-7552.