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 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.
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.
50.00%
43.01%
Percent
40.00%
30.00%
23.87%
20.00%
15.76%
8.11%
10.00%
9.25%
0.00%
1
2
3
4
Quintiles
5
Non attendance rates by quintile of
deprivation: (Maharaj, V & Rahman, F: Nov
2006)
30%
25%
DNA rates
25%
20%
15%
11%
13%
14%
14%
4
3
2
10%
5%
0%
5
Quintile
1
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)
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 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.
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.
DNA RATE PER MONTH 2010-2011
20
18
16
14
12
10
8
6
4
2
0
18.26
16.67
16.52
13.5
12.83
12.79
10.8
10.22
8.1
12.07
12.25
11.18
Apr- May- Jun- Jul-10 Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar10
10
10
10
10
10
10
10
11
11
11
Dr Fawzia Rahman - financial year 2010/11
Dr Fawzia Rahman - financial year 2010/11
All’s well that ends well
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
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:
16
15
14
14
12
12
10
8
6
4
2
2
1
1
0
30mins
45mins
50mins
55mins
60mins
Not
Stated
Estimated time spent after DNA
and before another appointment:
19
20
18
16
16
14
12
10
8
6
6
3
4
1
2
0
0-10mins
15-30mins
45-75mins
120mins
Not Known
Dr Fawzia Rahman - financial year 2010/11
Dr Fawzia Rahman - financial year 2010/11
dna rates per quintile using NHS numbers
new and follow up separate
25
22.1
% dna rate
20
17.55
17.4
15
new
13.4
13.77
8.5
10
7.87
6.59
5
followup
9.7
5
0
0
2
4
IMD quintile 2007
Dr Fawzia Rahman - financial year 2010/11
6
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
New DNA rates by source 2010 & 2011
25
20
15
10
5
0
CAMHS
Allied
including
Health
Education
clinical
Profesional
psychology
GP
Hospital/ex Internal
ternal
from comm
comm paed
paed
School
Nurse
/Health
Visitor
Social
Services
Unknown
year 2010
7.53
3.45
14.97
11.41
11.19
9.82
18.04
13.64
22.3
year 2011
22.1
0
9.65
9.71
14.29
9.72
17.77
3.9
11.65
Dr Fawzia Rahman - financial year 2010/11
Non attendance rates by quintile of
deprivation: (Maharaj, V & Rahman, F: Nov
2006)
Quintile
DNA rates
5 (Least Deprived)
11%
4
13%
3
14%
2
14%
1 (Most deprived)
25%
Any previous DNA?
2, 4%
21, 47%
22, 49%
Yes
No
D/K
Concern following the DNA
based on medical records/referral
letter/others.
7, 16%
38, 84%
Yes
No
Domain of Concerns:
19%
33%
32%
16%
Physical
Learning
Psycosocial
Mental
Letter sent out after DNA:
1
2%
13
29%
31
69%
Yes
No
Not recorded
Since this DNA any input provided to child’s
care by community paediatrician?
1, 2%
11, 24%
33, 74%
Yes
No
Not Recorded
In hindsight was the appointment deemed
necessary with a Community Paediatrician.
2%
22%
76%
Yes
No
Unsure
Has the child by now received the
health input he needed?
1
2
4% 2%
16
36%
Yes
No
26
58%
Unclear
Missing
Evidence that parent / YP consented to
referral:
9
12%
Yes
No
65
88%
Was the referral acknowledged by
letter?
24
32%
50
68%
Yes
No
Did the acknowledgement letter state
the source of referral?
11
15%
14
19%
49
66%
Yes
No
NA
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?
13
18%
22
30%
39
52%
Yes
No
NA
Did the acknowledgement letter ask for
mobile number + other details if not
already available?
1
5
1% 7%
24
32%
44
60%
Yes
No
NA
Missing
Was the appointment letter copied to
referrer ?
11
15%
63
85%
Yes
No
Was the appointment letter copied to
GP if other referrer?
4
5% 5
1
7%
1%
64
87%
Yes
No
NA
Missing
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?
2
16
22% 3%
56
75%
Yes
No
Unsure
Anything in the notes to predict a DNA?
1
1%
44
60%
29
39%
Yes
No
NA
Will you (community paediatrician) be
writing to Parent / GP / Referrer /
Other ?
14
19%
48
65%
55
74%
45
61%
Parent
GP
Referrer
Other
Will you be talking to referrer / GP /
Other?
2
4%
23
42%
30
54%
Referrer
GP
Other
Will you be sending another
appointment before anything else?
4
1
5% 14
1%
19%
55
75%
Yes
No
NA
Missing
Do you feel there is anything that could
have prevented this DNA?
1
1%
33
45%
40
54%
Yes
No
Missing
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 .