Assessment and Patient Pathways

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

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

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

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

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

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

7. Client focussed • Patient • Carer • Referring professionals

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

9. Examples of planned improvements Note : others

10. Patient Pathways

11. Patient Pathways Summary path

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

13. Referral Pathway

14. Referral Pathway WT = Waiting times WT < 1 day WT < ? WT = S WT = X 6 lists WT ????

15. Referral Pathway

16. Referral Pathway WT = Waiting times WT<<P WT < 1day 1 list WT = H WT = P WT = S

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

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

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

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

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

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

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

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

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

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