Approaches to reducing DNA and CNA

Transcription

1 Quality and Efficiency Support Team (QuEST) Directorate for Health Workforce and Performance Approaches to reducing DNA and CNA Lesley White, National Improvement Advisor, QuEST Mike Henderson, Consultant Clinical Psychologist, NHS Borders Jane McLachlan, Assistant Psychologist, NHS Borders Paul Devlin, Team Leader, Woodlands, NHS Greater Glasgow & Clyde

2 Objectives Receive an overview of information from a literature search on reducing DNAs and CNAs in mental health services Hear about promising tests of change taking place across mental health services in Scotland Have the opportunity to discuss the opportunities and challenges that services face in improving engagement with psychological therapy services

3 Where are we?

4 Where are we?

5 Where do we want to be?

6 Improvement Approach

7 Calculate DNA Rate

8 Where to focus? 1.3 Did Not Attend (DNA) DNA rate for 1st assessment slots calculate as (no. of 1st assessment slots missed/ no. 1st assessment slots offered)*100 DNA rate for individual follow-up slots calculate as (no. of follow-up slots missed/ no. of follow up slots planned)*100 Number 15.0% 10.0% Higher DNA rate for new appointments so you start there, right? ACTUAL This table shows time lost to DNA TIME LOST TO DNA Total Hours Average Hrs per week Time allocated for first assessments not used due to DNA Time allocated to follow-ups not used due to DNA Even with a lower DNA rate you should start with follow ups as they are more resource intensive

9 NHS Borders: Where to focus? At first glance, the problem DNA rate is for new appointments Attendance of first appointments for adult Psychological Therapies DNA Attended 11% Attendance of follow-up appointments for adult Psychological Therapies DNA Attended 8% 89% 92%

10 NHS Borders: Where to focus? But if we look at the data in a different way Hour lost to DNA new and follow-up appointments New Folow-up Hours New Folow-up

11 Chart DNA Rates Over Time

12 Detailed Assessment

13 Ideas for Improvement

14 Evidence Base

15 DNA Rate and the Day of the Week DNA Rate Weekday Effect Monday Tuesday Wednesday Thursday Friday Mon Fri Mon Fri N= N= N= N= N= Difference RRR 11% 10.9% 10.3% 10.1% 9.7% 1.3% 11.8%

16 DNA Rate and the Day of the Week

17 DNA Rate and the Day of the Week DNA Rate Weekday Effect Monday Tuesday Wednesday Thursday Friday Mon Fri Mon Fri N=2511 NA N=2856 N=3272 N=2256 Difference RRR 6.2% NA 5.9% 4.6% 4.2% 2% 32.3%

18 To Opt in or Not to Opt in? Non Attendance Rate Study Service Opt In Method Without Opt In, % (Sample Size) With Opt In, % (Sample Size) Wiseman & McBride Balfour Child & Family Psychiatry Adult clinical psychology Controlled Trial Appointment after response 29 (82) 0 (46) Before/after comparison over equivalent months in succeeding years 2 Appointment after response (3 months) 11 (46) 2 (41) Spector Clinical psychology Appointment after response (9 months) 35 (43) 12 (25) Srivasta & Allen Adult psychiatry Choose and book (12 months) 5 28 (106) 0 (85) Conaghan et al Adult clinical psychology Not clearly specified (4 months) 23 (unspecified) 23 (unspecified) Before/after with unspecified time before intervention 3 Anderson & White Primary care psychology Appointment after response (36 months) 25 (unspecified) 3 (1824) Yeandle Child psychology Appointment after response (12 months) 23 (435) 4 (unspecified) Concurrent comparisons with population not equivalent to the opt-in group Adams et al Child psychology Appointment after response 36 (31) 5 (25) Stallard & Sayer CAMHS Confirm appointment 6 27 (unspecified) 5 (36)

19 Appointment Reminder System Risk factors for non attendance Male Not prescribed medicine Psychoactive substance misuse Anxiety disorder Organic disorders

20 Social Influence Approach # 31 st 10am 403 Patients attended their appointments in this practice last month

21 Ideas in Practice

22 NHS Borders: Psychology service Trying an Opt In system Plan A Plan -> Do -> confirm attendance letter Study -> DNA rate falls, BUT oh no! ->2 at once! Discuss Act -> move to opt in (no time given) Plan B Study -> DNA rate still low, only 1 at a time and enough notice (and confidence) to fill a slot again

23 NHS Borders: Psychology service NHS BORDERS Psychology service: First appointment DNA rate: Total first appointment DNAs Median Introduction of first appointment opt in policy for the service Hours 60 Full partial booking system introduced Year

24 NHS Borders: CMHT Example Opt-ins Baseline Opt-in PDSA Part 1 Study Act Discuss Opt-in PDSA Part 2

25 NHS Borders: CMHT Example Opt-ins 10 Total hours per month lost to first appointment DNAs between June 2011 and September DNAs Median Nov-11: Initial appointment opt-in letters implemented Hours Nov-12: Initial appointment optin letters discontinued 0 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Month

26 NHS Greater Glasgow & Clyde Woodlands Centre Memory Clinic Function DCAQ approach Day Hospital Memory Clinic DNA rates Functional / Organic split Challenges Aston Team Performance

27 NHS Greater Glasgow & Clyde Text reminder Functional / Organic split Challenges Aston Team Performance

28 DNA RATES 25% DNA RATES: SEP AUG % 15% 10% 5% 0% Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13

29 TOTAL CONTACTS Total No. Of Appointments Sep- 12 Oct- 12 Nov- 12 Dec- 12 Jan- 13 Feb- 13 Mar- 13 Apr- 13 May- 13 Jun- 13 Jul- 13 Aug- 13

30 NHS Greater Glasgow & Clyde Paul Devlin Would be helpful if you could mention how you think location of clinics may have impacted CNA, do you have CNA charted? What approach you used? What impact did it have? (preferable a run chart with median on it) Challenges / issues you faced and how you overcame them?

31 Any immediate questions / thoughts / reflections on what you have heard?

32 Discussion / Sharing of Learning Impacting DNA & CNA rates What approaches have you used? What impact have they had? What approaches interest you and how can you see them working? What challenges have you encountered and how did you overcome them?

33 Objectives Revisited Receive an overview of information from a literature search on reducing DNAs and CNAs in mental health services Hear about promising tests of change taking place across mental health services in Scotland Have the opportunity to discuss the opportunities and challenges that services face in improving engagement with psychological therapy services

34 Further Information

35 Further Information Effective & Efficient CMHS Toolkit Optimising capacity reducing DNAs and CNAs Lothian DCAQ Phase 2 Report Optimising Capacity Reducing DNA and CNA

36 Contacts for Further Information Lesley White, National Improvement Advisor Phone Mike Henderson, Consultant Clinical Psychologist Phone Jane McLachlan, Assistant Psychologist Phone Paul Devlin, Team Leader, Woodlands Phone

37 Thank you