James Paget University Hospitals

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James Paget University Hospitals NHS Foundation
Trust
Working towards the delivery of one stop
diagnostic outpatient clinicsDonna Lorne,
Service Improvement Lead - CHD
Working Together for Excellent Care
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Overview of JPUH

• Small DGH 220,000 population
• Majority of patients from 1 PCT
• Located on Norfolk coast
• Non invasive cardiac diagnostics
• 1 FT cardiologist, 1 PT cardiologist OPD only,
  1 locum cardiologist 1 vacancy
• Closest cardiac tertiary provider is 95 miles or
  a 4 hr 20 min round trip
• Area of high deprivation with an ageing population

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Where we were - early 2006

• 14 week diagnostic wait
• 13 week outpatient wait
• High DNA rates for both

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• Presentation is broken up in to
• How we reduced and sustained diagnostic waits
• How we are reducing outpatient waits
• Working towards implementation of one stop.
• JPUH signed up to a HIP 18 week priority project
  to deliver 18 weeks by March 08. In addition,
  max 2 week wait from GP referral to 1st OPA 1st
  diagnostic

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Diagnostics Where did we want to be? (Before 18
weeks)

• CLINICAL MEASUREMENTS
• Reduce diagnostic waits
• Reduce pressure on department by reducing
  inappropriate referrals
• Increase staffing levels (keep trainees)

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How we started to reduce diagnostic waits

• Over last 6 yrs CM had 7 trainees (SHA funded)
• Devised in house training programme for echo
• Reviewed echo referral criteria (open access
  inpatient)
• Demand capacity study
• Audit

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Where are we now?

• All diagnostic waits 2 weeks (where clinically
  appropriate)
• Sustained diagnostic waits for past 18 months

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Sustainability

• Every slot is utilised no wasted capacity
• Cancellations filled immediately
• 50 of patients are appointed by phone (reduced
  DNAs) choice of appointment
• As waiting times shortened, DNAs reduced
• Constant review of capacity to meet fluctuating
  demand
• Flexibility of staff
• Ongoing screening of referrals inappropriate
  referrals returned to referring clinician
• Redesign admin processes

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Benefits

• Lower waiting times reduced DNAs
• Reduced admin time spent chasing dealing with
  appt queries
• Already achieving 18 week target
• Greater staff satisfaction
• Patient satisfaction
• Lower staff turnover

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Outpatients

• Reducing outpatient wait in accordance with stage
  of treatment milestones
• HIP 18 week priority project objective maximum
  2 week wait from GP referral to date of 1st OPA
  1st diagnostic (one stop)
• Could not implement one stop until OPD wait
  reduced (waste diagnostic capacity)

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Main aim of project

• New OPA 2 weeks
• New OPA 1st diagnostic one stop
• NewFUP ratio 1.4
• Reduce the number of follow up appointments
• Reduce DNAs (mainly follow ups)

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Where we are now

• Average New outpatient wait of 2 weeks
• Fully implemented one stop HF clinic
• One stop echos/OPA
• NewFup ratios greatly reduced by clinician
  although still work to do to change practice
• Reduction in DNAs (news Fups)

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Adopted action plan

• Audit
• Demand Capacity study
• Revised clinic templates
• Added an additional new patient clinic
• Implemented new referral process to turn
  referrals around lt24 hrs new triage process
• Review/publication of available slots on a weekly
  basis
• Utilise every available slot
• Telephone contact with new patients DNAs
  5.41 YTD
• CB 40 of referrals
• Reduce follow ups
• 18 week education/training clinicians
• Case note audits
• Data presentation to challenge clinical practice
• Follow up protocol
• Telephoning follow up patients prior to clinic to
  check attending
• Monthly reporting of clinicians OPD activity,
  DNAs NewFup ratio
• As OPD wait reduced, other processes required
  redesign

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Sustainability

• Ongoing training of admin staff to ensure minimal
  wasted capacity
• Change in clinicians practice follow
  ups/pathways
• Demand management pathways referral criteria
• Implement one stop follows up not required
• Maintenance of action plan

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Benefits

• Staff satisfaction that wait has reduced
• Patient satisfaction of rapid turnaround and
  early reassurance although initial concern of why
  being seen so quickly
• Reduction in GP visits whilst waiting for OPA
• Quicker referral to tertiary centre if needed
• Lessons learnt applied to other specialties

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What is next?

• Off site community clinics
• Redesign pathways eg open access ambulatory
  monitoring service, BNP
• Demand management/OPD referral criteria
• Further work to reduce follow ups, change
  clinical practice, follow up protocol
• Reduce 1st OPA wait even further
• One stop technician led ETT service
• Possible chest pain clinic amalgamate in to
  RACPC
• Increase referrals through CB
• Communication with patients 18 weeks
• Culture change

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Delivery of one stop

• Couldnt implement immediately wasted
  diagnostic capacity
• As OPD wait is reducing, started to look at one
  stop
• Took echo first
• Heart failure clinic
• two slots allocated per cons clinic per week for
  new patients
• on demand from clinic, echo then r/v with cons

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Whats next One stop?

• Combine ETT / RACPC clinic
• Open access ambulatory monitoring service
• BNP
• Instant review of referrals

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Challenges

• Working with colleagues who have other priorities
• Getting people together
• Gaining attendance at meetings from clinicians
  v- clinical time/treating patients
• Changing clinical practice
• Challenging the norm
• Getting commitment/agreement
• Maintaining motivation commitment
• Constant review of referrals to ensure always
  appropriate
• Constant review of clinics to ensure no wasted
  capacity
• Constant provision of support training to staff
  whilst maintaining waiting times (CM)
• Choose Book tying up OPA with diagnostic

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Requirements for seamless implementation

• Clinical engagement
• Senior manager support (CEO)
• Communication
• Feedback / Praise
• Supporting the team
• Sometimes just got to try it and see
• Pilot with one clinician, others will follow

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• Contact details
• Email donna.lorne_at_nhs.net
• Mobile [phone]