Dr John Oldham OBE

The Cycle of Fear Increase Fear Micromanage Messenger Information Kill the Messenger Micromanage Filter the Information ©John Oldham 2002

Every system delivers exactly the results it is designed to give ©John Oldham 2002

Diffusion of Innovation 35% Early Majority 35% Late Majority 13% Early Adopter 2% Innovators 15% Laggards ©John Oldham 2002

Collaborative Process An improvement method that relies on spread and adaptation of existing knowledge to multiple settings to accomplish a common aim. It is not: A research project for new knowledge A set of conferences A passive exercise ©John Oldham 2002

Collaborative Process Select Topic Participants Planning Group Identify Change Concepts P P A D A D S S Pre work LW0 LW1 LW2 LW3 Support Project Managers E-mail Phone Discussion Group Assessments Access to expertise Peers ©John Oldham 2002

Collaborative Culture Respect Group learning and rapid doing No blame Flexibility - ideas - methods Firm on results ©John Oldham 2002

Fundamental questions for improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement? ©John Oldham 2002

Model for improvement Act Plan Study Do rationally on results for next cycle the test execute it on results ©John Oldham 2002

Example of a PDSA Cycle Plan 2 doctors on Tues and Thurs evening after surgery to call list of identified patients with advance booked routine appointments to determine if the routine appointment is still necessary. Start 13th June. Do Carried out 13/15/20/22 June ©John Oldham 2002

15% appointments could be cancelled. Study 15% appointments could be cancelled. Some telephone numbers not updated, some patients no telephone, language problems. Required 2 - 7 minutes consultation time. High patient satisfaction. Act Timetable the telephone consultation in on Tues/Thurs evenings Extend to 3 doctors Assess non-contact rate ©John Oldham 2002

Repeated Use of the Cycle Theories Testing changes Changes resulting in improvement A P S D D S P A A P S D DATA A P S D ©John Oldham 2002

Advanced Access in Primary Care

Why?

“Every system delivers exactly the results it is designed to give”

30 30 30 30 30 Day Mon Tues Wed Thurs Fri Max no of avail 150 150 150 150 150 appointments Daily Demand 175 150 125 150 150 Blocked urgent for the day Filled routine Free routine 30 30 30 30 30 120 110 110 100 115 0 10 10 20 5 ©John Oldham 2002 © John Oldham 2001

30 30 30 30 30 Day Mon Tues Wed Thurs Fri Max no of avail 150 150 150 150 150 appointments Daily Demand 175 150 125 150 150 Blocked urgent for the day Filled routine Free routine 30 30 30 30 30 120 110 110 100 115 0 10 10 20 5 ©John Oldham 2002 © John Oldham 2001

Reservoir Wait Times Demand Supply DNAs 10days Efficiency Rework Mark Murray ©John Oldham 2002

In order to protect tomorrow, we pull work into today. Paradigm Shift Old In order to protect today, we push work to tomorrow. New In order to protect tomorrow, we pull work into today.

The Fears Schedule Saturated Demand is Insatiable

Components of Advanced Access Understanding profile of demand Adjusting the handling of demand Matching capacity to demand Contingency plans Communicate,communicate ©John Oldham 2000

Understanding the Profile of Demand

What is current daily demand? Any request for any type of appointment on a single day i.e. includes appointments for doctors and nurses for investigations and consultations. It includes all requests made on that day WHETHER FOR THE SAME DAY OR A FUTURE DAY.

How do we measure current daily demand? Count by tick box (e.g. as per demonstration sheet) each day for 5 days.

Demonstration tick sheet Appt Mon Tues Wed Thurs Fri Total with/for (wk) Doctor //// //// F-ups /// Nurse /// Practitioner F-ups Practice //// Nurses

Changing Demand

Responding to demand ©John Oldham 2002

Some Examples of Changing Demand Telephone follow-up reduces face-to-face consultation by 15-20% Telephone management of same day requests reduces consultation by 30-50% Advanced access reduces non-attenders by 50% E-mail consultation/queries Reduce follow-ups on Mondays ©John Oldham 2000

Chronic Disease Management Self-help Number % List % Variation against HA average Total number with asthma 689 7.7 + 0.9 Those with Asthma receiving:- Prophylactic Medication 457 83.0 + 30 Self Management Plans 525 80.0 n/a Admitted to hospital 1 0.8 -91.6 ©John Oldham 2000

Matching Capacity to Demand Work down backlog Anticipate associated needs Match team to work who does it now who could do it what is the next step

Contingency Plans Holidays Training Sickness Epidemics

Free appointments Pre-bookable follow ups Day Mon Tues Wed Thurs Fri Max no of avail 150 150 150 150 150 appointments Daily Demand 130 115 80 115 130 With adjusted Handling of demand Free appointments Pre-bookable follow ups ©John Oldham 2002

©John Oldham 2002

©John Oldham 2002

Dissatisfaction with life as you know it STEP 1 Dissatisfaction with life as you know it STEP 2 Understand the demand each day of a typical week STEP 3 Shape the handling of demand STEP 4 Match capacity to demand Work down the backlog STEP 5 Put contingency plans in place