Name Oisin Friel Location Ryde Drug & Alcohol Services Pretreatment dropout from outpatient substance abuse clinic Name Oisin Friel Location Ryde Drug & Alcohol Services

Mission Statement Project Aim: Time frame: Reduce the number of clients by 25% who fail to attend for scheduled first appointment Time frame: Proposed commencement date:7/07/08 Anticipated completion date: 7/09/08 Date of Review of Outcomes of Project: 8/12/08

Team Members & Role Guidance team member: Oisin Friel Project team members with fundamental knowledge and who worked on the project:  Oisin Friel,  Sue Weston,  Linda Miller,  Barbara Jane Murray,  Loretta Elkins,  Karen Hanzal-Jones

Evidence for there being a problem worth solving An monthly audit was conducted of clinician’s diaries for 2007 to determine the number of kept appointments in relation to scheduled appointments arranged for new clients to the service. 380 allocated appointments of one hour duration were reserved for new clients from January to December. The study revealed a 33% ‘failed to attend’ rate in the twelve month period.

Failed to attend rate 2007 (33%)

Evidence for there being a problem worth solving Clinicians experienced frustration due to: Time wasted waiting for client to attend appointment Uncertainty about why clients failed to attend appointment Inability to attend to other work responsibilities Difficulty in organising work diary events

High Order Flow Chart of Intake Process Development of drug problem Decision to consult GP Inability to resolve problem GP confirms problems is serious Referral to D&A service Contact D&A service See clinician for assessment Receive treatment Follow up care Discharge

Detailed Flow Chart of area of Interest Leaves message on voice mail Service returns call x 2 Message left Client contacts service Speaks to intake officer Confirms client’s request for this service Intake form completed Check for next available appointment Appointment made with clinician Appointment typed into computerised diary If other service requests appointment client must call to confirm Client calls to confirm Client given service details, date, time etc Completed intake form filed Client arrives / CTC / FTA If CTC new appointment arranged

Process Improvement Exercise Brainstorming possible reasons for problem Multivoting All team involved Group similar ideas / concepts together Secret ballot voting to choose biggest problem areas Represent as Ishikawa diagram (fishbone)

Cause and effect diagram Family / Money Motivation Other Missed the bus Shame Problem resolved Anxious No transport Crisis passed Scared Kids sick Slept in Too hard Too awkward to find place Too wet Not ready Assaulted Couldn’t be bothered No money to get there Too cold Client fails to show for appointment Too unwell Didn’t write appointment down In jail / hospital Drug, alcohol affected Had another appointment No one told me Too busy Forgot appointment Psychosis Partner forbade it Got date/time wrong Coerced Self harmed Confusion Got new job Co morbid problems Cognitive Impairment External agencies

Pareto Analysis Sheet Category Frequency Percentage Cumulative % Shame/fear 9 26 Lack of motivation 8 22 48 Forgot appointment 6 17 65 Overslept 5 13 78 Co morbid problems 4 11 89 Crisis passed 100 Total 36

Reasons for failure to attend scheduled appointment Pareto Chart Reasons for failure to attend scheduled appointment

Intervention Clinicians to call clients prior to assessment date to: Introduce oneself to client Confirm appointment date and time Develop initial rapport Alay anxiety about coming to service

Intervention Implementation period: Two months All clinicians involved Data collected by admin assistant APPOINTMENTS SCHEDULING LOG (7/7/08 – 7/9/08) Client Identifier Date of Client Call Date of Scheduled Appointment Did Client keep Appointment? If CTC date of new appointment 1 2/7/08 8/7/08 Yes 2 No 15/7/08 3 3/7/08 9/7/08

Outcome of Study

Strategies to Sustain Improvement Incorporate the changes made into the intake process Alter the method by which clinicians are notified of new clients placed in their computerised diaries so as to alert them to call the client prior to appointment time Monitor strategy on a monthly basis

Other PDSA Cycles to consider Reduce the lag time to first appointment Monitor dropout rate post assessment Record reasons clients give for cancelling appointments Stay linked to the ACTION Campaign (www.actioncampaign.org) to review research into addiction treatment improvements