Service Improvement Team Outpatient Services Improvement September 2010 SUMMARY The purpose of this report is to give an update on the service improvement project within the outpatient department. BACKGROUND There are currently 3 work strands for outpatient improvement which are: 1. Outpatient project looking at demand and capacity, reviewing patient flow and identifying different ways of working. This includes researching good/best practice in other health care providers 2. OPD development working with a small group of clinicians on determining the blue print for the outpatient department (see appendix 1) 3. OPD re-development the design and build of the new outpatient department (not within the remit of this report) All strands interlink and are working closely to ensure delivery METHODOLOGY The service improvement team have carried out detailed demand and capacity analysis for JRU/BT and foot & ankle. There are also unit demand and capacity meetings taking place on a regular basis to identity individual unit demand & capacity and service issues. The project group is monitoring progress against the action plan. There has been a small clinical working group which has looked at the current outpatient pathway and processes and developed the ideal patient pathway through outpatients. The basis of this work has informed the OPD blueprint. This has been done through the transformation and development team to ensure joined up thinking. ISSUES AND CHALLENGES The main issues identified are: Capacity - the current demand is out stripping the capacity which can be attributed to both room and slot availability dependant on the service Patient facilities - there is a lack of facilities / distractions for patients who have long waits in outpatients for example, they are unable to get refreshments at Stanmore site after 4pm and there is no visual distraction such as a plasma screen information system, television or similar. Diagnostic results there are delays obtaining test results particularly pathology results which are managed off site. There is a separate project tackling pathology. 1
X-ray - there is a high volume of requests for x-rays dependant on the individual service which has an impact both on patient flow through the department and on inpatient activity. Patients are sent to x-ray at the beginning of the clinic and therefore patient flow is impaired Administration booking processes can be convoluted, particularly around FU s. Cashing up of clinics is not always completed resulting in lost income. There are often delayed booking in procedures resulting in patient dissatisfaction and long queues. Clinic preparation is not always completed in the appropriate manner resulting in unnecessary or inappropriate tests particularly x-ray Job plans there are conflicts between clinic start times and inpatient sessions ward rounds and theatre lists IM & T there is a lack of telephones in rooms, access to electronic results and other information, issues with PACs for images which are archived DNA s/cancellations the rate is very variable across the units ACTIONS TO DATE The following actions have been undertaken: JRU/BT clinics templates have been separated to reflect demand and improve patient and staff experience. Sarcoma patients will now go to Bolsover Street Patient facilities improved signage, pilot of extended refreshment facilities for late running clinics, access to TV and pro-vision screen Review and mapping of current outpatient pathway and development of proposed patient flow via OPD clinical development workshops Establish of project group which meets fortnightly although this group requires a clinical lead/champion Establishment of unit demand and capacity meetings Development of discharge protocol for JRU Increased utilisation of Bolsover through booking 5 additional clinic rooms at Stanmore available from October onwards which will have a significant impact on capacity NEXT STEPS The following actions are recommended in order to improve patient flow, increase capacity, and improve staff and patient experience: Implement a supported discharge service for long term patients in collaboration with commissioners which will free up capacity for new patients Implementation of a discharge protocol to CNS service Telephone FU and results clinics by registrar and/or CNS Pilot one stop clinics 2
Automated self check in Improve patient flow through the use of an MDT and peripatetic model of care Improve booking processes whereby patients leave the department knowing the date and time of their next activity to include diagnostics, therapies and in-patient scheduling Reduce DNA through improved booking processes moving away from partial booking to telephone booking and alternative FU service IM & T to ensure that all information is accessible electronically in a timely manner and adequate communication facilities are available within the clinics Increase use of CNS posts across units Review outcomes and impact of physicians assistant posts and spread as appropriate CONCLUSION A significant number of service improvements have been identified which would improve the flow through the outpatient department and help resolve some of the demand versus capacity issues. There are also a number of processes which would benefit from improvements and it is essential that these are completed prior to the development and move to a new outpatient department. There is an ideal opportunity to pilot some of the initiatives with the additional facilities coming on board via the freeing up of the limb fitting accommodation 3
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APPENDIX 1 proposed patient pathway 5
APPENDIX 2 Pilot project action plan - Outpatient Services Review and Improvement (3 Clinician pilot) Project Plan Service Improvement Team Outpatient Services Review and Improvement (3 Clinician pilot) Action plan - updated 20th September 2010 Description Timescale Action Owned by / Lead Job plans. A review of individual job plans will Long-term This forms part of the unit D & C and General be carried out for each consultant and firm. workforce development plans Managers / This will include scheduling of outpatient and Clinical inpatient sessions to avoid conflict where Directors possible. Planning/Preparation. Clinicians should have information of future clinic slot availability when planning a patient s follow-up care in clinic. Arrangements should also be put in place for x-ray to receive notification of the numbers of patients that can be expected 48 hours in advance of the clinic. Overbooking. Overbooking should be rationalised and overbooked/double-booked slots spread over the duration of the whole clinic. Draft report on insight. Meeting set for 22/9/10 to review format etc and approve This is available on ICE provided the registrars notify requests two days ahead. Will be put onto insight OPD currently doing small audit on over bookings to be fed back to project team Siobhan Lalor- Mc Tague Surgical Teams Siobhan Lalor- McTague & Claire Euesden Due by December 2010 End September 2010 Ongoing Updated 17/09/10 4/10/10 6
Description Timescale Action Owned by / Lead Templates. Clinic start and finish times should Outpatient Team have short-term fix in Siobhan Lalorbe changed to reflect the number of patients place to improve patient flows. This is McTague & seen. being recorded in a database and will be Claire Euesden presented to units at D & C meetings Due by On going Updated A whole scale review of templates should be carried out with clinicians and outpatient management and alterations made accordingly. Consideration should be given to realistic start and finish times for clinics, practicability of moving fortnightly clinics to weekly and the impact that would have on rotations, staffing and room availability Mediumterm All Templates for JR surgical teams have been redesigned and signed off implementation due October Mr Tucker - templates to be agreed. Recruitment is in progress for a fellow to support Mr Tucker discussions with Mr Tucker ongoing to resolve capacity issues and recruit fellow Claire Euesden Philip Waugh Complete July 2010 now over due 7
Description Timescale Action Owned by / Lead Capacity for Follow-ups. In order to reduce Mediumterm Consultants involved have been given Alex the numbers of follow-ups in clinic and relieve this recommendation. Issues re: quality Bennett/Julie the stress on the department, it is of imaging from other trusts. CNS Vázquez recommended that clinical teams develop remote review pathway exists, uptake alternative ways to follow patients up (e.g. can be increased following development Telephone follow-up). This should include of discharge protocol (John Skinner) consideration for out-of-area patients to have JRU/BT currently reviewing benign follow-up diagnostics locally and only return to tumour LT FU caseload with view to RNOH clinic if necessary. discharge discharge protocol developed and awaiting implementation Due by ONGOING Updated In addition, consideration should be given to a nurse or registrar triage system for patients wanting appointments brought Forward To be developed in areas where CNS already exist and be incorporated in work plan of additional CNS. JRU/BT in process of recruitment Claire Euesden ONGOING It is recommended that a review and clinical assessment be considered out for long-term follow up patients in order to assess either suitability for onward referral to primary care/local hospital or discharge. Patients needing to return to clinic could then be triaged by a nurse as detailed above in order to assess suitability to return to RNOH clinics. Long-term A proposal has been taken to NCLACA for long term FU patients to be discharged from outpatients but with a clinically tested process for returning back into RNOH awaiting response and implementation Lesley MacLeod/Dir Ops Business case submitted to NCLACA Long term follow-up patients (yearly or twoyearly) could be booked using an outpatient partial booking list where a reminder is sent to patient 8 weeks before the patient needs to be seen prompting the patient to phone in and book. This would save on blocking clinics in advance and will reduce DNA rates. Long-term Discussion and Scope of implementation of partial booking for follow up patients and presented to working group Julie Vázquez / Siobhan Lalor McTague/ Kay Kyriacos Dec 2010 8
Description Timescale Action Owned by / Lead Long-term Discharge flow chart for JRU CNS Claire Euesden Referral and discharge criteria. Teams complete should consider the development of discharge criteria that is accessible and understood by middle grade doctors Sarcoma CNS follow up flowcharts to be worked up with CNS team Julie Vázquez Sarcoma patients. Teams in JRU are working towards the separation of Sarcoma and Joint Reconstruction patients in clinic. Ongoing Agree new clinic templates with clinicians and outpatient team Claire Euesden Due by COMPLETE IN PROGRESS COMPLETE Updated 20/9/10 It was also noted that the supporting nursing staff are often spending time in the clinic area with very little patient contact time during the clinic session. Consideration should be given to the redesign of the clinic template / patient pathway for new sarcoma patients following diagnosis to accommodate the breaking of bad news and facilitate the work of the Macmillan nursing team. One stop clinics for admitted patients. Patients coming in for surgery would benefit from a one-stop service in outpatients once the decision to admit has been made. A leaner patient pathway could be implemented whereby patients are given a date to come in (TCI) during consultation and then sent straight to pre-operative screening, thus avoiding delays and repeated visits to the department. This is a process that is currently reported to be working well in the RNOH Foot and Ankle service and should be considered for general roll-out. Mediumterm Long-term Patient pathway redesign to follow splitting of JR and Sarcoma patients This will be implemented as part of the Extended Recovery Programme pathway for joint replacement once the new pathway is stable and embedded and then rolled out to all surgery There is an opportunity to pilot these within units prior to development and move to new OPD to be taken forward within units Sarcoma CNS team Alex Bennett/Julie Vázquez A Bennett/dir OPS Oct 2010 IN PLACE 9
Description Timescale Action Owned by / Lead Review of current pager usage at Pagers at Stanmore. Patients who are experiencing delays in clinic at Bolsover street Mediumterm Stanmore received. On hold and to be McTague Bolsover undertaken, Quote for Siobhan Lalorare given pagers and allowed to leave the reviewed inline with redevelopment of premises. This eases congestion in the waiting OPD. areas and ensures that the patients do not miss their slot. This could be considered for Stanmore site. Due by ON HOLD Updated 20/9/10 Clinic Space. Restricted clinic space presents a substantial barrier to the management of demand and capacity in the department. it is recommended that additional rooms are found onsite and within local satellite clinics which can be used for outpatient consultation The Trust is looking at hub and spoke models of care for OPD. There is some capacity available at Edgware, West Herts. and Northwick Park An additional 5 clinic rooms are coming on board in October Dir ops Dir Ops/SLT ONGOING October 2010 OPD development should ensure the best possible utilisation of space for levels of demand and activity. Medium- Long term This will be part of the OPD development project. A clinical working group have designed the patient pathway Dir ops and Dir ST IN PROGRESS Refreshments. Discussions should be held with Medi-rest regarding extending the opening hours for the hot drinks facility at Stanmore site Medirest are conducting a 6 week trial on late opening on Wednesdays? extend to Fridays Kal Patel/Unica Webb Sept 10 ongoing Plasma screen / Television at Stanmore. Consideration should be given to visual distraction at Stanmore site Plasma screen now in place Pro-vision screen in place require disc Kal Patel SLT complete end Sept 20/9/10 Signage at Stanmore. There is no clear sign over main reception. This can be confusing for patients as there are various desks and waiting areas within the department. Signage in place Kal Patel complete 10
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