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DNAs - Reducing Did Not Attends


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DNAs - Reducing Did Not Attends
 


What is it and how can it help me?

This tool examines the causes for patient non-attendance and gives guidance on what you can do to reduce the level of 'did not attends' (DNAs) at your hospital.

See also:

DNAs have an enormous impact on the healthcare system in terms of cost and waiting time, significantly adding to delays along the patient pathway. You may well have some strategies already in place, such as overbooking slots, but if you have a higher than acceptable rate of DNAs, you may wish to reconsider what you and your staff can do to reduce them.

Think about what would happen if all the patients showed up? What would happen if there was a 50 per cent reduction in the number of patients who didn't show up? How many more patients could you see?

When does it work best?

When you are attempting to:

  • Reduce costs
  • Allow for efficient running of clinics
  • Reduce Variation
  • Enable more effective booking
  • Reduce mismatch between demand and capacity
  • Increase productivity

How to use it

Firstly, you need to determine whether you have a higher than acceptable rate of DNAs. You can assess this by looking at the level of DNAs over the past 2 years as a percentage of total appointments. Ask yourself: what is too high? What level are we aiming to reduce it to? What level is acceptable? To place the figures in context, look at the trust average, Strategic Health Authority averages and Delivering Quality and Value publications. (wouldn't you want to plot them weekly and create an SPC chart and not base your decision making on the back of one percentage?)

Diagnose the cause
Once you have established that DNA rates are unacceptably high, the next stage is to try and determine the causes. There is a tendency to always blame the patient, but you may also need to look a little closer to home. The two most commonly cited reasons are:

  • Patients forgetting
  • Clerical errors or communication failures which mean that the patient was unaware of the appointment

Some of the other causal factors are:

Socio-demographic factors which include:

  • Age and gender
  • Distance from hospital, GP/ PCT
  • Deprivation

Patient factors:

  • No longer need to attend
  • Too unwell to attend
  • Employment
  • Previous experience
  • Seriousness of illness
  • Nature of illness
  • Childcare
  • Cost of travel prohibitive
  • Travel difficult to organise
  • Public transport difficult to access

Hospital factors:

  • Difficulty in cancelling appointments
  • Incorrect recording
  • Poor appointment card design
  • Lack of notification
  • Short notification
  • Organisation of clinics
  • Booking (partial booking)
  • Time or day of appointment may be inconvenient
  • Appointment types - new or follow-up
  • Urgency of appointment
  • Transport / parking

Other factors:

  • GP/patient communication

Some of these causal factors, for example booking figures and appointment times, may be stored on your hospital computer systems. This enables you to identify whether patients DNA at certain times of the day. The following chart indicates that patients at this hospital tend to DNA in the early morning, at lunch and after 4pm.
DNA 1.jpg

 

 

 

 

 

 

 

 

 

With this information, you can look deeper and find out if these people are of a certain age, for example parents who may be taking children to school. If this is the case, you could ask when booking the appointment. The main aim is to understand the patient profile so that you can make attending the appointment as easy as possible.

Other causal factors, such as difficultly in understanding appointment cards or transport and parking problems, may be harder to diagnose. You could perhaps consider some qualitative analysis, a telephone or postal questionnaire; this may uncover factors that you hadn't previously thought of.

Once you have identified the key causes of DNAs, you can try some of the following strategies. Remember that you are tackling the causes, and not just the symptoms. 

Make sure the appointment is necessary
Reducing the number of inappropriate follow-ups not only frees up time, it also reduces the number of patients who don't attend because they feel the appointment is unnecessary.

Reduce patient anxiety
Reassure the patient by ensuring that they know what is going to happen and when; clear information is the key e.g. thorough pre-operative assessment.

Communication
Appointment cards/letters should be easy to read and understand.

  • Consider the size of font, the language style and layout
  • Should they be translated into a variety of common languages? See writing patient information

Aim for consistency of style by consulting receptionists, booking clerks, nurses and doctors. Tear-off confirmation slips and/or freepost envelopes make it easier for patients to respond.

Consider re-designing your appointment letters and cards and canvas a cross section of patients on a range of designs.

Cancelling the appointment
How easy is it for patients to contact the hospital or department?

  • Could you have dedicated telephone lines?
  • 24-hour answering machines and/or freephone telephone numbers?  Your staff may need training so they are able to record cancellations and reschedule appointments on computer

Reminding the patient
Send reminders to patients, especially in specialties with high rates of non-attendance or for patients who receive appointments a long time in advance.

  • Send reminder letters 2-3 weeks prior to an appointment
  • Text messages are a useful way of sending reminders from three weeks to one day before an appointment. (This may be more useful for some groups of patients than others)

Generally, the higher the rate of DNA, the greater the impact of reminders, so always check communication procedures.

Receptionists / booking systems
Ensure that appointments are made at a convenient time for both the patient and the hospital.

  • Your receptionists also play a key role in communicating, but this doesn't always come naturally and they may need training or guidance
  • Make sure your receptionists reconfirm an appointment verbally and make eye contact with the patient
  • It can be useful to ask the patient to repeat the information back to ensure that they have understood

Monitoring and control
Contact GPs as a matter of course if a new patient does not attend. GPs or consultants should then follow up to find out the reason why. Only request re-referrals if necessary.

Remember, all improvement is change, but not all change is improvement - so make sure you test your changes on a small scale before you roll them out. See PDSA cycles.

Examples

Reducing DNAs - Journal Article 

What next?

To see the impact of any changes, make sure you know the DNA rate for your service then compare the results. One of the easiest ways to monitor change is through the use of statistical process control charts (SPC).

It is also important to understand who has the responsibility for why a patient didn't turn up. The following example demonstrates who is responsible for the decision:

Individual

Mani

Jo

Lou

Matt

Decision

Information

Reception

Nurse

Dr

Do we find out why patient didn't turn up?

 

 

 

 

Do we make another appointment?  

 

Informed

Consulted

Responsible

Do we monitor?

Responsible

 

 

 

Do we make any changes to our systems?

Informed

Consulted

Responsible

 


For more information see responsibility charting.

The findings of the investigation must be shared with patients, management and clinicians. In this way other departments can learn and benefit from the conclusions.

At all stages of your changes keep the following informed:

  • Patients
  • User groups
  • Other operational managers
  • Clinicians
  • Administration staff
  • Person responsible for managing DNAs

Other useful tools and techniques on this website: 

Writing patient information
Statistical process control charts
Demand and capacity
How to measure demand and capacity
Responsibility charting
PDSA cycles: testing out your proposed changes
Cancelled operations: a form of DNAs
Pre-operatives assessments: to reduce DNAs
Choose and book: to reduce DNAs

Background

Reducing patients that do not attend has been a key focus of service improvement in hospitals for many years.

Acknowledgements / sources

Jenny Moss - Derby Hospitals NHS Foundation Trust

© Copyright NHS Institute for Innovation and Improvement 2008