In June 2011 the Trusts Service Improvement Team developed a Trust Wide service improvement strategy for Outpatients (OP) services. The purpose of the document was to define key areas for driving system wide improvement of OP services. The document set out to deliver OP services that are more: patient-centred.
• More efficient
• Engage staff in redesign of their service for the benefit of the patient
The Renal Directorate operates a stand-alone outpatient service based in the Sorby OP building at the Northern General site. In 2010-11 the Renal Directorate saw 1676 new and completed 11,737 follow-up patient consultations in its general nephrology, low clearance and dialysis clinics as well as 4,189 outpatient transplant reviews. The OP department also operates a busy emergency clinic providing urgent nephrology opinions during office hours.
Feedback from patients and staff has highlighted many positives within the service particularly the quality and dedication of our staff. However concerns regarding the delays in being seen, clinics overrunning and inadequately responsive scheduling have prompted us to fully review the service.
Assessing the System Using 5P's - 5Ps (Patients, Professionals, Purpose, Patterns, Processes) assessment work indicated the key opportunities for improvement:
- Long waiting times for patients
- Workload and utilisation across the week is variable
- There is a mismatch between capacity and demand in several clinics
- Turnaround times in admin processes need improvement
- DNA rates are high
To provide safe, effective, timely, efficient, equitable and patient-centred care for patients with a kidney related condition.
The main themes that came out of the analysis of the clinic were:-
- Clinic Flow
- Capacity and Demand
- Administration Process
- All of the above had an effect on waiting times.
From these themes staff prepared a ‘global aim statement’ and ‘specific aim statement’ to aid their decision about what to change. This type of analysis ensures that any change made is an improvement as opposed to trying to hit a target with no context.
Once they had established that waiting time was one of the major patient concerns they wanted to address the next logical stage on the Dartmouth Improvement Ramp was to try a PDSA cycle. ‘You cannot improve something you cannot measure, so each PDSA has a specific measure. Such numeric measures determine whether the changes to the process are actually having a measurable impact’.
‘If an operation or process can match supply and demand rates, it will also succeed in reducing its inventory levels (patients queuing)’ (Slack et al, 2012)
The following input changes were tested:-
- Staff designed a schedule based on actual timings of patient/doctor appointment times;
- Mutually agreed between the clinic staff and doctors that they would turn up at a specific time coinciding with the arrival of the first patient.
- Patients were sent a letter telling them exactly when their appointment time would be and not to turn up earlier because they would not be seen before that time.
- Administration staff and nurses were also given information regardingdedicated starting times and could therefore ensure the timely flow of patients through the process. Patients stopped being seen a first come first serve basis.
- Dedicated ambulance arrival appointments were built into the schedule to accept these patients when they were dropped off.
- Time slots for the predictable patients were set at the start of the day and those of the less predictable/more complicated patients were built in to be seen at the end of the day. Some predictability was therefore built into the process and flow at least could be continuous through the day until the more complicated patient arrived later in the day.
- Appointment times were set at 20 minute intervals with dedicated start and finish times. This new time slot was built to be capable of operating at 80% of variability. Approximately 50% of patients needed less than 15 minutes and this flexibility meant that the schedule could very quickly be recovered over the day if an appointment went over its allotted schedule time.
What did the work achieve?
Mean patient waiting times were reduced from 30.9 minutes to 11.4 minutes, a 63% reduction in waiting time. The scheduling recognised the importance of planning to known capacity constraints. It focused scheduling effort on the bottleneck part of the operation. By identifying the location of constraints, working to remove them, and then looking at the next constraint, an organisation is always focusing on the part that critically determines the pace of output (Slack et al, 2012).
With the new scheduling in place staff commented that the clinic was calm, the flow was smooth and the waiting room was generally quieter and emptier.
An indirect consequence of the redesign work was that DNA (Did Not Attend) rates reduced from 11% to 6%. An improvement in the service resulted in a drop in non-attendance rates.