Waiting Times: Performance, Improvement and Sustainability - - PowerPoint PPT Presentation

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Waiting Times: Performance, Improvement and Sustainability

Juliette Murray

Consultant Surgeon and Programme Clinical Lead, Scottish Access Collaborative

To provide an optimal service with finite resources Can we better utilise the resources we have to provide sustainable solutions?

The Challenge:

Lanarkshire Breast Service

• Historically 6 consultants, 3 sites
• 2012 four senior surgeons retired
• Forced to think about working differently

Current model

• Most surgeons 2-3 clinics, 1 full day operating
• Significant variation in surgical conversion rates
• Emergency work further reduces capacity
• Huge variability in elective workload and

capacity

Potential solutions

• Fewer consultants, working more flexibly.
• Committed long term staff for continuity.
• Advanced nurse practitioners for clinics and

minor procedures.

• Make changes to the way in which we work to

increase overall capacity.

Reducing clinical caseload

• Understand/ benchmark New : Return ratios
• Reduce routine long term follow-

up clinics : eg TCAT

• Virtual/ telephone clinics
• Unit protocols for surgery/ imaging
• One stop diagnostic clinics where possible perform

minor surgery or investigations during first appt

Team Job Plans

• Increase sessions as required
• Ability to flex to demand
• Match clinic conversion to

available theatre time

• Develop footprint for service
• Utilise all staff to cover it 50 weeks a year

Lanarkshire Breast Service now

• Sees all new breast patients within 10-14 days. Capacity and

demand in balance since 2013

• 4 Consultants, sessional speciality doctors, ANPs. Able to

cover peaks/troughs and planned/ unplanned leave

• Some fixed sessions, some flexible
• Annualised, can be delivered both when suits service and

individuals

Lanarkshire service changes

• Allowed us to offer support to Neighbouring Boards
• Able to manage 5-10% increase in referrals annually
• Can see and treat 50% more cancer patients with 50% fewer consultants
• Have repatriated breast screening patients
• Have established local plastics service
• Used similar models to reduce capacity/ demand mismatch in other

specialties locally

• Finished 2018/19 financial year £130,000 under budget

Programme Scope

Endorsed Challenges

• Active Clinical Referral Triage

(ACRT)

• Waiting List Validation
• Virtual Attendance
• Clinical Pathways Infrastructure

Endorsed Challenges

• Accelerating the Development of

Enhanced Practitioners (ADEPt)

• Flying Finish
• Effective and Quality Interventions Pathways (EQuIP)
• Team Service Planning

Clinical engagement in solutions

• Identify good practice and tell people about it
• Benchmark services and encourage teams to

communicate and cooperate

• Bring clinicians together to develop consensus
• Identify key emerging roles eg in advanced

practice and promote them

• Help services to develop a footprint of the capacity

required and identify gaps in staffing/ resource

Questions at the end of the session

Christine Divers

Operations Manager Surgical Division, Golden Jubilee National Hospital

Julie King

Performance and Improvement Manager, Golden Jubilee National Hospital

Whole Systems Approach to Improvement and Sustainability

Golden Jubilee National Hospital Golden Jubilee Conference Hotel Golden Jubilee Research Institute Golden Jubilee Innovation Centre

The Golden Jubilee Foundation

Patients at the heart of progress

Delivering Care through Collaboration

• National Health Board

increasing capacity for Scotland

• Collaborative working

with 14 Regional Boards

• Heart and Lung services

and National Elective Programmes

‘‘Putting people first to achieve and sustain excellence - in care, performance, quality, innovation and values”

Ophthalmology Growth

1000 2000 3000 4000 5000 6000 7000 8000 9000 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18 2018-19 2019-20 951 1549 2499 4146 4800 5794 7600 7650 8250

Number of Procedures Year

Ophthalmology Activity 2011- 2019

GJNH Ophthalmology Service

• 7600 cataract procedures in 2017/18
• 10,200 out patients per year (30% increase)
• Circa 240 patients per week
• National shortage of Ophthalmologists!!
• National Elective Programme

How can we do things differently?

Expanding Capacity Innovative models of care Reducing cancellations Phase 1 Expansion National Elective Programme

Whole Systems Approach to Innovative Care

Structure Processes Patterns

‘If we want fundamental and transformational change in a complex system we must consider interactions and changes in structure processes and patterns’

Working in Systems Improvement Leaders Guide 2005

Aim: Increase Out-patient Capacity by 30% by September 2018

Whole Systems Approach: Structure

Improvement 1

March 2017 Out-patient service relocated which allowed a redesign of flow to be tested

• 3 Optometrists to 1 Consultant model
• Daily debriefs over March and April

Adopt! Adapt! Abandon!

Whole Systems Approach: Process

3 Ophthalmology Technicians 3 Registered Nurses 3 Optometrists 1 Consultant

Station 1 Station 2 Station 3 Patient’s demographics and all ophthalmology measurements carried

• ut i.e. visual acuity,

biometry Past medical history, medicine reconciliation, vital signs, infection control questions, instillation of dilating drops, cancellations Seen by optometrist and consultant, consented for procedure

Improvement 2

Whole Systems Approach: Patterns

Improvement 3

• Department split into 3 teams

1 from each station

• Small Multidisciplinary team

within bigger clinical team

• Each team sees 8 patients

per session

1 Technician 1 Nurse

1 Optometrist

Visit time reduced by 50% to 1 hour 20 minutes

Whole Systems Approach: Outcome

Out-patient DNA rate: Process

1 2 3 4 5 6 01/06/2 017 01/07/2 017 01/08/2 017 01/09/2 017 01/10/2 017 01/11/2 017 01/12/2 017 01/01/2 018 01/02/2 018 01/03/2 018 01/04/2 018 01/05/2 018 01/06/2 018 01/07/2 018 01/08/2 018 01/09/2 018 01/10/2 018 01/11/2 018 01/12/2 018 01/01/2 019 01/02/2 019 01/03/2 019

Percentage Month

Out-Patient DNA July 2017 to March 2019

Median Measure

Improvement 4

Theatre Performance - Structure

• Mobile theatre opened May 2017
• Problems initially with microscope,

vibration and flow

• Only able to achieve 6 cataract
• procedures per session
• Perseverance = Productivity!
• Increased to 7 in May 2018

Maximising Theatre Capacity- Process

Improvement 5 Process agreed with multi disciplinary team to take appropriate patients directly from clinic to replace last minute cancellations. Piloted initially in Feb 18 with 1 consultant then the in house team then rolled out in Jun 18 to all

Benefits of Redesign

• Maximising capacity in clinic (94% utilisation)
• Released consultant time
• Increase in productivity
• Reduction of patient visit times (halved)
• Improvement in communication
• Cohesive team working across MDT
• Maximising theatre capacity (85% utilisation)
• Active Management of DNA’s and replacement from clinic

Design through Redesign!

Out Patient/Pre-Op Theatre Entrance Admission/Discharge Shared FM area FM/Staff Link

Patient Centred Care

Clinical Leadership Outpatient Team Theatre Team

Unit Coordinators

Booking OfficeTeam

Where we do it How we do it

Roles , Responsibilities and Engagement

Structure Process Patterns

Maximising theatre capacity - Process

0% 1% 2% 3% 4% 5% 6% 7% 01/04/20 17 01/05/20 17 01/06/20 17 01/07/20 17 01/08/20 17 01/09/20 17 01/10/20 17 01/11/20 17 01/12/20 17 01/01/20 18 01/02/20 18 01/03/20 18 01/04/20 18 01/05/20 18 01/06/20 18 01/07/20 18 01/08/20 18 01/09/20 18 01/10/20 18 01/11/20 18 01/12/20 18 01/01/20 19 01/02/20 19 01/03/20 19

Ophthalmology Cancellations April 17 to March 19

Median

Measure

Whole Systems Thinking Why should we focus on improving theatre cancellations?

Patient Journey – opportunities to improve

Patient Referral Outpatient Pre- assessment Theatre Booking Patient Admit Theatre Inpatient Stay

Enhanced Patient Experience

Theatre usage is heavily influenced by what comes before and after in the patient journey

Improved Staff Experience Best use of resources

Systems thinking is key to optimising theatre usage

Our approach

• Review our theatre cancellations each week – speciality by speciality
• Identify “avoidable” and “unavoidable” cancellations
• Capture the information needed to target the challenges – cancellation

comments tells you a lot about your system

• Engage a group of motivated stakeholders – clinical leadership is key
• Identify and agree ongoing improvement actions – each step of patient

journey

• Share, share, share the data and seek feedback –

teams feel involved and empowered to act

Performance Data – Orthopaedic

0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 04/17 05/17 06/17 07/17 08/17 09/17 10/17 11/17 12/17 01/18 02/18 03/18 04/18 05/18 06/18 07/18 08/18 09/18 10/18 11/18 12/18 01/19 02/19 03/19

Orthopaedic 'On the Day' Theatre Cancellations (April 2017 - March 2019)

Median Measure 53 45 13 11 10 6 5 4 4 3 3 2 2 2 2 2 1

10 20 30 40 50 60 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

• Surg. canx - pt not fit
• Anaes. canx - pt not fit

Mgmt canx - lack of OR time Pt canx - DNA Pt canx - no longer wishes… Mgmt canx - equip not…

• Surg. canx - proc. not…
• Hosp. canx - no HDU bed

Pt canx - unable to attend

• Hosp. canx - admin error

Mgmt canx - theatre staff…

• Anaes. canx - not avail
• Anaes. canx - pt not…
• Surg. canx - due to…
• Surg. canx - not avail
• Surg. canx - pt not prepared
• Anaes. canx - on call

Number of Patients Percentage of Patients

Orthopaedic Theatre Cancellation Reasons (April 2018 - March 2019)

Performance Data - Endoscopy

UCL LCL

0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% 04/2017 05/2017 06/2017 07/2017 08/2017 09/2017 10/2017 11/2017 12/2017 01/2018 02/2018 03/2018 04/2018 05/2018 06/2018 07/2018 08/2018 09/2018 10/2018 11/2018 12/2018 01/2019 02/2019 03/2019

Percent

Endoscopy " On the Day" Theatre Cancellations

52 30 26 25 18 9 3 3 2 2 10 20 30 40 50 60 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% P t c a n x

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Number of Patients Percentage of Patients

Endoscopy Cancellation Reasons (April 2018 - March 2019)

Endoscopy Specialty

• Short Life Working

Group

• Targeting main

reasons for cancellation

• Improved patient

literature

• Patient phone calls

Whole Systems Approach to Improvement and Sustainability

Patient Experience Patterns Structure Process Staff Experience

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