Hearing Services (STH)
Hearing Services forms part of the Ear, Nose and Throat (ENT) Directorate at STH and operates a range of services including hearing tests, hearing aid repairs, domiciliary visits as well as specialist clinics such as bone implanted hearing aids. The majority of patients are over 60 but the service caters for all age groups.
Technological advances have seen major clinical changes in recent years with the advent of digital hearing aids which has also led to increased competition from external providers. Hearing aid repairs form a large part of the service and the team recognised access times were not consistent with a quality service. Reductions in resources following a commissioning review have further driven the need to improve and review how services are delivered for patients.
The service is run independently of doctors and a team of 11 Audiologists and Audiology Technicians see approximately 19,000 patients per year.
An interdisciplinary lead improvement team was formed from clinical, admin, clerical and management staff and an initial assessment undertaken using a '5P Assessment' (Patients, Professionals, Patterns, Processes and Purpose). Existing hospital information, staff and patient surveys, process mapping and simple measurement and observation in clinic were all used to develop a 5P poster from which the team then identified themes to focus their improvement work on.
Strategically there were concerns that the department was struggling with access times for their repair service and this was adversely affecting the quality of the service patients received as well as placing the department at risk of competition from external providers. Using the 5P data the team identified that access and equity were major themes particularly with the repair service with patients waiting up to 3 weeks for an appointment. Although formal complaint levels from patients were low in the department staff reported spending excessive time explaining why there were delays and that patient satisfaction with this was low. Additionally, reorganising work due to the delay in availability was placing additional pressure on the A&C staff. Inter-professional processes were also poorly understood and the lead improvement group also wanted to strengthen working relationships between staff groups.
To better understand the repair service the team set aims and gathered additional data.
The team’s first global aim was:
“We aim to improve the repair service. The process begins with the patient arriving at clinic reception and ends with the consultation complete or the patient leaving their hearing aid for collection at a later date. By working on this process we expect to make our service more equitable and efficient, utilise our resources more effectively and improve collaborative working. It is important to work on this now because we have high clinician and administrative dissatisfaction with the current system, long waits for an appointment and capacity issues with the repair service.”
A more detailed process map was generated, steps measured in clinic and an initial specific aim to work on generated that was measurable and time bound.
“We aim to reduce the current wait for a booked appointment from current baseline of 3 weeks to 48 hours by February 2012.”
By studying the process in clinic the team were able to establish how many patients they could realistically see each session and identify any bottlenecks or constraining factors. Administrative processes were also examined as part of this review. In reaching a conclusion the team identified that the current design and delivery of the repair service was leading to major delays in access, poor flow during clinic, increased A&C work load and resulted in a wide variance in daily numbers seen. The team also concluded that current working also adversely affected patient and staff satisfaction.
By studying these daily patterns it was deduced that the wide range in daily numbers directly contributed to the wait for a booked repair appointment as demand was not effectively matched with available capacity.
The service was also found to be inequitable as patients unable to leave their aid for repair incurred a 3 week delay for an appointment and those able to leave their aid did not have the advantage of a face to face consultation.
In order to test their "change ideas" the lead improvement team considered various options to improve the flow of patients attending for a repair. To do this they decided to test the idea of offering on-day open access repairs: ‘open repairs’. Mindful that the service was already inequitable it was decided that any interventions should offer choice to patients of both booked and open appointments and the leave and collect service should be abandoned.
Over 2 cycles of testing the team designed a new process for open repairs. Initially these were offered 2 days per week and the effect measured. During this testing stage there was no discernible drop in the wait for a booked appointment although the percentage of patients able to have a repair within 48 hours rose. Considering all factors from the trial the lead improvement team felt confident enough to progress their ideas and decided to test more ambitiously by offering open repairs over the course of the whole week.
Throughout both testing cycles data was collected before, during and after the change to help demonstrate the effects of the changes implemented.
The team was able to demonstrate an increase in the percentage of patients seen in 48 hours or less from 19.5% to 77%. The average wait for a booked appointment was also reduced from a baseline of 3 weeks to less than 2 days and is increasingly a booked appointment is available on or the next day.
In addition to this open repairs have helped match capacity with demand. During the 2 day open repair trial daily numbers averaged at 68 patients per session. Patients incurred waits of over an hour at times and staff reported frustrations with regard to numbers and the quality of care they could provide. Following the introduction of the 5 day service daily patient numbers became more predictable at around 40. This pattern of arrival appears to be increasingly predictable which aids planning and administrative processes in both the booked and open sessions and session numbers are more manageable for staff with patients waiting no longer than 30 minutes to be seen. The open repairs are also highly predictable in terms of patient arrival times each day. This new knowledge within the department is also aiding decisions regarding the resource required to deliver the service as well as informing further work possible.
Because of the predictability of the open repair service the team are now planning on some further small scale tests of change aimed at reducing waiting times for appointments in other sections of their service. They hope to achieve this by identifying potential capacity within the repair sessions and measuring the effect of utilising this for alternative activity. To compliment this work on the theme of releasing capacity, work is also planned in conjunction with the ENT clinic where Audiologists are involved.