No Bones About It
Redesigning Orthopaedic Outpatient Services at CHW
Varun Sahni, Melissa Potts
Case for Change
Excessive number of
patients booked into
clinics each day – lack of
quality time with doctors
and clinicians
Increasing patient
complaints and decrease
in staff satisfaction
Up to 3 hours
Orthopaedic Clinic
Wait times
Diagnostics
Clinics are booked at 150%
capacity to meet demand
All we do is
wait!
We know how long
it takes, so we pack
a picnic and make a
day of it
Waited 4 hours but
did not see the
doctor yet!
We never see the
same doctor twice
and get different
opinions a lot!
Orthopaedic activity
Up to 16 half day clinics per week
Up to 60 patients in a half day
clinic
Equates to
approximately 25,000
patients/year
11% of referrals are conditions that
do not require review at a tertiary
service
30,000
10% increase in
appointments per
year over 10 years
25,000
Sign put up by
staff in Clinic
20,000
No structured arrival time
for patients - heavy
stream of patients during
varying periods within the
day
10,000
5,000
0
Goal
Paediatric patients with orthopaedic conditions
in the Western Sydney LHD that are referred to CHW
will receive consistent, coordinated, appropriate and
timely care by primary and tertiary health care
providers.
Objectives
1. Decrease episode times from 108 mins to 60 mins by April
2016.
2. Decrease clinic numbers from 40 to 35 patients per clinic
by February 2016.
3. Improve patient satisfaction regarding wait time from 61%
to 80% by February 2016.
Methods
Doctor
Long Wait
Times & short
consulting
periods
15,000
X-ray
46min
physio
Arrival
times result
in problems
with clinic
flow
Variable
wait
54min
AVERAGE TIME SPEND WAITING= 108 MIN
Queue for clinic at 1pm PreImplementation
Patient Arrival Time
250
Patients told to
arrive between
8-10 am.
First come, first
served
200
150
100
50
0
Before
1st Hour
Clinic Start
Planning and implementing solutions
Results
1. New Clinic Structure Defined
Appointment types
Names represent the order of clinical observation
or tests required
Staggered appointments
Based on patient flow data
Standardized follow-up guidelines
were developed for common fracture types. Orthopaedic
Specialists consulted & agreed process
Outpatient Clinics:
2nd Hour
3rd Hour
4th Hour
• Average episode time reduced from 108 minutes in June 2015
to 64 minutes in March 2016
• 85% of Patient arrival times were consistent with booked
appointment times
• Average number of patients per clinic reduced by 2.5 patients
(March 2015 vs March 2016)
• Improved staff satisfaction from 25% to 50%
• Improved patient satisfaction regarding wait time from 61% to
71%
Sustaining change
Outpatient Clinics
• New IT scheduler template installed; clinic numbers capped;
Appointment types (eg: possum) included as mandatory in
referral and booking request form.
• Education packs for new staff eg JMO’s at orientation
• Improved communication between administrative and clinical
staff on a daily basis through reinforcing importance of new
structure.
• June 2016 – implement information board visible to staff and
families about progress achievements and direct patient
feedback
Emergency Department
• Factsheets for parents and letters to the GP approved
• New process in ED procedure manual
• Splint orders embedded in ED process
• Regular audits to ensure splints only used on approved
injuries
Conclusion
Changes introduced into both the orthopaedic outpatient clinics
and the emergency department have resulted in
• Decreased episode time for patients to < 60minutes
• Improved patient satisfaction
• Decreased number of patients per clinic
• Streamlined procedures for non-tertiary injuries presenting to
ED– redirecting patients to receive follow up with local
services.
Staff Engagement and ownership of the changes was critical and
have resulted in improved staff satisfaction
Acknowledgements
Our sponsors: Dr Emma McCahon, James Stormon and Dr Paul Gibbons.
Clinical redesign leader, Christie Graham.
Sydney Children’s Hospital Emergency Department
Key Departments: Emergency Medical Imaging, Physiotherapy, EMR
services, Administration and Clinical staff.
2. Alternate treatment and referral pathway for non-tertiary
ED presentations
Contact
• GP consultation regarding advice to patients to visit GPs
post clinic appointment for certain follow-ups
Melissa Potts, CHW Outpatients Clerical Manager
[email protected] (02) 9845 2725
• Factsheets created and training of ED staff
• Protocol developed, approved and available online
• Project initiation including (project plan, sponsor
identification and steering committee establishment)
• Diagnostic Phase (Data analysis, Patient interviews and
Patient Experience Trackers, Staff Interviews, Time Stamp
Data, Referral Type audit)
• Solutions workshops x 2 (50+ attendees)
• Testing Phase: using the PDSA cycle (6 weeks x 2 clinics)
• Full Implementation to all orthopaedic clinics
22042016_finalposter_SCHNorthov3.pdf 1
Less crowded in the waiting room
3. Patient education material developed
• Parent information sheets (Fact sheets for parents about
home care post clinic for wrist splints)
Training regarding new process (All affected staff: ED, day
surgery, Orthopaedic ward, Surgeons, Junior medical staff,
administration, clinic nurses, radiology team,
physiotherapists)
Emergency Department
• New Referral Pathway followed for 33 patients
• No patients have represented to ED
• Reasons for patients not using new pathway
•
•
•
Splint size unavailable
Parents Request Cast
Child too young for splint
Changing the system is
the best thing ever!
Quick, friendly and professional
22/04/2016 4:51:46 PM