CREATING EFFICIENT OUTPATIENT SERVICES

Transcription

1 1 CREATING EFFICIENT OUTPATIENT SERVICES Measuring the Demand on the Service How many entry points are there into the service? Who manages the service entry points? Are all of them needed? 6 How can a prospective capacity modelling tool support a responsive service? Is there flexibility within Jobs Plans to provide prospective cross cover and respond to changes in demand? Is workforce activity monitored to facilitate service development? 2 Managing the Primary / Secondary Care Interface Are there effective referral protocols? Is useful feedback provided? Are advice only referrals possible? OUTPATIENT SERVICES 5 Maximising Workforce Productivity Are Medical Job Plans designed to deliver the requirements of the service? Is the nursing skill mix correct? What is the role of administrative staff in supporting the service? 3 4 Would the service benefit from Centralised Booking? Is referral triage timely, consistent and efficient? How many pathways are there and how big are they? Do clinic templates reflect current practice and do they need to be standardised to reduce clinical variation? Are all return appointments necessary? Who DNAs, and how are they managed? NHS Lothian University s Division: Operational Effectiveness Unit / Dr Gerry Beattie / Dr David Farquharson

2 1 Measuring the Demand on the Service How many entry points are there into the service? Who manages the service entry points? Are all of them needed? 6 How can a prospective capacity modelling tool support a responsive service? Is there flexibility within Jobs Plans to provide prospective cross cover and respond to changes in demand? Is workforce activity monitored to facilitate service development? 2 Managing the Primary / Secondary Care Interface Are there effective referral protocols? Is useful feedback provided? Are advice only referrals possible? OUTPATIENT SERVICES 5 Maximising Workforce Productivity Are Medical Job Plans designed to deliver the requirements of the service? Is the nursing skill mix correct? What is the role of administrative staff in supporting the service? 3 4 Would the service benefit from Centralised Booking? Is referral triage timely, consistent and efficient? How many pathways are there and how big are they? Do clinic templates reflect current practice and do they need to be standardised to reduce clinical variation? Are all return appointments necessary? Who DNAs, and how are they managed?

3 1 Measuring the Demand on the Service Liberton Edenhall Western General RoyaI Infirmary of Edinburgh St. John s RoyaI Infirmary of Edinburgh Leith Community Treatment Centre St. John s Leith Community Treatment Centre Edenhall Western General Historical Issues Liberton Multiple entry points into the service Little communication between sites Inequity of access for patients Variation in staff Health Records v Local A&C Variation in Waiting Time, average wait weeks.

4 2 Managing the Primary / Secondary Care Interface ADVICE ONLY REFERRALS A pilot of Advice Only referrals in SCI Gateway is being developed in Women's Services in Lothian. GP DIRECT ACCESS Direct access is available for GPs to book ultrasound scans for patients with post menopausal bleeding, avoiding unnecessary clinic appointments and investigations. REFERRAL PROTOCOLS Clear referral guidelines are being developed to enhance the quality of GP referrals ensuring patients are appropriately investigated in primary care. Electronic referral help lines already exist, but secondary care needs to take a lead in progressing this work. GPs WITH SPECIALIST INTERESTS Individual specialities should identify and work with designated GPs with special interests The added benefit of this is currently being explored in Women s Services in Lothian. TRIAGE AUDIT In October 2009 an audit of 800 Gynaecology referrals was undertaken by two Consultants at the point of referral triage. The results suggest that over 25% of referrals received could have been influenced had there been the opportunity for discussion between Primary and Secondary care thereby reducing the number of new outpatient appointments needed. 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Gynaecology Triage Audit - October 2009 TOTAL REFERRALS 1 - Appropriate and complete 2 - Appropriate and incomplete 3 - Discussion and / or more information may have prevented referral 4 - Inappropriate / dealt with in primary care

5 3 CENTRALISED BOOKING was introduced into Women s Services in Lothian between April and June It has resulted in: A single entry point to the service Equity of access across Lothian The ability to respond to variation in demand locally The assurance that patients see the right clinician, at the most appropriate site Optimal use of specialist clinics Rapid electronic triage by two Consultants with dedicated time. Following the introduction of centralised booking in Womens Services there has been a significant reduction in The time between a referral being received into the service and an appointment being sent to the patient. This is illustrated in the attached diagram

6 4 STANDARDISE CLINIC TEMPLATES In order to maximise the use of outpatient clinics there has been a progressive move to standardise clinic templates in Womens services. Most routine general gynaecology outpatient clinics (GOPD) now have templates set up with 10 New patient and 2 Return Patient slots RETURN APPOINTMENTS An audit of return appointments to GOPD in October 2008 by the clinicians who saw the patients, demonstrated that in excess of 30% of return appointments could have been dealt in Primary Care or by a Nurse Practitioner thereby creating capacity within clinics to see more new patients. In Womens service over 60% of the DNAs are return patients. DNAs A review of DNAs on the cohort of patients in the Triage audit demonstrated that sterilisation, menorrhagia and Pelvic Pain were the most common referring conditions in patients who did not attend. Gynaecology - Top 3 Conditions DNA Rate 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Menorrhagia Pelvic Pain Sterilisation

7 Maximising Workforce Productivity CONSULTANT JOB PLANNING Within Womens Services in Lothian the last two rounds of job planning have been informed by consultant activity reports including data on theatre and outpatient activity, reviews of clinic templates and scheduling of clinical activity in an attempt to ensure that 42 weeks of appropriate clinical activity is delivered. The management and co-ordination of leave, the planning of on-call rotas and the timing of sessional activities within the working week have significantly reduced the detrimental impact of compensatory rest on the service. NURSING SKILL MIX An audit of Nursing Skill Mix within Outpatient Departments across Lothian University s Division was undertaken in This identified some Outpatient areas with skill mix ratios in excess of 80% Registered staff: 20% Unregistered. A target was set for all areas to work towards a maximum ratio of 50% Registered: 50% Unregistered. In recent months a further review has been undertaken which demonstrated significant improvement in many areas. In the current climate however, more challenging targets of 20% Registered: 80% Unregistered have been set. With service redesign at its core, this is considered very achievable without any detriment to quality patient care.

8 6 FLEXIBILITY By rationalising PAs within job plans through the identification of service needs it has been possible for Womens Services in Lothian to progressively absorb EPAs into the basic contracts. In addition, consultants with flexible clinical sessions have allowed the service to provide cover for absent colleagues and ensure maximal theatre utilisation and minimal cancellations of clinics. PROSPECTIVE CAPACITY MODEL A Prospective Capacity Model (PCM) for New Outpatients in Lothian is being developed. The PCM provides an eighteen week, daily view of demand, capacity and activity for new outpatients. The benefit that such a PCM brings to a service is that it quickly highlights capacity pressures and identifies areas where capacity may be flexed. Unbooked clinic slots can be easily picked up. Leave requests can be factored in to asses the impact on service delivery.

9 Edenhall Leith CTC Royal Infirmary St Johns Western General All Sites Total Number of Days CREATING EFFICIENT OUTPATIENT SERVICES Dr Gerry Beattie, Consultant Gynecologist and Clinical Lead 18 weeks RTT, NHS Lothian University s Division Dr David Farquharson, Head of Service and Clinical Director for Women s Services, NHS Lothian University s Division Yvonne Elliot, Head of Operational Effectiveness Unit, NHS Lothian University s Division Emma Brown, Senior Project Leader, NHS Lothian University s Division 1 6 AIMS Outpatient services are the first point of contact that many patients will have with secondary care. In order to deliver a high quality outpatient service there is a need to continually examine the processes and pathways to maximise efficiency and productivity. We have developed a flow diagram illustrating key areas of work that need to be conducted in sequence within services to optimise service delivery. Some examples of how these principles have been applied in Women s Services in Lothian are presented in the panels below. 2 Measuring the Demand on the Service How many entry points are there into the service? Who manages the service entry points? Are all of them needed? Managing the Primary / Secondary Care Interface Are there effective referral protocols? Is useful feedback provided? Are advice only referrals possible? Would the service benefit from Centralised Booking? Is referral triage timely, consistent and efficient? How many pathways are there and how big are they? OUTPATIENT SERVICES 3 4 How can a prospective capacity modelling tool support a responsive service? Is there flexibility within Jobs Plans to provide prospective cross cover and respond to changes in demand? Is workforce activity monitored to facilitate service development? 5 Maximising Workforce Productivity Are Medical Job Plans designed to deliver the requirements of the service? Is the nursing skill mix correct? What is the role of administrative staff in supporting the service? Do clinic templates reflect current practice and do they need to be standardised to reduce clinical variation? Are all return appointments necessary? Who DNAs, and how are they managed? 1 Measuring the Demand on the Service 2 3 Managing the Primary / Secondary Care Interface Liberton RoyaI Infirmary of Edinburgh Edenhall Leith Community Treatment Centre Western General St. John s Historical Issues RoyaI Infirmary of Edinburgh Leith Community Treatment Centre Edenhall Multiple entry points into the service Little communication between sites Inequity of access for patients Variation in staff Health Records v Local A&C Variation in Waiting Time, average wait weeks. St. John s Western General Liberton Centralised Booking was introduced into Women s Services in Lothian between April and June It has resulted in: A single entry point to the service Equity of access across Lothian The ability to respond to variation in demand locally The assurance that patients see the right clinician, at the most appropriate site Optimal use of specialist clinics Rapid electronic triage by two Consultants with dedicated time. Following the introduction of centralised booking in Women s Services there has been a significant reduction in the time between a referral being received into the service and an appointment being sent to the patient. This is illustrated in the attached diagram. Da ys b e tw e e n Re fe rra l Re cieve d a nd Ap p ointme nt Booke d Site 02/03/09 to 08/03/09 24/05/10 to 30/05/10 ADVICE ONLY REFERRALS A pilot of Advice Only referrals in SCI Gateway is being developed in Women's Services in Lothian. GP DIRECT ACCESS Direct access is available for GPs to book ultrasound scans for patients with post menopausal bleeding, avoiding unnecessary clinic appointments and investigations. REFERRAL PROTOCOLS Clear referral guidelines are being developed to enhance the quality of GP referrals ensuring patients are appropriately investigated in primary care. Electronic referral help lines already exist, but secondary care needs to take a lead in progressing this work. GPs WITH SPECIALIST INTERESTS Individual specialities should identify and work with designated GPs with special interests The added benefit of this is currently being explored in Women s Services in Lothian. TRIAGE AUDIT In October 2009 an audit of 800 Gynaecology referrals was undertaken by two Consultants at the point of referral triage. The results suggest that over 25% of referrals received could have been influenced had there been the opportunity for discussion between Primary and Secondary care thereby reducing the number of new outpatient appointments needed. Gynaecology Triage Audit - October % 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% TOTAL REFERRALS 1 - Appropriate and complete 2 - Appropriate and incomplete 3 - Discussion and / or more information may have prevented referral 4 - Inappropriate / dealt with in primary care Maximising Workforce Productivity STANDARDISE CLINIC TEMPLATES In order to maximise the use of outpatient clinics there has been a progressive move to standardise clinic templates in Womens services. Most routine general gynaecology outpatient clinics (GOPD) now have templates set up with 10 new patient and 2 return patient slots RETURN APPOINTMENTS An audit of return appointments to GOPD in October 2008 by the clinicians who saw the patients, demonstrated that in excess of 30% of return appointments could have been dealt in Primary Care or by a Nurse Practitioner thereby creating capacity within clinics to see more new patients. In Women's service over 60% of the DNAs are return patients. DNAs A review of DNAs on the cohort of patients in the Triage audit demonstrated that sterilisation, menorrhagia and pelvic pain were the most common referring conditions in patients who did not attend. 30.0% 25.0% 20.0% 15.0% 10.0% Gynaecology - Top 3 Conditions DNA Rate CONSULTANT JOB PLANNING Within Women's Services in Lothian the last two rounds of job planning have been informed by consultant activity reports including data on theatre and outpatient activity, reviews of clinic templates and scheduling of clinical activity in an attempt to ensure that 42 weeks of appropriate clinical activity is delivered. The management and co-ordination of leave, the planning of on-call rotas and the timing of sessional activities within the working week have significantly reduced the detrimental impact of compensatory rest on the service. NURSING SKILL MIX An audit of Nursing Skill Mix within Outpatient Departments across Lothian University s Division was undertaken in This identified some Outpatient areas with skill mix ratios in excess of 80% Registered staff: 20% Unregistered. A target was set for all areas to work towards a maximum ratio of 50% Registered: 50% Unregistered. In recent months a further review has been undertaken which demonstrated significant improvement in many areas. In the current climate however, more challenging targets of 20% Registered: 80% Unregistered have been set. With service redesign at its core, this is considered very achievable without any detriment to quality patient care. FLEXIBILITY By rationalising PAs within job plans through the identification of service needs it has been possible for Women's Services in Lothian to progressively absorb EPAs into the basic contracts. In addition, consultants with flexible clinical sessions have allowed the service to provide cover for absent colleagues and ensure maximal theatre utilisation and minimal cancellations of clinics. PROSPECTIVE CAPACITY MODEL A Prospective Capacity Model (PCM) for New Outpatients in Lothian is being developed. The PCM provides an eighteen week, daily view of demand, capacity and activity for new outpatients. The benefit that such a PCM brings to a service is that it quickly highlights capacity pressures and identifies areas where capacity may be flexed. Unbooked clinic slots can be easily picked up. Leave requests can be factored in to asses the impact on service delivery. 5.0% 0.0% Menorrhagia Pelvic Pain Sterilisation CONCLUSION Over the last 18 months there has been a progressive reduction in the outpatient waiting times for general gynaecology within Lothian from 16 weeks to 6 weeks without any additional capacity. Consequently, we can demonstrate a more efficient use of general and specialist clinics within Women s Service in Lothian and an increased ability to flex capacity in response to service pressures. These results from Women s Services indicate that there is scope for significant service improvement when a systematic approach, as illustrated in the diagram, is adopted.