1. AHP Out-Patient Services Capacity and Demand Management Masterclass
Robert Jones Fiona Jenkins
3rd June 2011

2. 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

3. Before break Why waiting list management ?
Concepts of capacity and demand
IM&T
Managing change- taking staff with you

4. Your Expectations?

5. 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

6. Who has a Waiting List?

8. Physio Out patient longest waits

9. 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?

10. The DH waiting time definition
The time between:
the date that a referral is received
and the date the patient is treated.

11. 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?

12. Consider Do your patients and referrers want shorter waits?
What facilities have you got
Staff specialism
Skill mix profile – is it optimal?
Staff profile, activity and service costs
Infrastructure – admin, data collection, phones
How long per appointment
How many contacts per episode
Are you ready to pass control over to patients?
Is your service ready to re-design?

13. 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.

14. Wasted Slots Don’t confuse your DNAs and UTAs How to calculate?
Liberate capacity

15. 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 ?

16. Benefits
Information for:
Management
clinical
finance
workforce

17. Costs of your service Pay and Non Pay Overheads Capital charges Other
Largest element for AHPs is staff costs

18. Planning staff involvement

19. R

20. A Framework for the Management of Change
Moving From the Current to the desired - triggers for change
Essential Actions
Skills for Success
Evaluation
Learning Points F

22. Questions so far?

23. THE FINANCIAL CONTEXT - Public Sector Funding Restricted (Zero Growth)
- 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

24. THE 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!

25. SOME SHORT AND LONG TERM STRATEGIES
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?

26. 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

27. 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  

28. 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?

29. 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?

30. How referrals are handled affects waits

31. 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

32. Managing Flow
NHSI No delays achiever

33. 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.

34. 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?

35. 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 options
Manage flow
Create flow
Increase responsiveness

36. 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

37. 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.

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. Staff Activity Patient related Non patient related Leave patterns
What do staff do with their time?
Patient related
Non patient related
Leave patterns
Maternity leave
Seasonal variation
Daily variations
Carve out
Savings requirements

45. Activity Sample: Methodology
Development and prototyping
Snapshot of activity on a regular basis
Data collection form
Staff involvement
Computer software
Reporting methods
Use

46. Direct Patient Contact
Activity Sample Form
Direct Patient Contact
Face to face contact -individual
Face to face contact – group
Telephone contact with patient or carer

47. Activity Sample Form Ward rounds Case conferences
Patient Related
Ward rounds
Case conferences
Administration- patient related
Home assessment visits

48. Activity Sample Form Study leave In-service training
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

49. Activity Sample Form Other 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
Date of activity sample
Site
Location
Clinician code
Band
Post name/rotation
Absence? Reason

50. Examples of analysis
Percentage of time spent in different categories by:
Whole service
Team
Individual band
Individual staff member
Location
Profession comparison

51. Therapies staff activity Analysis

53. Its Your Turn!

54. Find your data You will calculate: Capacity Departmental demand
Backlog (waiting list)
Time per patient episode
Staffing resources required

55. What is your Capacity?

56. 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

57. A “Typical” Physiotherapist
1 WTE ,41 working weeks/pa = 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)

58. A department with 10 WTE Number of staff = 10 WTE
15375 hours/department
5110 new patients
12770 hours for patient contact
2605 hours for “other” activity

59. 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

60. 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

61. Develop a capacity plan

62. 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?

63. Its Lunch time!

64. 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

65. “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

66. “Choice”
What is “Choice”?
For patients
For referrers
For staff

67. 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

68. Our starting points DNA Too many cancelled appointments (12%)
Waiting times
Up to 16 weeks for “routine” in our areas
Significant numbers up to 6 months
156 weeks “routine” wait is known!
Waiting time complaints
Unstructured staff time for non patient contact
DNA
11-17% in our areas
Significant numbers with 15-20%
Up to 48% in highest
Too many cancelled appointments (12%)
Our average wait was 22 days – but up to 42 days
7% of appointments were cancelled per week by us – ie 19/week
Cancellations accounted for 12%of activity

69. What did we do?

70. Our Results
Eastbourne
System in place for 6 years
South Devon
4 years

71. Waiting time analysis and comparison

72. % DNA

73. Routine Waiting time (weeks)

74. Waiting time complaints

75. 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

76. 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

77. 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

78. Other information Trust 1 Trust 2 NP/ WTE, 12 15 NP/ WTE, 12 20
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
Trust 2
NP/ WTE,
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

79. Evaluation Patient satisfaction of those who attended
PPI
audits in both sites:
Patient satisfaction of those who attended
Feedback from those who failed to make contact.
Once only attenders
GP satisfaction
Clinical outcome
audit of workshop attendees

80. Was information provided by the service about appointment system clear?

81. Would any other information have been useful?

82. Did you find it easy to contact the department?

83. Could you make an appointment at a time convenient to you?

84. 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 quickly
Not a long wait on the phone
Excellent system.”

85. 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

86. 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!”

87. Audit: attended once only

88. Audit of non contactors
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
3 month period, letter sent to all non attenders for 1st and follow up appointment 250 letters (15% of referrals)
95 responded (38%)

89. 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

90. Audit: workshop attendees
790 people attended
longest waiting time 156 weeks
Highest DNA 48%
Highest 1st to follow up ratio up to 1:12
Variable implementation
Some implementing all aspects
Some implementing parts
Some planning implementation
Some maintaining “traditional” methods
Everybody scrutinising their booking system

91. Choice Appointments and Self-referral

92. GP Feedback Positive, liked reduced waiting time
Liked reduced administrative burden
Liked using for referral and discharge – where used

93. Challenges Savings Flexing capacity 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
Flexing capacity
Variable demand
Meeting cultural needs
How flexible can you be?
Commissioning arrangement
PBC, PBR
Self Referral
Organisational Arrangements
NHS Reconfiguration

94. Mandatory reporting of AHP waiting times (England)
2011 – 12?

95. 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?

96. 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

97. Revisiting your expectations

98. 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

99. What are you going to do?

100. Next Steps ??
Discuss with Trust management, patients, referrers, staff, commissioners
Project set up : project manager, team and time scales, base-line data and ongoing measurement

101. Any Questions
or further Discussion

102. Service redesign, management masterclasses and workshops, presentation
Other things we do
Service redesign, management masterclasses and workshops, presentation

103. Thank you!