Assessment and Patient Assessment and Patient Pathways Pathways

Geoff BardsleyGeoff BardsleyConsultant Clinical ScientistConsultant Clinical Scientist

Head of Assistive Technology,Head of Assistive Technology,

NHS Tayside.NHS Tayside.

SummarySummary Rapid Improvement EventRapid Improvement Event

BackgroundBackground ScopeScope

Strategy for improvementStrategy for improvement Planned developmentsPlanned developments

Patient pathwaysPatient pathways Assessment issuesAssessment issues

ConclusionsConclusions

Stimulate discussionStimulate discussion

Rapid Improvement Event (RIE) ?Rapid Improvement Event (RIE) ?

Management techniqueManagement technique Problems identified with a serviceProblems identified with a service Step change improvement to a serviceStep change improvement to a service Focussed on meeting client needsFocussed on meeting client needs Re-design actively involvesRe-design actively involves

ClientsClients StaffStaff ManagementManagement

Action planAction plan

External consultantsExternal consultants

RIE BackgroundRIE Background Increasing demandIncreasing demand Improving technologyImproving technology Increasing patient expectationsIncreasing patient expectationsBudget limitationsBudget limitationsEnding of short term fundingEnding of short term funding

Changing Children’s Services FundChanging Children’s Services FundWaiting list initiativeWaiting list initiative

Short cuts to meet demand Short cuts to meet demand AssessmentAssessment Staff training supportStaff training support

RIE BackgroundRIE Background

Complaints / dissatisfactionComplaints / dissatisfactionLengthening waiting listsLengthening waiting listsPoor control / organisation of waiting listsPoor control / organisation of waiting listsPoor information to patientsPoor information to patientsDeteriorating quality of serviceDeteriorating quality of serviceLow staff moraleLow staff morale

RIE ScopeRIE Scope

Entire serviceEntire servicePathwaysPathwaysEmphasis on clinical ‘front end’Emphasis on clinical ‘front end’

Client focussedClient focussed

PatientPatient

CarerCarer

Referring professionalsReferring professionals

Strategic directionStrategic direction

Improve the speed and efficiencyImprove the speed and efficiency patients are seenpatients are seen equipment providedequipment provided

Make best use of current staff Make best use of current staff experience and expertise experience and expertise (internal & external)(internal & external)

Make the service to users more Make the service to users more local, local, responsive, responsive, transparent transparent

Improve integration with other servicesImprove integration with other services etcetc

Examples of planned Examples of planned improvementsimprovements

Note : othersNote : others

Patient Patient PathwaysPathways

Patient Patient PathwaysPathways

Summary pathSummary path

1.1: Input into service, to Clerical staff

New referral Re-referral

3 Provision

RepairCollect

3.1 Direct to patient Via Clinician

3.12 Delivery / post deliveryBy technician

4.1 Review

4.3 ‘Discharge ?’

Technical SupportRequest for Information

1.3 Clinical Referrals Advice/Query

1.3:Screening

2.4.xScheduled

clinic

2.5 Main

waiting list2.3

Team Action

2.2 Urgent

assessment

2.6 Powered mobility

3.10 Fitting / adjustment

4.4.2 Workshop Repair

4.4.1 Residential Repair

4.5 Collect

3.6 / 4.7Stock device /

Store

Work progress ?

4.6 Refurbish

4.4.3 Drop-in Repair

3.6 / 3.9 Ordering / External supplier

4.4 Repair

Archive- Dormant

- Deceased- Moved

Clinical prescription

?

2.7 Clinical, assessment, prescription, design specification

3.2Hospital

3.3Priority

3.4Non priority

3.11Delivery by clinician

3.7, 3.8 ModificationsFabrication

Clinic options

2.1Paper-based

issue 2.8 Action following being seen

3.5 Care Homes

4.1 Annual letter

4.2 Clinical Review

Patient Patient PathwaysPathwaysDefined before RIE Defined before RIE (extensive work)(extensive work)

Few inefficiencies / redundancyFew inefficiencies / redundancyLargely unchangedLargely unchangedFurther workFurther work

RIE - Referral pathway modifiedRIE - Referral pathway modifiedImprove efficiencyImprove efficiencyBetter management / flow of workBetter management / flow of workWaiting time information for patientsWaiting time information for patients

Referral PathwayReferral Pathway

Referral screening

Urgent

Direct Issue

Home visits

Powered wheelchairs

Scheduled clinics

Priority Routine

Referral PathwayReferral Pathway

Referral screening

Urgent

Direct Issue

Home visits

Powered wheelchairs

Scheduled clinics

Priority Routine

WT < 1 day

6 listsWT ????

WT < ?

WT = S WT = X

WT = Waiting times

Referral PathwayReferral Pathway

Referral screening

Urgent

Direct Issue

Home visits

Powered wheelchairsScheduled

clinics

PriorityRoutine

Referral PathwayReferral Pathway

Referral screening

Urgent

Direct Issue

Home visits

Powered wheelchairsScheduled

clinics

PriorityRoutine

WT = S

1 listWT = H

WT = P

WT < 1dayWT<<P

WT = Waiting times

Next stepsNext stepsActive monitoring / management processActive monitoring / management process

Routine weekly meetingsRoutine weekly meetings IT data IT data (new reports in place)(new reports in place)

Reporting to higher managementReporting to higher management

Staff recruitmentStaff recruitment

Transitional phaseTransitional phaseManaging backlogManaging backlog

Assessment phaseAssessment phaseClinic inefficienciesClinic inefficiencies

Did not attends (DNAs) - Did not attends (DNAs) - 20 to 40% (1 or 2 out of 5)20 to 40% (1 or 2 out of 5)

Clinic frequency inadequateClinic frequency inadequateWaiting times increasingWaiting times increasingMinimise seeing patientsMinimise seeing patientsReview frequency lowReview frequency low

Quality of assessments ?Quality of assessments ?Reduced time / patientReduced time / patientReduced TORTC team (1)Reduced TORTC team (1)Reduced local staff involvementReduced local staff involvementNo outcome measuresNo outcome measures

Currently up to 12 wks (clinic)

Draft standard Ref – assess < 4 wks

RIE Target Ref – provision < 18 wks

Reducing DNAs Reducing DNAs (Did not attends)(Did not attends)

Pre appointment phone callsPre appointment phone callsPatient-focussed-booking (Clinic & repairs)Patient-focussed-booking (Clinic & repairs)

Letter to patient inviting to book appointmentLetter to patient inviting to book appointmentPatient responsibility to phone & bookPatient responsibility to phone & bookPatient chooses suitable timePatient chooses suitable time ( (More certain will attend) More certain will attend) Excludes those not interestedExcludes those not interestedBUT – disadvantages less ableBUT – disadvantages less able

Transportation / ambulances ?Transportation / ambulances ?

Clinic FrequencyClinic Frequency

Increase staff for clinicsIncrease staff for clinicsStaff recruitmentStaff recruitmentAdditional staffAdditional staffUtilisation current staff ?Utilisation current staff ?

Increase technicians’ clinical roleIncrease technicians’ clinical roleConcentrate clinical staff on clinics / complex casesConcentrate clinical staff on clinics / complex casesImprove quality of assessmentImprove quality of assessment

Technician utilisationTechnician utilisation

Mobile Technicians (x3)Mobile Technicians (x3)Current roleCurrent role

Repairs, collects & deliveriesRepairs, collects & deliveriesTravel throughout TaysideTravel throughout Tayside5 to 12 years experience each5 to 12 years experience eachKnow patients very wellKnow patients very wellNo clinical responsibilitiesNo clinical responsibilities

Additional Technician RoleAdditional Technician Role

Empower for basic clinical decisions, Egs:Empower for basic clinical decisions, Egs: Change of wheelchair sizeChange of wheelchair size Additional accessories Additional accessories (headrests, laterals, etc)(headrests, laterals, etc) Make adjustments Make adjustments (roho cushions, etc)(roho cushions, etc)

Rapid Rapid (during repairs / on request)(during repairs / on request)

TrainingTraining, Supervision, & Backfill, Supervision, & Backfill

Ears / eyes of the serviceEars / eyes of the service Tele-care (lap top, camera, phone)Tele-care (lap top, camera, phone)

Better use clinical staffBetter use clinical staffOther techniciansOther technicians

Additional Referrers’ RoleAdditional Referrers’ RoleNurses, TherapistsNurses, Therapists

Empower for basic clinical decisions, Egs:Empower for basic clinical decisions, Egs: Prescriptions (basic cases)Prescriptions (basic cases) Local environmental issues (access, ramps, house mods, etc)Local environmental issues (access, ramps, house mods, etc) Larger wheelchairLarger wheelchair Additional accessories Additional accessories (headrests, laterals, etc)(headrests, laterals, etc) Make adjustments Make adjustments (roho cushions, etc)(roho cushions, etc) Training in wheelchair useTraining in wheelchair use

Training, Supervision, Training, Supervision, Availability?Availability?

Better use TORTC clinical staffBetter use TORTC clinical staffWork with techniciansWork with technicians

More local serviceMore local service

One stop clinicsOne stop clinics

Rapid service Avoids delivery

BUTClinic timeStock available

Review proceduresReview procedures

Referrals for life BUT needs change Referrals for life BUT needs change (slow – rapid)(slow – rapid)

Review to identify change and respondReview to identify change and respondPreferably before need critical (pro-active)Preferably before need critical (pro-active)Currently Currently

Annual letterAnnual letter Children & a few critical casesChildren & a few critical cases

Future ?Future ? All have defined review programmeAll have defined review programme Resources? (creates extra demand)Resources? (creates extra demand)

Responsibility of Patients / Carers ??Responsibility of Patients / Carers ??

ConclusionsConclusions

Patient pathways have been definedPatient pathways have been definedReferral pathway improved Referral pathway improved

More structured clinicsMore structured clinicsImproved management of waiting listsImproved management of waiting listsBetter information to patientsBetter information to patients

Assessment improved / acceleratedAssessment improved / acceleratedStaff utilisation (technicians, therapists / nurses)Staff utilisation (technicians, therapists / nurses)One stop clinicsOne stop clinicsBetter use TORTC clinical staffBetter use TORTC clinical staffReviews ?Reviews ?