Proven approaches to reducing no shows for medical appointments
We’ve all missed appointments and here in the United States, the cost of missed healthcare appointments is $150 billion. One unused time slot costs a physician 60 minutes of time and $200 on average. No show rates can be as high as 30% nationwide. In this article, we discuss patient scheduling and ways to prevent patient no-shows. Missed appointments and patient no-shows could pose health risks for patients. By taking advantage of behavioral approaches we can reduce no-shows dramatically. Missed appointments have multi-factorial causes from a lack of time, transportation, family support, priorities etc. Yet, how much of this is in the patients’ control? What about the provider’s control? Can we nudge patients to make their appointments?
Just recently, a study was sponsored by INFLUENCE AT WORK, BDO and the National Health Service (NHS) in the US. DNAs (Did Not Attend/No-Shows) in doctor’s offices were examined. DNAs are a costly problem both in the U.K. and in the United States. Technology can make our lives easier but there are also non-technological approaches to healthcare that have greater efficacy in a particular situation. The pilot study sponsored by the NHS is in the process of being peer-reviewed by the Journal of the Royal Society of Medicine.
Is there a correlation between healthcare delivery mechanism e.g. telehealth visits and scheduling? Can we use this engagement factor to decrease no-shows? What roles does behavioral modification play in this? What about face-to-face visits? What role does behavioral modification play in face to face visits?
Smart Patient Scheduling and Predictive Modeling
Workflows in specialty care are complicated and providers are required to multi-task to provide patients with the best care possible. A single-focus approach allows you to save time and money because work can be done faster and the resources that you are using are more efficiently optimized. Theoretically, with continuous flow, everything is moving and only one patient is seen at any given time. Many items can be in the process but patients are not required to line up from the time a patient is seen to the time a visit is completed. This can be done behind the scenes without the need for patients or staff to be involved in tasks that would deter them from making appointments.
Little’s Law Formula describes the WIP = L or the average number of items in the system, A or Lambda = throughput or average arrival and departure rate and W = lead time = average time an item spends in the system. By limiting the number of patients waiting we can reduce the time a patient spends in the system. Currently, the wait times to see a cardiologist are about 22.8 days. Providers cannot offer direct patient care with while giving their attention to follow-ups and ongoing patient needs. Providers can be assigned to patient care and others can be assigned to test interpretation or follow up visits. Telehealth allows work to be completed faster and it saves time, money and space.
Quality improves because errors can be spotted in the process and an appropriate intervention can be implemented at the right time.
Physician morale improves due to variation in duties where a high rate of progress can be achieved by switching tasks that require those resources.
With smart scheduling patients have more flexibility in attending their appointments.
Note: one of the problems with ‘continuous flow’ is that it has limitations on how it can be used. The model works well for a small variety of services and if different patient presentations are clumped together this can cause more confusion and a loss of time and money.
How you divide up work and the number of physicians and staff members needs to be as efficient as possible. Earlier, I mentioned something about physician duties, and burnout does play a role in the lives of physicians. Quality of care can be affected if members of the team are doing the same tasks over long periods of time. Imagine doing the same task over and over. Even if it requires a large amount of skill and expertise it will become monotonous. A solution is to automate the simple tasks that are recurring but this requires an organized managed service that monitors these workflows on a daily basis.
In the BDO and NHS study test condition one, patients that were scheduling appointments where asked to verbally repeat the data and time for their next appointment before hanging up the phone. An immediate reduction in DNAs by 6.7% was observed.
Condition Two: nurses and receptionists asked patients to fill out the appointment cards themselves while scheduling appointments in-person as opposed to doing this for the patient. A small change produced an 18% reduction in DNAs.
Social Proof – in the UK medical offices have very visible signs in the waiting areas that highlight the number of DNAs for the previous month. It was found that these posters were actually encouraging DNAs by alluding to the notion that it is ‘common practice’ to miss appointments – ‘see one, do one’.
These signs were replaced with alternate signs that stated the message in another way. The alternative message said, 95% of patients at X office/hospital turn up for their appointments or call (phone number) if they have to cancel.
Could an email or text message be sent out to patients to remind them of their appointments? Could we make it easy to cancel? Could we educate patients on the importance of making their appointments with the right messaging e.g. 95% of patients that see Dr. X turn up to their appointments or text to cancel? We have to consider the patients’ willingness to use technology yet, texting and/or a platform that assists with notification may be a convenient solution. A reminder is sent at specified intervals with an option to cancel the appointment – almost like you can opt-out of a telemarketing campaign.
New approaches to areas in healthcare that cost us millions of dollars every year. Setting up this for your own hospital or practice is quite simple.
A Good Fit for Technology
By implementing some of the solutions above you can reduce no-shows and improve care for patients. This is only the beginning and by observing data retrieved from visits we can better predict patient outcomes. Patients can be presented with environmental cues that will nudge them to make their appointments. Text messaging reminders, brief 3 question surveys and check-ins with a physician extender can improve care coordination and foster improved compliance with clinical visits.
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