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Improving Timely Access and Attendance in Outpatients

Project Added:
9 December 2015
Last updated:
18 December 2015

Improving Timely Access and Attendance in Outpatients


This project implemented processes to improve the availability of appointments, including a referral triage system, appointment reminders and a new non-attendance policy.

View a poster of this project from the Centre for Healthcare Redesign graduation, 2014.


To increase the percentage of acute physiotherapy outpatients who are seen in less than 14 days from 60% to more than 80% and decrease the percentage of patients who don’t attend appointments, from 15% to less than 11%.


  • Improves resource allocation and provides staff with dedicated time to complete administration tasks.
  • Encourages patients to take responsibility for their healthcare and attend appointments.
  • Reduces lost revenue due to high ‘Did Not Attend’ (DNA) rates.
  • Delivers services more efficiently and effectively, to improve patient outcomes.
  • Improves communication between the patient and outpatient clinic.


In 2012, 342 (40%) acutely referred physiotherapy patients at Westmead Hospital breached the 14-day access time set as a key performance indicator. Delayed access to physiotherapy can lead to poor post-operative outcomes, increased disability and prolonged rehabilitation. In this same period, 991 (15%) booked appointments had patients that DNA. This represented $200,000 in potential lost funding annually.

These results, combined with the increased demand for acute outpatient services without any foreseeable increase in resources, indicated a need to redesign the delivery of outpatient physiotherapy services at Westmead Hospital.


  • Consultation took place with 36 physiotherapy staff, 10 patients and two carers to identify key issues with current process. These included:
    • no dedicated time for staff to make bookings
    • difficulty with the clinic contacting patients and vice versa
    • no free physiotherapy timeslots available for new patient appointments
    • patients forgetting to attend appointments, resulting in high DNA rates.
  • As a result of this consultation process, the following solutions were put in place:
    • a triage system for referrals was introduced, where referrals are prioritised as acute, 30 or 60 minutes in length
    • administration time was set aside for staff to perform acute bookings
    • a voicemail system was introduced so patients have a way to contact the clinic
    • dedicated physiotherapy time was allocated to new or acute cases to ensure more timely access for high-priority patients
    • an SMS and automatic telephone reminder system was introduced to remind patients of upcoming appointments
    • a robust non-attendance policy was introduced to encourage patients to inform the clinic in advance when they can’t attend an appointment.

Key dates

  • Project start: April 2013
  • Project finish: February 2014

Project status

  • Sustained - The project has been implemented, is sustained in standard business.

Implementation site

  • Westmead Hospital Physiotherapy Outpatients Clinic


  • Centre for Healthcare Redesign


  • DNA rates showed significant improvement. In 2013 we had 1080 appointments lost to DNA which equated to 13% of all appointments. SMS reminders were implemented in October 2013. In 2014 we had 894 appointments lost to DNA which equated to 10% of all appointments. This represents a 22% improvement in patient attendance.
  • The number of acute patients seen within 14 days continued to fluctuate from the project start in April 2013 (59%), project implementation in August 2013 (67%) and project completion in February 2014 (81%). It did not consistently achieve the goal of more than 80%.

Lessons Learnt

  • Further redesign is now being considered, including the use of a student workforce to support administration duties and further changes to the appointment structure.
  • It is expected that DNA rates will continue to improve, but more dramatic changes may be required to achieve timely access for patients.
  • The project was implemented at a time of reduced staffing due to school holidays and annual leave, which affected the ability to consistently implement changes.

Further Reading

  • Greensmith, S. Physiotherapy Outpatient Efficiency: a project that reduced DNAs by 47.7%. United Kingdom: NHS Foundation Trust; 2013.
  • Hasvold PE, Wootton R. Use of telephone and SMS reminders to improve attendance at hospital appointments: a systematic review. Journal of Telemedicine Telecare 2011; 17: 358-364.
  • Liew SM, Tong SF, Lee VKM et al. Text messaging reminders to reduce non-attendance in chronic disease follow-up: a clinical trial. British Journal of General Practice 2009; 59: 916-920.
  • NHS Institute for Innovation and Improvement. Improving Patient Flow in the NHS: Case studies on reducing delays. United Kingdom: Ealing Hospitals NHS Trust; 2008.
  • NHS Institute for Innovation and Improvement. DNAs – Reducing Did Not Attends. United Kingdom: Derby Hospitals NHS Foundation Trust; 2008.
  • Price H, Waters AM, Mighty D et al. Texting appointment reminders reduces 'Did not Attend' rates, is popular with patients and is cost-effective. International Journal of STD & AIDS 2009; 20: 142-144.
  • Taylor NF, Bottrell J, Lawler K, Benjamin D. Mobile telephone short message service reminders can reduce nonattendance in physical therapy outpatient clinics: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation 2010; 93: 21-26.


Caleb TehPosition: Physiotherapist
Westmead Hospital Physiotherapy Department
Western Sydney Local Health District
Phone: 0407 387 188

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