Name Oisin Friel

Location Ryde Drug & Alcohol Services

Pretreatment dropout from outpatient substance abuse clinic

Mission Statement

Project Aim: 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.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jan Feb Mar April May Jun Jul Aug Sept Oct Nov Dec

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

Inability to resolve problem

Decision to consult

GP

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

Client contacts service

Speaks to intake officer

Client given service details, date, time etc

Appointment typed into computerised diary

Appointment made with clinician

Completed intake form filed

Leaves message on voice mail

Service returns call x 2

Message left

Confirms client’s request for this service

Intake form completed

Check for next available appointment

Client arrives / CTC / FTA

If other service requests appointment client must call to confirm

Client calls to confirm

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

Other

Co morbid problems Cognitive Impairment External agencies

Client fails to show for appointment

Family / Money

Forgot appointmentPsychosis

Motivation

Too hard

Couldn’t be

bothered

Partner forbade it

No one told me Too busy

Had another appointment

Too wet

Too cold

Drug, alcohol affected

Too awkward to find place

No money to get there

Too unwell Didn’t write appointment down

In jail / hospital

Assaulted

Problem resolved

Coerced

Got new jobSelf harmed

Slept inScared

AnxiousShame

Crisis passed

Not ready

Got date/time wrong

Confusion

No transport

Missed the bus

Kids sick

Pareto Analysis Sheet

Category Frequency Percentage Cumulative %

Shame/fear 9 26 26

Lack of motivation

8 22 48

Forgot appointment

6 17 65

Overslept 5 13 78

Co morbid problems 4 11 89

Crisis passed 4 11 100

Total 36

Pareto Chart

0

1

2

3

4

5

6

7

8

9

10

Shame Lack ofMotivation

Forgot Overslept Co-morbid Crisis past

Fre

qu

en

cy

0%

20%

40%

60%

80%

100%

120%

Frequency

cum. Total

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

Did Client keep Appointment?

1 2/7/08 8/7/08 Yes

2 2/7/08 8/7/08 No 15/7/08 Yes

3 3/7/08 9/7/08 Yes

60%

81%

40%

19%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jul/Aug 2007 Jul/Aug 2008

Pre and Post

Att

end

ance

Attended

FTA

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