Lisa Ford, Alieke Van Middelaar, Jennifer Bilton, Alayne Healey, Caroline Ranchhod Acute Allied Health Musculo-Skeletal Outpatient Physiotherapy (MSOP) Waitlist Management ‘The Waitlist-ectomy Project’

MSOP Physiotherapy Waitlist Management Problem background MSOP waiting list growing Waitlist targets not being met Patients are waiting an unacceptable length of time to receive physiotherapy for their condition Aim Statements for this project By 31 March 2013, 80% of FSA referrals to MSOP will be seen within the set priority timeframes By 31 July 2013, 95% of FSA referrals to MSOP will be seen within the set priority timeframes Priority 1 (P1) = to be seen within 4/52 Priority 2 (P2) = to be seen within 6/52

Driver Diagram By 31 March 2013, 80% of FSA referrals to MSOP will be seen within the set priority timeframes By 31 July 2013, 95% of FSA referrals will be seen within the set priority timeframes P1 = within 4 weeks P2 = within 6 weeks Reduce the volume of referrals being received and accepted by MSOP service Maximise utilisation of MSOP appointment capacity Wide MSOP referral criteria Lack of information given on referrals Patient consent for referral Referral method (e.g. post, fax, ) Under-utilising other physiotherapy providers Model of care (1:1 vs class)Managing staff leaveTriage system Admin process for booking/scheduling Managing DNA’s and cancellations Accessibility of clinics (evenings / weekends etc) Primary Drivers AimsSecondary Drivers

Name of Measure Is this an Outcome, Process or Balancing Measure? Operational Definition (e.g., numerator & denominator) Number of referrals received by MSOP per month Balance Referrals accepted by MSOP Month Number of available appt slots per month Balance Num of MSOP appt slots available Month % of P1 patients seen within 4 weeks. Calculate monthly Outcome Number of P1 pts seen within 4/52 Total P1 on waitlist % of P2 patients seen within 6 weeks. Calculate monthly Outcome Number of P2 pts seen within 4/52 Total P2 on waitlist Average number of weeks a P1 patient waits from addition to waitlist until FSA. Monthly Outcome Total weeks P1 pts wait for FSA Total P1 pts seen Average number of weeks a P2 patient waits from addition to waitlist until FSA. Monthly Outcome Total weeks P2 pts wait for FSA Total P2 pts seen Measures

Change Concepts & Ideas for PDSA’s Idea for Testing in a PDSATheory and prediction about what will happen when you test this idea Telephone appt scheduling (instead of sending letter) Improved efficiency in booking and scheduling will lead to reduced wait times by 3/52 Telephone triaging P1 patientsWe will reduce the number of patients on the P1 waiting list by 30% Adding more physiotherapy resource We will increase capacity to see P1 FSA’s Telephone triaging for P2 patients We will reduce the number of patients on the P2 waiting list by 60% Clearly defining MSOP referral criteria and circulating to referrers We will reduce the volume of MSOP referrals accepted by 25%

Prediction: By telephoning patients we will reduce the Priority 1 waitlist by 30% Aim of this change: To reduce the Priority 1 waitlist by 30% and “clear the backlog” The Change: Priority 1 patients are now be contacted by admin team by phone within 1 week of receipt of referral PFB letter sent when no phone contact possible, 14/7 to respond. 83% have appointment within 4 weeks Average wait 2.7 weeks in Feb Measurement % of Priority 1 referrals who did not require appointment and could be removed from waitlist PLAN: DO:STUDY: ACT: Problem: 70 priority 1 patients on MSOP waitlist, 42 waiting >4 weeks Physiotherapist will call all patients to triage and either discharge or book appointment within 2-3weeks 55 patients called 39 booked within next 10/7 16 removed from waitlist = 29% Contact patients by phone instead of letter as per patient focused booking (PFB) Adopt

PDSA: Telephone Appointment Scheduling Number of weeks Month / Year

Prediction: Adding more physiotherapy resource will improve FSA throughput. Aim: I mprove access to Physiotherapist FSA appointment i.e. within 4/52 for priority 1 patients The Change: Available FSA slots 45-50/week Compared to FSA slots/ week in Nov/Dec 2012 Followup patients slots available Non clinical time is preserved SH reduced clinical load Morale boosted! Measurement Number of additional FSA times available PLAN: DO:STUDY: ACT: Problem: Insufficient Physiotherapist FTE to meet demand Recruit to longstanding vacant FTE which had been used for other area in AAH, experienced Physiotherapists, Borrow FTE Fill 2/12 rotator vacancy 16/1/13 - borrow 0.2 FTE 21/1/13 new 0.5 FTE starts & fill 1.0 rotator position 16/01/13 – 28/02/13 Additional 134 x 45 minute appointments created F/U patients seen within expected timeframes Adopt. (permanent increase in 0.5 FTE)

Prediction: Telephone triage of priority 2 patients will reduce waitlist by 60% Aim of this change: Improve waiting time for Priority 2 referrals to 6-10 weeks The Change: Measurement PLAN: DO:STUDY: ACT: Problem: Priority 2 waiting list numbers are increasing and length of wait >12 weeks Contact patients by phone Instead of letter as per patient focused booking (PFB) due to short timeframes from referral to appointment February 2013; Physiotherapist will call Priority 2 patients waiting since 1/10/12 to triage and either discharge or book appointment within 4 weeks Adopt P2 = contacted by phone 15 Removed from waitlist = 20% (6% of totalP2 waiting)

Re-defining MSOP Referral Criteria Month / Year Number of Referrals Accepted

Current Referral Trends Number of Referrals Accepted Month / Year

Process Changes and Results Percentage Month / Year

Process Changes and Results Percentage Month / Year

14 Profound Knowledge Worksheet Appreciation for a System Difficulty defining data required Difficulty accessing stats Human error & technology Psychology Staff morale / motivation Behaviour change challenge Pressure from referrers Team work Theory of Knowledge How are our prioritisation time frames set? Understanding Variation Staff triaging differently Admin process variation around DNA’s and cancellations (different from other OP services)

Where to from here? TEAMWORK & Sustainability of gains to-date Stats available weekly for closer monitoring Closer look at capacity/week+ Recruitment!! FSA as classes vs individual appointments Priority 2 phone triage strategy FOCUS to achieve 80% of referrals seen within timeframes by 31/7/13