Vinita Kapoor, Fawzia Rahman& the Derby Team 2006-2012

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 statisticsHospital 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.

9.25%8.11%

15.76%

23.87%

43.01%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

1 2 3 4 5

Quintiles

Per

cen

t

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

2006)

25%

14%14%13%11%

0%

5%

10%

15%

20%

25%

30%

5 4 3 2 1

Quintile

DN

A r

ate

s

A two pronged approach: using a reflective audit tool

Looking at retrospective ( 6 months old) DNAs

What happened since?( Reflect).

Looking at new (current) DNASWhat 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 ( £ 300-400 for new)

What did the team do ? (One)Doctors calculated their individual DNA

ratesShared rates and issues ( admin, time) at

meetingAgreed a stepped reduction in DNA rate

as a main service objective at annual service review day.

Seniors liaised with admin managersacross 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.

13.5

10.8

8.1

12.79

16.5218.26

10.22

16.67

12.0712.83 12.25

11.18

02468

101214161820

Apr-10

May-10

Jun-10

Jul-10 Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

DNA RATE PER MONTH 2010-2011

Dr Fawzia Rahman - financial year 2010/11

Dr Fawzia Rahman - financial year 2010/11

How did we do it ?Improve referral process & better selection20% cases did not require appointmentChange the perception of the whole teamRegular feed back to the doctors and the

admin staffsCongratulating the admin staffsAiming for a step wise reduction in the DNA

rateMost importantly all this was achieved at NO

extra cost

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:

12

14

1 1

15

2

0

2

4

6

8

10

12

14

16

30mins 45mins 50mins 55mins 60mins NotStated

Estimated time spent after DNA and before another appointment:

16

19

3

1

6

0

2

4

6

8

10

12

14

16

18

20

0-10mins 15-30mins 45-75mins 120mins Not Known

Dr Fawzia Rahman - financial year 2010/11

Dr Fawzia Rahman - financial year 2010/11

17.4

13.77

6.59

5

7.87

22.1

17.55

13.4

8.5 9.7

0

5

10

15

20

25

0 2 4 6

% d

na r

ate

IMD quintile 2007

dna rates per quintile using NHS numbers new and follow up separate

new

followup

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

Dr Fawzia Rahman - financial year 2010/11

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

QuintileQuintile DNA ratesDNA rates

5 (Least Deprived)5 (Least Deprived) 11% 11%

44 13% 13%

33 14% 14%

22 14% 14%

1 (Most deprived)1 (Most deprived) 25% 25%

Any previous DNA?

21, 47%

2, 4%

22, 49%

Yes No D/K

Concern following the DNAbased on medical records/referral

letter/others.

38, 84%

7, 16%

Yes No

Domain of Concerns:

33%

16%

32%

19%

Physical Learning Psycosocial Mental

Letter sent out after DNA:

3169%

1329%

12%

Yes No Not recorded

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

33, 74%

11, 24%

1, 2%

Yes No Not Recorded

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

76%

22%

2%

Yes No Unsure

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

2658%

1636%

24%

12%

Yes No Unclear Missing

Evidence that parent / YP consented to referral:

6588%

912%

YesNo

Was the referral acknowledged by letter?

5068%

2432% Yes

No

Did the acknowledgement letter state the source of referral?

1115%

1419% 49

66%

YesNoNA

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?

1318%

3952%

2230% Yes

NoNA

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

2432%

4460%

57%

11%

YesNoNAMissing

Was the appointment letter copied to referrer ?

1115%

6385%

YesNo

Was the appointment letter copied to GP if other referrer?

6487%

11%

45% 5

7%

YesNoNAMissing

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?

23%

1622%

5675%

YesNoUnsure

Anything in the notes to predict a DNA?

11%

2939%44

60%

Yes

No

NA

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

1419%

4865%

4561%

5574% Parent

GPReferrerOther

Will you be talking to referrer / GP / Other?

3054%

2342%

24%

ReferrerGPOther

Will you be sending another appointment before anything else?

5575%

45% 14

19%

11%

YesNoNAMissing

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

11%

3345%

4054%

YesNoMissing

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 .