ahp out-patient services capacity and demand management masterclass robert jones fiona jenkins 3 rd...
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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&TManaging 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
Time (in weeks)18171615 14131211109876543 21
Perc
en
t
6.0%
4.0%
2.0%
0.0%
Occupational healthWomen's/Men's healthNeurology (inc stroke)PaediatricsPain managementMusculo-skeletal
Specialty
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. Do your patients and referrers want shorter waits?
2. What facilities have you got
3. Staff specialism
4. Skill mix profile – is it optimal?
5. Staff profile, activity and service costs
6. Infrastructure – admin, data collection, phones
7. How long per appointment
8. How many contacts per episode
9. Are you ready to pass control over to patients?
10. 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. Moving From the Current to the desired - triggers for change
2. Essential Actions
3. Skills for Success
4. Evaluation
5. 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 YEARSTHE 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!
•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 waitsPhysiotherapy Out-Patients - Management of Referral for OP appointment DRAFT ‘TO BE’ PROCESS
Se
nio
r P
hys
ioP
hys
io R
ece
ptio
n Yes
No
No
Date stamp and prioritisation stamp referral letter/card
Is this urgent appointment?
File routine requests in waiting list drawer in date
order
Referral from Esperance
Complete prioritisation stamp with type of
appointment/speciality and prioritise as urgent or routine
Referral from Consultant
Referral from Occupational
Health
Is referral from out of area?
Put in tray for Senior Physio to
check
Patient rings for appt
Pick up referrals from tray
Referral from Horder Centre
Referral from out of area
Patient rings for appt
Referral from GP
Is this a respiratory appt requested by
consultant?
Hand back to Reception staff
File referral in relevant filing
drawer
Referral from IP Physio (card in traty)
Register referral on Tiara (checking
other episodes etc)
This is an additional step, but does not change
management of referral – prioritised and letter sent as
for rest of process
YesNo
Send standard letter (from Tiara) to GP asking for reply if
they do not agree to referral
Send standard letter (from Tiara) asking
patient to make choice appointment (letter sent
within 1-2 days)
Send choice appointment letters
to calculated number of NP
assessment slots
Self-referralSelf-referral
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 options1. Manage flow2. Create flow3. 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 relatedNon patient relatedLeave patternsMaternity leaveSeasonal variationDaily variationsCarve outSavings
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
Face to face contact -individual Face to face contact – group Telephone contact with patient or carer
Direct Patient Contact
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
Activity Sample Form
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 serviceTeamIndividual bandIndividual staff memberLocationProfession comparison
Therapies staff activity Analysis
36%
3%
2%
1%
0%
4%18%
1%
1%
2%
1%
6%
5%
2%
4%
4%
3%
1%
0%
0%
2%
3%
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
Other pt related
Liaison other services not pt related
Admin. Not pt related
Management duties
Study leave
Travel
Staff team mtgs
In service training
Teach your prof group
Teach student
Teach others
Clin. Super.
Other non pt related
Percentage Summary of All Paybands (All Activities)
0%
20%
40%
60%
80%
100%
All BAND9 BAND8D BAND8C BAND8B BAND8A BAND8 BAND7 BAND6 BAND5 BAND4 BAND3 BAND2
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 Other pt related Liaison other services not pt related Admin. Not pt related
Management duties Study leave Travel Staff team mtgs
In service training Teach your prof group Teach student Teach others
Clin. Super. Other non pt related
Its Your Turn!
Find your dataYou will calculate:
CapacityDepartmental demandBacklog (waiting list)Time per patient episodeStaffing 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 WTE15375 hours/department5110 new patients12770 hours for patient
contact2605 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 areasSignificant numbers
with 15-20% Up to 48% in
highest Too many cancelled
appointments (12%)
Waiting timesUp to 16 weeks for
“routine” in our areasSignificant numbers up to
6 months156 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
0
2
4
6
8
10
12
14
16
2002 2004 2006 2008
Trust 1
Trust 2
% DNA
0
2
4
6
8
10
12
14
16
18
2002 2003 2004 2005 2006 2007 2008 2009
Trust 1
Trust 2
Routine Waiting time (weeks)
0
2
4
6
8
10
12
14
16
2002 2004 2006 2008
Trust 1
Trust 2
Waiting time complaints
0
5
10
15
20
25
2002 2004 2006 2008
Trust 1
Trust 2
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
Admin staff IM&T use and support Telephone systems What if patient doesn’t
make contact? Leadership capability Staff comfort zones
Look at your use of facilities and space
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 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
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
Evaluation PPI audits in both sites:
Patient satisfaction of those who attended
Feedback from those who failed to make contact.
Once only attendersGP satisfactionClinical 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 quicklyNot a long wait on the phoneExcellent 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!”
Percentage analysis - reasons for attending once
35
9
8
1
2
11
20
4
3
7
0 5 10 15 20 25 30 35 40
Other reasons
1st appt not helpful
Medical reasons
Moved away
Private treatment
Work pressures
Got better
Unable to make contact
Did not know to phone
Told not necessary
Percentage response
Audit: attended once only
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 weeksHighest DNA 48% Highest 1st to follow up ratio up to 1:12
Variable implementationSome implementing all aspectsSome implementing partsSome planning implementationSome maintaining “traditional” methodsEverybody 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 Questionsor further Discussion
Other things we doService redesign, management masterclasses and
workshops, presentation
www.jjconsulting.org.uk
Thank you!