1. Anthony Larkins & Judith Swan, Hunter New England Local Health Network
ENT Express:
Improving the Patient Journey through the Royal Newcastle Centre Ear, Nose and Throat Clinics
Anthony Larkins & Judith Swan, Hunter New England Local Health Network
Introduction
The Ear, Nose & Throat (ENT) Clinics at the
Royal Newcastle Centre (RNC) deliver a
significant ambulatory care service to around
4,500 patients annually. The service was
experiencing complex problems including:
long waiting lists to get an appointment for new non urgent patients;
long wait times upon arrival in the clinic;
overbooking of clinics;
staff frustration; &
patients complaints.
The Patient Experience: Jo’s Story
“I went to my GP because I had a discharge from my ear. I waited for 3 months for an appointment [at the ENT Clinic]. On the day of my appointment I waited for 2 hours to be seen. I returned 6 weeks later for another appointment and went through the same procedure. I had a total of 5-6 appointments each about six weeks apart. I was very frustrated in that I saw a different doctor each time. I arrived for an appointment and had to repeat my story from the start every time. I only saw the specialist twice in 12 months. I felt…rushed after waiting for 2 hours to be seen. When I complained I was told that 3 patients can be booked into one appointment time.”
Key Issues
There is variation in internal processes for bookings and internal flows.
There is minimal capacity for non urgent new patients to be seen in the ENT service leading to long waiting lists.
There are no clear pathways and criteria articulated to transfer patient care both into the ENT Ambulatory Care service and back to their GP.
Key Opportunities for Improvement
The solutions fall into six clear categories:
The key solutions are:
1. Patient Centred Services
Referral pathways for high volume patient
groups with pre defined management and
investigations where appropriate. Standardised
referral template for GPs.
Criteria for transfer of care back to GPs.
Electronic discharge summaries.
Information about ENT services are available on
website.
2. Clinic Structure
Equipment and resources available
Reorganise clinics to meet patient demand
Nurse led clinics
3. Scheduling / Waitlist
Implement clinic template booking to 75%
capacity to allow for urgent reviews and post
operative appointments. Monitor compliance of
bookings to template.
Waitlist to be regularly reviewed, measured,
monitored and processes for action and
accountability to be put into place.
Minimise number of cancelled clinics.
The associated UWS visual analytics project will
develop a range of recommendations for
improved processes.
To implement these solutions a range of enablers
will need to be considered including training &
education and the development of ambulatory
care performance indicators and an associated
coding system.
Aim
The purpose of the project was to make recommendations that will ensure a patient centred ENT ambulatory care service that meets the needs of the community.
Objectives
Improve patient satisfaction.
Reduce the number of patient complaints.
Reduce the number of patients on the waitlist.
Improve staff satisfaction
Findings
Results from the 2009 NSW Health Patient Survey for Outpatients in the RNC found that patients:
ranked the courtesy of the staff very highly.
felt the health workers worked well together
and felt they had enough time with the person.
felt they waited too long in the waiting room
and the reason for the delay was not explained.
were not able to get an appointment when
wanted.
Method
The NSW Health Clinical Redesign
methodology was used to conduct the project
as shown below.
A variety of activities were utilised to diagnose
key issues and identify solutions. Stakeholders
were consulted and patient experience was
central to the approach. A literature search was
undertaken and leanings were shared with staff
from The Alfred Hospital Ambulatory Care
service in Melbourne.
The following guiding principles (written by
HNE Health clinicians) for the development of
non-inpatient services in HNE Health
underpinned the solution design phase:
Services are delivered as close to home as possible in a caring, efficient and timely way;
Care is evidence-based and continuously
improving;
The elements of care are integrated and
coordinated;
Care is supported by appropriate technology;
There is a focus on preventative healthcare;
Resources are used wisely;
There is strong leadership;
There is support for staff and their ongoing
education and training.
Project Timeline
July
August
September
October
November
December 1 2 3 4 5 6 7 10 9 8 13 12 11 14 15 16 17 18 19 20 21
i. Project
Initiation & Start-up
ii. Diagnostic Phase
iii. Solution Design Phase
20/9/2010 – 25/10/2010
iv. Implementation, Planning
As of 31 August 2010 there were 1,867 patients waiting for an appointment at the ENT Clinic. The majority of these patients (75%) were triaged as non urgent to be seen within 365 days.
Processes are complex. There are 14 major steps (first 5 shown here), just to go from referral to patient arrival in the waiting room. Each step has numerous associated detailed processes and tasks (shown as “+”). Source: University of Western Sydney, Visual Analytics Project
Conclusion
This ENT project has been important to RNC Ambulatory Care services as it provides a key set of leanings that may be applicable for other ambulatory services.
The guiding principles have been integral to the project and were well accepted by the clinicians, managers and staff involved.
Acknowledgements
Tracey McCosker, Director Clinical Operations (Executive Sponsor)
Dr Kelvin Kong, VMO, Ear Nose & Throat
Professor Nikolai Bogduk, Director Clinical Research, RNC
Todd McEwan, General Manager, Greater Newcastle Acute Network
Sue Waters, Service Manager/DON Royal Newcastle Centre
Wendy Pudney, Operations Manager, Ambulatory Care Centre, Royal Newcastle Centre
Julie Tait, Service Manager, Division of Surgery John Hunter Hospital
Jane Gray, Director Innovation Support
A/Professor Terry Sloane, University Western Sydney
Cathy Grahame, Nurse Unit Manager Paediatric Ambulatory Care John Hunter Children’s Hospital
Staff from the RNC Ambulatory Care Service & the Referral Management Centre
A/Professor Anneke Fitzgerald, University of Western Sydney (Visual Analytics Project)
Dr Joanne Curry & research team, University of Western Sydney (Visual Analytics Project)
Contact Details
Anthony Larkins.
Judith Swan.