How to reduce no shows

I am looking for strategies to decrease the no-show rate in our ambulatory physiotherapy department.

I work at a physiotherapy department in a hospital group with multiple sites. One of the therapies we deliver is ambulatory physiotherapy. People receive appointments for ambulatory physiotherapy after an initial visit to one of our PRM specialists. In one of our sites the no-show rate (patients with a physiotherapy appointment, not showing up) is between 25% and 30% for 4 consecutive years, this is way above the average of 12% in the other sites. We are not allowed to charge anything for no-shows so this causes an enormous pressure on the budget.

The hospital is located in the poorest part of town, with a low-income population, a lot of immigrants, many patients who don’t speak Dutch, French or English, …

Analysis of the problem shows that the biggest problem is caused by patients showing up a few times, then a few times not, again a few times, few times not, …

I am looking for strategies to decrease the no-show rate.


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Participant comments on How to reduce no shows

  1. I assume email and text message reminders could help to a limited extent considering the poor population target
    Probably trying to provide an extra benefit to that physiotherapy consultation would make sense (ie dietetary advice, etc)

    1. We also implemented a combination of the telephone reminder calls, text messages and e-mail dependent on the patients preference like many others on this discussion but were finding we could not drop our no show rate below 20%. Armadale also provides care to a low social economic population group and often our outpatient clerks were unable to contact the patient prior to or after a missed appointment. We ran a service improvement project for 6 months to map out the reasons why patients did not show and were able to reduce the no show rate to 10% with a free patient transport service. The reality was though that for many of these patients there were daily life challenges that were of a higher priority that attending an outpatient appointment so whilst it has been a difficult transition for our very caring staff we now formally discharge people after two consecutive no shows to an outpatient clinic.

  2. We have a telephone reminder service that calls individuals 48 hours prior to their appointments, but can be reset for any length of time desired. It is linked to our scheduling system to support the automatic calls being made. We also follow-up with every patient who is a “no show” within 24 hours of their visit to determine what contributed to their absence. In addition, we ask at registration of a new patient if there are potential barriers for them and we aid in coordinating support for them, which in our area, is usually transportation.

  3. Hi Jan,

    A combination of the telephone reminder calls, text messages and e-mail will effective for many patients, especially when you will be able to do it in the language they speak. In addition, you could also consider charging a fee for no shows. My dentist does if you don’t cancel your appointment prior to the scheduled time. Of course these people probably don’t pay either and than the story continues.

  4. Information leaflets with total number of treatments.
    Explaining the costs of no shows
    explaining the effect on the treatment of no shows

  5. Attached is a link to an MGMA study on decreasing no-show rates that you may find helpful:

    Additionally, do you have a policy regarding discharging patients who are repeated no shows? My organization allows a patient to no-show 3 consecutive times, at which point they are automatically discharged.

    I would also consider doing some information gathering regarding why the patients do not show. Is it transportation related? The absence of child care? Something else? This may help you figure out where to aim your efforts at improving your attendance rate if you know the barriers that are causing the no-shows.

  6. In the Netherlands we are allowed to send no show bills but only a few hosptials are doing it. In our hospital we recently debated again on this subject, as part as a “cut costs” project. In the end we decided not to send a bill for no show.
    In our hospital it would bring up 400 k. But we also have to invest in administration and in the end send a summoner.
    Experiences of other hospitals tells us that half of the people who do not show up won’t pay the bill. They probably are people with low income. So the trouble you have to make to get the money it huge.
    And in the end, we are talking about health care and part of our patients our the fragile people who really need care and no bills so think about if it is really worth the trouble.
    What we do is send a text message the day before the appointment as a reminder. Helpt a lot, worth the costs.

    Good luck, Viviane

  7. We use a combination of communication through our electronic scheduling and medical record. If the patient is enrolled, they will receive a text 24 hours from the appointment asking them to respond yes to confirm or no to cancel. If they are not enrolled in the text messaging system, they receive a phone call reminder. Since implementation, no shows have significantly reduced in number.

  8. We studied this at an urban hospital in DC and there were multiple reasons for the no shows and our primary strategy to address it was cab vouchers and reminders. These interventions move the needle a bit. I believe none of these interventions address the root causes of the no shows. In our population folks are not showing up because the experience is not positive, there are varying degrees of distrust and their lives are so cluttered with other challenges keeping a primary care visit is low priority. If they really need care they’ll go to the ED or delay until the situation is dire. A bit grim but real.

  9. I tend to agree with all of the above, particularly with Lisa where the overall healthcare experience for our poorer populations tends to be sub-optimal. A mix of front end customer service cognizant of the socio-economic situation and back end follow up (checking in) with friendly reminders of follow up could/should cut down on the no show rate.

  10. Following up Lisa comments … have you considered communication issue on your personnel side, if the only site is having such a high no shows rate for a longer period?

    I agreed with David
    Upfront communication with requiring SMS response could give you the feeling about the workload for the next day.
    In the case of no confirmation is made you could squeez some acute patients in between (I can imagine there are some in queue).

    Another example how to decrease cost a little bit is to book upfront a bit more patient over 100% capacity (as airlines do), i.e. by 10% (you can adjust the number … as it goes).
    This way you can utilise part of idle capacity you have and financially cover of cost of not showing, while not causing significant bottleneck in your daily operation.
    If you set the right expectation (frankly speaking we are fully booked but in some cases people will not confirm appointment), some people might appraciate your effort to give chance, i.e. on the waiting list (calling just a day upfront) and get the right heatlth care service sooner.

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