Health Roundtable Improving the Outpatient Journey

1. Health RoundtableImproving the Outpatient Journey Introduction & Overview 10 May 2007

2. An Innovation Clearinghouse • Share problems • Share solutions • Avoid reinventing wheels • “Seed” large scale projects • Provide CEO network Health Roundtable UHC IHI

3. 37 Organisational Members –66 Hospital facilities

4. Program for 2007

5. Health Roundtable The Roundtable Process

6. 5. Confirmation 2. Persuasion 3. Decision 3. Decision How to speed up action? The Roundtable Process: 1.Knowledge 4. Implementation

7. Expectations • No “Perfect Hospital” • But, each excellent at something • Lots of variation • No single “right answer” • No “magic bullet” solutions • Confidential, frank discussions • Find one idea to take back and implement

8. Agenda

9. Agenda

10. Some Background

11. Definitions • OutpatientAnother term for non-admitted patient. • Non-admitted patientsPatients who receive care from a recognised non-admitted patient service/clinic of a hospital. • Admitted patient A patient who has undergone a hospital’s formal admission process. This includes same-day patients (that is, patients who are admitted and separated on the same day). Admitted patient is synonymous with inpatient.

12. Our working definition Outpatient Services are the subset of Ambulatory Care Services that do not require the use of a hospital ward bed. These are typically provided in scheduled clinics at the acute facility or at one of its satellite units by professional staff of the health service including doctors, nurses, allied health, pharmacists, diagnostic imaging staff and/or pathology staff.

13. Inconsistent Measurement Non-inpatient? Dialysis Inpatient? Angiography Chemotherapy Outpatient? Bone Marrow Transplant Endoscopy Public? Private?

14. Lots of Data Issues!

15. Focus instead on outpatient journey My age? Do you mean now or when I first arrived?

16. An Outpatient Process: Source – Bate Robert

17. Not focused on efficiencyideas Source: www.CartoonStock.com

18. What are the Patients Saying? ‘The biggest untapped resources in the health system are not doctors but users. We need systems that allow people and patients to be recognised as producers and participants, not just receivers of systems … NHS Design Council, 2004

19. An Outpatient Process: Source – Bate Robert

20. What are the Patients Saying? • Dissatisfied about waits: • For Medical Officers – Poseidon, Athene (x2), Panther, Artemis • For Dietician – Tiger • For Radiologist – Orion • For Appointment – Dionysis • During Pre-admission Clinic – Athene • In general – Regulus, Sirius (x2), Tiger, Poseidon, Fury • Too many • Professionals – Athene • Letters – Panther

21. What are the Patients Saying? • Issues with privacy – Regulus, Orion (x2) • Make clinic times more convenient – Fury (x2), Eagle • Patient having to confirm appointment – Orion (x2) • Desire for closer service – Tiger, Artemis (Physiotherapy home service) • Need for better co-ordination of services – Tiger, Panther • Need for better information – Tiger, Poseidon, Panther, Orion • Need for better registering system – Polaris (x2) • Need for improved clinic conditions – Orion • Other: • Parking – Eagle (x2) • Free Bus – (Fury)

22. What are the issues? • Poor existing IT Systems • Lack of real & usable information • Compartmentalised services • Poor and non-standard referral information & systems • Tradition – “always done this way” • “Our service is different”

23. Some have very low DNA rates…

24. Some have high first-appt rates…

25. Patient receives an appointment date for initial assessment Patient referred by GP/ other Patient attends initial assessment Patient Attends for follow-up care 2 Weeks 5.3 Weeks 9.8 Weeks Value Stream Map – Diabetic Patient Time to 1st Appt Shortest: Vulcan, Hermes 4 weeks, Sirius & Poseidon 5 weeks Longest: around 14 weeks

26. Pre-admission Surgical Intervention Patient receives an appointment date for initial assessment Patient referred by GP/ other Patient attends initial assessment Patient Attends for follow-up care Decision 4 Weeks 11 Weeks 13 Weeks Value Stream Map – Orthopaedic (Knee) Patient Time to 1st Appt Shortest: 11 weeks (Eagle) Longest: 100+ weeks

27. We asked hospitals about the innovations implemented in each of the Clinic Areas:

28. Diabetic Clinic Innovations We asked you which of the following innovations you were using:

29. Diabetic Clinic Innovations We also asked “Do you have any additional innovations?” • Virtual Clinic for insulin stabilization (Tiger) • Clinic independent of medical management (Centauri) • Nurse led clinic (Regulus) • Multidisciplinary periodic diabetes review (Dionysis) • Vision impairment prevention program (Dionysis) • Group programs (e.g. insulin pump commencement) (Dionysis) • Foot screening (Dionysis) • Joint high risk foot clinics (Artemis) • Diabetes discharge clinic (Vulcan) • Multi-skilling Staff (Polaris) • Annual audit of diabetes patients (ANDIAB) (Polaris) • Electronic diabetes assessment form (Polaris) • Insulin medication chart (Sirius) • Type 1 clinic (Separation of type 1 patients) (Sirius) • Use of Nurse Practitioners (eagle) • Steno model of care (Eagle) • Lets Beat Diabetes program (Fury) • Appointment notification process (reduces time to appointment) (Orion) • Working with PHOs (Artemis) • Formal Education for Primary Care (Artemis)

30. Orthopaedic (Knee) Clinic Innovations We asked you which of the following innovations you were using:

31. Orthopaedic (Knee) Clinic Innovations We also asked “Do you have any additional innovations?” • Referral validation (audit) for long waits (Tiger) (Panther) • Patient focused bookings (Tiger) • Triage tool (questionnaire) (Centauri) • PJR Education (Dionysis) • OA hip and knee service (Regulus) • Use of education letters as part of referral (Regulus) • Pharmacist attends pre-admission clinic (Athene) • Review of pre-admission information (Athene) • Did not respond appointment slots (Panther) • GP Liaison – active review (Hermes) • Ghost clinics (Orion) • Joint assessment clinics (Artemis)

32. Outpatient Innovations And we asked “What other service innovations have you put in?” Responses included: • Nurse Practitioner led clinics for trauma and osteoporosis patients (Centauri) • General Practice Liaison Nurse created to improve access and communication with referring doctors (Polaris) • Changed structure of General Surgery Clinics to include a higher ratio of new to review patients (Regulus) • Remove semi-urgent Category (now only urgent or routine) (Regulus) • Orthopaedic Physiotherapy Screening Service (Panther) • Micromanagement of referral process (Orion) • Heart Function/Discharge Clinic assists in reducing emergency admissions (Polaris) • Medical ‘Hot’ clinics in Emergency Department (Panther) • OAS clinics for Physio and GP review of patients who may not require Consultant/surgery (Regulus) • GP involvement in managing skin lesions (Fury)

33. Orthopaedic (Knee) Clinic Innovations We asked you which of the following innovations you were using:

34. Some Reading Material:

35. Thought-starter Presentations

36. Ambulatory Care Fields 1. Principal diagnosis code for this intervention (ICD10 – first 3-characters but more is fine) 2. Primary Allied Intervention Code (Procedure code from ICD10-CM - first 5 digits) 3. Referring clinical unit name (text field - 40 character) 4. Date of referral by clinical unit 5. Location of intervention (Ward, Emergency Department, Allied Department, Outpatient Clinic, Community, Patient Home)

37. Action Planning

38. Idea Screening • Feasibility • R. Is it real? • Enough patients? • Evidence that it works? • W. Is it worth it? • Likely financial benefits • D. Can we do it? • Clinical champion available? • Minimal opposition? • Low risk? • Available expertise?

39. Aim Goal statement for improving the process To improve / reduce what ________ By what amount ________ By when __________ In what area ___________ To reduce waiting time for first appointment to less than 8 weeks by December 2007 for Patients with Back Pain

40. Aim Statements

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45. Aim Statements