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INTRODUCTION
Cancelled appointments are the persona non-grata of the schedule. Often ignored for their more popular sibling, “no-shows”, best practices on cancellations are rare and often a copy and paste from best practices on no-shows. Cancellations are even implicitly ignored by practice management systems. Pulling a no-show report is quite easy, but have you ever tried to pull a report on the percentage of cancellations filled? Still, many practices realize cancellations are a problem, but because the data isn’t readily available do not realize how large a problem they are nor what to do about them. That’s why we wanted to share the knowledge we’ve gained analyzing over 170,000 cancelled appointments for practices across the US.
THREE TYPES OF CANCELLATIONS
There are three types of cancellations: Cancellations, no-shows, and bumps. We will be treating them as three separate types of patient fails.

A cancellation is when a patient gives notice ANY TIME before the appointment that they won’t make it.

A no-show is when a patient does not show up for the appointment AND does not give notice. Some practices use the term no-show to describe a cancelled appointment with under 24 hours’ notice, we will not be using that.

A bump is when a doctor cancels on a patient. Traditionally doctors cancel on patients for emergencies. You will see a high rate of bumped appointments in surgery practices since doctors must rush to the OR for emergency surgery and in OB/GYNs where doctors will rush into the hospital to deliver babies. We will devote other guides to no-shows and bumps.
DRIVERS OF PATIENT CANCELLATIONS
Why do patients cancel?
While there are many reasons patients cancel, the probability of a patient canceling for any reason increases dramatically the longer the time between when an appointment is scheduled and when the appointment takes place. Here are the main reasons patients cancel:
Personal reasons
A time that worked for someone’s schedule a week ago, doesn’t work now. Some sub-reasons here include; transportation, lack of childcare, work obligations. 
Financial reasons
Healthcare is expensive. When a patient booked an appointment, their budget could fit another appointment, but when the appointment was coming closer they realized they couldn’t.
Window shopping
Some people book appointments with multiple providers trying to find the shortest wait. They then cancel the other appointments once they find the appointment that best fits their schedule.
HOW MANY CANCELLATIONS SHOULD A PROVIDER HAVE A DAY?
What is considered normal
While there has been extensive research on cancellations, all of it has been done using small sample sizes. The major reason is most Electronic Medical Record (EMR) and Practice Management (PM) Systems are closed. A great example of an EMR system utilizing the valuable data they have in an interesting manner is this FiveThirtyEight article by athenahealth employees analyzing whether the 2016 US Presidential election stressed people out enough to seek medical attention (it did not). More research like this is needed.

Because data is siloed, many practices are unsure what is considered a “normal” number of cancellations.
SAMPLE APPOINTMENT TYPES WHERE MISTAKES OCCUR
Here are the most important factors that dictate how many cancellations a practice has:
Patient quantity
The more patients a provider sees a day the more opportunities there are for patients to cancel.
Specialty
 Certain specialties see more patients and have higher cancellation rates.

    Orthopedics (30-40 patients/day)
    Dermatology (40+ patients/day)
    Primary Care (20-30 patients/day)
    Pediatrics (20-30 patients/day)
Patient mix
certain demographics of patients are more likely to cancel appointments.
Seasonality
A practice will likely have fewer cancellations in December and July when many providers (and patients) are on vacation. Also, certain specialties will have busier periods like flu season for internal medicine and allergy season for allergists, which will increase the number of cancellations but not necessarily the cancellation rate.
Time of day
After analyzing thousands of cancellations, we saw the majority of cancellations happen before noon.

A DEEPER DIVE INTO CANCELLATIONS
Day of the week
Mondays have the most cancellations, 23 % of appointments are cancelled on Monday. This makes sense because most offices are closed on the weekends so demand to cancel on Monday represents those who wanted to cancel on Saturday and Sunday as well.

Appointments on Wednesday are most likely to be cancelled. 21% of appointments scheduled on Wednesdays are cancelled, followed very closely by Thursdays.

Month of the year
No month stands out as having a very high number of cancellations but December, June and July stand out for having a lower number of cancellations. The reason is likely due to vacation calendars. Vacations for both patients and providers, resulting in fewer appointments to be made overall, thus fewer cancellations. 

WHAT APPOINTMENT TYPES ARE PATIENTS CANCELLING?
We grouped appointment types into 10 categories to figure out the most cancelled appointment type. The groups can be argued, but we tried to be consistent between practices. Office visits, for example, represent non-acute, non-follow-up appointment types for established patients in a practice. Annual visits represent well-visits, physicals, annual exams.

Follow-ups
Follow-ups were the most common type of appointment cancelled. Nearly 45% of the cancellations were follow-up appointments. This makes sense because follow-ups are the most common appointment type.

Most cancelled appointments
    44% Follow-ups
    20% New Patient
    15% Office Visit
    14% Annual Visit
    05% Procedure
GEOGRAPHICAL IMPACT ON CANCELLATION RATE
Certain specialties in certain geographical areas have lower cancellation rates than others. A major determining factor has to do with geographic demand and scarcity for a certain specialty.

For example, 19.2% of Americans live in rural areas, but only 11.4% of physicians practice in rural areas* The AAMC (Association of American Medical Colleges) published a study in 2012 detailing specialty shortages in certain states. This is despite the efforts of the federal government to alleviate these supply deficiencies. 

While higher demand caused by a lack of supply (vs. too much demand) can result in lower cancellation rates, high demand alone is not enough to lead to lower cancellation rates. There is another factor, “replaceability”. Replaceability is the ability for a patient to find another doctor in the same specialty.

If there is a high demand for a specialty AND high replaceability (lots of doctors in that specialty) that will lead to higher cancellation rates since the high demand will create long patient wait times and patients have the ability to find another doctor.

However, if there is high demand for a specialty and low replaceability, then it will lead to low cancellation rates.
HOW MANY CANCELLATIONS DO PRACTICES FILL ON THEIR OWN?
At the beginning of this guide, we talked about the difficulty practices face in measuring just how big of a problem cancellations are. Many practices run weekly or monthly reports on cancellations for their providers but cannot pull reporting on how many of those cancellations are filled.

How to calculate your own cancellation fill rate
We are going to walk through what data you need to pull and how to calculate whether an appointment was filled. This is data intensive, but if you do this via Excel and save your equations, you can repeat this process easily after the first time. An appointment has been filled if the following conditions are met
    1. The first appointment at a given time and date has been cancelled by the patient.
    2. A second appointment, for which a patient showed up, with the same provider, beginning appointment time and date, and appointment location were created AFTER the first appointment. - Note: This second condition is required because if a slot is double booked and one of them cancels, that is not a cancellation filled.
LISTEN TO YOUR DATA
Here is a comprehensive list of the data to pull and how to evaluate it to help you understand the impact cancellations are having on your organization.
    Pull all appointments (whether cancelled or not) for the last month including the following fields

      1. Provider
      2. Appointment time and dates
      3. Appointment location
      4. When the appointment was created
      5. Appointment status
      6. Cancellation reason

    Exclude the following appointment records
      1. Appointments that were bumped
      2. Appointments that no-showed
      Appointments that were cancelled and filled by the same patients (this represents the times the staff cancelled an appointment because they made a mistake during scheduling
        Remove both the appointment that was cancelled and the new one that was created

    Review the appointments left. If a cancelled appointment has an appointment where the patient arrived and matches all of the criteria listed below, the appointment was filled:
      1. Provider
      2. Appointment time and date
      3. Appointment location
For an arrived appointment, the appointment creation date and time must be greater than the cancelled appointment date and time.

Note: You will notice that we do not require the appointment type to be the same for an appointment to count as filled. To get even more advanced, you can calculate the revenue loss for cancellations by looking at the revenue lost from cancellations unfilled AND for cancellations that were filled but with a lower value appointment type.
WHAT WE FOUND
The average provider’s staff fills about 15% percent of cancelled appointments. We saw some deviations depending on the factors below.

    Lead time
    Staff fill rates for appointments cancelled within 24 hours of an appointment can be 50% lower than those appointments cancelled with more than 24 hours’ notice. The staff has more time to find a patient, while patients have more time to adjust their schedules to accommodate a doctor’s availability.

    Practice demand and replaceability
    practices with higher demand and low replaceability have higher fill rates. This is intuitive because there are more patients who want to fill that cancellation! However, there is seldom low replaceability.

    The number of schedulers A practice with a larger ratio of schedulers to cancellations will result in higher fill rates. It may not be cost-efficient, but the more schedulers you have, the more patients you can call which means, you have more opportunities to fill the vacancies in your schedule.

    Scheduler determination
    For small practices, every single scheduler matters. There have been incidents in very small practices where the schedulers and practice managers display Herculean effort, working nights and weekends to ensure all schedules are full and everyone shows up. This only occurs in very small practices, if you have one of these schedulers, double their pay.
BEST PRACTICES FOR FILLING CANCELLATIONS
Things that work well to keep your schedule full
Have a good system or process in place to fill your cancellations (the more automated the better). This process should:

    1. Be clear and concise
    2. Assign responsibilities to specific people
    3. Measure the impact, so you can continue to improve

Things that work but come at a cost
We’ve seen dozens of systems out there for filling cancellations, here are three of the most common ones and their downsides.

    Have patients call-in 
    This is the most common system. Sometimes patients are told explicitly to call-in, other times they do of their own volition. There are some major downsides to this system include:

      Unreliable, you are relying on patients to make a concerted effort to call every morning!

      Increase in call volume and backlog

      Poor patient experience, asking a patient to call-in requires work from a patient. But imagine if a patient puts in the effort and doesn’t get an appointment? Not only will they give up, but they may be very frustrated.

    Dynamic Scheduling
    Leaving part of every day open for patients calling in who want same day appointments. This requires a lot of staff training and work but can be very effective and is often used in pediatric groups where they see many acute/sick visits. However, there are additional limitations

      Financial inefficiency, This method rewards same day appointments vs more valuable appointment types.

      Fairness, patients who are booked out months and may be an established patient who has been with the practice for years is treated worse than a patient who just happened to call in at the right time.

    Double Booking
    Some organizations who think a patient is going to cancel or no-show, double-book that appointment time. But when they get it wrong, they have a really backed up waiting room filled with angry patients.

TACTICS THAT DON'T WORK FOR FILLING CANCELLATIONS
While many medical organizations have tried them, the following tactics have proven to be a bigger barrier to patient access

Waitlists
90% of practices don’t use the waitlist, but almost all of them wish they did. It’s time to give up here. Waitlists require far too much extra work and training. Many PM systems do not have them at all. There is no consistency in the process. The fact that 90% of practices don’t use the waitlist should tell us something! Read more about this in our Definitive Guide to Waitlists

Charging patients 
Charging patients for last minute cancellations, creates many obstacles. For starters, you need a credit card which is intimidating for patients. Second, your staff needs a way of charging them. Third, they need to actually charge them! Most offices use the threat of this, but never implement it.

CONCLUSION
Cancellations are a real problem that often goes ignored because it cannot be quantified. Often, cancellation rates are 4-5x greater than no-show rates but medical organizations don't always recognize them as a problem. Follow the numbers, create a new process and use technology wherever possible to improve your patient access.

The Definitive Guide to Cancellations

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