First, let me explain what I mean by the statistic I call the “Misery Factor.”  It is a measurement of the sum total of most of the patient related issues that negatively impact the quality of life within your practice.  Those issues are:

• Cancellations/reschedules with less than 24 hours notice
• Failed/no show appointments
• Patients who show up without an appointment
• Patients who show up early, expecting to be seen early
• Patients who show up more than 10 minutes late, expecting to be seen
• Emergency appointments – scheduled and unscheduled
• Patients not brushing their teeth
• Patients not clinically cooperative (not wearing elastics, appliances, broken/loose braces, etc.)
• Patients who are grossly rude, discourteous, or inappropriate in some significant way

To compute your Misery Factor, total the number of each of these instances that occurred throughout your day.  Then total the number of patients who were originally scheduled to be seen for that day.  Divide the problem number by the number of patients scheduled and you end up with a percentage that is your Misery Factor.

For instance, let’s say an orthodontic practice has 50 patients scheduled for the day.  Two have left messages on your machine canceling their appointments.  Four scheduled patients no show.  Three patients come in with bands, bonds, or wires loose or off.  Five more patients come in who have not been brushing their teeth, wearing their elastics, etc.  Four more patients show up for their appointments more than ten minutes late.  One patient who “just happened to be in the area” shows up and expects to be seen without an appointment.  One patient’s mother is so rude she leaves the Appointment Coordinator in shock.  That totals 20 problem patients.  That number, divided by the 50 patients originally scheduled to be seen that day gives you a percentage.  In this case, 40% is the Misery Factor for this practice for this particular day.  Forty percent of this practice’s patients caused problems impacting the quality of life for the practice in a negative way.

The Misery Factor, more than most any other statistic, defines the quality of life, for the doctor as well as the staff, within the practice.  In spite of the power and importance of such a statistic, few practices take the time to track it or even have any realistic idea what the statistic, in their particular practice, is.  Equally important, most practices do not know what a realistic goal for the Misery Factor should be.  These same practices do, however, spend plenty of time complaining about their Misery Factor.  Many practices have lived with a high Misery Factor for so long; they believe either that the problem is normal in the profession or that the problem is unsolvable.

In the above example, I used an extreme situation as a demonstration.  I hope that no practice would ever actually have a Misery Factor this high.  The goal is 10% or less, a goal few practices reach, primarily because most practices are unwilling to take pro-active steps to resolve these patient related problems.

The patient related problems that make up the Misery Factor are completely controllable.  I do not mean these problems can be eliminated but they can be kept under total control, where the total number of these problems is so small as to not be significant to the practice well-being.  Reaching that level of control is not going to happen if your primary concern is remaining comfortable or avoiding conflict or confrontation.  Have you ever in your life tried to educate somebody (your children perhaps) to do something they did not want to do.  Did that process always go smoothly and comfortably for all concerned?

So first understand that if you are truly committed to fixing this problem in your office you are going to have to accept some personal discomfort and, once in awhile, some conflict.  Most patients who contribute to these problems are innocent of any evil intent.  You, your staff, and probably all the doctors they have ever dealt with in the past, have educated them that missing an appointment, showing up late, etc., is acceptable behavior to the profession.  If you think you, personally, are immune to this mentality ask yourself how fast you drive on the freeway.  Do you always drive the speed limit or are you usually 10 miles over because you know you can get away with it?

I have seen a fair number of practices over the years that have resolved their problem with the Misery Factor and whose percentage is consistently healthy.  They all had one thing in common.  They each had a formal system in place in the office designed to educate patients that one condition of remaining a patient in the practice was they had to “follow the rules” when it came to these issues making up the Misery Factor.

A four-step process seems to be what works best.  Step 1 occurs the very first time a patient causes one of the Misery Factor issues.  Step 1 is simply a non-threatening communication to the patient regarding the problem, delivered by the employee who first notices the problem.  “Johnny, I notice you have not been brushing your teeth.” or, “Mrs. Smith, it is 10 minutes past your scheduled appointment time.”  There is nothing more to the communication part of Step 1.  Just acknowledge the misbehavior.  What makes this step effective is the communication itself, the fact it was done at the very first incident, and the fact that you document in the chart or clinical record that “Warning One” was given.

Step 2 occurs at the second incidence of misbehavior.  The words used in Step 2 are not critically important.  What is critical is that the communication occur and that there be some level of increase in the degree of communication – an increase in the sense of urgency created.  “Johnny, if you continue to not wear your elastics it is going to be very difficult for the doctor to get your braces off when you were promised.”  Alternatively, “Mrs. Smith, your appointment was for 20 minutes ago, let me check to see if we will still be able to see you today.”  At Step 2, the communication is delivered by a staff member directly to the offending party, even if a minor child, as long as the child has some personal accountability for the problem.  Remember that there must be documentation in the clinical record that “Warning Two” was given.

Step 3 occurs, as you may imagine, at the third incidence of misbehavior.  I said that in Step 2 the words used were not terribly important.  Just the opposite is true in Step 3.  It is imperative in this step that you call to the attention of the patient/parent the specific number of times this problem has occurred in the past and imply grave consequences if the problem were to continue.  Step 3 is never done directly to a minor child, although in cases of poor clinical cooperation the child will be present as “Warning Three” is given to the parent.  In larger practices, this level of warning is best given by a person, other than the doctor, who is viewed by the patient as an authority figure.  “Mrs. Smith, you have missed three out of the past six appointments you have scheduled with us.  That is a 50% failure rate and we are very concerned.  If this problem were to continue we will not be able to obtain the clinical result we desire and we would have to consider discontinuing further treatment.”  Alternatively, “Mrs. Jones, Johnny has come in with broken bands, loose brackets, or wrecked archwires, in each of his past three appointments.  We have been speaking to him about it but if this problem continues it will be impossible to have a good orthodontic result and we will not be able to keep him in treatment.”  “Warning Three” is noted in the clinical record.

Step 4 is the toughest for some practices and, for others, the easiest.  Step 4 is formal communication, in the office and “face to face,” with the patient/responsible party(s).  The responsible party is advised “in spite of numerous warnings/conversations on (specific dates), the problem with missed appointments, poor cooperation, being late, etc., has not been solved.  We have made a decision that if we cannot get an absolute commitment to total and immediate resolution of this problem further treatment in this office will be discontinued!”  The patient/parent is given the opportunity to stay in the practice but only as a result of a formal commitment to keeping his agreement to never again cause one of these problems.  A pragmatic doctor/staff person will realize that it is not in the cards for every patient to be able to make such a promise.

Because of the conversation in Step 4, it is reasonable to expect that up to 20% of the patients spoken to in this Step will make the decision to remove themselves from the practice.  Does that panic you?  Remember who these patients are!  They are those who are your most chronic problems.  They are those who are not following your clinical instructions.  They are those who are not allowing you to provide the quality of care you intend to provide.  They are those who are refusing to work on improving their behavior.  Most importantly, they are those who are making it impossible for you to enjoy a high quality of life within the practice.  Dismissal of this type of patient should not be much of a burden.

In the event you find that a patient or a family needs to be dismissed from your practice, it is important you remember to use an appropriate dismissal process which includes a certified letter notifying the responsible party of your decision.

The good news is that if you commit the practice to following each of these control processes, you will resolve the great majority of these patient related problems, and you will have a Misery Factor of 10% or less.  Because the process really does work, you will get to Step 4 very infrequently.  On the other hand, if you want to “play” with this process, do Steps 1 and 2 for instance but never take Steps 3 or 4, you will be wasting your time, your effort, and your credibility with your patients.  Your problems with the Misery Factor will become worse, not better.

The key to the success of any system like this is continuity, consistency, and credibility in your dealings with your patients.  You can use a different set of verbal skills if you wish.  You can have a three-step process or even a five-step process if you wish.  The details are not too important.  What is important is that your patients understand that a condition of them continuing to be your patient is that they must contribute to your practice in a manner equal to your contribution to them.  You, your staff, and your cooperative patients can have, and deserve to have, a quality experience in the practice, every single day.  You can make it that way if you wish!