Did Not Attend and Unable to Attend Policy

Did Not Attend (DNA) and Unable to Attend Policy Did Not Attend and Unable to Attend Policy Doc. Ref. No. Title of Document Author s Name Author s job title Dept / Service Doc. Status DNA/UTA 1314 Did Not Attend and Unable to Attend Policy Claire Madsen Andy Blews Consultant Physiotherapist and Deputy Clinical Director Business Intelligence & Data Quality Manager Clinical Directorate Informatics V6.2 Based on Signed off by Publication Date April 2014 Next review date April 2017 Bristol Community Health (2014) Did Not Attend (DNA) Policy Clinical Cabinet Distribution Senior Management Team and Operational Managers Consultation Version Date Consultation V1 28 th November 2013 Circulated to DNA / UTA Working Group for comment V4 16 th December 2013 Re-Circulated to DNA / UTA Working Group for comment V5 February 2014 Clinical Cabinet V6 April 2014 Desktop Review V6.1 June 2016 Working Group for comment V6.2 July 2016 Re-Circulated to DNA / UTA Working Group for comment M:\BCH\Divisions\Business Planning and Development\Performance\Policy and Guidance Notes

Did Not Attend (DNA) and Unable to Attend Policy Checklist for Approving Committee / Board Has an equality impact assessment been compiled? Has legal advice been sought N/a Has the policy been assessed for its impact on Human rights? N/a Have training issues been considered? Have any financial issues been considered? Will implementation be monitored? Is there a cascade mechanism in place to communicate the policy? - with staff - with patients - with the public Are there linked policies / procedures?, at a service level. Should also be read in conjunction with the BCH DNA Policy for Safeguarding Children and Young People, and the BCH Discharge Policy. Has a review date been set? June 2017 Is this related to the Care Quality Commission (CQC) essential standards of patient safety and quality? M:\BCH\Divisions\Business Planning and Development\Performance\Policy and Guidance Notes

Did Not Attend (DNA) and Unable to Attend Policy Did Not Attend (DNA) and Unable to Attend (UTA) Policy Date approved by the BCH Clinical Cabinet: 24 th February 2014 Date of Implementation: February 2014 Date of Review: June 2017 August 2016 M:\BCH\Divisions\Business Planning and Development\Performance\Policy and Guidance Notes

Did Not Attend (DNA) and Unable to Attend Policy Contents Consultation...1 Contents...4 1. Introduction...5 2. Scope...5 3. Principles and Purpose...5 4. Definitions...6 5. Roles and Responsibilities...7 6. Equalities Impact Assessment...7 7. DNA New Appointment...7 8. UTA New Appointment...9 9 DNA/UTA Follow up Appointment...9 9. Application of Department of Health Allied Health Professional (AHP) Referral to Treatment Time (RTT) Guidance...9 10. Communication...10 11. Clinical Risk...11 12. Non Access...11 13. Audit...11 14. References and Links to Other Documents...11 15. Appendices...12 M:\BCH\Divisions\Business Planning and Development\Performance\Policy and Guidance Notes

1. Introduction 1.1 The procedures set out in this policy are a pragmatic guide to assist clinicians in determining the best response to patients who do not attend (DNA) their appointment, are unable to attend (UTA) their appointment, or clinical care cannot be given due to there being no access. The objective of the policy is to provide appropriate definitions of DNA and UTA and to ensure consistency is applied in our communication to patients and their carer s or relatives across Bristol Community Health (BCH) services. The policy has also been designed to minimise lost productivity in appointments that cannot be filled due to DNA, cancellation or UTA, whilst improving our waiting times and general accessibility to BCH services. It also outlines the implications of DNAs, UTAs on referral to treatment pathways. 1.2 We know from local service user, carer and referrer feedback that by managing the way in to our services in an effective way will improve the accessibility of our services to all members of the community. The use of a DNA and cancellation policy will mean that: A patient who needs BCH support will spend less time and effort trying to get an appointment, often having to wait for less time for an appointment, and will have a positive experience with our services before they see a member of staff Administration staff will waste less time re-booking appointments Clinicians will waste less time waiting for patients who do not turn up BCH will manage scarce resources more effectively Service performance will be less impacted. 2. Scope 2.1 This policy covers all adult community healthcare services provided by Bristol Community Health. A separate DNA ( Was not Brought ) policy applies to children and young people to ensure their safety and welfare is not compromised if they fail to attend. 1 3. Principles and Purpose 3.1 The purpose of this policy is to lay out some key principles to support the management of patients who fail or are unable to attend appointments. The objective of the policy is to ensure that Bristol Community Health: Can deliver excellent services that reflect our organisational values and aims and are responsive to patients and carer feedback Protects the safety and wellbeing of a patients who miss an appointment or home visit Complies with Department of Health guidance and meets relevant targets 1 Bristol Community Health (2009) Did Not Attend (DNA) Policy for Safeguarding Children and Young People M:\BCH\Divisions\Business Planning and Development\Performance\Policy and Guidance Notes Page 5

Can adopt best national practice in the management of DNA s and cancellations Promote patient s management of their own care. 3.2 The following principles will be adhered to in the policy: 3.2.1 Each clinical service has in place local procedures and risk management arrangements that support the standards in this policy; 3.2.2 The over-riding factor in the management of any access process will be for all patients best interests and satisfaction; 3.2.3 Services have good communication processes in place with referrers and patients e.g. timely response times, agreed referral pathways, regular discussion; and 3.2.4 All staff will treat patients, carers and referrers as they would expect to be treated: 3.2.4.1 With clear and concise communication and information 3.2.4.2 With dignity and respect 3.2.4.3 With choice offered wherever possible 3.2.4.4 With information to keep them informed and updated. 3.3 This policy should be used in conjunction with individual service policies, guidelines and standard operating procedures. This needs to be communicated with all staff members and should be adopted as part of the service specific induction process. The Policy should also be included within the service specific IT system SOP (Standard Operating Procedure) e.g. EMIS, System One. 3.4 Where children are not brought to health appointments, practitioners / clinic staff must refer to the DNA Policy for Safeguarding Children and Young People. 4. Definitions 4.1 DNA Appointment A patient DNAs when they do not attend a planned appointment, (face to face or telephone call) and provide no advanced warning, or arrive late to an appointment and are not able to be seen. 2 4.2 Unable to Attend Appointment (UTA) Where a patient provides prior notice that they are unable to attend an appointment, they are recorded as being Unable to Attend. This is also known as a cancellation. 3 4.3 No Access Visit/Failure to Gain Access 2 Health and Social Care Information Centre (2013) NHS Data Model and Dictionary for England Version 3 3 Health and Social Care Information Centre (2013) NHS Data Model and Dictionary for England Version 3 M:\BCH\Divisions\Business Planning and Development\Performance\Policy and Guidance Notes Page 6

If the staff member is unable to gain access to provide the care / service as arranged and the staff member is unable to establish contact with the patient as a result of: No response Access refused by client or third party. Then the visit will be classified as a failed access to home and therefore also as a DNA. (for more information please see the BCH Failure to Gain Access Policy) 5. Roles and Responsibilities 5.1 All service leads who manage provider services will be responsible for ensuring the dissemination and implementation of this policy. 5.2 Employees have the responsibility to adhere to the policy. 6. Equalities Impact Assessment 6.1 Equalities monitoring against the protected characteristics specified by the Equalities Act (2010) will be used to monitor any trends in DNA and UTA rates by location and service. DNA and UTA information will be aggregated, analysed and monitored by BCH to evaluate any impact on different equality groups and communities at least once a year This will be used to develop and deliver services that promote equality and eliminate unlawful discrimination on the grounds of age, disability, ethnicity, sexual orientation, gender including transgender, religion or belief and human rights. The needs of carers, people in vulnerable communities, such as Asylum Seekers, Gypsies and Travellers, and homeless people are also considered in the context of DNA and UTA management. Communication with patients will also be adapted where necessary to meet the needs of different patient groups, including those with mental health problems, sensory loss cognitive impairment or learning disability(as per the Accessible Information Standard). 6.2 A variation of procedure has been put in place for these patients and has been attached in Appendix 2. 6.3 When applying this policy individual services should also consider: 6.3.1 Any local service specific policies already in place 6.3.2 The application of Referral to Treatment rules in EMIS (Appendix 1); and 6.3.3 Local policies and protocols which specifically protect the clinical interests of vulnerable patients e.g. children and adult safeguarding These should be agreed with clinicians, commissioners, patients and other relevant stakeholders. 7. DNA New Appointment 7.1 Patients will be discharged if they DNA their first appointment, providing that: 7.1.1 The service can evidence clear communication to the patient or carer on the appointment date, such as a telephone conversation or a letter M:\BCH\Divisions\Business Planning and Development\Performance\Policy and Guidance Notes Page 7

7.1.2 Discharging the patient is not contrary to the patients best clinical interests 4.(or there is no prior knowledge of the patient having a lack of capacity to refuse or decline treatment.) 7.1.3 The BCH Discharge Policy has been referred to. 7.2 Where it is not appropriate to discharge the patient and the service needs to offer another appointment, then the original referral date should be used for agreeing a future appointment. 7.3 Unless there is something that is explicit on the referral or further information is received that suggests it is clinically unsafe to discharge a patient, then the patient will be discharged back to the referrer or GP when they DNA a new appointment. Figure 1: Process for Managing Patients who DNA their First Appointment Patient DNA s first appointment Service specific policy implemented (if appropriate) to evaluate clinical risk Is it clinically appropriate and safe to discharge? Refer back to referrer within maximum of 7 days from discharge, copying in the patient to any correspondence Discharge patient No In line with service specific guidelines offer another appointment (having taken into account clinical risk) (see appendix 2) Patient DNA s second appointment 4 The patient s mental capacity to refuse treatment or decline an appointment should always be considered. If in doubt the decision to discharge should always be discussed with a clinical lead or line manager. (see appendix 2) M:\BCH\Divisions\Business Planning and Development\Performance\Policy and Guidance Notes Page 8

8. UTA New Appointment If the patient provides advanced notice that they are unable to attend a first appointment, or any subsequent appointment, prior to first definitive treatment, then the appointment should be rebooked and the original waiting time clock will continue to tick. All patients will be expected to provide at least 48 hours notice to cancel an appointment or with enough prior notice to re use that slot. (services should use their own judgement as to whether to action as a UTA) 8.2 If the patient DNAs the second new patient slot offered, follow the guidance in Figure 1 on the management of DNAs. 8.3 If a patient chooses to delay an appointment for more than 3 weeks then a discussion should be held with the patient on the option of discharging them from the service and rereferring them at a later point. For services that are RTT monitored and using EMIS Web see appendix 1 9. DNA/UTA Follow up Appointment 9.1 If a patient fails to attend a follow up appointment then the patient will be managed according to locally agreed guidelines. 10. Application of Department of Health Allied Health Professional (AHP) Referral to Treatment Time (RTT) Guidance 10.1 The Department of Health Allied Health Professionals RTT regulations were published on Dec 22 nd 2011 and can be accessed from the following link: http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/d H_131948 10.2 The AHPs required to collect RTT data, whether working autonomously or within a multidisciplinary team are: Art Therapists Drama Therapists Music Therapists Chiropodists / Podiatrists Dietitians Occupational Therapists Orthotists Physiotherapists Prosthetists Diagnostic and Therapeutic Radiographers Speech and Language Therapists Mental Health and Learning Disabilities services M:\BCH\Divisions\Business Planning and Development\Performance\Policy and Guidance Notes Page 9

10.3 Where a patient fails to attend (DNA) the first appointment after the initial referral that started their 18/13 week clock, their 18/13 week clock will be nullified (i.e. it is as if their referral never existed). The patient can be discharged providing there is sufficient evidence to show the appointment was clearly communicated to the patient. The service also needs to establish the reason for why the patient DNA d which should be documented in the patients electronic care record e.g. EMIS Consultation. See Local guidelines Reasons for DNA could include: Patient forgets Clerical errors or communication failures which mean that the patient was unaware of the appointment Childcare Nature of illness Time or day of appointment was inconvenient 10.4 If the service decides that it is appropriate (due to clinical/vulnerability reason) to contact the patient to rebook the appointment (i.e. the patient is not referred back into primary care), then the clock should be reset to the date that the new appointment was agreed. 10.5 If a DNAs a follow up appointment then a patient can be discharged back to the care of their GP or other referrer providing that: 12.5.1 The service establishes the reason why the patient DNA d the appointment. or 12.5.2 Discharging the patient is not contrary to their best clinical interests; and or 12.5.3 Discharging the patient is carried out according to a local, publicly agreed and available policy on DNAs 11. Communication 11.1 Any patient who notifies BCH that they cannot attend an appointment if possible should have another appointment or event arranged at the time of notification. If the patient notifies by telephone, if possible a new appointment should be made there and then. If the patient notifies by letter or email, an immediate response should be sent asking them to contact BCH by telephone to make a new appointment. 11.2 The minimum standard following DNA is to notify the patient and the referrer or GP. If the patient has been removed from a waiting list then clear instructions should be included on how the patient can be returned to the waiting list and what to do if the patient has a serious condition that requires urgent attention. 11.3 Whatever the language skills of the patient a written record i.e. letter of patient contact must be made and included within the electronic patient record following a DNA. If language barriers are known to inhibit service uptake a letter in the patients preferred language or a telephone contact in the preferred language should be used. M:\BCH\Divisions\Business Planning and Development\Performance\Policy and Guidance Notes Page 10

11.4 Text reminders for clinic appointments should be sent to patients where possible to reduce the likelihood of DNAs, providing consent has been obtained. 5 11.5 Any communication with patients should comply with Accessible Information Standards. 13.5.1 Reasonable adjustments should be made for patients to support patients to communicate with services. 12. Clinical Risk 12.1 When a patient is referred to a service, the clinical risk stands with the referring agent until they have been assessed. However, as the clinical duty for that service is to only offer assessment, if the patient doesn t attend a first appointment, information, clinical risk and clinical duty is transferred back to the referring agent/gp. This can be achieved by discharging the patient and communicating this information with the referrer and other key professionals. This sharing of information supports improved communication and thus support for the patient to regain access to any health care service as required. 12.2 If the patient has already been assessed and thus the clinical risk is known to the service or clinician, the service has to decide what the best course of action is for that patient. This must be communicated to the key professionals involved so that they can support the patient to access services as required. 12.3 If a patient has a known disability or identified access requirements of any kind which restricts their attendance to appointments, this must be taken into consideration when agreeing the pathway for patients who DNA/UTA appointments. 13. Non Access 13.1 Please refer to the Failure to Gain Access Policy accessible on the BCH website. 14. Audit 14.1 To ensure adherence to this policy each service should utilise business intelligence reports and care records, reviewing a selection of individual care records on an annual basis. 15. References and Links to Other Documents Department of Health (2011) Community Information Programme: Allied Health Professional Referral to Treatment Revised Guide 5 The BCH strategy for reducing DNAs is to set up text reminder appointments for patients and their carers at least 24 hours before their appointment is due. Overbooking of clinics to allow for DNA s should be used as a last resort. M:\BCH\Divisions\Business Planning and Development\Performance\Policy and Guidance Notes Page 11

Bristol Community Health (2009) Did Not Attend (DNA) Policy for Safeguarding Children and Young People Bristol Community Health Modification of Care Policy Safeguarding Adults and Cause for Concern Guidance BCH (2016) EMIS Web Standard Operating Procedure EMIS QRG Referral to Treatment V1 BCH (2013) Discharge Policy BCH (2014) Failure to Gain Access Policy (All policies can be found on the Bristol Community Health Website http://www.briscomhealth.org.uk/) Information Standards Board for Health and Social Care (2013) Allied Health Professional Referral to Treatment Guide Specification 16. Appendices 1. Application of Referral to Treatment (RTT) Rules in EMIS 2. DNA and UTA Procedure for Patients with Learning Difficulties, cognitive impairment, mental health conditions and where English is not the first language 3. Local Guidelines for the management of DNA & UTAs. M:\BCH\Divisions\Business Planning and Development\Performance\Policy and Guidance Notes Page 12

Appendix 1. Application of Referral to Treatment (RTT) Rules in EMIS Did Not Attend and Unable to Attend Rules- EMIS non RTT Referral made by GP/Other Health Professional 33- Did not attend- the patient did not attend the first care activity after the referral 35- Patient declined offered treatment EMIS Field: Discharge Referral> New RTT Status Referral Discharged e.g. pt DNAs No Admin Note: enter any relevant information around the DNA if necessary DNAs should not be recorded as a consultation EMIS Field: Inbound Referral>Referral received date Referral received by service Referral Triaged Restart RTT Clock once new appointment booked. See note 1 & 2 Patient DNAs first appointment Policy to offer another appt? EMIS DNA Field: Change Appointment Book>Slot Status to: Patient DNA (clinic slot) Visited patient not in (home visit slot) Telephoned but no answer (tel. slot) Referral inappropriate or transferred out of service? No Referral Rejectede.g. inappropriate, moved out of area Referral Accepted Appointment No Booked? Referral Discharged e.g. pt died, refused appt Patient is unavailable for treatment Patient attended first appointment EMIS Field: Completing a admin note Add Care Contact > RTT Status EMIS Field: Completing a consultation Add Care Contact > RTT Status CLOCK STOP 31- Start of active monitoring initiated by the patient CLOCK STOP All subsquent contacts and discharge following treatment EMIS Field: Add Care Contact> New RTT Status EMIS Field:Reject Referral> New RTT Status 35- Patient declined offered treatment 34- Decision not to treat- decision not to treat made or no further contact required 36- Patient died before treatment EMIS Field: Discharge Referral> New RTT Status 35- Patient declined offered treatment 34- Decision not to treat- decision not to treat made or no further contact required 36- Patient died before treatment Patient Cancelled First Appointment 30- Start of first definitive treatment 31- Start of active monitoring initiated by the patient 32- Start of active monitoring initiated by the care professional EMIS Field: Cancellation 1.Cancelled for Clinical Reasons/Cancelled for Non-clinical Reasons 2.Appointment cancelled or postponed by Health Care 98- Activity not applicable to RTTP (clock stopped previously) 90- First definitve treatment occured previously 91- Active monitoring- care activity during active monitoring CLOCK KEEPS TICKING Provider/Appointment cancelled by, or on behalf of, THE PATIENT Note 1: Rebooking after DNA - If a new first appointment has been offered enter a new consultation on the date the appointment was offered and restart the clock. M:\BCH\Divisions\Business Planning and Development\Performance\Policy and Guidance Notes Page 13 Note 2: Rebooking after Patient Unavailable - If the patient cannot commence treatment either through being admitted or becasue of social reasons (extended holiday) then an admin note entry should be made on the date on which the patient declined the offered appointment. The clock should then be re-started on this date by entering the RTT code 11- End of Active

Did Not Attend and Unable to Attend Rules- EMIS non RTT Admin Note: EMIS Field: Inbound Referral>Referral received date Referral made by GP/Other Health Professional Referral received by service EMIS Field: Discharge Referral Referral Discharged e.g. pt DNAs No enter any relevant information around the DNA if necessary DNAs should not be recorded as a consultation EMIS DNA Field: Change Appointment Book>Slot Status to: Patient DNA (clinic slot) Visited patient not in (home visit slot) Patient DNAs first appointment Policy to offer another appt? Telephoned but no answer (tel. slot) Referral Triaged Referral inappropriate or transferred out of service? Referral Accepted Appointment Booked? Patient is unavailable for treatment EMIS Field: Completing a admin note Add Care Contact No Referral Rejectede.g. inappropriate, moved out of area No Referral Discharged e.g. pt died, refused appt Patient attended first appointment EMIS Field: Completing a consultation Add Care Contact All subsquent contacts and discharge following treatment EMIS Field: Add Care Contact EMIS Field:Reject Referral EMIS Field: Discharge Referral EMIS Field: Cancellation 1.Cancelled for Clinical Patient Cancelled First Appointment Reasons/Cancelled for Non-clinical Reasons 2.Appointment cancelled or postponed by Health Care Provider/Appointment cancelled by, or on behalf of, THE PATIENT M:\BCH\Divisions\Business Planning and Development\Performance\Policy and Guidance Notes Page 14

Use if no previous RTT period status National code National code definition Impact on RTT? 10 First activity in referral to treatment period. Clock continues 12 The first activity at the start of a new RTT period following a decision to refer directly to the consultant for a separate condition. 21 Transfer to another health care provider subsequent activity by another health care provider during a referral to treatment period anticipated. Clock continues Clock continues 30 Start of first definitive treatment. Clock Stop 31 Start of active monitoring initiated by the patient. Clock Stop 32 Start of active monitoring initiated by the care professional. Clock Stop 33 Did not attend the patient did not attend the first care activity after the referral. Clock Stop Clock Stop 34 Decision not to treat decision not to treat made or no further contact required. 35 Patient declined offered treatment. Clock Stop 36 Patient died before treatment. Clock Stop 92 Not yet referred for treatment, undergoing diagnostic tests by general practitioner before referral. 98 Not applicable activity not applicable to referral to treatment periods. No impact on clock activity not part of RTT period No impact on clock activity not part of RTT period 99 Not yet known. No impact on clock activity not part of RTT period M:\BCH\Divisions\Business Planning and Development\Performance\Policy and Guidance Notes Page 15

Use if previous RTT period status is present National code National code definition Impact on RTT? 10 First activity in a referral to treatment period. Clock continues 11 Active monitoring end first activity at the start of a new Clock continues referral to treatment period following active monitoring. 12 The first activity at the start of a new RTT period following a decision to refer directly to the consultant for a separate condition. Clock continues 20 Subsequent activity during a referral to treatment period further activities anticipated. Clock continues 21 Transfer to another health care provider subsequent activity Clock continues by another health care provider during a referral to treatment period anticipated. 30 Start of first definitive treatment. Clock Stop 31 Start of active monitoring initiated by the patient. Clock Stop 32 Start of active monitoring initiated by the care professional. Clock Stop 33 Did not attend the patient did not attend the first care activity after the referral. Clock Stop Clock Stop 34 Decision not to treat decision not to treat made or no further contact required. 35 Patient declined offered treatment. Clock Stop 36 Patient died before treatment. Clock Stop 90 After treatment first definitive treatment occurred previously (e.g. admitted as an emergency from A&E or the activity is after the start of treatment). No impact on clock activity not part of RTT period 91 Active monitoring care activity during active monitoring. No impact on clock activity not part of RTT period 98 Not applicable activity not applicable to referral to treatment periods. No impact on clock activity not part of RTT period M:\BCH\Divisions\Business Planning and Development\Performance\Policy and Guidance Notes Page 16

Appendix 2 DNA and UTA Procedure for Patients with Learning Disabilities, cognitive impairment, mental health conditions, English not first language etc. Rationale BCH has an overarching DNA policy that sets out guidelines and expectations regarding staff actions following an appointment where the patient has not attended. The policy sets out a requirement for service to have a local policy that broadly follows the overarching one while making reasonable adjustments for any specific patient needs. The process detailed below is to be followed by staff working with the patients mentioned above and is designed to support them to enable and empower patients to attend appointments and engage in treatment. Procedure Before a first appointment is made staff will contact the individual, carer or referrer to discuss preferred communication styles or needs.(as per AIS) Staff will arrange an appointment/visit based on the patients preferences and choices wherever possible. If the patient DNA s the appointment/visit the member of staff will contact them, carer or referrer to understand the reasons for the DNA and arrange a further appointment/visit based on any changes that may have come to light. 48 hours prior to the appointment/visit staff will make contact with the patient to confirm their attendance. If the patient DNA s the second appointment/visit the member of staff will contact them, carer or referrer to understand the reasons for the DNA and discuss if the service is really wanted or required. If it is agreed that another appointment/visit should be arranged the professional shall discuss and agree strategies with the patient, carer or referrer to support attendance. If it is agreed that another appointment/visit is not appropriate the patient will be discharged. If the patient DNA s the third appointment/visit the staff member will contact the patient, carer or referrer to discuss reasons for DNA and will recommend the patient is discharged unless there are exceptional extenuating circumstances that warrant a final fourth appointment/visit. If the patient DNA s the fourth appointment/visit they will be discharged from the service. M:\BCH\Divisions\Business Planning and Development\Performance\Policy and Guidance Notes Page 17

Guidance When discussing preferences with a patient, carer or referrer it may be helpful to bear the following in mind: Mental Capacity Consent Preferred communication style Ethnicity/Culture Location Time of day Other activities Gender of professional Support The above procedures are intended to offer structure and a framework to work within for the majority of patients, there will always be those patients that we work with who do not fit within the procedure who will need to be the subject of discussion either in team meetings or with your line manager to formulate the best course of action. Julie Collison Learning Difficulties Service Manager July 2016 M:\BCH\Divisions\Business Planning and Development\Performance\Policy and Guidance Notes Page 18