An Audit of Failure to Attend Rates

An Audit of Failure to Attend Rates

Louise Robertson

Smita Putti

Manor crescent Dental Centre,

Tullibody

Aim

It is beneficial to the economic running of a practice for available surgery time to be used as fully as possible for the treatment of patients. If appointments are not kept or are cancelled at short notice this results in underutilisation of surgeries which is uneconomical. This also affects patients who are waiting for appointments, or whose appointments are sometime in the future who would prefer to attend sooner if possible.

The aim of this audit is to try to reduce the level of appointments that are cancelled at short notice or not attended by 50% and also to develop a system by which such appointments can beallocated to other patients. In order facilitate this it is important to try and discover if possible why appointments are not kept and if this is related to particular groups of patients or types of treatment.

Method

We planned to collect baseline information about missed appointments for 1 month. This would then be analysed and a meeting held to discuss the results and develop a strategy for improvement. Any changes decided on would then be implemented for a period of 2 – 3 months after which point a second round of data would be collected for a month (in the same manner as the first round) This would then be analysed and compared to the baseline data to assess the efficacy of the new procedures.

Round 1.

For one month a log was kept for both of the dentists involved in this audit of all for appointments not kept or cancelled at short notice (i.e. less than 24 hours).

Dentist A works for 8 sessions every week, and dentist B works for 3 sessions each week. Both dentist work for one evening session.

In each instance the following information was recorded:

1)Day of the week /time of appointment (morning /afternoon /evening)

2)FTA/ reason given for cancellation.

3)Duration of the appointment missed.

4)Amount of notice given (to the nearest hour – 0 for FTA)

5)If the appointment was then offered to another patient.

6)Could the patient be described as a regular attender?

7)Type of treatment planned.

8)Dentist

The data collected is shown on page 13.

Analysis of first round data and discussion.

The data collected showed a total of 55 missed appointments over the 4-week period in question.

Only 9 (16%)of these appointments were subsequently allocated to other patients.

Of the 55 appointments 16 were classed as FTA (29%) in that they were not cancelled in advance by the patient.

Reasons for cancellation.

For the appointments which were cancelled several reasons were given. The most common was illness (or that of the patient’s child/children), accounting for 19 of the 55 appointments. Other reasons given:

1)unexpectedly having to work/ unable to get time off work (10 appointments)

2)transport difficulties (car break down /traffic/ bus not turning up) (7 appointments)

3)other reasons (waiting for workmen /no babysitter etc.) (3 appointments)

this information is shown as percentages in tables 1and 2 below.

Timing of missed appointments.

We found thatthe most likely time for appointments to be missed was Friday afternoon, as seen (combined with round 2 data) in the table 8, p10.

There did not appear to be any correlation between the dentists as to what time of day the missed appointments occurred (AM/PM/EVE) (see table 3)

Treatment missed.

We looked at the type of treatments due to be carried out at the missed appointments and correlated this information as to whether the appointment was cancelled or not.

We found that the most common type of appointment missed was actually an examination appointment (19 out of 55 appointments), with 45% being classed as FTA.The only other correlation with treatment type and FTA that was seen was for emergency or pain appointments .3 of these appointments were missed in the month in question – all being classed as FTA.

Of the 17 filling appointments missed, all but 1 were cancelled and the same applies to the 7 appointments for extractions.

(see tables 4 &5)

This data collection has highlighted several areas within our practice appointment system which could be improved. We decided at this point to choose one or two areas to concentrate on for the moment.

It was felt that the percentage of FTA exam appointments would be a good issue to tackle to begin with. If the number of examinations being carried out could be increased this would benefit practice profitability, but also if more patients attended for routine check-up appointments they would be less likely to require emergency appointments. The majority of regular attenders make their 6-month recall appointment on completion of their course of treatment. It was suggested that some patients may be forgetting these appointments as they were made so far in advance. We decide to telephone these patients in advance to remind and/or confirm the appointments. The practice had also been sending out examination appointments to irregular attenders and it was felt it would be beneficial to try and make these appointments by telephone in the future if possible.

We were not surprised by the small number of appointments that were reallocated, as there had not been much emphasis on this in the past. Most cases where the appointments were reallocated were due to another patient telephoning or attending the practice looking for an appointment at short notice when a cancellation had been made, rather than due to any proactive attempt to rebook. Many of our patients live close to the practice so it was decided to start keeping a list of patients who would be interested in short notice appointments, so that they could be offered any cancellation that arose.

Table 1

Table 2: Number of broken appointments per dentist

Table 3:Timing of missed appointments (percentage of all missed appts per dentist)

Table 4: type of treatment missed.

Table 5

Treatment missed in round 1 per dentist

Action

It was decided that we would attempt to telephone patients 1-2 days before their examination appointments in order to confirm them (or remind those who had forgotten). If the patient could not be reached a voice mail was left where possible. If the number was unavailable/incorrect, a message was placed on the patients record so that the number could be updated when the patient next attended.

Patients who were likely to need multiple appointments were asked if they would like to be placed on the new short notice list. For many people this was not suitable, due to work commitments or the inability to attend at short notice. However, for those who indicated they would find the service useful the reception staff kept a list of names and contact numbers, (sorted by dentist) at the reception desk.

Round 2

Unfortunately ,implementation of these changes has not progressed smoothly due to one nurse leaving and two other members of staff experiencing serious illness of close family members .The practice has therefore experienced severe staff shortages meaning that there has only been a member of staff dedicated to reception duties for 1.5 days a week for the last 3 months instead of reception being manned full time ( 5 days including 2 evenings ).On days when there is no dedicated reception staff it has not often been possible for someone to telephone patients from the short notice list to try and fill cancelled appointments , however ,It has still been possible to contact a large number of patients by telephone in advance of their appointments so we decided to go ahead with the collection of a second set of data as planned in order to assess the effect of the work which has been completed

Round 2 of data collection was carried out over a period of 4 weeks as with round 1 and the results are detailed on page 15.

Analysis of second round data and discussion

The number of missed appointments was found to have decreased from 55 to 31, of these 8 were offered to other patients (26%)

The overall number of appointments classed as FTA in round 2 is 7 (22%), compared to 16(29%) in round 1.

The percentage of broken appointments for each dentist has not changed considerably between the 2 rounds of data collection. In each round 81% of the missed appointments were for appointments with dentist A. This is not in proportion to the number of hours each dentist works (dentist A works 30hrs/week and dentist B works 9 hrs/week) however it was felt that this was due to the fact that dentist A’s appointment book is busier than that of dentist B . We have not assessed the number of broken appointments in relation to either the total number available or the number of appointments that were kept.

Reasons for cancellation

It can be seen that there is a drop in the percentage of missed appointments classed as FTA. This inevitably increases the percentages of the other reasons for missed appointments, but if a patient is telephoning the practice to cancel an appointment it is likely that they will make another appointment at that point. This is preferable for the practice as it reduces surgery down time; that less time is spent on trying to contact and reappoint patients who FTA; and that more patients can take advantage of short notice appointments.

The most common reason for a missed appointment in round 2 was given as illness (42%). this now accounts for a larger proportion of missed appointments than FTA. (see tables 6&7- including comparisonwith round 1.)

Timing of missed appointments.

For most days the number of missed appointments has decreased. Wednesday afternoons and Monday mornings remain the same but the non-attendance rate has actually risen for Monday afternoons. (see table 8)

It may be that Mondays are a problem due to the fact that patients are unable to contact the practice over the weekend if they are unwell or anticipate difficulties in attending.

Treatment missed.

The types of treatments due to be carried out at missed appointments for both rounds is shown in tables 9&10.There is a general reduction in all categories , but this is most marked with the examination appointments. It is more difficult to see any effect in the figures for dentist B , but this is most likelt due to the small numbers involved .

Table 6

Table 7: Number of broken appointments per dentist -round 2

(round 1 shown in red)

Table 8

Table 9

Table 10: treatment missed in Round 2 per dentist

(round 1 shown in brackets)

Conclusion

The results of this audit are somewhat disappointing.

We aimed to achieve a reduction in FTA (appointments cancelled with no notice or not attended)of 50%, but in fact have only achieved a reduction of 25%.The total number of missed appointments ( including those cancelled with some notice) has fallen by approximately 46%.

We had also hoped to increase the number of cancelled appointments being offered to other patients. This has risen by approximately 60% on previous level, but still only represents 30% of the total number of appointments cancelled at short notice that are potentially available to other patients.

Future Action

As mentioned above, implementation of the changes proposed after round 1 has been hampered by staffing problems. These have now been rectified, so it is hoped that the changes can now be implemented more fully, which should result in further improvements in the future.

We are also looking into the options of upgrading our computer system to enable automatic text messaging of patients with reminders of their appointments. This would radically decrease the amount of time currently spent telephoning patients, so would be less affected by future staffing problems.

We have decided our first priority is to continue to focus on reducing the overall number of missed appointments as far as is possible and intend to repeat the data collection / analysis after a further 3-6 months to monitor the situation. Our second priority is to try and rebook more of the cancelled appointments by means of lists of patients seeking short notice cancellations.

There are several issues which we have not investigated, but which would be interesting to pursue in future audits. These could include:

1)measuring the number of missed appointments in relation to the number available and / or the number of appointments that were booked initially.

2)considering the amount of surgery time that is lost due to missed appointments, rather than just the number of appointments lost.

3) the effect of cancellations due to patients having to work – would a change in opening hours (earlier or later) be useful?

FTA audit Data collection sheet – round 1

FTA audit Data collection sheet – round 2

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