Service Improvement Team Outpatient Services Review and Improvement (3 Clinician pilot) Full Report - SUMMARY The purpose of this report is to present the findings from the outpatient services review and to make recommendations as to how improvements can be delivered. BACKGROUND & METHODOLOGY The Service Improvement Team were requested to look into improving the experience for patients and staff in outpatient clinics at RNOH. The first phase of this work has concentrated on the clinics of Professor Tim Briggs, Mr John Skinner and Mr Stewart Tucker, with a view to extending any agreed changes across the entire outpatient service. A review has been carried out at both sites including demand & capacity analysis (referrals and activity for new and follow-up patients), a review of clinic templates, and appointment booking processes, clinic observation and patient pathway walk-through. In addition front-line and back-office members of staff have been shadowed or interviewed. The team have also researched best practice in other NHS Trusts, primary care and in the independent sector. A detailed project plan can be found in Appendix A. CLINIC PROFILES A profile of clinics for each consultant is shown in Appendix B. Clinics which are regularly (over)booked in excess of manageable levels are shown in red. Those shaded in amber are slightly above tolerance levels. The remainder are routinely being booked at acceptable activity levels. It should be noted that the overbooking and DNA figures shown are based on average numbers for the last financial year.
Capacity/activity profile The data was collected for a 6 week period from 22 nd March 30 th April. All data has been extracted from Insight and has undergone validation to ensure accuracy. The graphs below demonstrate the actual demand, capacity and activity. Professor Briggs Outpatient Activity Analysis 22nd March 2010-30th April 2010 250 200 Number of Patients 150 100 50 0 Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Activity Demand (Booked + referrals) Actual Capacity DNA Mr Skinner Outpatient Activity Analysis 22nd March 2010-30th April 2010 250 200 Number of Patients 150 100 50 0 Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Activity Demand (Booked + referrals) Actual Capacity DNA Mr Tucker Outpatient Activity Analysis 22nd March 2010-30th April 2010 100 Number of Patients 50 0 Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Activity Demand (Booked + referrals) Actual Capacity DNA RNOH Service Improvement Team Page 2 of 17
Professor Briggs and Mr Skinner both hold clinics at Bolsover Street and Stanmore whilst Mr Tucker runs clinics on the Stanmore site only. The majority of patients seen within the clinics are follow ups. Prof. Briggs and Mr Skinner s joint fortnightly clinics are typically heavily overbooked with the majority of over-bookings being made for the follow-up patients. Clinics often begin late due to competing demands. Slot durations range from 15-30 minutes for new appointments and 10-30 minutes for FU s. Mr Tucker specialises in spinal deformity although there were patients with degenerative & cervical spine seen within the sessions observed. Mr Tucker s demand is managed by slightly overbooking each clinic (by an average of 3 patients) and diverting additional patients into extra (ad-hoc) clinics, this results in his level of overbooking s appearing tolerable in his clinic profile (Appendix B), although it can be seen in the tables on page 3 that his demand also outstrips capacity. Often ad-hoc clinics are arranged with insufficient notice for patients resulting in high levels of patients failing to attend (DNAs). Clinic Observations Observations were carried out across site where applicable during March and April. It was noted that clinical staff were productive and worked efficiently and there were no notable delays once the patient was in the consulting room. However, due to the large numbers of patients being overbooked and late starts in clinics, patients waited a long time to be seen. A summary of the time spent in the consulting room and the time patients waited to go into their consultations is shown below. Observations would indicate that the current slot length for new patients is sufficient, but that 15 minute duration for follow-up patients may better reflect the actual current length of consultation. A summary of the time spent in the consulting room and the time patients waited to go into their consultations is shown below. New Patients Template slot length Consultation length Time waited to be seen Min Max Avg Min Max Avg Briggs 20mins 11mins 20mins 15.5mins Skinner Tucker 15-20mins 20-30mins 2hrs 58mins 3hrs 22mins 5mins 16mins 8.5mins 2mins 25mins 9mins 23mins 12.5mins 12mins 1min 3secs 3hrs 10mins 54mins 5secs 28mins 10secs Follow-up Patients Briggs Skinner Tucker 10-20mins 10-20mins 10-30mins 3mins 3mins 3mins 1hr 44mins 30mins 16mins 15mins 53secs 16mins 30secs 7mins 35secs 48mins 5mins 12mins 3hrs 26mins 3hrs 43mins 1min 3secs 1hrs 59mins 1hr 54mins 28mins 10secs RNOH Service Improvement Team Page 3 of 17
RNOH Service Improvement Team Page 4 of 17 Clinic Times - planned versus actual Briggs Skinner Tucker Planned Times Actual Times 0 0 0 0 16:00 16:10 16:20 15:20 15:30 15:40 15:50 14:40 14:50 15:00 15:10 14:00 14:10 14:20 14:30 13:20 13:30 13:40 13:50 12:40 12:50 13:00 13:10 12:00 12:10 12:20 12:30 11:20 11:30 11:40 11:50 10:40 10:50 11:00 11:10 10:00 10:10 10:20 10:30 9:20 9:30 9:40 9:50 8:40 8:50 9:00 9:10 8:00 8:10 8:20 8:30 Planned Times 0Actual Times 0 0 0 0 0 0 0 0 0 17:20 17:30 17:40 17:50 16:40 16:50 17:00 17:10 16:00 16:10 16:20 16:30 15:20 15:30 15:40 15:50 14:40 14:50 15:00 15:10 14:00 14:10 14:20 14:30 13:20 13:30 13:40 13:50 12:40 12:50 13:00 13:10 12:00 12:10 12:20 12:30 11:20 11:30 11:40 11:50 10:40 10:50 11:00 11:10 Planned Times Actual Times 0 0 0 12:00 12:10 12:20 11:20 11:30 11:40 11:50 10:40 10:50 11:00 11:10 10:00 10:10 10:20 10:30 9:20 9:30 9:40 9:50 8:40 8:50 9:00 9:10 8:00 8:10 8:20 8:30 Key: Scheduled Appointment start Time in consultation room
New to follow up ratios All 3 Consultants are not meeting the new to follow up target ratios for the Trust of 3 follow ups for every new attendance. However the ratios for cancer patients are higher due to the nature of the condition treated and long term FU. Actual ratios for 2009-10 are shown below: Professor Briggs 1:5 Mr Skinner 1:4 Mr Tucker 1:3.3 This pattern is reflected in the allocation of new to follow up slots within the respective consultant s clinic templates. FINDINGS The specialty breakdown and case mix varies between the 3 clinicians, however the majority of findings, issues and recommendations are common to all the clinics studied. There was a high volume of activity within the clinics but no major patient flow issues were identified although there were some delays in x-ray. The main areas which need to be considered are: 1. Conflict with outpatient and inpatient sessions. In almost all afternoon clinics observed, the impact of theatre overruns resulted in patients having to wait to be seen. The cumulative effect of a late start impacts on subsequent appointments. 2. Conflict with outpatient sessions and ward rounds. Morning clinic sessions start as early as 8.00 am at which time the surgical teams are completing ward rounds that seldom finish before 9.30 am. During the ward rounds there is no doctor available to see outpatients. This diary conflict results in a late start to clinics on the day which will have a knock-on effect throughout the day. 3. Advance knowledge of available capacity in future clinics. Many clinics are fully booked weeks or months in advance with appointments being given to 6 monthly and annual followups. High volume over bookings could be avoided if clinicians have advance notice of slot availability. 4. Overbooking. The clinics were generally overbooked with as many as 4 patients booked into 1 slot. The last afternoon appointments are often booked at 14.30 despite knowledge that the clinic will run until at least 5 pm due to volume of over bookings. This results in patients having to wait longer than is necessary. Clinic finish times need to reflect volume of work and over bookings should be evenly spread across clinic. After investigation it was found that there were various reasons for overbooking. For new patients overbooking s tended to occur to avoid breaching 18week targets. Patients that are not new are followed up at fixed points during their care e.g. 6 weeks after going home after surgery (Ward discharge patient), every 6 months for joint replacement and will be booked during that week, regardless of whether that week s clinic is already fully booked. In addition patients that are in pain or are having problems with implants/prostheses will request an appointment at short-notice via the consultant s medical secretary. 5. Large volume of Follow-Up patients. The new to follow-up ratios for all 3 clinicians are over the RNOH target. A significant number of patients travel long distances for regular long-term follow-up or routine monitoring. In addition very few follow-up patients are discharged within clinic. An audit of clinic attendances for the 3 consultants for the last 6 months shows a 4% discharge rate for follow ups. RNOH Service Improvement Team Page 5 of 17
6. Inconsistent approach to diagnostic requests. There is an inconsistent approach to diagnostic requests, irrespective of how far a patient has to travel to attend clinic. This results in patients either being expected to travel back to the RNOH or sent back to their local provider. The Trust should consider one stop clinics were appropriate. 7. Sarcoma patients. Sarcoma patient appointments are often mixed randomly with those of other patients which often results in inadequate time being spent with these patients. 8. Admin and Nursing. The workforce in the department has a high skill mix and work efficiently and cohesively under pressure. It was also observed that the admin and nursing teams are courteous in dealing with patients and have demonstrable good levels of customer care. ISSUES AND CHALLENGES Capacity. There is limited capacity in the waiting area and this is particularly evident on the Stanmore site particularly on Wednesdays. Stress within the department. Due to sheer volume of patients the team is under considerable pressure to achieve the smooth-running of clinics. There are a significant number of complaints due to the lack of space in the waiting areas and the long wait times. 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. Clinic Rooms. Patients leaving consulting rooms after just being told they have cancer would benefit from having a room available in which to further discuss their diagnosis with a specialist nurse. There is currently no availability for this. Impact on x-ray. High numbers of outpatients requiring an x-ray will impact negatively on inpatient work by delaying ward rounds and discharge. There is currently no system in place to enable the x-ray department to advance plan in order to be able to flex radiography and portering staff according to anticipated workload. RNOH Service Improvement Team Page 6 of 17
RECOMMENDATIONS The main recommendations of the review are listed below. These have been tabled below and divided into short, medium and long-term changes in recognition that some will take longer than others to implement Description Timescale Predicted duration to completion Workplans. A review of individual workplans should be carried out Long-term 4-6 months for each clinical firm. This should include scheduling of outpatient and inpatient sessions to avoid conflict where possible. Planning/Preparation. Clinicians should have information of future clinic slot availability when planning a patient s follow-up care in clinic. Short-term 2-4 weeks 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. Templates. Clinic start and finish times should be changed to reflect the number of patients seen. 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 Capacity for Follow-ups. In order to reduce the numbers of follow-ups in clinic and relieve the stress on the department, it is recommended that clinical teams develop alternative ways to follow patients up (e.g. Telephone follow-up). This should include consideration for out-of-area patients to have follow-up diagnostics locally and only return to RNOH clinic if necessary. In addition, consideration should be given to a nurse or registrar triage system for patients wanting appointments brought forward 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 follow-up patients (yearly or two-yearly) 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. Short-term Short-term Short-term Mediumterm Mediumterm Short-term Long-term Long-term 2-4 weeks 2-4 weeks 2-4 weeks 2-3 months 2-3 months 2-4 weeks 4-6 months 4-6 months RNOH Service Improvement Team Page 7 of 17
Referral and discharge criteria. Teams should consider the development of discharge criteria that is accessible and understood by middle grade doctors Booking process change. A new booking process for follow ups should be developed to avoid overbooking above tolerance levels. Sarcoma patients. Teams in JRU are already working towards the separation of Sarcoma and Joint Reconstruction patients in clinic. 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. General Pagers at Stanmore. Patients who are experiencing delays in clinic at Bolsover street are given pagers and allowed to leave the premises. This eases congestion in the waiting areas and ensures that the patients do not miss their slot. This could be considered for Stanmore site. 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 OPD development should ensure the best possible utilisation of space for levels of demand and activity. Refreshments. Discussions should be held with Medirest regarding extending the opening hours for the hot drinks facility at Stanmore site Plasma screen / Television at Stanmore. Consideration should be given to visual distraction at Stanmore site 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. Long-term Medium Term Ongoing Long-term Short-term Mediumterm Mediumterm Medium- Long term Short-term Short-term Short-term 4-6 months 2-3 months 2-3 months 2-3 months 4-6 months 2-3 months 2-4 weeks 2-6 months 2-4 weeks 2-4 weeks 2-4 weeks RNOH Service Improvement Team Page 8 of 17
ACTION PLAN & TIMESCALES The Service Improvement Team circulated a summary version of this report during April 2010 giving initial findings and recommendations of the review. Each of the 3 clinicians discussed the finding with the team and agreed an action plan for implementation within selected clinics. The details of this are shown in the table below. Consultant Prof. Briggs Affected clinic code(s), frequency and site BRT13REG1A, fortnightly at Stanmore BRTTHREG1, fortnightly at Bolsover BRTTHREG2, fortnightly at Bolsover Identified Improvement(s) Alteration of clinic templates to reflect actual start and end times Pilot start date June 2010 Clinical Lead Tim Briggs Operational Lead Claire Euesden / Siobhan Lalor- McTague Expected outcome Reduced patient complaints. Reduced time spent waiting in clinic BRT12BOLFU, monthly at Bolsover Additional CNS required Tim Briggs Claire Euesden Increased telephone clinics / triage / development of remote follow up pathway - Capacity to increase monthly clinic to weekly ALL Scope implementation of Partial booking for follow ups Mr Skinner ALL Review of clinic templates to split JRU from Sarcoma June 2010 Tim Briggs John Skinner Siobhan Lalor- McTague, Kay Kyriacos Claire Euesden Assess suitability for RNOH patients Improved Service for sarcoma patients Development of protocol for discharge to CNS service / primary care John Skinner Claire Euesden development of remote follow up pathway, reduced numbers of follow up appointments Mr Tucker TUS14FOL, fortnightly at Stanmore TUS15REG, fortnightly at Stanmore TUS1FRIFOL, fortnightly at Stanmore TUS1NEWFRI, fortnightly at Stanmore Additional CNS and admin support required Review of clinic templates June 2010 John Skinner Stewart Tucker Claire Euesden Philip Waugh as above Reduced patient complaints. Reduced time spent waiting in clinic CONCLUSION The RNOH outpatient department has a dedicated multidisciplinary team who are striving to maintain the delivery of high quality care. They have expressed a willingness to undertake improvement pilots by means of tools and guidance from the service improvement team. Completing these activities and making the appropriate changes as a result of the analysis of the data; along with improved discharge protocols and additional CNS support will bring about further improvements to the patient experience. RNOH Service Improvement Team Page 9 of 17
APPENDIX A Outpatient Services Review and Improvement (3 Clinician pilot) Project Plan Project Name Project Aim Statement 3 Clinician Outpatient Service Improvement Project Plan The aim of the project is to review and improve the outpatient service for 3 clinicians in order to improve processes and improve quality of service whilst meeting key recommendations Project Objectives To establish demand and capacity for clinics To review the patient pathway in order to reduce delays To review access and booking processes To review current ways of working To review clinical pathway criteria and discharge protocols To improve access to diagnostics To improve provision of tests and diagnostics from primary care To apply service improvement tools to redesign services to meet project aim To improve the patient experience To pilot changes in service and evaluate for wider implementation RNOH Service Improvement Team Page 10 of 17
Project Work stream Initiative/ Improvement Actions/Progress Milestone/Outcome Project team To establish project team Identify key stakeholders Develop team Project group with appropriate representation and understanding of roles Milestone Date / outcome COMPLETE Communication plan To ensure that stakeholders are well informed on project progress and share learning Identity key arenas for reporting on project progress i.e. internal meetings Project progress is available to all ONGOING Demand and Capacity Determine current demand on service and capacity within the service for named clinicians Carry out Demand & Capacity work for each clinic Review clinic templates Report on demand and capacity to help determine service redesign 28/04/2010 Develop Models for individual consultants Review room usage at both sites Review alternative venues for clinics Clinic observation and Data analysis Determine current practice Collect data - clinical case mix and outcomes Report on observation to help determine service redesign 28/04/2010 Review of follow ups Process Map patient journey and compare with pathway Pathways To work up criteria for referral and discharge Review current pathway Develop referral, diagnostic and discharge criteria Pathways and Criteria in place 04/05/2010 Review alternatives to outpatient appointments Review current referral process Review current booking process One-stop Services Outpatient To improve patient experience and reduce waste Review way patients attend for test for new and FU OPA Robust process in place which reduces delays within OPD 04/05/2010 RNOH Service Improvement Team Page 11 of 17
Review best practice across the NHS and independent sector healthcare New service To establish new service provision Implement service redesign and improvement Project evaluation To determine outcomes of project Review data Set up patient satisfaction review Embed ongoing annual audit in department Evaluate outcomes Determine satisfaction Compile report New service in place Patient satisfaction complete- report Audit embedded as part of annual departmental review Evaluation complete Report complete and presented to appropriate stakeholders Examine potential rollout of changes to other services Pilot phase 17/05/2010 onwards Post Pilot Work stream members (core members) Additional members will be co-opted onto project team as appropriate Stakeholders Jon Scott Tim Briggs, John Skinner, Stuart Tucker Alex Bennett, Julie Vazquez Unica Webb, Helen Burrows S. Lalor-McTague EMT, General Managers Diagnostics Senior reporting officer Clinical Leads Service Improvement leads Outpatient Nurse Leads General Manager (OPD) PCT Booking teams ICS team RNOH Service Improvement Team Page 12 of 17
Project Plan RNOH Service Improvement Team Page 13 of 17
Project Plan - continued RNOH Service Improvement Team Page 14 of 17
APPENDIX B - Clinic Profiles Professor Briggs Consultant Clinic Code Clinic Description Site Weekday Frequency Time of day New Slots Duration of New slots Follow Up Slots Duration of F/up slots Combined slots Duration of combined slots Total Slots Average Activity DNA Rate Average number of new overbooked Average number of follow ups overbooked Briggs BRT12BOLFU Long term follow up Bolsover Tuesday Monthly AM 0 0 12 15 0 0 12 4 1% 0 0 Briggs BRT13REG1A Registrar Stanmore Wednesday Fortnightly AM 0 0 31 10 0 0 31 60 12% 0 26 Briggs BRT14CBPM General Bolsover Thursday Fortnightly PM 8 20 2 10 0 0 10 15 8% 1 1 Briggs BRT14TUM Tumour Bolsover Thursday 3 a month PM 3 20 4 20 1 20 8 16 8% 3 3 Briggs BRT15NURSE Nurse Specialist Telephone Stanmore Friday Weekly PM 0 0 12 15 0 0 12 33 0% 0 0 Briggs BRT1ADHOC Ad-hoc Stanmore any any any 0 0 0 0 13 15 13 9 8% 0 0 Briggs BRT1AM3N Knee & Bone Tumour Stanmore Wednesday Fortnightly All Day 1 3 20 32 10 0 0 45 52 8% 5 6 Briggs BRTTHREG1 Registrar Bolsover Thursday Weekly PM 0 0 13 15 0 0 13 27 7% 0 15 Briggs BRTTHREG2 Registrar Bolsover Thursday Weekly PM 0 0 13 15 0 0 13 20 9% 0 8 RNOH Service Improvement Team Page 15 of 17
Mr Skinner Consultant Clinic Code Clinic Description Site Weekday Frequency Time of day New Slots Duration of New slots Follow Up Slots Duration of F/up slots Combined slots Duration of combined slots Total Slots Average Activity DNA Rate Average number of new overbooked Average number of follow ups overbooked Skinner SKIJ1CNSPM Nurse Specialist Bolsover Monday Weekly PM 0 0 12 15 0 0 12 10 5% 0 0 Skinner SKIJ1REGPM Registrar follow ups Bolsover Monday Weekly PM 0 0 15 10 0 0 15 26 10% 0 14 Skinner SKIJ1WDPM Follow up post discharge from ward Bolsover Monday Weekly PM 0 0 6 10 0 0 6 9 7% 0 4 Skinner SKJ13AM Tumour Stanmore Wednesday Fortnightly AM 0 0 0 0 7 15 7 4 3.5% 0 0 Skinner SKJ13CNSAM CNS Stanmore Wednesday Fortnightly AM 0 0 21 15 0 0 21 20 9% 0 1 Skinner SKJ13REG Registrar Stanmore Wednesday Fortnightly AM 0 0 27 10 0 0 27 42 7% 0 16 Skinner SKJ14FEL Fellow Bolsover Friday Fortnightly PM 6 15 5 15 0 0 11 9 2% 0 0 Skinner SKJ15NURSE Nurse Specialist Stanmore Friday Weekly AM 0 0 12 15 0 0 12 11 0% 0 0 Skinner SKJ1ADHOC Ad-hoc Stanmore any any any 12 15 0 0 0 0 12 11 0% 0 0 Skinner SKJ1AM3N General Stanmore Wednesday Fortnightly AM 10 20 7 20 0 0 17 19 3.5% 1 3 Skinner SKJ1FEL2PM Fellow Stanmore Tuesday Weekly PM 4 20 8 10 0 0 12 12 4% 0 0 Skinner SKJ1PM1N General Bolsover Monday Weekly PM 8 15 4 10 0 0 12 19 7.5% 5 4 Skinner SKJ1TELWED Nurse Specialist Stanmore Wednesday Weekly AM 0 0 20 15 0 0 20 18 0% 0 0 RNOH Service Improvement Team Page 16 of 17
Mr Tucker Consultant Clinic Code Clinic Description Site Weekday Frequency Time of day New Slots Duration of New slots Follow Up Slots Duration of F/up slots Combined slots Duration of combined slots Total Slots Average Activity DNA Rate Average number of new overbooked Average number of follow ups overbooked Tucker TUS14FOL Ward discharge Stanmore Thursday Fortnightly PM 0 0 10 15 0 0 10 10 4% 0 1 Tucker TUS15REG Registrar follow up Stanmore Friday Fortnightly All Day 0 0 33 10 0 0 33 34 7% 0 3 Tucker TUS1ADHST Ad-hoc (registrar) Stanmore any any All Day 0 0 0 0 14 30 14 15 4% 0 0 Tucker TUS1CONADH Ad-hoc (cons) Bolsover any any any 0 0 0 0 6 30 6 7 6% 0 0 Tucker TUS1FELADH Ad-hoc (Fellow) Stanmore Friday Monthly All Day 0 0 0 0 14 30 14 11 18% 0 0 Tucker TUS1FRIFOL Follow up Stanmore Friday Fortnightly AM 0 0 18 10 0 0 18 19 6% 0 2 Tucker TUS1LECADH Ad-hoc Stanmore any any any 0 0 0 0 7 30 7 7 28% 0 0 Tucker TUS1NEWFRI New patients Stanmore Friday Fortnightly PM 6 20 0 0 0 0 6 8 3% 1 0 Tucker TUS1TELCL Telephone clinic Stanmore Monday Weekly AM 0 0 5 30 0 0 5 5 0% 0 0 RNOH Service Improvement Team Page 17 of 17