Using Simulation To Understand Orthopaedic Flow Through Triage

1. Using SimulationTo Understand Orthopaedic Flow Through Triage Ekwutosi ChigboEzeh Supervised by Dr Navid Izady 16/10/13 University of Southampton University Hospital Southampton - Solent NHS – ISTC (CARE UK) Southampton City Clinical Commissioning Group

2. Background • When patients require orthopaedic assessment they are referred by their GP to an Integrated Medical Assessment and Treatment (IMAT) service for triage to determine the appropriate referral pathway • For orthopaedics, these routes include physiotherapy, podiatry, rehabilitation programmes, pain management services, and community re-ablement services, as well as orthopaedic surgery (three tier system) • Evidence that some patients are routed incorrectly, leading to wastage and poor patient experience • Aims: to identify how patients are referred, then triaged then routed; quantify where patients are initially routed incorrectly and subsequently rerouted; use simulation to test alternative pathway designs

3. Providers modelled • In 2012-13 the Southampton Musculoskeletal service (including IMATs, physiotherapy, rheumatology and pain management) served 16,000 patients and provided 38,000 outpatient appointments • Southampton City CCG (Tier 1) • NHS Solent (Moorgreen Hospital) – community-based outpatient clinics, physio and reablement (Tier 2) • Independent Sector Treatment Centre at the Royal South Hants hospital (Tiers 2 & 3) • University Hospital Southampton (Tiers 2 & 3) • Many others – highly complex patient flow through different sectors with a multiplicity of providers and over 400 pathways, which were modelled as a series of clinics

4. Patient flow between providers

5. Challenges • Limited data available for modelling the whole system (lack of referral numbers; medical conditions recorded; referral destination; no entrance data for cohort) • Significant differences in data across providers • No universal identifiers linking data • Appointment scheduling procedures required to model waiting times, but were not available

6. Moorgreen Hospital Simul8 Model 160 pathways in total!

7. Outpatient Clinics

8. Solent : Accepted & Cancelled Referrals

9. Top 95% of pathways in Solent NHS

10. Number of consecutive appointments per pathway

11. Conclusions • Many limitations of model due to data challenges • Enhancement of current data available needed to effectively model this • We found less inefficiency in the system than was perhaps initially perceived by our “client”: the majority of patients are correctly triaged at Tier 1, while 94% of patients referred to Tier 2 attend only the first clinic they are referred to • Despite the data limitations, the modelling process highlighted many key issues for the providers to think about

12. OR - clinical perspective Dr Cathy Price UHS FT

13. NHS perspective • Are pathways of care • Timely? - treatment delivered within an acceptable waiting period (need to understand rate of deterioration whilst waiting) • Effective? - no bounce around, minimal follow ups • Efficient? - minimal number of follow ups

14. Commissioning Landscape • Multiple Providers within small geography • Confusing entry criteria • One large teaching hospital • Multiple Signposting “Tier 2” services for GP’s • Collaboration difficult across providers • Commissioned time points for providers to meet to review cases (“virtual clinics”) • Patient experience “confusing” • Clinical effectiveness unclear

15. Modelling /OR – comments • Brought some clarity on efficiency (minimal follow ups) in Signposting service – pretty efficient • Clinical Effectiveness hard to ascertain within timescale (no follow ups per provider – needed to be accurately agreed ) • Model built that allowed for varying scenarios • Concerning number of differing outcomes for patients (400+ pathways ) • No easy way to ID patient through whole system i.e. more confident modelling would require this