Orthopaedic Flow Presenter: Martin McCall-White

1. Innovation Poster Session HRT1215 – Innovation Awards Sydney 11th and 12th Oct 2012 Orthopaedic Flow Presenter: Martin McCall-White Geelong 3-3b_HRT1215-Session_McCallWHITE_BARWON_VIC

2. KEY PROBLEM Increased demand for elective Orthopaedic services resulting in a long-waiting patient list which ebbed and flowed based on DH incentive programs.

3. AIM OF THIS INNOVATION Reduce the number of Orthopaedic long-waiting patients from 624 to 170 by Nov 2011 using incentive elective surgery funds; and Maintain the waitlist at a steady state until Orthopaedic theatre capacity can be added (in the Operating Theatre expansion) using redesign.

4. BASELINE Waitlist large numbers of pre-existing long waiter patients with uncertain health/RFC status Preadmission inconsistent information was provided to patient prior to elective surgery Theatre anaesthetic preparation time was variable; and surgery rarely started on time Concerns that anaesthetists varied in their clinical process and that expectations between anaesthetists and surgeons were unclear Ward inconsistent forward planning of discharge hindered by poor consensus on what constitutes an appropriate inpatient vs home rehabilitation referral

5. BASELINE Ward weekend physiotherapy constraints meant that patients regressed over the weekend and it was difficult to safely discharge patients on the right discharge day if that day fell on a weekend. Rehabilitation communication, discharge planning and involvement of the patient were all noted to be issues for improvement whilst awareness of what community services offered the Orthopaedic patient and the process for referral to community services was poor.

6. KEY CHANGES IMPLEMENTED Waitlist Orthopaedic surgery team access data to track and plan for ESWL long waiters using the Treat-In-Turn strategy in their weekly planning meeting Preadmission education provided by medical, nursery and allied health staff, is standardised and more emphatic with patients indicating they are more prepared for their surgery and acute care Theatre standardised post-operative analgesia (acute pain management) protocols for defined procedures (namely total hip replacement and total knee replacement), which include guidelines for ward staff

7. KEY CHANGES IMPLEMENTED • Ward standardised clinical and process guidelines enable early mobilisation, rehabilitation referral and acceptance, seven day-a-week physiotherapy • Rehabilitation clear rehabilitation plan and patient care handover from acute to the rehabilitation centres using electronic patient records. • There is also now a single point of referral for community services to support patients at home via the Barwon Health Information & Access Service.

8. OUTCOMES SO FAR Orthopaedic long-waiting patients reduced from 624 to 272 by Nov 2011 (using incentive elective funds) Further reduced to 230 by April 2012 (using redesign)

9. Acute to subacute interface DRGs I29 & I03

10. LESSONS LEARNT Redefine what constitutes the orthopaedic ‘team’ in healthcare Analyse the identified issues Keep the improvement opportunities, rather than the failings, as the focus of discussion Create performance indicators, and forum for discussion when performance varies and 30-day improvement plans Aim for clarity of roles, responsibilities and team behaviours Patient involvement as part of the infrastructure