Ensuring patients arrive for appointments – reducing DNA rates [QSI Ref: XR-705]

In many radiology departments, Did Not Attend (DNA) rates remain high with resulting unnecessary resource wastage. This audit aims to measure and improve attendance rates for radiology appointments.

DNA rates for radiology appointments are often high, particularly in urban areas. The reasons are often complex, but can include simple patient forgetfulness, poor mobility, transport issues, social isolation, language and cultural issues, communication problems, and less-structured lifestyles.  In some areas, frequent address changes can also be a problem.

As demographic changes bias radiology referrals towards an older, potentially more-dependent population, many of the above underlying issues are likely to worsen.

Many radiology departments have already taken steps to improve attendance rates. This audit aims to assist the analysis of attendance rates and provides references which may provide some guidance on how to improve attendance rates prior to re-auditing.

The standard: 

High attendance rate for appointments.

Target: 

Will vary with target population. Choose an achievable target. 97% may be attainable. No National KPI but a 3% local DNA rate is considered acceptable in Radiology.

Indicators: 

Percentage of patients arriving within 10 minutes of their appointment time.

Data items to be collected: 

For patients who did attend:

   1. An anonymised identifier for each patient appointment

   2. The date, time and place of appointment

   3. True / false answer to the question “Did patient arrive for appointment."

For patients who did not attend:

   1. Review previous imaging record - are they recurrent non-attender?

   2. When was the appointment sent out? Was it too late to reach patient in time? Was second or first class post used?

   3. When was the appointment request made? e.g. 12 months previously

   4. Was the patient an in-patient at the time of the appointment? If so, does hospital information system / RIS alert to this?

   5. From telephone follow up: A reason given by the patient for non-arrival.  Such enquiries require sensitive handling by appointments staff

Suggested number: 

1 week to provide sufficient numbers for reasonable analysis and cover all sessions

There are many means available to improve arrival rates for appointments and these should be tailored to local needs, as identified by patient correspondence following a missed appointment.

The below references cite several of these ways, including:

   1. Closed (rather than leading) questioning to check patients’ current addresses, telephone numbers and email addresses at first patient contact. Be aware that addresses, especially in an urban, mobile environment, frequently change

   2. Partial booking systems

   3. Telephone confirmation of appointments a few days after appointment made

   4. A telephone and/or SMS message 24 hours prior to appointment to check that patient will arrive

   5. A telephone discussion for all missed appointments to inform the process

   6. For recurrent non attenders - introduce policy of phoning 48 hours in advance to check if the patient is attending

   7. If there is a high DNA rate for appointments requested months earlier, contact referrer to ensure that the examination is still required

- Trust Audit Department

- Radiology appointment staff time:

   • 2 min per case to complete survey for DNA cases

  • 10 minutes per case for telephone calls enquiring as to reasons why he/she was unable to attend

- Excel spreadsheet or similar

- Time: to analyse and summarise spreadsheet – 30 minutes recurring

- Time to discuss results with involved staff and decide appropriate action

1. DNAs – Reducing Did Not Attends. NHS Institute For Innovation and Improvement. [Accessed on 14 February 2017] http://webarchive.nationalarchives.gov.uk/20121108093633/http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/dnas_-_reducing_did_not_attends.html

2. Improving Cardiac Patient Pathways: The Sustainability Toolkit. Outpatients: Did Not Attend (DNA) Rates. NHS Improvement.  [Accessed on 4 Oct 2013] http://www.improvement.nhs.uk/heart/sustainability/outpatients/dna.html

3. Hasvold PE, Wootton R. Use of telephone and SMS reminders to improve attendance at hospital appointments: a systematic review. J Telemed Telecare. 2011 October; 17(7): 358–364. [ Accessed on 4 Oct 2013]  http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3188816/pdf/jtt-11-07-007.pdf

4. Royal College of Radiologists. AuditLive – 100+ Recipes: Patient arrival times for appointments.originally published in:  de Lacey G, Godwin R, Manhire A. 100+ Audit Recipes. (1996) Royal College of Radiologists, London. [Accessed on 4 Oct 2013] https://www.rcr.ac.uk/audittemplate.aspx?pageid=1020&audittemplateid=19

5. NHS England.  Quarterly Hospital Activity. http://www.england.nhs.uk/statistics

Dr David Tennant, updated by J Iles