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Did Not Attend (DNA) and Cancellation
Policy and Operational Guidelines
Document Number
Version
Ratified By & Date
Name of Approving Body(s) &
Date(s)
FPE-004
V1
Safety and Effectiveness Sub-Committee
Safety and Effectiveness Sub-Committee
Job Title of Document Author
Name of Responsible Committee
Executive Director
Date Issued
Expiry Date (Maximum Two Years)
Target Audience
Corporate Performance and Information Lead
Safety and Effectiveness Sub-Committee
Director of Finance and Resources
December 2014
December 2016
All staff involved in booking appointments and
staff that conduct appointments
This document may be made available in a different format
By contacting the Author of the Document
Did Not Attend (DNA) and Cancellation Policy and Operational Guidelines V1 Final
Version Control – Review and Amendment Log
Version
V1.0
V1.1
V1.2
V1.3
V1.4
Type of Change
Document Update
Date
Description of Change
20.02.2014
Update policy following
feedback from Commissioners
Feedback
from 01.04.2014
Updated policy into Trust Policy
initial
consultation
format.
and
User
and
Patient Forum
Further
feedback 25.04.2014
Update policy following
following
above
comments regarding feasibility
revision
of offering two appointments
Feedback
from 02.05.2014
Change to 6.2.3 from six weeks
Safety
&
to three weeks
Effectiveness SubCommittee
Feedback
from 26.08.2014
Changes following feedback
Commissioners and
from Commissioners and User
User Forum
Forum
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Did Not Attend (DNA) and Cancellation Policy and Operational Guidelines V1 Final
DOCUMENT SUMMARY
Document Title
DNA/Cancellation Policy
Document Status
New
X
Date of Publication
9 April 2014
Key Points
Revision
The length of time that a patient waits for an appointment or treatment can impact on
their experience with the Partnership Trust. It is also an important quality issue and
is a visible public indicator of the efficiency of the Partnership Trust.
The NHS constitution provides patients with the right to access services within
maximum waiting times. Commissioners have also identified a number of local
targets whereby patients must be offered an appointment and seen within a set
number of weeks. Contractual penalties can be imposed should the Partnership
Trust fail to meet these targets.
The Partnership Trust will seek to ensure that all patients/service users are seen as
early as possible during their pathway. However, one of the major obstacles to this
is when a patient/service user Does Not Attend (DNAs) their appointment. This
results in an inefficient use of clinical time and also the slot to go unused rather than
it being offered to another patient. The Partnership Trust has a contractual target
that DNA’s account for no more than 7.5% of appointments. Currently, in 2013/14
the Partnership Trust is within its target at 4.7%, however, this equates to 81k DNA’s
out of 1.7M appointments. Using an average shadow cost and volume tariff, this
would equate to lost revenue of £5M+ across the whole Partnership Trust area.
The policy provides the process for dealing with patients/service users who
DNA/cancel appointments by:
Advising how patients/service users should be dealt with should they DNA
their first or subsequent appointment. It also details when patients/service
users continually cancel or rearrange their appointments
Clarifying the exceptions to the policy
Complying with all national Referral to Treatment (RTT) Guidance
Detailing how the rules of the policy affect the RTT and local waiting time
clocks
The guiding principle of this policy is to support the treatment of all
patients/service users and so, therefore, flexibility will be maintained where
the clinical judgement is that it is in the best interests of the patient to refrain
from any part of the policy
Available Support
Professional Leads
Performance Team
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Did Not Attend (DNA) and Cancellation Policy and Operational Guidelines V1 Final
Contents
1. Introduction .......................................................................................................... 5
2. Purpose ............................................................................................................... 5
3. Explanation of Terms ........................................................................................... 6
4. Duties and Responsibilities .................................................................................. 6
5. Exceptions ........................................................................................................... 7
6. Quick Reference Guide ....................................................................................... 7
7. Training and Resource Implications..................................................................... 9
8. Consultation, Approval and Ratification Process ................................................. 9
9. Equality Analysis Summary ............................................................................... 10
10. Monitoring Compliance with the Document ....................................................... 11
11. References and Supporting Documents ............................................................ 11
12. Policy Review .................................................................................................... 11
Appendix 1 - Equality Analysis ................................................................................. 12
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Did Not Attend (DNA) and Cancellation Policy and Operational Guidelines V1 Final
Did Not Attend (DNA) and Cancellation
Policy and Operational Guidelines
1.
Introduction
This Policy ensures that all relevant staff (including admin / clerical) employed
by Staffordshire and Stoke-on-Trent Partnership NHS Trust (Partnership
Trust) apply a clear and consistent approach to dealing with patients/service
users that DNA or cancel their appointment. This policy is disseminated to
patient/service user groups so that there is maximum awareness of the
implications of the policy.
2.
Purpose
The policy aims to inform all relevant staff and patients/service users about
how the Partnership Trust will respond when patients/service users DNA,
cancel or postpone an appointment. It adheres to the principles of the RTT
national guidance and aims to ensure that all patients receive treatment in
accordance with the NHS Constitution.
The guiding principle of the policy is to support the effective treatment of
patients/service users through their respective pathways. Whilst it is
acknowledged that there are many reasons for appointments to be moved,
regular postponements, particularly at short notice, can hinder a
patient/service user’s treatment/support. Along with DNAs, this can lead to
unused appointment slots which is both an inefficient use of staff time and
delays the treatment of other patients/service users.
The NHS constitution states that patients have the right to access certain
services commissioned by NHS bodies within maximum waiting times. The
Partnership Trust also has a number of contractual waiting times for access to
services. There are penalties for failure to meet these waiting times.
Patients/service users often choose to wait longer for an
appointment/treatment and the Partnership Trust is keen to support
patient/service user choice. However, it is essential that procedures are in
place to ensure that the Partnership Trust is not penalised for supporting this
patient choice, should this impact on waiting time performance. Therefore,
the policy also includes reference to how DNAs and cancellations impact on
various waiting time clocks.
The Partnership Trust should also ensure that it considers ways to reduce
DNAs where possible by utilising technologies to send reminders prior to
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Did Not Attend (DNA) and Cancellation Policy and Operational Guidelines V1 Final
appointments and ensure that patients/service users are contacted in the
most appropriate manner taking into account the diverse needs of
patients/service users.
3.
Explanation of Terms
For the purpose of this document, the following terms apply
Term
Patient/Service
User
DNA
Cancellation
RTT
Clock
Discharge
Vulnerable
Adult
4.
Explanation
The term “patient” and “service user” refers to all adults
aged 16years and over
Where a patient/service user does not attend an
appointment, without giving prior notice
Where a patient/service user gives prior notice that they are
unable to attend a previously agreed appointment
The time waited from Referral to Treatment (Consultant-led
and Allied Health Professional)
Each patient on a pathway has a waiting time clock, which
counts the time from referral to clock stop. Depending on
the particularly pathway, the clock can be stopped at the
first appointment, commencement of treatment, or nontreatment such as a DNA.
The discharge of a patient/service user out of the Trust’s
services and back to the referring agency
A person aged 18 years and over “who is or may be
in need of community care services by reason of
mental or other disability, age or illness; and
Including some people who may have capacity as
well as those who do not.
Who is or may be unable to take care of him or
herself or unable to protect him or herself against
significant harm or exploitation
Duties and Responsibilities
It is the responsibility of all professionals to ensure documentation, and
information for patients is legible and free of abbreviations, dated and timed,
and signed with their name and designation clearly printed. Any information
given to patients should be made available in the appropriate language and
format preferred by the patient. Interpreters should be engaged where
necessary to ensure patients have as full an understanding as possible as to
the implications of this policy.
It is the responsibility of all staff that arrange or conduct appointments with
patients/service users to ensure that they are familiarised with the
requirements of the policy and that they are assured that these requirements
have been conveyed to patients/service users.
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Did Not Attend (DNA) and Cancellation Policy and Operational Guidelines V1 Final
5.
Exceptions
Flexibility will be maintained where the clinical judgement is that it is in the
best interests of the patient to refrain from any part of the policy (other than a
DNA for a first appointment). Other exceptions include children and young
persons, vulnerable adults, cancer pathways, offender health and sexual
health.
A Vulnerable adult is defined in accordance to the Department of Health
(2000) No Secrets:
•
As a person aged 18 years and over “who is or may be in need of
community care services by reason of mental or other disability, age or
illness; and
•
Including some people who may have capacity as well as those who do
not.
•
Who is or may be unable to take care of him or herself or unable to
protect him or herself against significant harm or exploitation”
Procedures will be developed for these excepted areas and included as
appendices to this policy.
6.
Quick Reference Guide
6.1
DNA
6.1.1 First Appointment for all service types
Patients/Service Users who DNA their initial appointment will automatically be
discharged. This will be communicated to the patient and also the referrer
within five working days. It is important that the Partnership Trust can
demonstrate that the appointment was communicated to the patient/service
user therefore this must be recorded within the patient/service user record.
The patient/service user is removed from the waiting list with immediate effect
and the 18-week clock nullified.
However, if there are clinical reasons why another appointment should be
offered, then a second offer will be made and a copy sent to the referrer
advising them of the initial failure to attend. This would commence a new 18week clock start.
6.1.2 Follow-Up Appointment for all service types
Patients/Service Users who DNA any subsequent appointment will be
discharged unless there are clear clinical reasons otherwise. This will be
communicated to the patient and also the referrer within five working days. It
is important that the Partnership Trust can demonstrate that the appointment
was communicated to the patient/service user therefore this must be recorded
within the patient/service user record. Should the patient/service user still
wish to receive treatment, then they must be re-referred and this starts a new
clock.
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Did Not Attend (DNA) and Cancellation Policy and Operational Guidelines V1 Final
The Partnership Trust should endeavour to ascertain reasons for DNAs in
order to identify any recurring themes and identify any improvements required
to the appointment booking process.
6.2
Cancellations/Alterations
6.2.1 Partnership Trust Cancellations for all service types
It is important to distinguish between cancellations by the patient/service user
and cancellations by the Partnership Trust. Where the Partnership Trust
cancels a patient/service user’s appointment, this will not stop the clock and a
new appointment should be offered to be held within four weeks of their
original appointment.
6.2.2 Patient/Service User Does Not Require Appointment for all service types
Where a patient/service user cancels their first appointment stating that
treatment is no longer required then the patient/service user is removed from
any waiting list and their clock stopped. The referrer must be informed of the
patient/service user’s decision to cancel the referral.
6.2.3 First Appointments
Consultant Led/AHP 18 week RTT pathways
Upon receipt of a referral, a patient/service user will be offered two
appointments within three weeks.
For patients who decline these offers, should the patient/service user be
available within a further period of four weeks from this appointment then a
further offer of an appointment should be made. Should the patient/service
user not be available within this four week period, then they shall be referred
back to their referrer.
Local Waiting Time Targets
Upon receipt of a referral, a patient/service user will be offered two
appointments within a reasonable timescale. This will be dependent upon the
particular target for the service.
For services with a local waiting target, the clock will stop following the decline
of one offer of an appointment and the decline of a further offer of an
appointment within a two week period of the original offer. Should the patient
not be available within this two week period, then they shall be referred back
to their referrer.
6.2.4 Patient/Service User Alteration of First and Follow-Up Appointments for all
service types
If a patient/service user wishes to alter their appointment for a period of up to
six weeks then a further offer of an appointment will be made. If the
patient/service user wishes to alter their appointment for a period in excess of
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Did Not Attend (DNA) and Cancellation Policy and Operational Guidelines V1 Final
six weeks the Trust will discharge them back to the referrer recommending a
new referral is made when the patient/service user is able to be seen.
Any requests for a second alteration within a pathway will be rejected and, if
the patient/service user is unwilling to keep their appointment, then the
patient/service user will be discharged back to the referrer unless there is
clear clinical objection.
7.
Training and Resource Implications
A suitable training package is being developed for all appropriate staff to
ensure the awareness of the policy and the RTT/waiting times. These are
currently covered in the clinical IT system induction training but a more
tailored approach is necessary. The RTT/Local Waiting Group will lead on the
development of this training, so that the needs of staff can be configured into
the training.
Understanding the reasons for DNAs and cancellations could require
additional resource to record and collate this information, therefore, this will be
reviewed following the implementation of the policy.
Utilising technologies for appointment reminders will require additional
resource, although current clinical IT systems already have the functionality.
It is acknowledged, however, that support from the Information management
and Technology function of the Partnership Trust will be necessary to facilitate
this.
The Trusts approach to waiting list management is currently being reviewed
with the intention of implementing a Trust-wide Access Policy, of which this
DNA/Cancellation policy will form part of. Once the DNA/Cancellation policy is
approved it will be necessary to revisit business processes to ensure
compliance with all elements.
8.
Consultation, Approval and Ratification Process
Consultation
The draft policy has been shared widely to ensure that the policy is complete,
correct and acceptable as a working document. The comments generated
from the consultation have been considered by the author and appropriate
colleagues.
The author of procedural documents has identified relevant stakeholders and
the level of involvement for development, consultation or receipt of final
procedures.
The author has consulted with operational colleagues, commissioners and
User and Patient Forums in developing the final version.
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Did Not Attend (DNA) and Cancellation Policy and Operational Guidelines V1 Final
As part of the Trust’s commitment to employee involvement and the
agreement with staff side representatives, the procedural documents which
have an impact on employee practice and their working lives are subject to
consultation with staff side representatives.
Document Approval & Ratification
Committees
The Committees reporting to the Trust Board must consider and comment on
relevant strategic and policy documents in the context of their terms of
reference and provide support and/or suggested change.
A report will be provided to the Trust Board at each meeting of the approved
procedural documents for ratification, in the form of a report. The aim of this is
to provide assurance that procedural documents are in place and available for
staff to implement (via the intranet and the Register of Procedural
Documents).
The Committees are not required to approve guidance, procedures and
protocols unless it is deemed appropriate. The Groups and Sub-Groups will
approve these documents.
The Committee will receive a report for assurance and where necessary
ratification at each of its meetings on those documents which have been
approved by the Groups.
Committee and Group members will be included as appropriate as part of the
consultation procedure.
9.
Equality Analysis Summary
Staffordshire & Stoke on Trent Partnership NHS Trust considers how the
decisions it makes affects people who share different protected characteristics
(race, disability, sex, gender re-assignment, religion/belief, sexual orientation,
age, marriage and civil partnership, pregnancy and maternity). The Trust also
recognises that there are groups/communities that are recognised at a local
level within society as excluded or disadvantaged in addition to those listed as
protected groups above and this document is inclusive to these groups also
for example, young teenage parents, homeless people etc.
A completed equality analysis is presented at Appendix (1) of this document.
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10.
Monitoring Compliance with the Document
Some groups in society, who are vulnerable to social exclusion, are forgotten
simply because not enough is known about their particular circumstances, this
is also true of the processes surrounding DNAs and cancellations. The
Partnership Trust will monitor the DNA/cancellation process and the functions
covered in this policy to ensure that it is implemented fairly irrespective of age,
race, gender, sexual orientation, disability or religion. Statutory duties exist
under the Equality Act 2010 and, where appropriate, equality data will be
published in the Equality and Human Rights Annual Report and to the Trust
Board.
Compliance with this policy will be monitored by formal Trust groups. Where
any monitoring has identified deficiencies, a risk assessment must be
included on the appropriate local risk register, with an action plan to address
any gaps identified. The action plan will be monitored in accordance with
Trust Policy: Risk Management and Assurance Strategy.
11.
References and Supporting Documents
NHS Constitution http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Pages
/Overview.aspx
Consultant-led RTT Guidance
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/
198930/Referal_to_treatment_Rules_Suite.pdf
Allied Health Professional RTT Guidance
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/
215248/dh_131969.pdf
12.
Policy Review
This policy will be reviewed in two years following ratification or sooner if the
necessity arises as part of the Trust-wide Access Policy.
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Did Not Attend (DNA) and Cancellation Policy and Operational Guidelines V1 Final
Appendix 1 - Equality Analysis
DNA/Cancellation Policy
STEP 1: What is the background and starting point for this policy?
How the Partnership Trust deals with patients/service users that DNA/cancel their
appointments differs across services. Although there is national guidance on RTT
pathways, some of this guidance can only be implemented once it has been
agreed locally. In addition, there are many services not applicable to RTT,
therefore, local guidance is required for these services.
STEP 2: What do we want to achieve?
A consistent methodology for dealing with patients/service users that DNA or
cancel appointments and to ensure that patients/service users are aware of the
implications of such actions.
STEP 3: What do we know?
Procedural documents should not be developed in isolation and their introduction
should be balanced against the priorities of the Trust. The organisation needs
formal written documents which communicate standard ways of working. These
help to clarify strategic and operational requirements and they can improve the
quality of work and increase the successful achievement of objectives.
STEP 4: What consultation has been taken: engagement and involvement?
Consultation has been undertaken with a number of target audiences in
developing this procedural document. An initial draft was communicated to
professional leads prior to approval by the Safety and Effectiveness SubCommittee. Following review by Commissioners, the policy has been revised
following liaison with operational staff and patient groups.
STEP 5:
The policy clearly references (section 10) the importance of ensuring that the
consent process is not prejudiced by any factors outlined in the Equality Act
(2010). Advice is given to staff as to help individuals receive adequate and
appropriate information to make informed decisions.
Support will be given by the Performance Team, Professional Leads and
Corporate Governance Team for the implementation and supporting of the
DNA/Cancellation Policy and process. Support will be in a variety of ways eg face
to face meetings, telephone, email or in the form of training and awareness
sessions when indicated at a mutually convenient time, day and venue.
This policy is explicit that this will not affect the treatment or care of any person or
impact upon by race, age, gender, disability, religion or belief,
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Did Not Attend (DNA) and Cancellation Policy and Operational Guidelines V1 Final
STEP 6: Have you identified any actions:
The comments received as part of the consultation procedure have been taken
into consideration and subsequent amendments have been made as outlined in
the Version Control section of this document.
Resources are available to provide advice and support on this policy which will be
available to all members of staff.
STEP 7: How will we know that the policy has been successful?
The monitoring and reporting arrangements are provided within this policy.
Performance activity is reported monthly as part of the Trust’s contractual Key
Performance Indicators. An annual audit will be implemented with a report been
presented to all relevant Boards, Committees and Groups.
STEP 8: Executive Summary
The guiding principle of this policy is to support the treatment of all patients/service
users and so, therefore, flexibility will be maintained where the clinical judgement
is that it is in the best interests of the patient to refrain from any part of the policy
.
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Did Not Attend (DNA) and Cancellation Policy and Operational Guidelines V1 Final