@nhsscotlandevent #NHSScot19
Waiting Times: Performance, Improvement and Sustainability
Juliette MurrayConsultant 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 andminor 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 DiversOperations Manager Surgical Division, Golden Jubilee National Hospital
Julie KingPerformance 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 FoundationPatients 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
0
1000
2000
3000
4000
5000
6000
7000
8000
900020
11-1
2
2012
-13
2013
-14
2014
-15
2015
-16
2016
-17
2017
-18
2018
-19
2019
-20
9511549
2499
41464800
5794
7600 76508250
Num
ber o
f Pro
cedu
res
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
careReducing
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: StructureImprovement 1
March 2017 Out-patient service relocatedwhich allowed a redesign of flow to betested
• 3 Optometrists to 1 Consultant model• Daily debriefs over March and April
Adopt! Adapt! Abandon!
Whole Systems Approach: Process
3 Ophthalmology
Technicians3 Registered
Nurses3 Optometrists 1 Consultant
Station 1 Station 2 Station 3
Patient’s demographics and all ophthalmology measurements carried out 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: PatternsImprovement 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
1Nurse
1Optometrist
Visit time reduced by 50% to 1 hour 20 minutes
Whole Systems Approach: Outcome
Out-patient DNA rate: Process
0
1
2
3
4
5
601
/06/
201
701
/07/
201
701
/08/
201
701
/09/
201
701
/10/
201
701
/11/
201
701
/12/
201
701
/01/
201
801
/02/
201
801
/03/
201
801
/04/
201
801
/05/
201
801
/06/
201
801
/07/
201
801
/08/
201
801
/09/
201
801
/10/
201
801
/11/
201
801
/12/
201
801
/01/
201
901
/02/
201
901
/03/
201
9
Perc
enta
ge
Month
Out-Patient DNA July 2017 to March 2019Median
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/
2017
01/0
5/20
1701
/06/
2017
01/0
7/20
1701
/08/
2017
01/0
9/20
1701
/10/
2017
01/1
1/20
1701
/12/
2017
01/0
1/20
1801
/02/
2018
01/0
3/20
1801
/04/
2018
01/0
5/20
1801
/06/
2018
01/0
7/20
1801
/08/
2018
01/0
9/20
1801
/10/
2018
01/1
1/20
1801
/12/
2018
01/0
1/20
1901
/02/
2019
01/0
3/20
19
Ophthalmology Cancellations April 17 to March 19 MedianMeasure
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%
04/1
705
/17
06/1
707
/17
08/1
709
/17
10/1
711
/17
12/1
701
/18
02/1
803
/18
04/1
805
/18
06/1
807
/18
08/1
809
/18
10/1
811
/18
12/1
801
/19
02/1
903
/19
Orthopaedic 'On the Day' Theatre Cancellations
(April 2017 - March 2019)Median
Measure
53
45
13 11 106 5 4 4 3 3 2 2 2 2 2 1
0
10
20
30
40
50
60
0%10%20%30%40%50%60%70%80%90%
100%
Surg
. can
x - p
t not
fit
Anae
s. c
anx
- pt n
ot fi
tM
gmt c
anx
- lac
k of
OR
tim
ePt
can
x - D
NAPt
can
x - n
o lo
nger
wis
hes…
Mgm
t can
x - e
quip
not
…Su
rg. c
anx
- pro
c. n
ot…
Hos
p. c
anx
- no
HD
U b
edPt
can
x - u
nabl
e to
atte
ndH
osp.
can
x - a
dmin
erro
rM
gmt c
anx
- the
atre
sta
ff…An
aes.
can
x - n
ot a
vail
Anae
s. c
anx
- pt n
ot…
Surg
. can
x - d
ue to
…Su
rg. c
anx
- not
ava
ilSu
rg. c
anx
- pt n
ot p
repa
red
Anae
s. c
anx
- on
call
Num
ber o
f Pat
ient
s
Perc
enta
ge o
f Pat
ient
s
Orthopaedic Theatre Cancellation Reasons
(April 2018 - March 2019)
Performance Data - Endoscopy
UCL
LCL
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
04/2
017
05/2
017
06/2
017
07/2
017
08/2
017
09/2
017
10/2
017
11/2
017
12/2
017
01/2
018
02/2
018
03/2
018
04/2
018
05/2
018
06/2
018
07/2
018
08/2
018
09/2
018
10/2
018
11/2
018
12/2
018
01/2
019
02/2
019
03/2
019
PercentEndoscopy " On the Day"
Theatre Cancellations
52
3026 25
18
9
3 3 2 20
10
20
30
40
50
60
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pt can
x - D
NA
Pt can
x - un
able
to…
Surg. c
anx -
pt no
t fit
Surg. c
anx -
proc
.…
Surg. c
anx -
pt no
t…
Pt can
x - no
long
er…
Hosp.
canx
- adm
in…
Surg. c
anx -
due t
o…
Pre-op
guida
nce…
Surg. c
anx -
not a
vail
Num
ber o
f Pat
ient
s
Perc
enta
ge o
f Pat
ient
s
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
@nhsscotlandevent #NHSScot19
Top Related