Performance TOOLKIT in Scheduled Care January 2013
Patient Toolkit Pathways Performance in Scheduled Care Setting the context and initiating whole systems change for the delivery of scheduled care and Contingency 2 of 58 53
to the Scheduled Care Toolkit What is the scheduled care support toolkit? The scheduled care support toolkit consists of a number of tools related to patient waiting list planning and management which aim to give hospitals guidance for improving their performance in the delivery of scheduled care. How should the toolkit be used? The scheduled care support toolkit aims to introduce scheduled care management concepts to hospital Operational Directors, Medical Directors and other relevant staff. The toolkit can be used either to support systematic improvements or it can be used on an ad-hoc basis as required. The toolkit should be used in conjunction with the NTPF Waiting List Policy (2013). What areas does the toolkit focus on? The toolkit focuses on the organisational and operational changes necessary to improve patient experience of scheduled care in Ireland. Firstly, it provides a self assessment tool for hospitals to understand their current capabilities and performance around scheduled care. Secondly, it addresses areas for the hospital to focus on improving based on the organisational assessment: Effective leadership and Gathering and using data and information effectively Addressing patient back-log issues and improving scheduled care management processes Communicating change to hospital staff and engaging them for sustainable improvement Why is this support toolkit important? Achieving health services access targets for improving scheduled care in Ireland is dependent on improving patient flow and waiting times. All hospitals are going to be increasingly under pressure to improve scheduled care management processes as waiting time targets will continue to reduce. Current targets, January 2013, are outlined later in this pack. What is the scheduled care support toolkit s end goal? The scheduled care management toolkit should be used with the aim of improving waiting times and patient flow, the overall patient experience and achieving the health services access targets. 3 of 58
Background Health Service Targets for Scheduled Care The Department of Health plans to improve overall performance in the delivery of scheduled care in Ireland and requires that hospitals: - Have demand and capacity for scheduled care in balance - Reduce any existing patient back-logs for scheduled care to a manageable size in line with the specific targets outlined below Three health services access targets* have been set in relation to patient waiting times for scheduled care: - All inpatient and day cases for scheduled care should be spending less than 8 months waiting from the time their name is put on the hospital waiting list to hospital admission - All inpatient and day cases for paediatric care should be spending less than 20 weeks from the time their name is put on the hospital waiting list to hospital admission - All inpatient and day cases for routine GI endoscopy should be spending less than 13 weeks waiting from the time their name is put on the hospital waiting list to hospital admission The change in performance required to achieve these targets requires engagement at an organisational and operational level within the hospital The Department of Health and the Special Delivery Unit (SDU) / NTPF have therefore, in cooperation with PA Consulting Group, designed a scheduled care support toolkit to help hospitals improve their performance in this area and achieve the set targets The overall support toolkit for scheduled care contains two main strands which aim to provide hospital staff with the necessary support, tools and techniques to achieve the Health Services Access targets (*Please note that these are the current target as of January 2013 and will change in the future) 4 of 58
Target State for Scheduled Care Achieve The Health Services Access Targets Improved Patient Experience Access to Data and Build Flexibility into the Existing System No breaches of the 8 month waiting time target for scheduled care, 20 week target for paediatric care and 13 week target for regular GI endoscopy procedures Demand and capacity for scheduled care are in balance Reduction and eventual elimination of back-logs for scheduled care patients Introduce chronological scheduling Shorter waiting times, limited cancellations, access to the required diagnostics, consistent experience across the patient pathway Hospitals will analyse and present their own data regularly updated to facilitate short and long-term decisions about managing patient flows and capacity Enable the current scheduled care booking system to effectively manage peak activity while maintain efficiency over time 5 of 58
Patient Pathways Blockages and Issues in the Pathway This toolkit aims to provide an understanding of common blockages in specific parts of the patient pathway and identify the underlying issues for these blockages Elective admission from list Pathway Potential Delays GP Appointment = Blockages Referred to Hospital Admission Patient entry onto Waiting List Patient is not listed in a standardised format across specialities in the organisation Clock Starts Hospital Appointment Patient is booked in standard list with no context of overall wait GREATER THAN 8 MONTHS Procedure Clock Stops Planned admission - Discharge Underlying Issues Insufficient primary care options to hospitals Increasing demand for medical procedures Poor information, lack of understanding, lack of ownership No demand management in place Lack of standardisation and consistency Inefficient use of resources process bottlenecks Capacity not coping with demand 6 of 58
Patient Pathways Solutions for Smooth Patient Flows in the Pathway This toolkit aims to also provide potential solutions for common blockages identified on the patient pathway and recommendations on how to implement these solutions Elective admission from list Pathway Potential Delays GP Appointment = Solutions Referred to Hospital Admission Patient entry onto Waiting List Patient is listed in a standardised format across specialities in the organisation Clock Starts 8 MONTHS OR LESS Hospital Appointment Patient is booked in within context of overall wait Procedure Clock Stops Planned admission - Discharge Solutions Agreed pathways which optimise resources Effective waiting list management team and process in place A waiting list management policy is embedded within the hospital 8 month target is prioritised and aligned with personal objectives High quality performance information regularly available structure is realigned so team members used to best effect 7 of 58
Overview of Toolkit and The scheduled care support toolkit contains two core strands: 1. The upper strand aims to introduce key scheduled care management and delivery concepts to senior management and clinical leaders 2. The lower strand focuses on facilitating operational improvements in scheduled care waiting list management for hospital staff The aim of both strands of the toolkit is to equip hospitals with the skills and know-how to achieve the key targets Whole system changes and areas of focus for senior management and clinical leadership consideration Audience: team Setting the context and initiating whole systems change for the delivery of scheduled care and Contingency Operational changes based on areas identified in upper strand aimed at key operational and medical staff this toolkit focuses on waiting list management Audience: Operational and medical staff Delivering targets in scheduled care Demand and Capacity Ensuring Efficient Use of Resources 8 of 58
How the toolkit is structured 1. Hospitals complete the organisational assessment questionnaire to evaluate current capability and performance levels and identify areas for improvements 2. Strand 1 contains five core system parts; each of which is a section in this toolkit as outlined by the tabs to the left - This strand identifies what needs to be done and where the effort should be focused 3. Each of the operational parts in strand 2 is analysed by each core system part in strand 1 - The toolkit identifies a number of key issues for senior management before providing considerations and solutions for each issue - This strand aims to provide a guide for implementing the required change identified in the previous step - Good practices identified during visits to Irish hospitals are then outlined at the end of each section Conduct Questionnaire Strand 2 Strand 1 Setting the context and initiating whole systems change for the delivery of scheduled care Demand and Capacity and Contingency Ensuring Efficient Use of Resources 9 of 58
Section Conduct Questionnaire Click here to begin the organisational assessment questionnaire Instructions on how to complete the questionnaire are embedded within the spread sheet go straight to the Tab: Title Page & Instructions. 10 of 58
Questionnaire (1/3) Underperforming Acceptable Best Practice 1 The hospital does not have a published waiting list policy setting out roles, responsibilities, accountabilities and procedures for management of the waiting list The hospital has a published waiting list policy which reflects the NTPF Policy (2013). This is used to underpin the processes used by the hospital to actively manage its waiting list The hospital waiting list policy is published, reflects the NTPF Waiting List Policy (2013) and is actively used across all specialties to manage waiting lists. The policy underpins all waiting list management procedures within the hospital and is actively updated to reflect best practice 2 The hospital has a dedicated executive lead who does not have a clearly defined role and has no responsibility for delivering waiting list performance targets There is a dedicated executive lead for the hospital but they lack accountability for delivery of waiting list performance targets to a member of the Board There is a dedicated executive lead who has responsibility for booking teams, waiting list performance management and is accountable to the CEO or a member of the waiting list management project group for delivery of national access targets 3 4 The majority of routine patient bookings are handled by medical secretaries who are accountable only to a consultant Consultants control the routine patient booking process with no accountability for the delivery of national access targets Some routine patient bookings are handled by a dedicated patient booking team who are accountable to a dedicated executive lead Consultants do not get involved in the booking of routine patients as these are handled by a secretary within the specialty All routine patient bookings are undertaken by a dedicated patient booking team who are accountable to a dedicated executive lead Routine patient booking dates are determined by a centralised booking team which allows for sufficient capacity to treat urgent cases as appropriate 11 of 58
Questionnaire (2/3) Underperforming Acceptable Best Practice 5 6 The waiting list management project group reviews waiting time performance on an ad-hoc basis and puts action plans in place to deal with underperformance when necessary The waiting list policy identifies a single executive lead for waiting list performance management with little limited devolution of accountability for delivery of targets to specialties or individual consultants The waiting list management project group reviews waiting time performance as a standing item on their monthly agenda and develop specialty based action plans for those who require it There is executive and speciality level responsibility for the delivery of waiting time performance targets. Specialty managers/consultants meet regularly to discuss local performance and create action plans for improvement where targets are not being delivered There is an accountable waiting list management project group member who reviews waiting time performance on a weekly basis. Key risks and issues are identified and contingency plans are put in place for specialties who require it There is executive, speciality and clinical level responsibility for waiting time performance. Specialty multidisciplinary teams meet regularly to discuss local performance and create action plans to ensure compliance with national access targets 7 8 The dedicated executive lead is empowered to challenge poor performance and request that patients are booked in a specific manner which is compliant with the waiting list management policy The hospital has a training and support programme to ensure that all staff with responsibility for booking patients are aware of where they can access knowledge, best practice and guides to help them deliver national access targets The dedicated executive lead is empowered to review booking practices and request that specific non-urgent patients are moved by specialty level staff to a more suitable date which is compliant with the waiting list management policy There is training available for those responsible for booking patients which covers the skills and approaches required to book patients in a manner which ensures the organisation is compliant with waiting time targets The dedicated executive lead has the authority to change routine patients to come in dates without the consent of specialty level staff to ensure that routine patients are treated chronologically in line with the waiting list management policy There are training courses, refresher sessions and a suite of published material available which covers the skills and approaches required to book patients in a manner which ensures the organisation is compliant with waiting time targets 12 of 58
Questionnaire (3/3) Underperforming Acceptable Best Practice 9 10 11 There are transparent guidelines setting out how staff should escalate concerns of actual or forecast breaches of national access targets Clearance plans are not developed for specialties with patients on their waiting lists who are in breach of national access waiting times The waiting list management project group receive reports which highlight the specialties and consultants who are not delivering national access targets and the actions being undertaken to remedy the situation There are clear escalation lines in place for staff requiring additional support in meeting the national access targets. High performance is acknowledged from a senior level and promoted throughout the organisation Clearance plans are developed for specialties with patients on their waiting lists who are in breach of national access waiting times. Plans are developed based on current waiting list performance data. There is responsibility for executing plans at some level within the organisation Individual specialties and consultants waiting time performance is benchmarked against each other and underperformance is challenged to ensure that appropriate actions are taken to address breaches of national access targets There are action learning groups in place for booking staff to support each other with difficult issues and great work is shared and celebrated throughout the organisation Clearance plans are developed for specialties with patients on their waiting lists who are in breach of national access waiting times. Plans are developed based on current waiting list performance data, available capacity and clearance times. There is responsibility for executing plans at a specialty and senior management level. Progress is regularly assessed. Specialties and consultants are benchmarked not only against each other and challenged to improve their position within the organisation but also benchmarked nationally and challenged to improve their position relative to other hospitals nationwide 13 of 58
Questionnaire (1/2) Underperforming Acceptable Best Practice 1 An organisation PTL is produced on a weekly basis which identifies those patients who are breaching national access targets along with those forecast to breach in the next quarter A PTL is produced every week for each speciality and highlights patients who are breaching in addition to those who are likely to breach in the next quarter if no TCI date is assigned this week A PTL is produced every week for each speciality and distributed to booking and clinical teams for review. The PTL shows waiting times, breaches and proposes a TCI date for routine patients who are either breaching or forecast to breach national access targets in the next month. This is based upon a chronological principle taking into account urgent capacity requirements 2 3 The board make use of a number of key performance indicators on an ad-hoc basis to monitor waiting time performance and these are regularly reviewed (e.g., DNA rates, cancellations, suspensions and CNAs) The scheduling team have an understanding of scheduled and unscheduled care demand and the impact this has on the clearance times / plans forecast for the delivery of national access targets The board make use of waiting list trend data, capacity and demand data and waiting list performance indicators on a regular on-going basis to improve performance (e.g., DNA rates, CNAs, cancellations, capacity, demand) The scheduling team have an understanding of high volume demand services and procedures and recognise the risk management and contingency planning that needs to be applied to ensure that safe and sustainable services are delivered A waiting time performance dashboard is produced weekly for the accountable waiting list management project group member which includes associated key performance indicators by speciality. This is used to support decision making risk assessment and contingency planning The scheduling team give consideration to key performance measures to ensure that capacity and demand is managed effectively and that risk and outcomes are managed effectively 14 of 58
Questionnaire (2/2) Underperforming Acceptable Best Practice 4 information on consultant waiting time performance and breaches of access targets are monitored by the dedicated executive lead information on consultant waiting time performance is monitored by the dedicated executive lead with benchmark reports being used to highlight underperformance information on individual consultant performance is collected, benchmarked and shared with the consultant group and the waiting list steering group. Those in the lowest quartile are challenged to discuss issues and actions required to improve performance with their peers 15 of 58
Questionnaire (1/2) Underperforming Acceptable Best Practice 1 2 Routine patients are booked using an ad-hoc methodology with limited or no consideration for the need to deliver national access targets The organisation wide PTL / PTR is reviewed on an ad-hoc basis to validate numbers of breach patients All routine patients are booked chronologically based on their decision to treat date with a clear recognition of the need to deliver national access targets Waiting lists are reviewed weekly at speciality level to validate breach patients who require treatment All routine patients are booked chronologically based on their decision to treat date and a maximal algorithm is used to ensure that patients are treated within national access targets Waiting lists are reviewed weekly at a specialty level to ensure there is accuracy around patient s continued suitability for treatment and that their status (e.g., suspended ) is correct 3 Decisions to treat are communicated using electronic communication to booking teams and paper communication is minimised as far as possible All decisions to treat are communicated to booking staff using electronic communications e.g., an e-mail to a named individual All discharges and decisions to treat are communicated to booking staff using electronic communications e.g., an e-mail proforma to a dedicated booking team mailbox 4 There is no pre-operative process in place. Patients are contacted by phone near the time of their procedure to remind them of the date, time, location and consultant performing their procedure There is a pre-operative process in place. Following this clinical validation all patients are contacted 48 hours before their procedure to request confirmation of attendance and remind them of the date, time, location and consultant performing their procedure There is a pre-operative process in place. Following this clinical validation all patients are contacted 48 hours before their procedure to request confirmation of attendance and remind them of the date, time, location and consultant performing their procedure. There is a standby list of patients who are willing to be contacted at short notice and have their procedure performed should a patient be unable to attend their procedure 16 of 58
Questionnaire (2/2) Underperforming Acceptable Best Practice 5 Consultant cancellation rates are recorded and monitored Consultant cancellation rates are recorded and monitored. Consultants who have high levels of cancellations are challenged on their individual performance There is a clear policy on consultant cancellations, with minimum 6 week notice required to cancel a procedure list and a clear requirement to source cover before the request is approved. There is a maximum number of cancellations allowed per year (not counting staff sickness etc.) 6 Ad hoc action plans are put in place to deal with speciality waiting time breaches. These do not follow a consistent format and are not monitored by the hospital dedicated executive lead Speciality based action plans are developed in a consistent format where breaches of national access targets are identified or forecast. These action plans are routinely monitored for progress and mitigating actions undertaken where delivery is not as planned Speciality and consultant based action plans are put in place where breaches of national access targets are identified or forecast. These action plans are monitored weekly by the accountable waiting list management project group member and progress reported to the group monthly. Escalation processes are reviewed by the waiting list management project group. 17 of 58
Questionnaire (1/2) Underperforming Acceptable Best Practice 1 Directors, consultants and service managers have visibility of PTL/PTR and waiting list demand and breaches of national access targets The hospital executive team and clinical directors receive monthly reports detailing PTL/PTR performance, trend and forecast waiting list breaches of national access targets The hospital executive and clinical management teams receive monthly reports highlighting breaches and forecast breaches of national access targets, summaries of contingencies in place to deal with these breaches and a forecast revised assessment subject to the delivery of action plans 2 Individual specialty based action plans are in place but these do not reflect any risk management and contingency planning required within support services to ensure delivery Individual speciality based action plans are in place and these take account of the need for integrated service delivery e.g., support from bed management, theatres and diagnostics Specialty action plans are reviewed by the CEO/GM and an Executive Director has accountability for ensuring that dependencies are managed across the hospital to ensure successful delivery 3 The hospital has a consolidated risk and issues log which details potential risks to delivering national access targets The hospital has an integrated risk and issues log which details potential risks to delivering national access targets. Consideration is given to the risk management and contingency planning required to ensure that risks and issues are successfully mitigated or avoided Risks to delivering national access targets are well understood, anticipated and have been captured with agreed risk militating actions and a likelihood of impact analysis 18 of 58
Questionnaire (2/2) Underperforming Acceptable Best Practice 4 The waiting list management project group reviews performance and general capability for waiting list management performance on an ad hoc basis A regular reporting cycle has been established whereby the organisation can assess its own performance and capability for waiting list management performance A regular reporting cycle has been established whereby the organisation can assess its own performance and capability for waiting list management performance and track whether progress is being made or not. Results of this regular assessment inform an action planning process 5 There are contingency plans in place to ensure a focus remains on waiting time reduction should major incidents or unpredictable events occur (e.g., very bad winter weather) There are strong contingency plans to ensure that even if major incidents or unpredictable events occur (e.g., very bad winter weather) waiting time reduction remains a priority for the organisation There are strong contingency plans to ensure that even if major incidents or unpredictable events occur (e.g., very bad winter weather) waiting time reduction remains a priority for the organisation. Key staff members understand their roles and responsibilities in such events 19 of 58
Questionnaire (1/2) Underperforming Acceptable Best Practice 1 The hospital does not have a clear and consistent approach to celebrating the success of waiting list performance improvement initiatives 2 3 There is a documented communications plan in place for engaging stakeholders in waiting list performance improvement initiatives There is an annual staff survey for use in the organisation The hospital makes use of a single communication channel to celebrate the success of waiting list performance improvement initiatives s on the benefits of shorter waiting times have been produced for staff in the organisation and published through multiple channels Staff are surveyed irregularly or infrequently to measure satisfaction and their views on the waiting time reduction programme of work The hospital makes use of multiple communication channels to celebrate the success of waiting list performance improvement initiatives and seeks feedback on performance through these channels s on the benefits of shorter waiting times have been produced and tailored to the different stakeholder groups of the organisation Staff are regularly surveyed and the data gathered from this exercise is used to track trends in engagement and build action plans for improved engagement 4 The hospital has undertaken limited training and development for staff involved in waiting list management The hospital has reviewed training and development needs for staff involved in waiting list management and ensures that staff receive regularly updated training based on their needs Waiting list training and development initiatives are integral to all staff training, courses, seminars, etc. These initiatives are delivered on an on-going basis to all staff and learning sets are facilitated across the hospital 20 of 58
Questionnaire (2/2) Underperforming Acceptable Best Practice 5 The hospital has sent out the waiting list management policy across the hospital The hospital has sent out the waiting list management policy across the hospital in addition to setting-up a communication channel for feedback and questions The hospital has sent out the waiting list management policy across the hospital in addition to setting-up a communication channel for feedback and questions. Training and learning days are run across the hospital to help integrate new practices and processes outlined in the policy 21 of 58
Result Overview of Using the Results from the The organisational assessment questionnaire is as an interactive excel tool Hospitals should complete the questionnaire using the tool and will be assigned a rating for each of the areas: - - - - - Depending on their rating for each area, hospitals will then know what areas they need to focus on for improvement and can refer to that section within this toolkit 22 of 58
Section Setting the context and initiating whole systems change for the delivery of scheduled care Delivering targets in scheduled care Demand and Capacity and Contingency Ensuring Efficient Use of Resources This section covers issues and best practices for leadership and governance in waiting list management Firstly, it aims to make senior management aware of the key issues at a high-level related to leadership and governance Secondly, it provides detail around each issue in addition to recommended actions for each to improve performance in waiting list management The recommended actions provide both senior management, operational and medical staff with the know-how to improve performance and achieve the key targets 23 of 58
Overview Poor waiting list governance and management is the biggest single reason that hospitals fail to meet their waiting list targets Regular issues include lack of formalised processes such as issuing to-come-in (TCI) dates, a lack of executive ownership for performance in this area and little to no best practice training based on the NTPF s Policy (2013) for those who book patients There are three key organisational components for effective waiting list management, summarised below: 1. Organisation Structure 2. Roles and Responsibilities 3. Skills and Training Is there a waiting list management policy in place which sets out roles and responsibilities? Do you know at any given time how many patients are breaching the national access target? Which executive director does your dedicated executive lead report to? Do you have visible escalation policies for waiting list issues? Do you have a dedicated executive lead who has overall responsibility for waiting times? Is the waiting list management role clearly defined and separate from other duties, e.g., medical secretary? Do consultants have a proportion of a waiting list reserved for urgent patient vs. routine patient bookings? Can the dedicated executive lead book patients onto the list without consultant oversight? Do you have regular training / refreshers available for waiting list teams to learn best practice? Are there tools and templates available to support dedicated executive lead to make decisions? Does the dedicated executive lead have access to peer support in the organisation? e.g., action learning sets Is there a collaborative relationship between waiting list and bed management teams for capacity and demand planning? 24 of 58
1. Organisation Structure Clearly defined reporting line to the director of operations (or equivalent) with clear and well communicated escalation policy There is a waiting list management policy in place which clearly defines individual roles and responsibilities Potential Issue Unclear reporting lines hampering clarity of ownership of the problem Waiting list management function positioned at low or inappropriate level within the organisational structure leading to a lack of strategic overview and the ability to influence delivery outcomes Dedicated executive lead reporting to person or function with no voice or visibility at senior executive level Lack of senior clinical buy-in and resistance to change processes and practices to improve waiting list management performance No waiting list management policy in place which leads to a lack of guidance for recommended process e.g., escalation policy Recommended Action Develop and implement a waiting list management policy which defines roles, responsibilities, reporting structure and a clarity of ownership Dedicated executive lead reports to director of operations or equivalent, giving senior management team visibility and the ability to challenge existing practice Obtain senior level and clinical lead buy-in through engagement and joint reviews of waiting lists Clearly define escalation procedures that are easily accessed and can be invoked rapidly Operational specialty booking teams are clearly defined and understand who to speak to if escalation required 25 of 58
2. Roles and Responsibilities Appropriate senior level person with oversight of waiting time performance, with clear role description and the authority to challenge and influence existing practice Potential Issue Consultant influence to the booking process and a lack of non-urgent patient to-come-in (TCI) dates issued lead to an unbalanced and non-chronological waiting list No senior dedicated executive lead in post leading to inability to execute change or make fully effective strategic decisions to improve performance Lack of role description leading to reactive rather than proactive behaviour a focus solely on tactical actions rather than adapting a tactical and strategic approach Waiting list management role treated as part of another key role leading to insufficient time dedicated to the job Key responsibilities ill-defined or poorly communicated leading to lack of authority to challenge the status quo. Recommended Action Booking responsibilities should rest entirely with an appointed individual Appoint a senior level dedicated executive lead with the skills and clinical understanding to enable them to challenge at all levels/professional groups Agree a clear dedicated executive lead role description with all relevant stakeholders such as bed and theatre management teams Ensure that the senior dedicated executive lead is tasked solely with reducing waiting times Work with operational and medical staff to ensure they have protected time to focus on effective booking and waiting list management Operational waiting list booking role formalised in job descriptions underlining ownership of specialty level performance 26 of 58
3. Skills and Training A focused range of training and development sessions to ensure staff throughout the organisation have the capability to drive performance by executing improvement initiatives on both a strategic and tactical level Potential Issue There is a variation in the capability of the operational booking staff throughout the hospital meaning that there is a lack of capability in some specialties Staff have been performing the role for a number of years and have devised their own ad-hoc processes for booking leading to a lack of use of best practice methodologies There is no mechanism for high performing teams to share their knowledge meaning that local intelligence and success stories do not spread throughout the hospital Good performance goes un-noticed, leading to a lack of motivation for staff to improve or share good practices across the organisation Recommended Action Benchmark performance across all specialties and map against individual performance to identify issues and required actions to improve performance Devise a training programme which will educate staff on best practice and ways to improve performance and manage risk over time Deliver the training programme in a manner which is flexible and suitable for busy staff with other duties e.g., use e-training materials and action learning sets Facilitate sessions between staff from different specialities where issues can be discussed and strategies for high performance can be shared Acknowledge and celebrate high performing teams to reward excellence and motivate others to strive for success 27 of 58
Key Learning from Irish Hospital Visits Formalised Hospital Policy Develop and issue a local waiting list policy which reflects NTPF guidance and recommended process flows. It should include at a minimum the following: - An overview of the organisational structure responsible for waiting list management - Clear definitions of roles, responsibilities and accountabilities for waiting list management - Definitions used for categorisation of patients waiting urgent and routine - Waiting list validation processes - Cancellation/suspension/DNA/CNA processes - Mechanisms that will be used to support chronological booking - es for development of specialty based action plans where waiting list management problems identified by data based on performance tracking at a consultant and specialty level - es for providing support to specialties who are at risk of failing to deliver against action planning and national targets - es for identifying how NTPF support can be utilised to facilitate improvements in access times for scheduled care in a sustainable manner Establish a working team to provide on-going tactical support to specialties who are breaching national access targets The NTPF Policy (2013) can be accessed here: 28 of 58
Key Learning from Irish Hospital Visits Action Plans for At-Risk Specialties Agree action plans with those specialties who are currently breaching or at risk of breaching the national access targets. Each specialty action plan must identify: - The numbers of patients currently breaching and those at risk of breaching targets from a validated waiting list - Available theatre and forecast bed capacity ensuring that a contingency is applied for treatment of unscheduled patients and that clinical leave is identified and factored into this - Indicative TCI dates for those patients at risk of breaching with a primary focus on the longest waiters - The numbers of patients who will still breach national access targets should additional capacity be found in the short term to treat the longest waiters within available capacity - The mechanisms for treating those patients who still breach including use of additional in house capacity/ outsource options - with a clear identification of the number of patients who will still breach following remedial short term action - The processes to be used to monitor delivery of the action plan and - The processes to be used to take remedial action where targets are not delivered 29 of 58
Key Learning from Irish Hospital Visits Group Establish a dedicated inpatient and day case waiting list management project group who focus on: - Identifying specialties who are currently breaching waiting list targets - Identifying those specialties at risk of breaching - Working with the theatre management team to re-assign theatre slots in the short-term to specialties at risk of breaching - Identifying proactive measures to reduce/eliminate breaches with specialty clinical and managerial teams including allocating theatre sessions where consultants are on annual leave to those specialties/consultants who have significant waiting list problems in the short term - Reviewing performance against agreed action plans, ensuring that additional support measures are utilised where performance does not meet agreed targets - Providing weekly summary action plan review reports to the hospital CEO for review and to the Hospital Board/ senior management group monthly Strengthen the governance structure for the waiting list group to increase visibility of performance against national waiting list targets and to provide improved accountability for delivery of those targets Accountability Appoint a single point of operational accountability for the performance of scheduled care waiting list management who is accountable to the CEO and/or hospital board 30 of 58
Examples of Good Practice Hospital A Implemented a Directorate structure within the hospital - Each Directorate is made up of a number of specialties grouped together - There is a Business Manager assigned to each Directorate who is responsible for operational efficiency - The Directorate structure provides a solid platform for the implementation of chronological booking - The bed management team conduct a daily bed capacity review to inform directorate planning Hospital B There is an effective governance structure in place for the day case ward which facilitates a high bed utilisation for patients and quicker turnaround times Hospital C Hospital management conduct a weekly review of waiting list data to review progress, identify atrisk specialties and agree required actions to clear breaches Hospital D The waiting list management team conduct a weekly review to identify at risk specialties, issues and track performance on an on-going basis 31 of 58
Section Setting the context and initiating whole systems change for the delivery of scheduled care Delivering targets in scheduled care Demand and Capacity and Contingency Ensuring Efficient Use of Resources This section covers issues and best practices for effectively using data and information in waiting list management Firstly, it aims to make senior management aware of the key issues at a highlevel related to data and information Secondly, it provides detail around each issue in addition to recommended actions for each to improve performance in waiting list management The recommended actions provide both senior management, operational and medical staff with the know-how to improve performance and achieve the key targets 32 of 58
Overview Strategic decision making and understanding where to take decisive action requires a strong understanding of organisation and specialty performance There are three key data and information components for effective waiting list management, summarised below: 1. Understanding Performance 2. Primary Targeting Lists (PTLs) 3. Key Performance Indicators Do you have a good understanding of how the hospital is currently performing? Do you make use of a performance dashboard to identify underperforming areas? Do you examine speciality/ consultant level performance? Do you use data/dashboards to track performance and issues over time to identify specific trends? Do you understand which parts of the scheduled care pathway are causing long waiting times? Do you make use of organisation and specialty level PTLs? Are PTLs produced internally and regularly (ideally weekly) to ensure current performance is understood? Do your booking teams use PTLs to drive chronological booking for routine patients? Do you collect performance metrics on areas which might influence overall waiting times? Do you take strategic decisions based on performance against key performance indicators? Do you regularly share performance against KPIs with staff and other stakeholders to influence change? Do you complete clearance plan in collaboration with individual specialties? 33 of 58
1. Understanding Performance The production of a weekly performance dashboard showing the organisation s current performance and waiting times by specialty and consultant. Potential Issue There is no single and accurate data based measure of scheduled care waiting list performance Clinical specialities do not understand their current performance or how they compare to other specialties leading to a lack of engagement and an inability to focus attention on underperformance There is no measure of waiting time by individual consultant teams, making it difficult to engage individuals for improving waiting list management practices There is little understanding of how long patients wait at different stages in a clinical pathway, meaning pressure points cannot be highlighted for targeting e.g., theatre capacity planning Recommended Action The design and production of a weekly dashboard for executive and general manager review would inform decision making and ensure agreed actions were undertaken to meet targets Specialty level performance should be produced and circulated on a weekly basis to help teams understand their performance, and motivate those performing poorly Consultant level performance should be produced to ensure targeted engagement of underperformance can occur (see communication and engagement for more) High volume pathways should be mapped and indicative waiting times for each stage calculated so that pressure points can be highlighted and addressed 34 of 58
2. Primary Targeting Lists (PTLs) Produce an organisation and speciality level PTL every week which is distributed to booking teams and general managers throughout the organisation. Potential Issue Without a definitive list of patients who are booked/ need to be booked, specialties cannot book routine patients in a chronological order leading to potential breaches Specialties which do not have a list of booked patients cannot easily identify breaches or likely breaches and therefore cannot take mitigating actions Hospitals who do not have a centralised list of all patients booked, or those who have to be booked are unable to engage speciality waiting list teams to ensure waiting list performance targets are met Recommended Action Produce an organisation and speciality level PTL every week which is distributed to booking teams and general managers throughout the organisation. The PTL should clearly show: - patient details, - procedure required, - date added to the list, - date booked in for, - indicative waiting time and - current status on the list. Use the PTLs produced to engage problem specialties and create action plans for patient cohorts which are breaching or likely to breach waiting time targets. 35 of 58
3. Key Performance Indicators Agree a set of Key Performance Indicators (KPIs) on which your organisation s ability to meet the waiting list target can be measured against Use these KPIs to identify issues and required actions to deal with issues and clear breaches Potential Issue There is no understanding of the factors which cause long patient waiting times There is no data or information based view of performance in areas which affect patient waiting times Strategies to reduce waiting times are not evidence based and therefore may be targeted at the wrong places Recommended Action Define and agree a set of KPIs for your organisation e.g., DNA rates, cancellation rates, number of 8 month breaches, patients waiting for diagnostics and suspension volumes Produce a weekly performance report of performance against the agreed KPIs and use this to inform strategic decision making Engage staff using the KPIs as an evidence base for intervention in specific areas of underperformance 36 of 58
Key Learning from Irish Hospital Visits Consistent Classification Ensure that the hospital has a consistent approach to classifying patients on its scheduled care waiting list in line with national guidance This should include agreement for two classifications; urgent and routine, and working with clinical teams to reclassify patients as appropriate Data Visualisation and Presentation Present waiting list data visually to show trend analysis, consultant benchmarking, clearance times, bed and theatre management This data should be used by the Director of Operations (or equivalent) to engage in discussions with speciality teams, the hospital bed manager, theatre managers on improvement actions or to celebrate success in delivery of waiting list initiatives Data Driven Discussions Make better use of data management and analysis e.g., the use of dashboards, trend analysis and clearance time analysis to facilitate data driven discussions for waiting list performance with: - Individual consultants and specialties - Bed and theatre management teams 37 of 58
Examples of Good Practice Hospital A Data analysis has greatly improved within the hospital through the use of almost real-time data collection and analysis through a SAP system (Systems, Applications and Products in Data ing). See www.sap.com/ country-selector.epx for further information. The implementation of the system has helped to support effective waiting list management through data management and analysis such as: - Trend analysis - Integrated bed management - Theatre and capacity analysis Hospital B The hospital has undertaken a data visualisation exercise to analyse its Primary Targeting Lists (PTL) data trends this is used to facilitate data-driven discussions between management and clinicians (illustrations on the following two pages) In addition, the data analysis helps to provide an understanding of demand and capacity for planning purposes 38 of 58
Sample Dashboards Current by Week added to List WL Urgency: Group Date on WL Year: 2012 Episode Status: Multiple Selections WL Entries Total * * * If patients have been given a different clinical priority, such as soon or other (as in this dashboard), they will need to be re-categorised into the new taxonomy: Urgent or Routine. Each hospital must decide the internal process for this re-categorisation to occur safely. See page 9, section 3.2 of the National Policy (2013) The process for determining priority. 39 of 58
Sample Dashboards Admissions off within 3 months by Specialty and WL Urgency WL to Admit Wait Group (Mths): 0-3 Months Date on WL Indicator: Yes Admission Year: 2012 * * If patients have been given a different clinical priority, such as soon or other (as in this dashboard), they will need to be re-categorised into the new taxonomy: Urgent or Routine. Each hospital must decide the internal process for this re-categorisation to occur safely. See page 9, section 3.2 of the National Policy (2013) The process for determining priority. 40 of 58
Sample Dashboards An effective dashboard will allow for trend analysis to track performance over time and identify specific issues and areas to focus on The dashboard will facilitate data-driven discussion in relation to waiting list performance with individual consultants and specialties Specialties are ranked by the number of active waiting patients on the list The red bars to the right represent the number of patients waiting over 9 months/the breach period on the list and currently in breach of the future target Each blue and red bar on the graph represents one week in a year 41 of 58
Section Setting the context and initiating whole systems change for the delivery of scheduled care Delivering targets in scheduled care Demand and Capacity and Contingency Ensuring Efficient Use of Resources This section covers issues and best practices for process improvement in waiting list management Firstly, it aims to make senior management aware of the key issues at a highlevel related to process improvement Secondly, it provides detail around each issue in addition to recommended actions for each to improve performance in waiting list management The recommended actions provide both senior management, operational and medical staff with the know-how to improve performance and achieve the key targets 42 of 58