Improving attendance at ENT clinics
Exploring ways to reduce DNAs at the North Riding Infirmary, Middlesbrough.
- Why was the initiative launched?
- What was done?
- Did it work?
- Tips for success
- For more information contact
Why was the initiative launched?
As part a programme of work across the Trust a new process was developed to manage outpatient clinics. This built on earlier success in using EFQM methodology ( ImpAct 4 November 1999). Introduction of the new process delivered many benefits for patients, such as shorter waiting times in clinics. It was recognised, however, that the full benefits would not be realised unless ways could be found to reduce the number of patients not attending clinics (did not attend, DNAs), a common problem in the NHS.
It was argued that if the clinics were set up in the right way, reflecting the concerns and interests of patients and staff, the number of DNAs would reduce. Experience showed that the new process had only limited impact on the number of DNAs, so the ENT Department at North Riding Infirmary set out to explore other ways to reduce their DNAs.
What was done?
When the new process for managing outpatients was introduced in 1998 it included a series of steps to try to reduce the number of DNAs. These were:
- A template was provided to help GPs provide the right information about patients.
- Patients would be sent an appointment letter immediately and a reminder letter two weeks before the appointment.
- Efforts would be made to avoid inappropriate appointment times, for example when ambulances would not be available
- Advice would be given to patients about how to cancel appointments.
- Arrangements would be made to ensure that any cancellations received by the hospital were passed on promptly to the clinic.
There was some initial success in reducing the number of DNAs. Before the new system was introduced the (1997) DNA rates for ENT were 14% for new appointments and 20% for review appointments. By mid-1999 the new rates had settled around 12% for new appointments and at about 13% for review appointments.
The ENT Department at North Riding Infirmary decided to explore whether a further reminder to patients by telephone would improve the situation. An action plan was agreed for one month in which:
- All new patients would be telephoned one week before their appointment between 5pm and 7.30pm.
- If the patient had an answering machine a message would be left.
- If the patient record did not include a telephone number the GP surgery would be contacted.
- Jackie Burton and Karen Poole, clerical staff in the ENT office, would make the telephone calls.
Did it work?
During the month-long experiment about 500 patients were telephoned Some of the results are surprising (Table). About half of the patients did not know their appointment times or why they were coming for the appointment. Most thought that it was a good idea to remind them of their appointments. The telephone calls confirmed the problems patients were experiencing in trying to contact the Department by telephone.
|North Riding Infirmary: Results of telephone reminders|
|253||GPs contacted to check number|
|34||Wrong number recorded|
|94||Patients did not answer|
|7||Patients cancelled appointments|
The initiative did not, however, make any significant improvements in attendance levels. The DNA rate for new appointments for the month before the experiment was 10% and for the period of the experiment it was 8%. This 8% represented 60 patients, and during the experiment:
- 11 said they would attend
- 36 had no telephone
- 10 did not answer
- 3 were left messages
The initiative involved about 50 hours staff time. The ENT Department has concluded that the idea of additional telephone reminders did not offer a practical way of reducing DNAs. However, two local issues about the use of telephones have been clarified. First, patients had real problems if they tried to contact the Department by telephone to cancel their appointment because there is only one telephone line. Action is in hand to remedy this situation. Second, changes to local telephone numbers and the growing reliance on mobile phones mean that information about patients' telephone numbers is not readily available.
The ENT Department is now exploring other ways of tackling the problem. It is analysing information about DNAs to see if other solutions can be found - are the problems about access, public transport or car parking etc.
Tips for success
- Don't expect that a better system for managing clinics will necessarily eliminate the problem of DNAs.
- Build on the proven success of written reminders.
- Don't expect the use of telephone reminders to make a sizeable impact on the number of DNAs.
- Remember that everyone does not have a home telephone: only 80% of the patients involved in the North Riding experiment had a telephone.
- Link with GP surgeries to keep patients' telephones up to date - cover both home and mobile numbers.
For more information contact
North Riding Infirmary
South Tees Acute Hospitals NHS Trust
Middlebrough TS1 5JE
Telephone 01642 854006
Fax 01642 854064
The following material is available
- Copy of ENT protocols and standards
- Samples of appointment and reminder letter
- Report of telephone reminder initiative
ImpAct bottom line
- Don't be afraid to try new ideas, and have the courage to stop if they don't work.