Virtual Clinic Review - A Patient- Centred Mechanism for Optimising Flow. Katie Cuthbertson Lech Rymaszewski Gavin Love Jane McEachan

Transcription

1 Virtual Clinic Review - A Patient- Centred Mechanism for Optimising Flow Katie Cuthbertson Lech Rymaszewski Gavin Love Jane McEachan

2 National Programme Aims Reduce Variation Achieve reliable implementation Spread across NHS Scotland and other outpatient settings Right patient, right time, right place, right team, every time

3 Support National WSPFIP Team Clinical support Lech Rymaszewski Margaret Nugent Review of variation Understand current pathways of care Consider and develop real time data resources to monitor change and ensure change is an improvement Development of Evidence Base Provide clear evidence base of best practice Economic Evaluation Sharing Dedicated web page Clinical support network Patient leaflets Central site for resources

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5 NHS INERTIA v slow to adopt change BARRIERS?

6 GENERIC PROBLEMS OF MEDICINE? BEST PRACTICE Everyone wants to do what is best for patients Medical culture of divergence in opinion BUT - not everyone can be right Unwarranted variation impacts negatively on overall clinical care (potential overtreatment) Costs of poor clinical decisions, both diagnostic and treatment, borne by the patient and society

7 If maths was taught like medicine

8 BETTER VALUE Docs / Nurses Casts / crutches Xrays Physio Admin / clerical Management Transport - Ambulance/taxis Porters / Domestics Estates

9 NHS CHANGE MANAGEMENT ELECTRONIC TOOLS CULTURAL CHANGE EVIDENCE-BASED MANAGEMENT

10 DON BERWICK We have to be weaned from this volume-driven system -no longer asking How much did we do today? But How much did we help today?

11 PRINCIPLES - a bottom-up process Start with patient clear, patient-focused aims Clinically-driven vision Grass-root consensus inclusive (Patient Information Leaflets) Real-time database > accountability allows trouble shooting + audit cycles > credibility and trust Informal communication crucial

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13 Virtual Fracture Clinic Experience Mr Gavin Love Consultant Orthopaedic Surgeon

14 Traditional Fracture Clinic All new out-patient fractures/injuries over previous 24hrs Large numbers Often little done Duplication of ED work Unnecessary visit Poor training opportunity

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16 Aims To improve patient flow To reduce local variation To bring the right patient at the right time to see the right person Free up time and re-invest

17 Process Expedition to Glasgow

18 Process Redesign Element 1 Discharge patients with agreed injuries straight from ED with self-care advice and a leaflet Paediatric clavicle fracture Buckle/torus fracture Minimally displaced radial head fractures Mallet fingers Fifth Metacarpal fractures Fifth Metatarsal fractures Adaptation/Adoption of 6 discharge leaflets

19 Collaboration Close liaison with ED Medical and Nursing Staff

20 Process Redesign Element 2 Use Velcro splints/boots All cases where clinically appropriate (saves plastering time and materials and doesn t make a return appointment inevitable)

21 Process Redesign Element 3 Tayside wide protocol for specific fractures agreed Apply to all ED and MIU departments Adopt as SOPs

22 Process Redesign Element 3 Conduct Virtual review and only see patients who need something done All new ED referrals via virtual clinic Virtual clinic daily (1 st hour of a fracture clinic) Senior nurse and Consultant XR and ED notes reviewed Letter to patient (and exercise/advice sheets) and copy to GP Nurse telephones patient after VC Brought back at the right time to the right clinic to HAVE SOMETHING DONE Virtual discharge if nothing to be done Open access giving patient Option to return

23 Result 6 Leaflets Snapshot audit sample size Pre-redesign 127 Post-redesign % overall reduction in weekly referrals from ED to virtual/fracture clinic

24 Result The 6 discharges from ED 437 NW patients from Jan-Oct Ninewells PRI Total Nov Dec Jan Feb Mar April May

25 Number of apts Result Monthly number of Urg ent Appts - F rac ture C linic NW Urgent Median Tes t w ith 6 frac ture pres entations virtual c linic introduc ed Oct-11 Nov-1 1 De c-11 J an-12 F eb-12 Mar-12 Apr-12 May-12 J un-12 J ul-12 Aug-12 S ep-12 Oct-12 Nov-1 2 De c-12 J an-13 F eb-13 Mar-13 Apr-13 May-13 J un-13 J ul-13

26 Result Oct-11 Nov-1 1 Monthly number of Urg ent Appts - F rac ture C linic P R I De c-11 J an-12 F eb-12 Mar-12 Apr-12 May-12 J un-12 J ul-12 Urgent Median Aug-12 S ep-12 Oct-12 Nov-1 2 Tes t w ith 6 frac ture pres entations De c-12 J an-13 F eb-13 Mar-13 Apr-13 May-13 J un-13 J ul-13

27 Result pre redesign post redesign cast splint

28 Result 100% 80% 60% 40% 20% admission from virtual return appt.from virtual discharge code from virtual 0% Feb Mar Apr

29 Patient Satisfaction Enough info from ED-injury Enough info ED follow-up Prefer clinic to phonecall Used contact number Happy with outcome and info Yes No

30 Effect on the Service Fewer patients More time for those that do attend, quality service, less rushed More direct access to subspecialist clinics Fewer inappropriate attendances More focussed Consultant led and delivered Time freed up for training of juniors Virtual clinic used as teaching clinic Adoption by plastics for all hand injuries Possibility of merging some fracture clinics in Angus Time before fracture clinic to anticipate who/what is coming and request XRs digitally in advance, streamlining their attendance

31 Teething Problems Very few! ED Nursing staff concerns over time/expertise to apply splints Some disquiet towards plaster room staff

32 Tips and Advice Ensure an adequate safety net Radiologist report for ED XRs Consultant virtual clinic review within 24-48hrs Telephone call and letter to patient Contact numbers given to patient at time of ED attendance and at virtual clinic Open door policy Paper/audit trail Normal process for GP contact with Ortho Reg continues ED Consultant can over-ride at their discretion

33 Summary Patient centred Patients like it Less unwarranted variation Better quality care ED like it Surprisingly straightforward to initiate

34 Questions?

35 Virtual Hand Clinic Queen Margaret Hospital, Fife

36 Virtual Hand Clinic Based on GRI Virtual Fracture Clinic Aims to reduce number of Out Patient Visits Streamlining of pathways Cut waiting times Improve patient understanding

37 Virtual Hand Clinic

38 Information Ganglion Mucous Cyst Carpal Tunnel Syndrome Lumps / Bumps

39 Information - key to patient understanding

40 Information - set out in black and white

41 Last 1 year RMS outcomes New = 56% Total Number of RMS Referrals = 1911

42 Last 1 year results Total number of results reviewed in virtual clinic = 1606

43 Last 1 year results Total number of results reviewed in virtual clinic = 1606

44 Tippers!

45 PRINCIPLES Evolution not revolution - using a bottom-up process Start with patient Grass-root consensus inclusive (Patient Information Leaflets) Real-time database > audit cycles > credibility Informal communication crucial

46 PRINCIPLES Evolution not revolution - using a bottom-up process Start with patient Grass-root consensus inclusive (Patient Information Leaflets) Real-time database > audit cycles > credibility Informal communication crucial