Using quality improvement methodology to reduce Did Not Attends in healthcare within a UK prison

His Majesty's Prison East Sutton Park is an open prison and young offender institution for women in Maidstone, England. In 2022, it developed a high Did Not Attend (DNA) rate of 21% per week across all five core healthcare clinics. Services with a high DNA rate increase waiting times for other patients, increase cost wastage and reduce efficiency and resource management. DNAs occur across all parts of the National Health Service with different levels of severity; however, DNAs within a prison create a unique challenge not shared with community services due to the setting. This quality improvement project aimed to reduce and sustain a below 10% DNA rate.

The healthcare team worked in partnership with the prison to develop a quality improvement project using the Model for Improvement, which had a clear aim, measures and change ideas tested using Plan-Do-Study-Act cycles. The outcome measures were plotted using Statistical Process Control charts to highlight and track the improvements.

There was an 86% decrease in DNAs across all five core healthcare clinics. The overall DNA rate was reduced from a pre-intervention rate of 21% per week to 3% per week post-intervention. Clinical time wasted decreased by 76% from a pre-intervention of 284 minutes per week to 66 minutes per week post-intervention. Cost wastage for missed appointments decreased by 67% from a pre-intervention of £303 per week to £99 per week post-intervention. These core outcome measures have been sustained for more than 35 weeks (August 2023 to April 2024) and continue to be sustained.

Implementing standard processes and systematic change ideas, including developing partnership working with the prison and better engagement with patients, led to a significant and sustained reduction in DNAs. During the project time frame, there was also no change in the number of patient complaints about healthcare.