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How We Think About Accountability

Particularly when someone misses an appointment, whether the commitment is cancelled in advance or the person just no-shows without warning

· Accountability,Micro-Consultation,Healthcare,Commitment,Promises

When you miss an appointment--a Veeto micro-consultation, for example--what should you do?

First, read this.

So much contention follows failure to be accountable.

Party A and party B enter into an agreement, and party B fails to hold up his end of the bargain. When that happens, both party A and party B get to decide how to handle the situation. How party B handles the situation regards party B's commitment to being accountable for his own shortcomings. How party A handles the situation regards which kinds of post-shortcoming behaviors party A wishes to reward/deter.

Both parties have a choice.

[Accountability] is the readiness or preparedness to give an explanation or justification to relevant others (stakeholders) for one’s judgments, intentions, acts and omissions when appropriately called upon to do so.
 

It is [also] a readiness to have one’s actions judged by others and, where appropriate, accept responsibility for errors, misjudgments and negligence and recognition for competence, conscientiousness, excellence and wisdom. It is a preparedness to change in the light of improved understanding gained from others.

 

Geoff Hunt

Let me give you an example with which you're probably very familiar.

Let's say that you schedule an appointment to see a doctor about a cough.

Your appointment is at 10 AM two days from now. On the day of your appointment, you arrive at 9:55 AM and sit down in the chair to await being called back to see the doctor. Forty-five minutes later, they call your name--forty minutes after your appointment start time. You follow the nurse back to a room where you sit down and once again wait. The nurse might ask you some preliminary questions before leaving you alone in the room, but in any case, the doctor does not enter the room until fifteen minutes after you entered it--fifty-five minutes after your appointment start time.

No-shows, or missed appointments, are a problem for many medical practices. They result in fragmented care and reduce access for all patients.

 

a study funded by the Massachusetts General Hospital Physician Organization and the Internal Medicine Associates

Now, do you suppose the doctor will either apologize for being fifty-five minutes late or offer to make it right? No, probably not. Sadly, this scenario is commonplace in American doctors' offices.

Doctors pay lobbyists and interest groups millions of dollars per year to study how much money doctors lose due to no-shows ("Missed appointments cost providers $150 billion annually, report says"), yet doctors don't even admit that the problems related to appointments not being kept also affect their patients--at least to the patients themselves.

This is hypocrisy, and it breeds further lack of accountability. In fact, it trains patients to be a little less accountable for their own behaviors, merely as a defense against doctors who don't behave fairly.

When buyers and sellers are not mutually accountable...

The reason I use healthcare practices as my example is because it's a good microcosm of both the unfairness and financial harms at play when buyers and sellers are not mutually accountable. Just look at this example cancellation/no-show policy:

cancellation policy

In the example depicted above, there are some parts I agree with but also some parts with which I take issue.

  • I agree with charging patients who do not cancel appointments in advance, or who just don't show up. Why do I agree with this? As Alice Schroeder writes in The Snowball: Warren Buffett and the Business of Life, Warren Buffett's dad taught him "that commitments are so sacred that by nature they should be rare." This applies just the same to buyer-seller relationships: a key part of mutual accountability is that both parties keep their commitments to one another. The thing that rubs you the wrong way when you show up to a doctor appointment on time but are not seen by the doctor until fifty-five minutes later is that the doctor did not keep her commitment to you--that pang is precisely the thing that both parties should strive to avoid causing in the other. That's fair.
     
  • I don't agree with the basis the doctor gives for this policy, in the sense that I don't think the doctor is being straightforward. Doctors have this policy because the business of their practice depends heavily on how they spend their time. The policy first gives the reason that a no-show prevents "another patient from getting much needed treatment," and then gives the reason that you could be that patient who is not seen in the future if someone else were to no-show. Although this is true, I think that it's disingenuous to only include these reasons in the policy explanation. What's missing is a straightforward admission to the effect of: by not showing up to your scheduled appointment, you squander one of the key resources in the doctor's business (their time), to the effect that the doctor is not able to earn fees for treatment during that time. The doctor should just admit this in the policy. Otherwise, it's not clear what the connection is between the only two reasons the policy does give and the stated no-show penalty of a $50 charge. True, the doctor might consider the $50 charge to be a deterrent against the kind of no-show behavior she wishes to discourage, but on the other hand, the charge is obviously the doctor's attempt to recover some of her business's economic loss due to your failure to keep your commitment.
     
  • I don't agree with the 24-hour advance notice requirement to avoid the $50 penalty. Here's why. Emergencies do happen. They happen to all of us, and, yes, they cause disruption to both the patient's and the doctor's schedules. But here's the thing: if the doctor's stated problem with no-shows were genuine--that people who call last-minute to get an appointment can't because of the doctor's full schedule--then an advance cancellation would actually solve that problem provided that the cancellation occurred far enough in advance for one of the last-minute callers to coordinate taking over the cancelled appointment slot--and in that case, I think 24-hour advance notice is unnecessarily excessive. Most last-minute callers probably want to be seen immediately, and since the average doctor's office is only open eight hours per day, the max advance notice requirement should be 8-hours, not 24. Again, if it were the case that the doctor's policy included a statement of how its financial interests are adversely affected by no-shows, then I would be more amenable to the 24-hour advance notice requirement. But because the doctor apparently preferred to hide behind explanations that made it seem as though the doctor's only interests were the next patients', I don't grant the doctor that leeway.
     
  • I don't agree with the absence of contingency in this policy. Here's what I mean. I've already explained that I think the doctor is really trying to protect her financial interests--even though she lacks the courage to say so--and in the sense that a cancelled appointment leaves a gaping hole in the doctor's schedule on a given day, and that this gaping hole represents economic loss for the business unless/until it is filled with a new patient appointment, there should be a provision in the policy that says something like: "we'll only charge you this $50 penalty if we're not able to back-fill your cancelled appointment slot." That's fair, because if the slot does end up being filled by another patient, then none of the reasons the doctor cites for the policy remain valid. Further, the reason I have inferred--the economic interest one--also does not remain valid. Thus, a cancellation penalty that allows for the possibility that no harm will ultimately befall the doctor's business would ensure that the $50 penalty does not inadvertently serve as a profit-center of its own. Now, I should add that I don't think that the doctor should have any extra obligation to feverishly try to fill that cancelled appointment slot last minute--because that would become its own kind of economic loss if practice productivity had to be allocated for that purpose--but if the patients wishing to be seen do in fact come inbound and ask to be seen on a day that was previously booked-up, then giving that patient the cancelled slot should not cost the doctor's office much in the way of diverted productivity.
     
  • I don't agree with the lack of reciprocity in this policy. If a doctor is late to my appointment, then the doctor should suffer the same penalty as I would if I were late. The part of the policy about a 15-minute buffer speaks to this. Suppose I arrive to my appointment 16 minutes late. In that case, according to the policy, I would have no-showed, which would result in a $50 penalty, and I would have no choice but to reschedule. I think that is perfectly fair. In fact, I think that a 5-minute buffer would also be fair, given my stance on the importance of keeping your commitments. However, the glaring problem with this policy is that the doctor is not eating her own dog food. She is subjecting the patients to this policy, but she is not subjecting herself to the same. If I had $50 for each time a doctor was more than 15 minutes late to see me, I would be Warren Buffett. But the thing is, it's not about the money: when you're sick, you want to be seen and get better. Who cares about $50? But the reason the doctor should face the same $50 penalty is that, by doing so, the doctor participates in the same system of incentives and deterrents as the patients, theoretically to the effect that both parties get better at keeping their commitments. If you want to cut costs in healthcare, do that.

Accountability is a core Veeto value.

We built Veeto to give "the little guy" a way to force bad-acting sellers to be accountable, and it's become a powerful tool for that purpose. In many of our use-cases (meaning one type of contract with one opponent), for example, we've never actually lost a case. The average ROI on every dollar spent with Veeto exceeds 30x. Where else in your life/business can you consistently get that kind of return?

We built Veeto to give "the little guy" a legal advantage. But we did not build it to give unaccountable people a way to defend their unaccountability. For this reason, we have a very stringent filter upfront for deciding who we will work with. In short, if you give any indication that you are not someone to be trusted--which is the basis of mutual accountability--then we will simply decline to work with you. In this way, we ensure that we're actually making the world a better place rather than just amplifying the vices of anyone who happens to find us. We say "no" at least once per month. It's an extremely small percentage of cases to which we say "no," but it happens often enough for us to be aware of the way that this makes us different as a company.

You can see this by how we constantly strive to dismantle barriers to mutual trust with our customers. We obsess over full disclosure. We list not only features of every service we provide but also some of its limitations. We recommend that you not hire us when we don't think we're best positioned to help you. And on and on...

Building a culture of accountability at every level of your business is essential to success, and setting up a company for true victory requires all workers to feel as though what they do (or don’t do) has consequence. This actually applies to customers as well—while they’re not a part of the internal ecosystem, a company that is accountable for its actions in the world at large will have an easier time holding its constituents accountable when something is not working.

Once you know this, all of the interactions you have with Veeto might make more sense.

Accountability is not about punishment and reward.

Rather, it's about admitting when you mess up. The punishment of no-show fees and so forth are just mechanisms to encourage accountability in those people who either lacking in sufficient fortitude or unsure of what is expected of them following a commitment.

If you admit when/if you mess up, and then put the decision in the hands of the other party whose time your mistake wasted, then you're being accountable, and you should be proud of yourself--too few people have the courage to do this, nowadays.

Any other response after you miss an appointment, that is not preceded by this hat-in-hand admission will likely not yield the results you're hoping for--which you might be accustomed to getting from other businesses. Veeto is just different. So be prepared to be accountable, or be prepared for us to decline to work with you.

Time is a non-renewable resource.

It doesn't matter whether you show up to the appointment or not--if the service provider allocates some of its finite time to spend with you during a particular calendar slot, that time cannot be recovered once that calendar slot passes by. Keep that in mind when you schedule an appointment with any service provider: if you treat the service provider's time as precious as your own, and as precious as it is, then you should be able to find sufficient motivation to be a good steward of it.

Now, of course, emergencies will sometimes happen. They happen to everyone, and when they happen to you and they cause a conflict with a previously scheduled appointment, you should do two things immediately:

  1. Cancel the appointment, so that the service provider has as much time as possible to back-fill the slot.
  2. Realize that your emergency is not your service provider's emergency.

In cancelling the appointment, you should apologize for the change and offer to make it right. Why do I say that?

This is how Veeto handles situations in which we make a mistake.

It's simple: we apologize and offer to make it right. As simple as that may strike you, think about how rare it is nowadays for people to do that.

But over the last decade, we've found that this simple approach works wonders in the face of schedule-change.

For example, if someone is new to Veeto, then they are probably not already using our inbox-sync service Hubscriber (whereby we manage all of your vendors/contracts for you on an ongoing basis, directly from your existing inbox). In that case, because we're not already familiar with your vendor/contract problem, the process has to begin with some exchange of information so that we know enough about the case to advise how we can help. For that purpose, we use 10-minute micro-consultations, for which we charge $32 (including payment processing).

Now, obviously no one is getting rich off of $30. So why do we charge it? It's an effective way to encourage commitment-keeping, and it generally works in two ways:

  1. People who want/need our help have no problem booking a micro-consultation, whereas people in more of a tire-kicking mode tend to bristle at paying any amount of money to access our time and expertise. This is exactly what we want: to filter out people who aren't serious about solving their issue and who do not sufficiently value our time to pay a meager $30 for it. The $30 fee, therefore, is a filter, not a profit-center, but its role is to make our overall business more profitable by making sure that we're only spending time helping people who want/need it.
     
  2. It causes people to treat the scheduled call (the micro-consultation) with more reverence, in the sense that they tend to cancel in advance when necessary and reschedule when their calendars demand it. No-shows are extremely rare, and it's largely due to this $30 fee.

There is a third consequence of the $30 fee that, while also rare, we care an awful lot about as a company. One of our core values is accountability, and for this reason, we strive to only do business with people who share that value. It's probably only happened 6 or 7 times in ten years, but there have been occasions when someone missed the micro-consultation appointment without warning and later tried to aver accountability. One example of this was when someone did not answer his phone or email for 20 minutes beginning a few minutes before the start of the scheduled 10-minute slot. An hour later, he called back demanding that we speak with him immediately, and he accused us of not calling him. So we sent him the email and phone records proving otherwise, and he changed his approach, only then switching to apology mode. He rescheduled the call, and we advised him on his case during the micro-consultation. But when he asked us to handle his case for him thereafter, we declined, and we were straightforward with him that our reasons had a lot to do with what appeared to be our different stances on accountability.

We try to treat people how we want to be treated, and when someone does not treat us that way, we have no qualms declining to work with that person/business.

Everyone makes mistakes.

When it happens to me, I get a sinking feeling in my stomach. I hate that feeling, realizing that I totally dropped the ball.

Because of what Veeto does, we deal with a lot of ball-droppers on a regular basis. Usually the ball-droppers are the vendors on the other side of a dispute with our client, and many of them could easily teach a masterclass on avoiding accountability. But sometimes, even if rarely, the ball-dropper is our client, and the most common way this reveals itself is when our client misses a scheduled appointment with us.

But you know what? Sometimes, even if also rare, we make mistakes too. Sometimes we have missed appointments too. In those cases, our response is simple: we apologize and offer to make it right. Specifically, we offer to reschedule or refund the micro-consultation fee immediately. When we mess up, the choice is the other party's to make. We don't coerce, and we don't let sales quotas influence our decision to leave it entirely up to the customer how to proceed. When we mess up, in short, we account for it.

This thing that some people do wherein they try to paint the other party as the culprit for the painter's own mistake--yeah, we try really hard not to do that, and we have no problem losing money, profit, or time if it's what making it right requires.

It's a high standard, but it's also a fair and simple standard. We curate our customers just as our customers curate who they do business with.

...and the result is that we tend to only work with really good people/businesses, with whom mutual accountability seems to be a shared value.

So no hard feelings if we don't consider you to be one of them.

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