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2. End of section Introduction Introduction What is the Pre-op and Elective Management toolkit for? The pre-op and elective toolkit has been designed to assist organisations with the formation of an innovative elective strategy to and reduce unnecessary patient delays. Who should use the toolkit? The toolkit will promote discussion and ideas around solutions to elective process constraints. Anyone involved in elective process will benefit from this toolkit. What are the aims of the toolkit? The Patient Flow Collaborative aims to remove unnecessary constraints in the patient process; to effectively do this elective pathways need to be designed to flow patients to the right person, at the right time, with the right resources and in the right place. How should we use the concepts in this toolkit? Each clinical team will need to discuss the ideas within this toolkit, stimulate innovation and adapt concepts to their local environment. Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Back to menu

3. End of section Goals of the toolkit Introduction Introduction The elective and pre-op toolkit is based on whole system thinking and includes a whole of health service perspective. Goals Specific goals of the toolkit are to: Your Feedback This first version of the elective and pre-op toolkit will stimulate further development of guides, resources and tools. Feedback is essential to the future development of subsequent versions. Goals of the toolkit Overview and strategy Health service team • Promote seamless patient flow from clinical decision to operation to discharge • Build awareness of how key elements in elective process rely on other steps • Identify possible solutions to elective constraints • Smooth variation in waiting times Processes Data Resources Diagnostics and tools Back to menu

4. Overview and strategy Introduction Goals of the toolkit Whole system approach A whole system approach is needed to effectively manage the variation in capacity and demand involved in bed management. This approach can be broken down into two; executive strategy and frontline operational management. Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 1 of 11 Back to menu

5. Overview and strategy Introduction Clinical decision to operate Goals of the toolkit Referral Overview and strategy Pre-operative questionnaire Discharge Health service team Processes Waiting list Ward Data Resources Pre-operative assessment Surgery Diagnostics and tools Admission Click to continue Page 2 of 11 Back to menu

6. Overview and strategy Introduction Referral Goals of the toolkit Discharge Overview and strategy Admission • Referral •   Information on waiting times and available surgical procedures given to GP’s will allow correct referral to provider • Simple referral protocols from primary care containing; • - Patient Identification • - Presenting condition • - Previous history • - Medications • will assist with prioritisation and administration management. • Referral administration routes need to be simple and understood by all stakeholders. Health service team Processes Data Resources Diagnostics and tools Click to continue Page 3 of 11 Back to menu

7. Overview and strategy Introduction Clinical decision to operate Goals of the toolkit Discharge Overview and strategy Admission Health service team • Clinical discussion to operate • Registration waiting list and clinical categorisation • Once decision to operate has been made, a clear explanation of the next steps needs to be given to the patient • Remember this may be familiar to practitioners but may be the first time for a patient. Concise explanations and pre-planning of the next steps will assist with a smooth process and patient satisfaction increased. Processes Data Resources Diagnostics and tools Click to continue Page 4 of 11 Back to menu

8. Overview and strategy Introduction Preoperative questionnaire Goals of the toolkit Discharge Overview and strategy Admission Health service team • Pre-operative Questionnaire • Pre-operative questionnaires are an effective way to triage patients who are not ready to be added to the waiting list. • Elements to pre-operative questionnaires are: clarification of patient understanding of the process, pre and post op expectations, simple health check (including blood pressure, weight, fitness for anaesthesia etc), and checks on admission planning, i.e. home care support. Processes Data Resources Diagnostics and tools Click to continue Page 5 of 11 Back to menu

9. Overview and strategy Introduction Goals of the toolkit Discharge Waiting list Overview and strategy Admission Health service team • Waiting List Management • Waiting list management can become complex, however simple waiting list procedures will assist with administration. • Waiting list policy needs to be consistent with Department of Human Service’s policy, endorsed organisation wide and routinely monitored for effectiveness. • Waiting list policy should endorse fit for operation principles, treatment routes for patients not ready for care, pre-operative process, auditing principles and timescales and methods for monitoring and reporting waiting list activity (use Health Service KPIs). Processes Data Resources Diagnostics and tools Click to continue Page 6 of 11 Back to menu

10. Overview and strategy Introduction Goals of the toolkit Discharge Overview and strategy Preoperative assessment Admission Health service team • Pre-operative assessment • Pre-op assessment needs to be delivered in a timely manner by qualified staff. • A mix of junior medical staff and nurses carrying out pre-operative assessment can prove to be effective and not reduce clinical training time. • Treatment plans for patients who are not fit for surgery need to be in place before a patient is added to the waiting list. This may require communication between primary and secondary care to agree where the patient can be better managed. Processes Data Resources Diagnostics and tools Click to continue Page 7 of 11 Back to menu

11. Overview and strategy Introduction Goals of the toolkit Discharge Overview and strategy Admission Health service team • Admission to Hospital • Confirmation calls with patients two days before admission may reduce cancellations/ FTA. • Patients who are prepared for admission and are informed on the length of stay will reduce potential delays. • Admission can be to an admission area giving time to prepare wards and allows later discharge for previous patients, this also can reduce anaesthetic and surgical ward round times as all patients are in one area. Processes Data Resources Diagnostics and tools Click to continue Page 8 of 11 Back to menu

12. Overview and strategy Introduction Goals of the toolkit Discharge Overview and strategy Surgery Admission Health service team • Surgery • Effective communication, responsibility and accountability is essential to promote a seamless journey for the patient from admission to theatre, to recovery ward. • Bed management, theatre scheduling, and length of stay management are essential components to effective elective and pre-operative care. Processes Data Resources Diagnostics and tools Click to continue Page 9 of 11 Back to menu

13. Overview and strategy Introduction Goals of the toolkit Discharge Ward Overview and strategy Admission Health service team • Ward • Communication between theatres and wards, handover documents agreed processes and equipment all need to be discussed to effectively manage delays to and from theatre, and hand over to wards. Processes Data Resources Diagnostics and tools Click to continue Page 10 of 11 Back to menu

14. End of section Overview and strategy Introduction Discharge Goals of the toolkit Overview and strategy Admission Health service team • Ward to discharge • Patients who have been involved in their discharge planning will assist with reducing delays during length of stay and discharge. • Estimated length of stay, pre-planning and empowering patients to chase their process reduce delays and promote safety. Processes Data Resources Diagnostics and tools Back to menu

15. Health service team Introduction Introduction Elective and Pre-operative care teams need to be skilled, trained and given leadership to progress effective patient processes. Staff members need orientation, training and monitoring against policies, working practices and procedures to manage patient processes. Goals of the toolkit • Effective teams will show: • Team work, shared responsibility and effective communication • Empowerment of each other and patients • Clear reporting • Recognition of tasks and outcomes. Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 1 of 2 Back to menu

16. End of section Health service team Introduction Health service team Clear organisational policy, processes with leadership and support Goals of the toolkit Innovations Agree reporting lines and timescales Develop organisational wide policies for waiting list management that are consistent with DHS principles. (Pre-operative care, cancellations, bed management) Identify reasons for cancellations and develop planned response, that is monitored and evaluated for effectiveness Develop flexible scheduling practices, accounting for predictable emergency demand. Develop pre-operative questionnaire, pre confirmation calls, and pool of assessed patients Issues/constraints Unclear reporting /confusion on aims No clear policies Regular cancellations Theatre schedules change at last minute Pre-operative assessment cancellations/FTA/patients not clinically fit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Back to menu

17. Not fit for operation treatment plan developed with primary care Clinical decision to operate Pre-op questionnaire Processes Introduction Added to waiting list Goals of the toolkit Pre-op assessment Theatre and bed scheduled Overview and strategy Understand patient flow and use tools to assist the ideal patient process. Agree the most effective and efficient process for the organisation Confirmation Call with patient Health service team Admission Processes Theatre Data Effective length of stay management Ward Resources Telephone Outpatient follow up Discharge Diagnostics and tools Outpatient appointment Discharge information to GP Click to continue Page 1 of 5 Back to menu

18. Processes Introduction • Auditing • Auditing not only ensures waiting lists are not overstated, it also prevents time wasted on patients who do not require surgery. • Auditing is one element of effective management of the patients journey and are consistent with DHS policy and procedures. • Auditing can be built into queue management procedures. • Auditing can be broken down into: • Data auditing • Patient auditing • Clinical auditing • Primary care auditing • Methods of auditing involving patients can be by telephone or letter. • Letter auditing has some short falls as patients who have moved, died or do not respond to mail will be missed. Time scales can be over 3 weeks for the auditing process as patients are provided with opportunity to respond. • Telephone auditing has some advantages over written auditing for example, personal interaction with patient, quick response times, alleviate anxiety and provide explanations to patients. Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 2 of 5 Back to menu

19. Processes Introduction • Clinical auditing • Where a clinician assesses whether a patient still requires a procedure, this can take the form of notes review following patient auditing or an outpatient review. Regular auditing of patients on the ‘not ready for care’ list is encouraged. • Primary care auditing • Joint auditing with primary care can help to identify if patients have moved away or whether their condition has changed. This can assist primary care organisations to better understand exactly who is waiting for treatment and thus increases ownership of waiting lists. • Data auditing • Data auditing is an administrative function consisting of a review of the waiting list for example; • patients who have had an operation and have not been removed from the waiting list • patients who have asked to be removed from the waiting list following patient and clinical auditing • double entries for the same patient or procedure. • A data auditing check needs to be undertaken on a regular basis to ensure that only patients ready for surgery are offered an admission date. • Patients on the ‘not ready for care’ list should also be reviewed in the same way. Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 3 of 5 Back to menu

20. Processes Introduction  Every 13 weeks for two evenings, the management team of a 532 bed acute hospital took over the outpatient call centre (10 telephone lines) and called all waiting elective patients, average removals were around 250-300 patients. Queue management principles were used and a clinical colleague was available to answer any clinical questions. Not only did this assist to reduce the waiting list and ensure all remain patients information was up to date, it also promoted team building and involved the executive team in frontline patient contact. Goals of the toolkit Example of telephone audit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 4 of 5 Back to menu

21. End of section Processes Introduction Goals of the toolkit Categorisation To assist with categorisation of patients who need treatment from the waiting list, a simple tool called a primary target list (PTL) can be used. Primary target list can be applied to a group of patients who need surgery within a set time scale. Once a date has been agreed for the group of patients to be treated, surgical teams can then manage the expected throughput of each category of patients. Primary target lists provide a focus for the whole surgical team and allow for greater planning and scheduling. Overview and strategy Health service team Processes Data 30 days Resources Cat 1. 90 days Cat 2. PTL Diagnostics and tools Cat 3. Waiting patients Back to menu

22. Data Introduction • Suggested Measures • Patient Journey Time on Waiting List by Category (SPC chart) • Patient Waiting Times for Admitted Patients from Waiting List (Pareto chart) • Number of Patients waiting broken into monthly/quarterly cohorts (Bar chart) • Average waiting times by category/specialty • Hospital Initiated Postponements per 100 Admissions (Line chart) • Postponements by reason – e.g. No Bed, No ICU/CCU Bed, Surgeon Unavailable… • Preadmission did not attend (DNA) rates per day/week • Average Admissions & Discharges by day of week (Bar chart) • - Elective v Emergency Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 1 of 2 Back to menu

23. End of section Data Introduction Information systems Goals of the toolkit Accessing information from current data bases can prove to be essential to management of elective waiting lists. The Elective Surgery Information System (ESIS) can be imported into an database or data warehouse for additional data reporting and analysis. Overview and strategy Health service team Processes Data Resources Diagnostics and tools Back to menu

24. End of section Resources Introduction • Change Concepts • Establish pre-operative service to assess patient at the clinical decision to operate • short assessment in out patients • by a questionnaire • any patient who is not fit for operation should be given a treatment plan before they are placed on an active waiting list • telephone pre-operative assessment should be used for all patients who need hospitalisation or have a clinical condition prompting assessment • protocol driven pre-operative care via GP • Increase nurse lead pre-operative service • Develop protocols for standardised pre-operative assessment and training of nurses and junior medical staff • Agree Anaesthetic support for pre-operative clinic • Develop first stage assessment within Outpatient Department via outpatient nursing staff • Develop information for day case, inpatient and 23 hour stay patients • Agree care pathways for patients who are not fit for their operation in the community • Manage patients on waiting list: maintain fitness via exercise, diet, smoking, etc Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Back to menu

25. End of section Diagnostics and tools Introduction • Rigorous diagnostics • Good practice day case assessment (PDF) • Good practice inpatient assessment (PDF) • Pre-operative inpatient and day case checklist Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Back to menu