Assessment and Patient Pathways Geoff Bardsley Consultant Clinical Scientist Head of Assistive Technology, NHS Tayside.

Summary Rapid Improvement Event Rapid Improvement Event Background Background Scope Scope Strategy for improvement Strategy for improvement Planned developments Planned developments Patient pathways Patient pathways Assessment issues Assessment issues Conclusions Conclusions Stimulate discussion

Rapid Improvement Event (RIE) ? Management technique Management technique Problems identified with a service Problems identified with a service Step change improvement to a service Step change improvement to a service Focussed on meeting client needs Focussed on meeting client needs Re-design actively involves Re-design actively involves Clients Clients Staff Staff Management Management Action plan Action plan External consultants

RIE Background Increasing demand Increasing demand Improving technology Improving technology Increasing patient expectations Increasing patient expectations Budget limitations Budget limitations Ending of short term funding Ending of short term funding Changing Children’s Services Fund Changing Children’s Services Fund Waiting list initiative Waiting list initiative Short cuts to meet demand Short cuts to meet demand Assessment Assessment Staff training support Staff training support

RIE Background Complaints / dissatisfaction Complaints / dissatisfaction Lengthening waiting lists Lengthening waiting lists Poor control / organisation of waiting lists Poor control / organisation of waiting lists Poor information to patients Poor information to patients Deteriorating quality of service Deteriorating quality of service Low staff morale Low staff morale

RIE Scope Entire service Entire service Pathways Pathways Emphasis on clinical ‘front end’ Emphasis on clinical ‘front end’

Client focussed Patient Patient Carer Carer Referring professionals Referring professionals

Strategic direction Improve the speed and efficiency Improve the speed and efficiency patients are seen patients are seen equipment provided equipment provided Make best use of current staff Make best use of current staff experience and expertise (internal & external) experience and expertise (internal & external) Make the service to users more Make the service to users more local, local, responsive, responsive, transparent transparent Improve integration with other services Improve integration with other services etc etc

Examples of planned improvements Note : others

Patient Pathways

Summary path

Patient Pathways Defined before RIE (extensive work) Defined before RIE (extensive work) Few inefficiencies / redundancy Few inefficiencies / redundancy Largely unchanged Largely unchanged Further work Further work RIE - Referral pathway modified RIE - Referral pathway modified Improve efficiency Improve efficiency Better management / flow of work Better management / flow of work Waiting time information for patients Waiting time information for patients

Referral Pathway

WT < 1 day 6 lists WT ???? WT < ? WT = SWT = X WT = Waiting times

Referral Pathway

WT = S 1 list WT = H WT = P WT < 1day WT<<P WT = Waiting times

Next steps Active monitoring / management process Active monitoring / management process Routine weekly meetings Routine weekly meetings IT data (new reports in place) IT data (new reports in place) Reporting to higher management Reporting to higher management Staff recruitment Staff recruitment Transitional phase Transitional phase Managing backlog Managing backlog

Assessment phase Clinic inefficiencies Clinic inefficiencies Did not attends (DNAs) - Did not attends (DNAs) - 20 to 40% (1 or 2 out of 5) 20 to 40% (1 or 2 out of 5) Clinic frequency inadequate Clinic frequency inadequate Waiting times increasing Waiting times increasing Minimise seeing patients Minimise seeing patients Review frequency low Review frequency low Quality of assessments ? Quality of assessments ? Reduced time / patient Reduced time / patient Reduced TORTC team (1) Reduced TORTC team (1) Reduced local staff involvement Reduced local staff involvement No outcome measures No outcome measures Currently up to 12 wks (clinic) Draft standard Ref – assess < 4 wks RIE Target Ref – provision < 18 wks

Reducing DNAs (Did not attends) Pre appointment phone calls Pre appointment phone calls Patient-focussed-booking (Clinic & repairs) Patient-focussed-booking (Clinic & repairs) Letter to patient inviting to book appointment Letter to patient inviting to book appointment Patient responsibility to phone & book Patient responsibility to phone & book Patient chooses suitable time (More certain will attend) Patient chooses suitable time (More certain will attend) Excludes those not interested Excludes those not interested BUT – disadvantages less able BUT – disadvantages less able Transportation / ambulances ? Transportation / ambulances ?

Clinic Frequency Increase staff for clinics Staff recruitment Staff recruitment Additional staff Additional staff Utilisation current staff ? Utilisation current staff ? Increase technicians’ clinical role Increase technicians’ clinical role Concentrate clinical staff on clinics / complex cases Concentrate clinical staff on clinics / complex cases Improve quality of assessment Improve quality of assessment

Technician utilisation Mobile Technicians (x3) Mobile Technicians (x3) Current role Current role Repairs, collects & deliveries Repairs, collects & deliveries Travel throughout Tayside Travel throughout Tayside 5 to 12 years experience each 5 to 12 years experience each Know patients very well Know patients very well No clinical responsibilities No clinical responsibilities

Additional Technician Role Empower for basic clinical decisions, Egs: Empower for basic clinical decisions, Egs: Change of wheelchair size Change of wheelchair size Additional accessories (headrests, laterals, etc) Additional accessories (headrests, laterals, etc) Make adjustments (roho cushions, etc) Make adjustments (roho cushions, etc) Rapid (during repairs / on request) Rapid (during repairs / on request) Training, Supervision, & Backfill Training, Supervision, & Backfill Ears / eyes of the service Ears / eyes of the service Tele-care (lap top, camera, phone) Tele-care (lap top, camera, phone) Better use clinical staff Other technicians

Additional Referrers’ Role Nurses, Therapists Empower for basic clinical decisions, Egs: Empower for basic clinical decisions, Egs: Prescriptions (basic cases) Prescriptions (basic cases) Local environmental issues (access, ramps, house mods, etc) Local environmental issues (access, ramps, house mods, etc) Larger wheelchair Larger wheelchair Additional accessories (headrests, laterals, etc) Additional accessories (headrests, laterals, etc) Make adjustments (roho cushions, etc) Make adjustments (roho cushions, etc) Training in wheelchair use Training in wheelchair use Training, Supervision, Training, Supervision, Availability? Availability? Better use TORTC clinical staff Work with technicians More local service

One stop clinics Rapid service Avoids delivery BUT Clinic time Stock available

Review procedures Referrals for life BUT needs change (slow – rapid) Review to identify change and respond Review to identify change and respond Preferably before need critical (pro-active) Preferably before need critical (pro-active) Currently Currently Annual letter Annual letter Children & a few critical cases Children & a few critical cases Future ? Future ? All have defined review programme All have defined review programme Resources? (creates extra demand) Resources? (creates extra demand) Responsibility of Patients / Carers ?? Responsibility of Patients / Carers ??

Conclusions Patient pathways have been defined Patient pathways have been defined Referral pathway improved Referral pathway improved More structured clinics More structured clinics Improved management of waiting lists Improved management of waiting lists Better information to patients Better information to patients Assessment improved / accelerated Assessment improved / accelerated Staff utilisation (technicians, therapists / nurses) Staff utilisation (technicians, therapists / nurses) One stop clinics One stop clinics Better use TORTC clinical staff Better use TORTC clinical staff Reviews ? Reviews ?