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AHP Out-Patient Services Capacity and Demand Management Masterclass Robert Jones Fiona Jenkins 3rd June 2011 Objectives Reasons for considering new approaches to AHP booking systems The concepts of backlog, capacity and demand modelling in relation to out-patient appointments systems, using data to inform decision-making Familiarisation with a system for managing and reducing waiting lists and DNA Sustainability of a new system Impact of reduced delays on AHP pathways Concepts of service re-design to be able to implement and sustain change National reporting Before break Why waiting list management ? Concepts of capacity and demand IM&T Managing change- taking staff with you Your Expectations? Jargon Buster Demand - what we should be doing Activity - what we are doing Capacity - what we could be doing Backlog - what we should have done but haven’t Carve out- sub-dividing service into specialties Who has a Waiting List? Physio Out patient longest waits Specialty Musculo-skeletal Pain management Paediatrics Neurology (inc stroke) Women's/Men's health Occupational health Percent 6.0% 4.0% 2.0% 0.0% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Time (in weeks) How do you calculate your waits? When do you count the start of the wait? When do you count the end of the wait? Does the way that patient access your service influence the wait time? The DH waiting time definition The time between: the date that a referral is received and the date the patient is treated. What are you aiming for? What has worked previously? Was it sustainable? Who pays for your service(s)..what difference does this make? Are you needing to scrutinise costs? Contestability...is this coming? What do your patients think? What do your referrers think? What do your commissioners think? Consider 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Do your patients and referrers want shorter waits? What facilities have you got Staff specialism Skill mix profile – is it optimal? Staff profile, activity and service costs Infrastructure – admin, data collection, phones How long per appointment How many contacts per episode Are you ready to pass control over to patients? Is your service ready to re-design? Validating waiting lists – have you tried it? Validation is checking to see that the patients require appointment Has their condition improved so they no longer require the appointment? Do by sending letters or telephoning …especially if you have a long waiting list Gives you a clearer understanding of 'real' demand in the system. Wasted Slots Don’t confuse your DNAs and UTAs How to calculate? Liberate capacity Data and Information What is data? What is information? What have you got? How do you collect it? How do you use it ? What do you need ? Benefits Information for: Management clinical finance workforce Costs of your service Pay and Non Pay Overheads Capital charges Other Largest element for AHPs is staff costs Planning staff involvement R A Framework for the Management of Change 1. 2. 3. 4. 5. Moving From the Current to the desired - triggers for change Essential Actions Skills for Success Evaluation Learning Points F Questions so far? - Extraordinary Public Sector Debt - Public Sector Funding Restricted (Zero Growth) - Higher Inflation and Downward Pay Pressure - Tariff reduced by 1.5% - 2% per annum -Population Increase (elderly, LTC) -Medical and Drug Advances (Technology) - Shift from Secondary to Primary Care - Expensive Infrastructure - Financial Deficits in Organisations THE NEXT FIVE YEARS • • • • • • • • Continuing Tariff Reduction At least 2.5% inflation Cost Pressures Organisations with Recurring Deficits Efficiency Requirement Less Money to do More Activity or Work differently Activity Volumes too High to be affordable Insufficient Community and Primary Care Infrastructure • Variation in Length of Stay • Too many Follow-ups and too many DNAs • Too Many Staff and too Many Beds! SOME SHORT AND LONG TERM STRATEGIES •Improved Effectiveness and Efficiency •Organisation Development Structure •Patient Level Costing Driving Strategy (SLR) •Improved Productivity •Vertical Integration, e.g (Stroke, COPD, Hospital at Home •Horizontal Integration (e.g Path, Backroom) •Quality, Patient Safety Initiatives •Reduced Activity •Disease Management - Self Care) •Effective, Lean ( Programme Management) •Less Money, therefore Less Beds, Less Staff •Less expensive Management Structures •Tendering •Any Willing Provider? Have you thought of Benchmarking? Valuable tool to determine how your service compares Requires collection and interpretation of data Can be wide-ranging or very focussed Can speak louder than your single voice ….or identify where efficiencies can be made Edited by Robert Jones and Fiona Jenkins Foreword by Karen Middleton The Jigsaw of Reform: Pushing the Parameters Money, Money, Money: Fundamentals of Finance Commissioning for Health Improvement: Policy and Practice Striking the Agreement: Business Case and SLAs Thriving In the Cash Strapped Organisation Information is Power - Measure it, Manage it Information Management for Healthcare Professionals Allied Health Records in the Electronic Age Data ‘Sanity’: Reducing Variation Outcome Measurement in Clinical Practice Improving Access to Services: demand and capacity to support service re-design Benchmarking AHP Services Management Quality and Operational Excellence Evaluating Management Quality in the Allied Health Professions Evaluating Clinical Performance in Healthcare Services Project Management for Allied Health Professionals with Real Jobs Marketing for AHPs Effective Report Writing Demonstrating Worth: Marketing and Impact Measurement Self – Referral Any Patients Waiting? Do you have a waiting list? What is the size of the list? Is it a problem? What is your target? Are you meeting it? What have you tried before to manage it? What size what it last year? ..and the year before? How many waiting lists do you have? Do you carve out? How do you prioritise? Who puts patients on the waiting list? Do you have referral criteria? Questions • • • • • • • • • • • What is you waiting time? What is your DNA rate? Do you have carve out? What are the causes of waits? Does it fluctuate? Why does it fluctuate? How do you currently manage waiting lists? What info systems do you have? Do staff accurately input data? Do you make full use of it? Does Choose and Book impact? How referrals are handled affects waits Physiotherapy Out-Patients - Management of Referral for OP appointment DRAFT ‘TO BE’ PROCESS Patient rings for appt File referral in relevant filing drawer Referral from Consultant Referral from GP Send standard letter (from Tiara) asking patient to make choice appointment (letter sent within 1-2 days) Physio Reception Referral from Horder Centre Referral from Esperance Is this urgent appointment? Referral from out of area File routine requests in waiting No list drawer in date order Send choice appointment letters to calculated number of NP assessment slots Patient rings for appt No Referral from IP Physio (card in traty) Referral from Occupational Health Is this a respiratory appt requested by consultant? Put in tray for Senior Physio to check No Register referral on Tiara (checking other episodes etc) Self-referral Self-referral Senior Physio Yes Date stamp and prioritisation stamp referral letter/card Pick up referrals from tray Complete prioritisation stamp with type of appointment/speciality and prioritise as urgent or routine Hand back to Reception staff Is referral from out of area? Yes Send standard letter (from Tiara) to GP asking for reply if they do not agree to referral This is an additional step, but does not change management of referral – prioritised and letter sent as for rest of process Why do queues form? Because demand exceeds capacity? Mismatch between demand and capacity? We want queues to keep us busy? Variation in demand + variation in capacity = queue Occasionally demand > capacity Managing Flow NHSI No delays achiever How to Measure Capacity Understand how you use time, patient and non patient contact time Expertise available, staff hours in WTE and grade, and hours the service is open for If equipment or facilities are an essential element, their availability need calculating. How to Measure Demand Understand your referral patterns and type Multiply the number of patients referred from all sources by the time it takes to complete a patient episode Measure true demand- are there some not accessing your service that should be? Patient Flow In healthcare flow is the movement of patients, information or equipment between departments, staff groups or organisation as part of a patients care pathway. Three options 1. Manage flow 2. Create flow 3. Increase responsiveness How to Measure the Backlog Multiply the number of patients waiting by the time it takes to complete the patient episode. For example, 100 patients on the waiting list x 30 minute treatment time each = 50 hours backlog. If you are working towards a 6 week wait, and have 16 weeks on your waiting list, backlog = 10 weeks Need to consider the number of patients waiting and the time that represents Planning to Match Capacity and Demand If services are planned so that average capacity is higher than average demand, waiting lists rarely build up and should decrease ;as long as the capacity is used. The level to aim for is to set capacity higher than the average demand. The famous have said: “You will never solve the problem with the mindset that created it” Albert Einstein “Every system is perfectly designed to achieve the results it gets” Don Berwick Where do we get extra capacity from? New Money ££££££££££! Map process re-design process measure bottleneck demand/capacity/activity/backlog analyse data :- reduce variation continue to measure and analyse Activity What do staff do with their time? How much of each activity Who does it Where it happens Methodology to ascertain accurate picture of what staff are doing with their time Ability to drill down Why do we need to know this? Development of staffing profiles Case load management Skill mix management Evidence-based staff deployment Clinical issues Audit and R&D Why do we need to know this? Clinical governance Effectiveness and quality Evidence-base for service development Business environment and strategy Service and workforce planning Service re-design “tool” Capacity and demand management Paediatrics and long term disability management Traditionally heavy caseloads and long waits Even more important to undertake capacity/demand management Do you want to see the patient? Or do they need to see you? Episodes of care philosophy Patient self-referral Caseload management tools Regular review Skill mix Staff Activity What do staff do with their time? Patient related Non patient related Leave patterns Maternity leave Seasonal variation Daily variations Carve out Savings requirements Activity Sample: Methodology Development and prototyping Snapshot of activity on a regular basis Data collection form Staff involvement Computer software Reporting methods Use Activity Sample Form Direct Patient Contact Face to face contact -individual Face to face contact – group Telephone contact with patient or carer Activity Sample Form Patient Related Ward rounds Case conferences Administration- patient related Home assessment visits Activity Sample Form Non patient related Study leave In-service training Other CPD activity Teaching Supervision Liaison with other services Administration Management duties Travel Staff/team meetings Other Activity Sample Form Other Date of activity sample Site Location Clinician code Band Post name/rotation Absence? Reason Your contracted working hours today Your actual working hours today Number of group sessions you have done today Number of home assessment visits you have done today Number of patients on your caseload today Examples of analysis Percentage of time spent in different categories by: Whole service Team Individual band Individual staff member Location Profession comparison Therapies staff activity Analysis 2% 0% Face contact ind 0% Face contact group 1% Tel contact patient / relative 3% 3% Ward round 4% Case conf. 4% Liaison other services pt related Admin. Pt related 36% 2% Home visits Clinics Other pt related 5% Liaison other services not pt related Admin. Not pt related Management duties 6% Study leave Travel Staff team mtgs In service training Teach your prof group 1% 2% 1% 1% 3% Teach student Teach others Clin. Super. Other non pt related 2% 18% 4% 1% 0% Percentage Summary of All Paybands (All Activities) 100% 80% 60% 40% 20% 0% All BAND9 BAND8D BAND8C BAND8B BAND8A BAND8 BAND7 BAND6 BAND5 BAND4 BAND3 Face contact ind Face contact group Tel contact patient / relative Ward round Case conf. Liaison other services pt related Admin. Pt related Home visits Clinics Management duties Other pt related Study leave Liaison other services not pt related Travel Admin. Not pt related Staff team mtgs In service training Teach your prof group Teach student Teach others Clin. Super. Other non pt related BAND2 Its Your Turn! Find your data You will calculate: Capacity Departmental demand Backlog (waiting list) Time per patient episode Staffing resources required What is your Capacity? Capacity CALCULATE : WTE staff by grade Slots: length of appointments Ratio 1st: Follow Up Total time per patient episode Capacity per staff member /year Facilities issues DNA time A “Typical” Physiotherapist 1 WTE ,41 working weeks/pa = 1537.5 hours 511 new patient pa =12.5new patients per week Average contact 4 = 2.5 hours 511 X 2.5 hours= 1277hours patient activity 260.5 hours for “other” activity (6 hours per WTE) A department with 10 WTE Number of staff = 10 WTE 15375 hours/department 5110 new patients 12770 hours for patient contact 2605 hours for “other” activity Demand Total referrals How many currently on your waiting list What that equates to in patient contact time Have you the right number of staff? Unmet need? Trends over time A Worked Capacity Example Total referrals = 6000 Waiting list =500 1250 hours work (500x 2.5) Need 1 WTE more activity to meet this demand Develop a capacity plan Backlog How long is your longest wait? Do you have a maximum waiting time target? What is the match/mismatch between your capacity and demand? What is you backlog? Its Lunch time! What is “Choice Appointments” ? A system of same day outpatient appointments for physiotherapy patients; made by telephone for first and follow up appointments Based on capacity planning In place in Eastbourne for 4+ years and Torquay for 2+ years “Choice Appointments” Calculate department demand and capacity Patients referred Patient telephones to book an appointment on the day that they want treatment Minimal pre booking Patient agreed goals to achieve before re accessing further intervention Follow up appointment procedure User involvement Evaluation “Choice” What is “Choice”? For patients For referrers For staff Why did we go this way? Effectiveness and efficiency To minimise DNAs Inability to keep waiting lists down consistently Wanting to improve clinical effectiveness Economic and political drivers Better use of clinical and non clinical time Workforce Improve throughput Complaints about waiting time Transferability to other services Our starting points DNA 11-17% in our areas Significant numbers with 15-20% Up to 48% in highest Too many cancelled appointments (12%) Waiting times Up to 16 weeks for “routine” in our areas Significant numbers up to 6 months 156 weeks “routine” wait is known! Waiting time complaints Unstructured staff time for non patient contact What did we do? Our Results Eastbourne System in place for 6 years South Devon 4 years Waiting time analysis and comparison 16 14 12 10 Trust 1 Trust 2 8 6 4 2 0 2002 2004 2006 2008 % DNA 18 16 14 12 Trust 1 10 Trust 2 8 6 4 2 0 2002 2003 2004 2005 2006 2007 2008 2009 Routine Waiting time (weeks) 16 14 12 10 Trust 1 Trust 2 8 6 4 2 0 2002 2004 2006 2008 Waiting time complaints 25 20 Trust 1 Trust 2 15 10 5 0 2002 2004 2006 2008 Possible Barriers to Implementation Lack of willingness to take risk Staff comfort zones Data collection! Availability of data Local resistance Lack of demand control Infrastructure Stringent cost improvement programmes Commissioner views Other issues to consider Look at your use of facilities and space Admin staff IM&T use and support Telephone systems What if patient doesn’t make contact? Leadership capability Staff comfort zones Administration How non contactor referrals are handled How receipt of referrals is handled and processed Staff diary sheets Patient information Follow up arrangements Discharge information Procedure for onward referral Other information Trust 1 NP/ WTE, 12 15 Follow up reduces from 3.5 to 2.55 New patient appointment some 60 mins some 30 mins Follow up appointment 30mins Rolled out to small dept with 4.27 WTE Trust 2 NP/ WTE, 12 20 Follow up reduces from 3.5 to <2 New patient appointment 45 mins Follow up appointment 30 mins Rolled out to Trust 3 With 2 smaller departments Evaluation PPI audits in both sites: Patient satisfaction of those who attended Feedback from those who failed to make contact. Once only attenders GP satisfaction Clinical outcome audit of workshop attendees Was information provided by the service about appointment system clear? yes no no answer Would any other information have been useful? yes no no answer Did you find it easy to contact the department? yes no no answer Could you make an appointment at a time convenient to you? yes no no response Key messages Over 94% patients were satisfied with access, timing and organisation of appointment. “Judging by previous appointment I felt very lucky to get through so quickly Not a long wait on the phone Excellent system.” Patient Feedback: Eastbourne “ I was very impressed by the Eastbourne DGH physio dept. Yesterday I had a letter about their “patient choice” scheme inviting me to phone for an assessment appointment and at 10.00am I was being seen. Short of sending a physiotherapist to meet me at the ward on discharge the serviced could not be bettered! Thanks for your efforts on my behalf” Extract from a patient’s letter to his OT at RNOH Patient feedback “the system seems efficient and responsive to patient needs “totally satisfied with phone in on the same day” “the service has been first class and really excellent” “ ….can choose the time which is convenient to you” “I visited my GP this morning and here I am 2 hours later, fantastic!” Audit: attended once only Percentage analysis - reasons for attending once Told not necessary 7 3 Did not know to phone Unable to make contact 4 20 Got better Work pressures 11 2 Private treatment Moved away 1 8 Medical reasons 1st appt not helpful 9 35 Other reasons 0 5 10 15 20 Percentage response 25 30 35 40 Audit of non contactors 3 month period, letter sent to all non attenders for 1st and follow up appointment 250 letters (15% of referrals) 95 responded (38%) Reasons for not making contact 4 Unable to make contact 10 Did not know it was necessary to make contact with physio department to make appointment 24 Got better didn’t need appt 15 Unable to afford time due to work pressures 8 Arranged own private treatment 2 Moved away 3 Previous treatment for same problem 29 Other reasons Comments from non attenders Apologies but thought if I didn’t ring it would be taken that all was well. As I had to make an appointment rather than being sent one I thought it unnecessary to phone Would be easier to book several advance appointments 10 patients claimed not to have received a letter to ask to make an appointment. As I hadn't heard from you I went to a Chiropractor who I am still seeing Audit: workshop attendees 790 people attended longest waiting time 156 weeks Highest DNA 48% Highest 1st to follow up ratio up to 1:12 Variable implementation Some implementing all aspects Some implementing parts Some planning implementation Some maintaining “traditional” methods Everybody scrutinising their booking system Choice Appointments and Self-referral GP Feedback Positive, liked reduced waiting time Liked reduced administrative burden Liked using email for referral and discharge – where used Challenges Flexing capacity Variable demand Meeting cultural needs How flexible can you be? Commissioning arrangement PBC, PBR Self Referral Organisational Arrangements NHS Reconfiguration Savings Costing and Pricing Contestability Provider/purchaser arrangements Configuration of AHP services National workforce planning agenda Rolling out to other disciplines New models of service delivery Mandatory reporting of AHP waiting times (England) 2011 – 12? RTT and AHPs Does it affect you? Which part of your pathways? Can you flag the AHP part of the wait? Can you calculate accurately and alert others? Do you need to address your waits? Do your waits affect others? What about non consultant- led pathways? To Summarise What “Choice Appointments” is Why change? Information and capacity planning Looking at your service Working it out Results - what it's done for our services can it do this for you? Framework for the Management of Change Challenges for the future Practical “workout" What you are going to take away and do Revisiting your expectations The Challenge of Implementation Is this for you? All of it, elements of it or none of it? Are you ready to lead this work? Include staff, patients, commissioners, referrers Plan and prepare Use improvement tools and techniques What are you going to do? Next Steps ?? 1. Discuss with Trust management, patients, referrers, staff, commissioners 2. Project set up : project manager, team and time scales, base-line data and ongoing measurement Any Questions or further Discussion Other things we do Service redesign, management masterclasses and workshops, presentation www.jjconsulting.org.uk Thank you!