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

1. Decreasing “Did not attend” (DNAs): the power of reflective audit & routinely collected data: Vinita Kapoor, Fawzia Rahman & the Derby Team 2006-2012

2. 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.

3. 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.

4. 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.

5. Deprivation Quintiles: Attendances.

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

7. 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)

8. 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)

9. 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.

10. 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.

11. (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.

12. 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.

13. 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.

14. 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)

15. 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.

16. 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).

17. Dr Fawzia Rahman - financial year 2010/11

18. 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.

19. 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

20. Any Questions? Thank You.

22. Dr Fawzia Rahman - financial year 2010/11

23. Dr Fawzia Rahman - financial year 2010/11

24. All’s well that ends well

25. 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

26. 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 ?

27. Time allocated for initial appointment:

28. Estimated time spent after DNA and before another appointment:

29. Dr Fawzia Rahman - financial year 2010/11

30. Dr Fawzia Rahman - financial year 2010/11

31. Dr Fawzia Rahman - financial year 2010/11

32. 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

33. Dr Fawzia Rahman - financial year 2010/11

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

35. Any previous DNA?

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

37. Domain of Concerns:

38. Letter sent out after DNA:

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

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

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

42. Evidence that parent / YP consented to referral:

43. Was the referral acknowledged by letter?

44. Did the acknowledgement letter state the source of referral?

45. 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.

46. Did the acknowledgement letter state the reason for referral?

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

48. Was the appointment letter copied to referrer ?

49. Was the appointment letter copied to GP if other referrer?

50. 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.