Presentation on theme: "AHP Out-Patient Services Capacity and Demand Management Masterclass"— Presentation transcript:
1 AHP Out-Patient Services Capacity and Demand Management Masterclass Robert Jones Fiona Jenkins3rd June 2011
2 ObjectivesReasons for considering new approaches to AHP booking systemsThe concepts of backlog, capacity and demand modelling in relation to out-patient appointments systems, using data to inform decision-makingFamiliarisation with a system for managing and reducing waiting lists and DNASustainability of a new systemImpact of reduced delays on AHP pathwaysConcepts of service re-design to be able to implement and sustain changeNational reporting
3 Before break Why waiting list management ? Concepts of capacity and demandIM&TManaging change- taking staff with you
5 Jargon Buster Demand - what we should be doing Activity - what we are doingCapacity - what we could be doingBacklog - what we should have done but haven’tCarve out- sub-dividing service into specialties
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 receivedand 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 gotStaff specialismSkill mix profile – is it optimal?Staff profile, activity and service costsInfrastructure – admin, data collection, phonesHow long per appointmentHow many contacts per episodeAre 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 appointmentHas their condition improved so they no longer require the appointment?Do by sending letters or telephoning…especially if you have a long waiting listGives 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 ?
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% inflationCost PressuresOrganisations with Recurring DeficitsEfficiency RequirementLess Money to do More Activity or Work differentlyActivity Volumes too High to be affordableInsufficient Community and Primary Care InfrastructureVariation in Length of StayToo many Follow-ups and too many DNAsToo Many Staff and too Many Beds!
25 SOME SHORT AND LONG TERM STRATEGIES Improved Effectiveness and EfficiencyOrganisation Development StructurePatient Level Costing Driving Strategy (SLR)Improved ProductivityVertical Integration, e.g (Stroke, COPD, Hospital at HomeHorizontal Integration (e.g Path, Backroom)Quality, Patient Safety InitiativesReduced ActivityDisease Management - Self Care)Effective, Lean ( Programme Management)Less Money, therefore Less Beds, Less StaffLess expensive Management StructuresTenderingAny Willing Provider?
26 Have you thought of Benchmarking? Valuable tool to determine how your service comparesRequires collection and interpretation of dataCan be wide-ranging or very focussedCan speak louder than your single voice….or identify where efficiencies can be made
27 Edited by Robert Jones and Fiona Jenkins Foreword by Karen MiddletonThe Jigsaw of Reform: Pushing the ParametersMoney, Money, Money: Fundamentals of FinanceCommissioning for Health Improvement: Policy and PracticeStriking the Agreement: Business Case and SLAs Thriving In the Cash Strapped Organisation Information is Power - Measure it, Manage itInformation Management for Healthcare ProfessionalsAllied Health Records in the Electronic AgeData ‘Sanity’: Reducing Variation Outcome Measurement in Clinical PracticeImproving Access to Services: demand and capacity to support service re-design Benchmarking AHP Services Management Quality and Operational ExcellenceEvaluating Management Quality in the Allied Health ProfessionsEvaluating Clinical Performance in Healthcare Services Project Management for Allied Health Professionals with Real JobsMarketing for AHPsEffective 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?
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 = queueOccasionally demand > capacity
33 How to Measure Capacity Understand how you use time, patient and non patient contact timeExpertise available, staff hours in WTE and grade, and hours the service is open forIf 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 episodeMeasure true demand- are there some not accessing your service that should be?
35 Patient FlowIn healthcare flow is the movement of patients, information or equipment between departments, staff groups or organisation as part of a patients care pathway.Three optionsManage flowCreate flowIncrease 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 weeksNeed 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 processre-design processmeasure bottleneckdemand/capacity/activity/backloganalyse data :- reduce variationcontinue to measure and analyse
40 Activity What do staff do with their time? How much of each activity Who does itWhere it happensMethodology to ascertain accurate picture of what staff are doing with their timeAbility to drill down
41 Why do we need to know this? Development of staffing profilesCase load managementSkill mix managementEvidence-based staff deploymentClinical issuesAudit and R&D
42 Why do we need to know this? Clinical governanceEffectiveness and qualityEvidence-base for service developmentBusiness environment and strategyService and workforce planningService re-design “tool”Capacity and demand management
43 Paediatrics and long term disability management Traditionally heavy caseloads and long waitsEven more important to undertake capacity/demand managementDo you want to see the patient?Or do they need to see you?Episodes of care philosophyPatient self-referralCaseload management toolsRegular reviewSkill mix
44 Staff Activity Patient related Non patient related Leave patterns What do staff do with their time?Patient relatedNon patient relatedLeave patternsMaternity leaveSeasonal variationDaily variationsCarve outSavings requirements
45 Activity Sample: Methodology Development and prototypingSnapshot of activity on a regular basisData collection formStaff involvementComputer softwareReporting methodsUse
46 Direct Patient Contact Activity Sample FormDirect Patient ContactFace to face contact -individualFace to face contact – groupTelephone contact with patient or carer
47 Activity Sample Form Ward rounds Case conferences Patient RelatedWard roundsCase conferencesAdministration- patient relatedHome assessment visits
48 Activity Sample Form Study leave In-service training Non patient relatedStudy leaveIn-service trainingOther CPD activityTeachingSupervisionLiaison with other servicesAdministrationManagement dutiesTravelStaff/team meetingsOther
49 Activity Sample Form Other Your contracted working hours today Your actual working hours todayNumber of group sessions you have done todayNumber of home assessment visits you have done todayNumber of patients on your caseload todayDate of activity sampleSiteLocationClinician codeBandPost name/rotationAbsence? Reason
50 Examples of analysisPercentage of time spent in different categories by:Whole serviceTeamIndividual bandIndividual staff memberLocationProfession comparison
56 Capacity CALCULATE : WTE staff by grade Slots: length of appointments Ratio 1st: Follow UpTotal time per patient episodeCapacity per staff member /yearFacilities issuesDNA time
57 A “Typical” Physiotherapist 1 WTE ,41 working weeks/pa = hours511 new patient pa =12.5new patients per week Average contact 4 = 2.5 hours511 X 2.5 hours= 1277hours patient activity260.5 hours for “other” activity (6 hours per WTE)
58 A department with 10 WTE Number of staff = 10 WTE 15375 hours/department5110 new patients12770 hours for patient contact2605 hours for “other” activity
59 Demand Total referrals How many currently on your waiting list What that equates to in patient contact timeHave you the right number of staff?Unmet need?Trends over time
60 A Worked Capacity Example Total referrals = 6000Waiting list =5001250 hours work (500x 2.5)Need 1 WTE more activity to meet this demand
64 What is “Choice Appointments” ? A system of same day outpatient appointments for physiotherapy patients; made by telephone for first and follow up appointmentsBased on capacity planningIn place in Eastbourne for 4+ years and Torquay for 2+ years
65 “Choice Appointments” Calculate department demand and capacityPatients referredPatient telephones to book an appointment on the day that they want treatmentMinimal pre bookingPatient agreed goals to achieve before re accessing further interventionFollow up appointment procedureUser involvementEvaluation
66 “Choice”What is “Choice”?For patientsFor referrersFor staff
67 Why did we go this way? Effectiveness and efficiency To minimise DNAs Inability to keep waiting lists down consistentlyWanting to improve clinical effectivenessEconomic and political driversBetter use of clinical and non clinical timeWorkforceImprove throughputComplaints about waiting timeTransferability to other services
68 Our starting points DNA Too many cancelled appointments (12%) Waiting timesUp to 16 weeks for “routine” in our areasSignificant numbers up to 6 months156 weeks “routine” wait is known!Waiting time complaintsUnstructured staff time for non patient contactDNA11-17% in our areasSignificant numbers with 15-20%Up to 48% in highestToo many cancelled appointments (12%)Our average wait was 22 days – but up to 42 days7% of appointments were cancelled per week by us – ie 19/weekCancellations accounted for 12%of activity
75 Possible Barriers to Implementation Lack of willingness to take riskStaff comfort zonesData collection!Availability of dataLocal resistanceLack of demand controlInfrastructureStringent cost improvement programmesCommissioner views
76 Other issues to consider Admin staffIM&T use and supportTelephone systemsWhat if patient doesn’t make contact?Leadership capabilityStaff comfort zonesLook at your use of facilities and space
77 Administration How non contactor referrals are handled How receipt of referrals is handled and processedStaff diary sheetsPatient informationFollow up arrangementsDischarge informationProcedure 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 2.55New patient appointment some 60 mins some 30 minsFollow up appointment 30minsRolled out to small dept with 4.27 WTETrust 2NP/ WTE,Follow up reduces from 3.5 to <2New patient appointment 45 minsFollow up appointment 30 minsRolled out to Trust 3With 2 smaller departments
79 Evaluation Patient satisfaction of those who attended PPIaudits in both sites:Patient satisfaction of those who attendedFeedback from those who failed to make contact.Once only attendersGP satisfactionClinical outcomeaudit of workshop attendees
80 Was information provided by the service about appointment system clear?
82 Did you find it easy to contact the department?
83 Could you make an appointment at a time convenient to you?
84 Key messagesOver 94% patients were satisfied with access, timing and organisation of appointment.“Judging by previous appointment I felt very lucky to get through so quicklyNot a long wait on the phoneExcellent 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!”
88 Audit of non contactors Reasons for not making contact4 Unable to make contact10 Did not know it was necessary to make contact with physio department to make appointment24 Got better didn’t need appt15 Unable to afford time due to work pressures8 Arranged own private treatment2 Moved away3 Previous treatment for same problem29 Other reasons3 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 phoneWould be easier to book several advance appointments10 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 attendedlongest waiting time 156 weeksHighest DNA 48%Highest 1st to follow up ratio up to 1:12Variable implementationSome implementing all aspectsSome implementing partsSome planning implementationSome maintaining “traditional” methodsEverybody scrutinising their booking system
92 GP Feedback Positive, liked reduced waiting time Liked reduced administrative burdenLiked using for referral and discharge – where used
93 Challenges Savings Flexing capacity Costing and Pricing ContestabilityProvider/purchaser arrangementsConfiguration of AHP servicesNational workforce planning agendaRolling out to other disciplinesNew models of service deliveryFlexing capacityVariable demandMeeting cultural needsHow flexible can you be?Commissioning arrangementPBC, PBRSelf ReferralOrganisational ArrangementsNHS 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 planningLooking at your serviceWorking it outResults - what it's done for our services - can it do this for you?Framework for the Management of ChangeChallenges for the futurePractical “workout"What you are going to take away and do
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, referrersPlan and prepareUse improvement tools and techniques