Vinita Kapoor, Fawzia Rahman & the Derby Team

Did not attend (DNA)= was not brought DNAs are frustrating for clinicians and referrers. Exposes vulnerable children to significant risks. Major financial implications in current payment by result (PbR) era & in credit crunch. Limited information in published literature on DNA rate in community paediatrics.

DNA available statistics Hospital paediatrics OPD 15% (HES 2006). (highest of medical specialties) Mental health 25%. No HES data for community paediatrics. Derby community paediatrics : 21.4% in 2006 – 2007: unchanged for years.

Factors affecting DNA rates: ( known from our activity data) Case mix (behaviour, Autistic Spectrum Disorder). Admin support. Venue. Source of referral. Grade.( linked to admin support?) Deprivation.

Deprivation Quintiles: Attendances.

Non attendance rates by quintile of deprivation: (Maharaj, V & Rahman, F: Nov 2006)

A two pronged approach: using a reflective audit tool Looking at retrospective ( 6 months old) DNAs What happened since? ( Reflect). Looking at new (current) DNAS What can be done now? prospective ( Act)

Two audits overlapping each other: (A) Retrospective audit: 2 cases per doctor in each clinic location who did not attend a new clinic appointment in previous 6 months (March 06 and 31 August 06) All community paediatricians in the service completed a locally devised questionnaire after reviewing the notes 45 completed questionnaires received.( 46 expected)

Retrospective audit : the questions: Any previous DNA? Paediatricians concern-degree and domain. Was a letter sent out after DNA and to whom? Response from parents/young person. Time allocated for appointments. Time spent by clinician on dealing with the DNA. Was request for appointment appropriate? Input into child’s health care after DNA.

Findings of the Retrospective DNA audit: Half of the patients had DNA’d before to another service. So DNAs can be predicted. A risk assessment must be made. Some appointments are unnecessary. DNAs take time ! “21 Min” on an average. No patient was lost to health follow up.

(B) Prospective audit period –between 01 July 07 to 30 September 07: This prospective audit (overlapped with the retrospective audit) looked at the chain of events starting immediately after the DNA. We asked the community paediatricians to audit next 5 DNA at their clinic, so that they could put new ideas into action with a view to reducing the DNA rate 74 completed questionnaires were received.

Prospective DNA audit Summary: Reminders sent by phone in 9 (12%), text 0 (0%), others 10 (13.5%). All (100%) appointment letters stated how dates and times of appointments could be changed. Evidence in notes to predict DNA- 29 (39%). Community paediatricians felt 40 (54%) of DNAs were preventable.

Conclusions: Our two audits demonstrated that: -DNAs are both predictable and therefore theoretically preventable in a significant proportion of cases. Clinicians should assess risk before and after the appointment and act jointly with the whole team to transform “would be” DNAs into “definite” attendees.

Recommendations: Improve referrals and appointments process. Identify patients who are at a high risk of defaulting with appointments and especially target this group (Previous DNA, high deprivation, carer factors). Assess referrals from school nurses/ health visitors ( twice as likely to DNA as GP referrals) These were often for minor problems & parental consent/ concern was not clear Publicise cost of appointment ( £ for new)

What did the team do ? (One) Doctors calculated their individual DNA rates Shared rates and issues ( admin, time) at meeting Agreed a stepped reduction in DNA rate as a main service objective at annual service review day. Seniors liaised with admin managers across more than 20 venues in 2 PCTs and one acute unit to ensure contact with family before appointment.

What did the team do? (Two) Agreed referral process with team. Agreed telephone reminders ( no dedicated staff). New patient information form. Immediate consent/ contact form for use by school nurses/ health visitors ( highest dna referrer%). The doctors and admin staffs fed back their individual clinic DNA rates at their appraisal. All these interventions did not require any extra staff ( but they did take time).

Dr Fawzia Rahman - financial year 2010/11

Audit works for quality improvement! The team’s perception, both clinicians and admin staff was changed by the audit. From a blaming patients perspective to exerting their power to enable patients to access the health care they need.

Main learning points Feeding back individual DNA rates & mandating discussion at appraisal was a turning point in securing “ownership” of the problem by Doctor & admin pairs Feeding back the service rate had only resulted in collective hand wringing ( & gnashing of teeth by Fawzia)! The reflective power of the audit questionnaire helped people see they could change things Naming the problem as a major service objective No blame attached to anyone but the system

Any Questions? Thank You.

Dnas : Target 12.5% we analysed: Absolute numbers month by month variation (variation by referral source for new) (variation by referral reason) For new For follow up Dr Fawzia Rahman - financial year 2010/11

All’s well that ends well

Time Spent as a result of DNA: Mean time spent on each patient after DNA but before next appointment is 21 mins Mean time allocated for each appointment 46 mins.

An attempt at predicting and minimising DNAs and associated risks. Aims of the study: - to look at our current practice. - are we putting in enough effort to prevent DNAs? - Make recommendations to improve attendance. - Assess impact of recommendations made.

Anything that could have prevented DNA? Telephone reminder (21/40). Text message reminder (2/40). Reminder by school nurse (3/40), Health visitor (2/40). Sending appointment letter earlier (2/40). Others.

(B) Prospective audit period –between 01 July 07 to 30 September 07: This prospective audit (overlapped with the retrospective audit) looked at the chain of events starting immediately after the DNA. We asked the community paediatricians to audit next 5 DNAs at their clinic, so that they could put new ideas into action with a view to reducing the DNA rate 74 completed questionnaires were received.

Prospective DNA audit :The 74 completed questionnaire received were analysed: Looking at the measures taken before the scheduled clinic appointment to improve clinic attendance. Were the measures adequate? To suggest recommendations with a view to reducing DNA rate.

Prospective dnas audit summary (ONE) Letter acknowledging referral was sent out in 50 (68%). Acknowledgement letter stated: 1)Reason for referral in only in only 22 (30%). 2) Source of referral in only in only 49 (66%). 3) Mobile phone number + other details 5 (7%). Appointment letter copied to the referrer 63 (85%). Appointment letter copied to GP if another referrer 5 (7%).

We closed the audit loop - By looking at the impact of the recommendations made. The improvement of service was achieved without any extra financial investment. Here are the figures!

Impact of Recommendations: the first 18 months post audit Pre-introduction of policy Post-introduction of policy (April September 2007) (October March 2008) DNA Attended Dna rate20.7%15.1% Odds RatioBaseline0.68 ( 95% CI ) P valueBaselineP <0.001

Impact of Recommendations: 2 01 Apr 06 – 1 March Apr Sep Oct Mar 08 DNA Attended DNA rate 21.4%19.4%15.1% Odds Rate Baseline (95% CI ) (95% CI ) P Value Baseline0.187<0.001

How did we do it ? Improve referral process & better selection 20% cases did not require appointment Change the perception of the whole team Regular feed back to the doctors and the admin staffs Congratulating the admin staffs Aiming for a step wise reduction in the DNA rate Most importantly all this was achieved at NO extra cost

And the dna rate is New 12.2% Follow up 12.1% Dr Fawzia Rahman - financial year 2010/11

Drivers for the DNA audit : DNA makes the heath of deprived children even worse. To look at our DNA rates? Can it be predicted ? Are we doing enough to prevent it ? What can we do to improve attendance ? Were they lost to follow up ?

Time allocated for initial appointment:

Estimated time spent after DNA and before another appointment:

Dr Fawzia Rahman - financial year 2010/11

Was this improvement sustained? will the downward trend in DNA rate continue? we started with a dna rate of 20% It went down to 15% we set a 2.5 % stepwise reduction as a service objective year on year

Dr Fawzia Rahman - financial year 2010/11

The 64 million dollar question Did we meet our DNA target of 12.5% (remember it was 22% three years ago) ????? Dr Fawzia Rahman - financial year 2010/11

Non attendance rates by quintile of deprivation: (Maharaj, V & Rahman, F: Nov 2006) Quintile DNA rates 5 (Least Deprived) 11% 413% 314% 214% 1 (Most deprived) 25%

Any previous DNA?

Concern following the DNA based on medical records/referral letter/others.

Domain of Concerns:

Letter sent out after DNA:

Since this DNA any input provided to child’s care by community paediatrician?

In hindsight was the appointment deemed necessary with a Community Paediatrician.

Has the child by now received the health input he needed?

Evidence that parent / YP consented to referral:

Was the referral acknowledged by letter?

Did the acknowledgement letter state the source of referral?

Recommendations: Spend those lost “21 mins” of administrative work as result of DNA before scheduled appointment. Convert DNAs to definite attendees. Send a questionnaire to admin staffs and paediatricians after 3 months to assess the impact of changes recommended as a result of DNA audit.

Did the acknowledgement letter state the reason for referral?

Did the acknowledgement letter ask for mobile number + other details if not already available?

Was the appointment letter copied to referrer ?

Was the appointment letter copied to GP if other referrer?

Was a reminder send by phone / text / other. Only 9 (12%) reminders were sent by phone. None by text. 10 (13.5%) were sent by other methods.

Did the appointment letter state how the appointment time/date could be changed ? 100% of appointment letters stated how the time & date could be changed.

Is there a possible language/reading problem?

Anything in the notes to predict a DNA?

Will you (community paediatrician) be writing to Parent / GP / Referrer / Other ?

Will you be talking to referrer / GP / Other?

Will you be sending another appointment before anything else?

Do you feel there is anything that could have prevented this DNA?

Prospective audit period - between 01May 2007 to 31 August 2007: This prospective audit (overlapped with the retrospective audit) looked at the chain of events immediately after the DNA.