Cancellations and no-shows draining your schedule? Jeff Blumberg breaks down why today’s confirmation systems fall short—and what you can do to fix it.
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Questions From This Episode
Why are cancellations and no-shows happening more often?
Jeff found that many offices now rely 100% on patient management software for confirmations, with zero human contact. The offices with the worst show rates were using text-only confirmation for new patients, implant consults, and large procedures on the doctor's schedule. Patients find it much easier to bail on a text than on a person they spoke to.
How did the old confirmation process keep no-shows low?
Patients got a postcard about four weeks out, a reminder call two weeks out, and a confirmation call three days out, with follow-up calls on each remaining day until the office reached them. Cancellations typically surfaced two weeks ahead, which left plenty of time to fill the opening.
Why does online scheduling lead to more no-shows in the US?
CareCru found that patients who booked their own appointment online showed up over 80% of the time in Canada, but only about 23 to 25% in the US. They adjusted the US version so the office reviews and accepts each request, which lets the office call patients with a poor track record first.
What does Jeff recommend instead of text-only confirmation?
A hybrid approach. Note each patient's communication preference and track record, send postcards and texts two weeks out, and then call three days, two days, and one day before until you reach the patient. Always call new patients and implant consults, and have experienced staff confirm the doctor's schedule.
How should you orient staff who handle the schedule?
Their job is not just to schedule and confirm. It is to get people physically into the practice. Confirmations are a building block toward that goal, so a patient who replied "C" or "Y" to a text is not a finished job.
Episode Transcript
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If you were to survey the average dentist or office manager and ask them to list the top five sources of stress in their practice, almost every one of them would include cancellations and no-shows somewhere on the list. These things are not fun, and it's not just limited to dentistry. I would bet every business hates them. It's not hard to see why. If your business depends on pre-scheduled appointments, even if it's not as tight as the 10-minute increments of a dental schedule, having someone not show up or cancel 10 minutes before their appointment can throw the entire day off, and in some cases create a ton of chaos.
Believe me, cancellations and no-shows have always been an issue to some degree, at least since I've been in the profession. But I seem to be hearing about them more now than I did 10 or even 20 years ago. So what gives? While you can't completely eliminate these things, because they're going to happen, it's just a matter of how much, and what percentage. For this week's episode, I want to discuss a few ways you can keep cancellations and no-shows at a very low level. My name is Jeff Blumberg and I'm your host.
I'd like to start with what we found recently when digging into this issue with newer clients, because, as I mentioned, we're hearing about it more now than we used to. If I were to ask you how you prevent cancellations and no-shows, what would you say? You could say it's how you schedule the appointment. But I would bet money that the majority of you would say it has a lot to do with your confirmation process, and you'd be right. Why do we confirm appointments? Because we want to make sure our patients show up and don't cancel or no-show.
Digging into this, we found something very interesting. To explain, I'd like to compare the confirmation process from back in the day, maybe 20 years ago, before all the technology we use now, to the process today.
Let's look at the old process, specifically for hygiene. How would hygiene confirmation work in the average practice that had its act together? When a patient finished their hygiene appointment, say in July, I'd book my next one six months out, in January. I would also fill out a postcard to myself, addressed to me, with the date of the appointment I had just set. The scheduling coordinator would take that postcard and file it in a little card box, separated by month, under January of the following year.
Then the months would go by with no problems, dentally or otherwise. Four weeks prior to my January recall appointment, sometime in December, that postcard would come to me in the mail, because the office would have pulled that stack of postcards, put stamps on them, and mailed them.
Now say the average person looks at it and thinks, "I'm scheduled for January 17th. There's no way I can come, I'm going to be out of town." They would normally call, because there was no text or email back then. "Hey, I can't make it on the 17th." If the office had its act together, they would reschedule me for another date, maybe January 24th or February 6th. If I looked at the card and saw that I could make it, I might call to confirm, though in a lot of cases patients wouldn't. But the office would call me two weeks before with a reminder. They may even have called four weeks earlier, but in most cases it was two weeks prior. So if my appointment is January 17th, they call me January 3rd: "Hey, we sent you that card two weeks ago. Your appointment is on January 17th at 1:00 PM." And they would tell me that a few days before the appointment, they'd give me a final confirmation call.
Three days before the appointment, I'd get the phone call. This is the official confirmation call, while the two-week call was a reminder call. If I picked up and said, "Yes, no problem, I can make it," they would put a little C next to my name in an analog appointment book, or if they had software, they would mark me as confirmed.
If they didn't reach me three days before, they would call two days before, and if they didn't reach me then, they would call the day before. With my appointment on the 17th, they would call on the 14th, 15th, and 16th until they reached me. If they still didn't reach me on the 16th, they would leave a message saying that if they didn't hear back from me by a certain time, they might fill my appointment slot with somebody else. The office has to make sure it can fill these appointments. That cutoff would usually be noon, two o'clock, or three o'clock the day before. If they didn't hear back by then, they'd put somebody else in my slot, or maybe move tomorrow's two o'clock up to one, to give themselves time to fill the opening.
That was how I was trained as a patient. I had numerous points of personal contact: a postcard, reminder calls, confirmation calls. Did people have cancellations and no-shows back in those days? Yes. But if this was being done well, the cancellation would usually occur two weeks prior to the appointment, when the first reminder call occurred. That is plenty of time to fill a hygiene opening. You weren't finding out that morning. Did they have flat-out no-shows? Once in a blue moon, but it was rare. The other term we used was a "failed appointment," meaning they just didn't show. That was rare. Cancellations would happen, but if you talked to the patient early enough, you had time to do something about it. And yes, things happen. People got in car accidents or had to leave town for family emergencies, and you'd end up with last-minute cancellations. But for the most part, unless the office was not following basic confirmation procedures, they didn't have a cancellation or no-show problem that consistently hurt production.
The doctor's schedule depended on the situation. You may be selling a case on Thursday for a patient coming in Tuesday, so there isn't a week to call ahead. You schedule the appointment on Thursday for Tuesday of the next week, and you call Monday to double-confirm and make sure they're all set, especially if it's a productive appointment.
New patients were always confirmed verbally. This is also part of the issue: you don't want a new patient scheduled weeks in advance. That's ridiculous. You want to get them in immediately unless there's a reason you can't. The only reasons I can think of are, say, I'm your patient and my wife wants to come see you but she's out of the country, or a friend referred me and I can't come in any sooner than two weeks from now. Generally you want to get a new patient in within 24 to 48 hours. That's the rule of thumb, because the longer you stretch out the confirmation process, the more risk you have of the person not showing up. And new patients were always called the day before. Always.
That's how it used to go. Now let's compare it to today. Most offices have some form of cloud-based patient management software, such as Adit, Weave or CareCru. Let me start by saying I think these things are great. They're an incredible tool. The problem is that, just like any tool, if I use a hammer the way a hammer is supposed to be used, great. If I try to use it to drive a screw, we're going to have problems. The tool gets misused in an attempt to be more efficient and create less work.
In the offices where we find the biggest problems, the confirmation process is 100% reliant on this software, with zero human contact. Why is this a big deal? I've mentioned this on the podcast before. I say that a lot, don't I? If you haven't been listening for a while, you may be wondering where I mentioned it. When you send a broad reactivation text to your inactive patient base, say you have 4,000 inactive patients and you send a big text saying, "Hey, you're overdue for your cleaning," what percentage of patients do you think will actually schedule? I would bet it's no more than 20% on average. Why? Because these are your low-hanging fruit. They're the more compliant patients, or maybe someone who happens to have getting their teeth cleaned on their mind. They looked in the mirror, didn't like how their teeth looked, were thinking of calling you, and then boom, they got a text. You're not going to get 100% compliance. You're going to get maybe 20%.
Is 20% better than 0%? Of course it is. That saves me hundreds of phone calls. That's awesome. But it's not going to solve my problem in its entirety. It's going to require human contact.
I mentioned CareCru. It's one of these patient management softwares that texts patients, and it has some really cool features. They're a member of our group purchasing organization, DDS Overhead Management, and I'll put a link to that on the episode webpage. They have a setup where you text a patient, "Hey, you're overdue for your cleaning," the patient clicks the link, and it goes to your website, where you've built in a widget. The patient can pick which hygienist they want to see, see that hygienist's schedule, and book.
CareCru started in Canada. What they found there was that when a patient scheduled online, say with your hygienist Helen at three o'clock next Thursday, and the appointment was written directly into your software, the average show rate was over 80%. You would still confirm in whatever way you confirm, but just by booking their own appointment, patients had an 80-plus percent chance of showing up. Because it's great software, they came to the United States and ran it the same way. What happened in the US is that the show rate was 23 to 25%. I remember it being in that range, but let's just say it was really low.
So they made a modification for the US market. I can book with Helen next Thursday at three o'clock, but you don't technically accept the appointment. Say I did it at night. You come in the next morning and look at who it is. "Okay, it's Jeff, and Jeff is pretty good about keeping his appointments." You accept it. But if Jeff has blown off his last eight cleanings, you might want to call Jeff before you let him have the appointment.
The point is that when you schedule online, it's a lot easier to blow it off. It's a lot easier to confront a link in a text than to talk to an actual person.
With that in mind, how does the confirmation process work now? The person gets a text four weeks before from their software. They may or may not get a physical postcard, and I understand postage is expensive. Then they get another reminder text two weeks before, then a text three days before, and so on. In some cases, and I've seen this, the patient doesn't respond at all. Hopefully they'll call. In some cases they don't, which is beyond me. Or a patient confirms three days before but blows the appointment off anyway.
If you're doing this for hygiene and ending up with a lot of openings, I would do a little research into how many patients confirmed via text and then did not show up. Where it gets bad is when I've seen offices use this for new patients, with no actual verbal contact other than the initial appointment. Or they use it for implant consults from an implant funnel, which I would never do. Or for large procedures on the doctor's schedule, with no human contact. Those were the offices where we saw terrible show rates. I think it's easier to bail on a text than to bail on a person I actually spoke to.
Part of the problem is how your office is structured from a staffing perspective. I want to use the word accountability, but not in a negative sense with regard to your staff. If you've got a good, willing staff member, they're going to try to produce whatever product you ask them to produce. But if I orient my staff toward "you need to get confirmations, and this is how you get them, with a C or a Y response to a text we send out," then in their mind, they got the product. They got the job done.
I would orient whoever is handling the schedule differently: "I think it's great that you schedule people and great that you confirm people, and these are all building blocks to the ultimate reason I have you here, which is a person who is physically in the practice." Sure, schedule the hygiene appointment. Sure, confirm it. Both are important. But the reason they're being paid is so that the hygiene patient is actually sitting in the hygiene chair with a hygienist. That's their ultimate responsibility. It's not to schedule or confirm. It's to get people here.
There's a big difference in my mind, say I'm supposed to be doing four veneers on a patient today and the patient doesn't show. I look, and it says they were confirmed via text. That's a lot different than if the patient confirmed with my schedule coordinator in a conversation, said, "Yes, I will be there," and blew the office off. That's a much bigger deal than blowing off a text. You may or may not agree with me, but to me it's a lot easier to blow off a text.
You might say, "Jeff, I don't have time for my staff to make confirmation calls." But how much more time are you costing yourself? Say you bake in 45 minutes a day for confirmation calls, and you also find out which people aren't really going to be there. Compare that to the time you spend trying to fill a last-minute opening or salvage your day because five patients didn't show. I would much rather have some prediction of what's happening tomorrow and the day after than find out on the day, because everybody said yes to their text. If that makes sense, it's a lot more chaotic and problematic when people don't show than to book some time to reach out to people.
What would I recommend? Again, I think these softwares are great tools, but I would take a hybrid approach. On our online platform, DDS Success, we have a whole course on how to structure your schedule, called Artistic Scheduling, and we have a scheduling coordinator training course that has all of this in its lessons. One of these courses includes a policy on hygiene reminders and confirmations. I'm going to make it available as a free download on the episode webpage. The name of the policy is Hygiene Reminders and Confirmations. It's a Word document, and you can use it to develop your own policy.
To that end, if you want to check out DDS Success, and this is my shameless plug, we have a special for Dental Business Rx. When you sign up for DDS Success, it's $289 a month. I'm going to give you a coupon code: RX269. You can save $20 a month on the subscription. There's no contract, so you can try it and cancel if you don't like it, but that would make me sad. I'm kidding. Check it out. It gives you a general structure of how your confirmation process will work. It's primarily targeted at hygiene, because that's the schedule where patients are scheduled furthest in advance. But I would take a hybrid approach to all of this, and it might look something like the following.
The first thing I would do is set each patient's communication preferences. I've seen this in a couple of these softwares, and maybe even in your practice management software. Every patient is different. I'm a scheduled person. I can pull up my Outlook and my whole schedule is there. If you book an appointment with me and send me a reminder two weeks or a week before and ask me to confirm, I'll confirm and I will show up. I do not need a phone call. It's the same thing I'd arrange with a dental practice: you don't have to call me. If you send me a text a certain number of days before, I'll reply. And I have a track record of showing up for my appointments.
Other people don't operate that way. A lot of people keep a schedule, but some don't. Some people need more calls. You've got people all over the place as far as communication preferences and consistency. This is part of the problem. That's why I would always call a new patient, because I don't know this person yet. With an implant consult, I'm always calling because I don't know them, and I don't know if they'll show when they say they will. Whereas if I have a patient of 10 years and all I have to do is send a text and I know they'll show up, then that's all I'm going to do. So I would have some way of noting that.
Back in the day, it was all phone calls and postcards, with no text and no email. Everybody got the same treatment. Now you have a way to give certain people one type of treatment and others another, based on what they prefer and their track record with you. If you can notate that, someone who doesn't have a great track record of showing up gets phone calls, and someone who always shows up just gets texts, and you're fine. You don't want to treat everybody exactly the same. If you treat everybody the way you'd treat the person who always shows up when you text, the people who won't do that won't show up.
The second thing I would do, for hygiene as an example, is a hybrid approach. I would still send my postcards, because postage isn't that expensive. I would send texts, and maybe emails if you like, two weeks out. Then I would call everybody three days out. If I call three days out and they confirm, I'm not calling two days and one day out. But if I don't reach them, I call two days out, and I call the day before.
If you're scrambling from a resources perspective and don't have enough staff to make all these confirmation calls, then prioritize who you call. The doctor's schedule needs to be confirmed. New patients have to be confirmed. Consultations have to be confirmed. Then hygiene has to be confirmed. If I have newer employees, I'm not going to have them confirm the doctor's schedule. I'll have them confirm the hygiene schedule, which is easier to teach. If I've got a $10,000 procedure, or procedures, on the doctor's schedule the day after tomorrow at 11 o'clock, I'm not having my new employee call. I'm calling as the scheduler.
Then I would orient your staff to the responsibility of getting people to show up, not just confirming them. Confirming is a building block toward getting them to show up. Obviously they have to confirm the patient, because they can't leave the patient unconfirmed, but what we're really going for is that the patient actually arrives in the practice, not just confirms.
The other thing I would do, and I've talked about this before, is with larger procedures on the doctor's schedule. This is funny: the newer clients we talked to who had some basic sales training had the patients who showed up most consistently for larger procedures. Why? Because these patients were prepaying for their treatment. With a big case, you do your presentation and get the patient to prepay or work out their financial arrangements at the close, and there's a better chance they're going to show up. But I would take a hybrid approach to this too. I would bring phone calls back in.
Every office is different, so you may want to develop a policy that works for you. If I'm the doctor, maybe with the office manager and a highly experienced scheduler, the three of you can sit together and brainstorm about what has worked versus what has not. You have to be honest with yourselves here. You're not looking for the easiest thing to do. You're looking for what has worked, and then maybe turn that into your policy. In my mind, the added work of a good confirmation process is worth it. It will cost you a lot more time when people don't show up anyway.
That's a shorter episode this week. I have that policy for you as a free download if you'd like it. I also have the DDS Success code, RX269, if you want to save some money on DDS Success. I do hope this helps. I do recommend that you do this. The technology is great and I would use it, but I'm not trying to sound weird here: you can't replace people with technology in every sense. There still has to be someone to run the technology. We're not there yet. It might seem easier, and yes, it can increase efficiency, but you still have to keep people involved if you want your schedule to be as close to 100% full as you'd like it to be.
I hope this helps. If you have more questions about MGE or want to find out more, you can find us online at mgeonline.com or call us at (800) 640-1140. Folks, have a great week, and we'll see you next episode.