vinita kapoor, fawzia rahman & the derby team 2006-2012
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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 .
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