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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

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11-1

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2012

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2019

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9511549

2499

41464800

5794

7600 76508250

Num

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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

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Perc

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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%

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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%

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6.0%

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705

/17

06/1

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701

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06/1

807

/18

08/1

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10/1

811

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12/1

801

/19

02/1

903

/19

Orthopaedic 'On the Day' Theatre Cancellations

(April 2017 - March 2019)Median

Measure

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13 11 106 5 4 4 3 3 2 2 2 2 2 1

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Num

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Orthopaedic Theatre Cancellation Reasons

(April 2018 - March 2019)

Performance Data - Endoscopy

UCL

LCL

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

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PercentEndoscopy " On the Day"

Theatre Cancellations

52

3026 25

18

9

3 3 2 20

10

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30

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50

60

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90%

100%

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Num

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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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