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Improving Capacity Through Reducing DNAs

Wednesday 24th Jul 2013 - Kate Hodkinson

The way that the population view the NHS has changed dramatically over recent years. There are tremendous expectations regarding what should be delivered to them and how. Many practices talk about patients “wanting it all” and “wanting it now”   and an expectation that everything is curable.

The changes to the NHS structure and responsibilities have been pushed through on the basis of being able to respond to the needs of the local population quickly, tailoring services and improving the quality of service delivery.

These rising expectations and perceptions are putting greater pressure than ever on practices in a number of ways:

  • The need for exceptional levels of both clinical and customer services
  • High availability of routine appointments
  • The ability to respond to urgent need in primary care rather than secondary where appropriate
  • Having to demonstrate compliance with CQC standards and be open to public scrutiny

The need for a strong team approach to meeting these challenges is vital, but while the CCG, CQC and the development of new DES’s are taking up the time of practices managers, they need to look for quick and effective solutions.

Reducing DNAs

Demand for appointments has never been greater, yet practices are still seeing worryingly high levels of DNAs (Did Not Attends) for both routine and urgent appointments. Recent studies on appointment capacity and DNA rates have shown that practices need to be offering between 66-70 GP appointments per week per 1000 population and that there is average DNA rate of 3.5%. This varies from practice to practice so it is an essential piece of work for every team, to establish their own position. This equates to around 15 DNAs every week for an average practice – a number that might make a significant difference in reducing patient aggravation, pressure on clinical and admin staff and improve patient feedback.

First Steps

It is essential for practices to determine if they have a higher than acceptable level of DNAs as the first step in this process.

Ask yourself the question – what would happen if every patient turned up?

Start by assessing your figures over the last two years to discover the average level of DNAs and whether there are any trends or patterns evident from this information.

Then it is important to start considering the reasons for the patient’s non attendance and whether this can be influenced in any way.   The main reasons for non attendance could fall into the following categories:

  • Forgot
  • Error in communication
  • Appointment no longer necessary
  • Attended somewhere else
  • Difficultly in cancelling
  • Lack of support for attendance

Some of these reasons are more amenable to action than others.  Practices should also look at further details about DNAs before planning action, including:

  • Demographic information about the patient
  • Time of day of booking
  • Time of appointment
  • Type of appointment booked
  • The clinician being seen

These factors might enable the practice to plan specific actions for specific groups of patients or to take other action internally to reduce the problem.

Is it Easy to Cancel?

This is always an essential question to ask – from the patient’s perspective. Most patients are responsible users of the service and would take some appropriate action if they had forgotten the time or date of an appointment or no longer needed it. What the practice needs to ensure, is that there are several, easy ways in which they can do this. Always remember that patient’s time is also limited and their opportunities for ringing the surgery may be restricted – if they encounter difficulties in getting through, they might not have further chances to ring again.

Think about some of the following options:

  • Text reminders with an option to text back to cancel
  • On line cancellation
  • A dedicated phone line for cancellations with a message taking option – available 24 hours if possible
  • Checks on future appointments that people already have booked to ensure that are still required

On average, people visit their surgery 5.5 times per year, although there are patients with complex needs that are far more frequent attendees. Are the appointments for these patients always well coordinated to ensure that they are being called in by the practice as few times as necessary?

Poor Communication or Forgotten Appointment

These can be more difficult problem to address due to the impact of patient understanding. The reception and administration team can play an important role in improving communication and reducing the numbers of missed appointments.

As the population becomes more diverse – consider using the 24hour clock as standard timings to avoid confusion. It has been known for European patients to turn up at 6.15 am for appointment!

Research has shown that the number of forgotten appointments and communication errors can be reduced by:

  • Using written appointment cards; and
  • Asking the patient to confirm back the time and date

The effectiveness of a written appointment time increases if the patient writes it down them self whilst in the surgery and then repeats it back to the receptionist.

Many practices circulate messages on the number of missed appointments every month.  This has only had a limited effect, partly because the people who need to see it either don’t realise the problem they have caused or are not there anyway. These messages are generally seen by the good attendees who feel they are being unfairly targeted.

It might be worth changing this to a more positive message by showing the very high percentage of patients who do attend and thanking those who cancelled for letting the practice know. Reinforcing positive message can be more effective than trying to stop behaviour with a negative one.

Perhaps the most effective way of dealing with problem levels of DNAs is for the practice to communicate directly with the problem patients and improve communication and understanding with them.

Thornfields offers a range of customer service and communication skills workshops which could help make life easier in your practice. Contact us for details of our courses on:

We can tailor sessions to meet your specific needs and can deliver half day workshops to a practice team or a small group of practices working together.
 


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