Published: 03/10/2002 Volume II2, No.5825 Page 24 25
Working more closely with patients and implementing a partial booking system helped one trust to transform its outpatient performance. Elaine Scarborough reports
How can a trust turn around its outpatient performance? In August 2000, Aintree Hospitals trust was identified as one of the seven trusts failing to meet national standards in outpatient performance. It was missing its target by 64 per cent.
A performance management team was established and a recovery plan was produced to reverse the trend in waiting times and bring the trust back in line with agreed targets by 31 December 2000. The team comprised the chief executive, medical director, directors of information and finance, the chief nurse, general managers for surgery, medicine, trauma and orthopaedics and theatres, the patient access manager and the information manager.
The key elements of the plan included:
Producing an integrated policy for inpatient and outpatient waiting lists.
Attending the National Patients Access Team learning sets.
Reviewing outpatient clinic efficiency in trauma and orthopaedics, ear nose and throat, cardiology and urology.
Implementing partial booking in two specialties by December 2000. In the event, four specialties were involved.
Senior managers took responsibility for different elements of the recovery plan. An outpatient validation team was set up in January 2000 and made good progress verifying the lists.
The waiting lists for those specialties that had been validated were up to date, and those patients on the lists were genuinely waiting for outpatient appointments. The team continued to validate the remaining specialties, while partial booking was being established.
It was discovered that some clinicians were putting patients on waiting lists for operations on the basis of referral letters. These patients would not be seen in outpatients, so could be removed from the waiting list for an appointment.
We established a policy whereby clinic clerks were told when this happened so they could take these patients off the list.
Before the hospital started its partial booking scheme, patients were simply sent an outpatient appointment notification and not consulted on whether the allotted time was convenient for them.
So if the appointment was unsuitable, they either cancelled or failed to attend.
In some specialties, appointments were booked months ahead. So if a non-urgent appointment was rescheduled by the hospital, these patients had to wait months for their revised appointment date. This contributed to the long waiting time in some specialties.
We wanted to ensure that the majority of consultants in the trust were exposed to partial booking, so we chose one consultant from cardiology, rheumatology, ENT and trauma and orthopaedics. It was agreed they would have nonurgent patients partially booked.
The Department of Health publication A Step by Step Guide to Improving Outpatient Services was used as guidance for establishing partial booking.
1The trust commissioned a centralised operator call centre at a cost of£47,000. This went live in January 2001, employing three whole-time equivalent staff.
The establishment of the call centre encountered several obstacles. The trust's outpatient software did not recognise partial booking, so all patients had to be monitored via a manual recording system. This was time consuming but essential, as the trust had to show that partial booking was effective in reducing waiting times and non-attendance.
Several weeks before a non-urgent appointment becomes available, an invitation letter is sent to the patient asking them to contact the appointment centre to agree a mutually convenient appointment date. If a patient fails to make contact within three weeks of the invitation being sent, they are discharged back to the care of their GP. This has reduced waiting times and non-attendance.
The scheme showed that: Waiting times were reduced. By March 2001, the trust achieved its target and had 1,948 patients waiting more than 13 weeks for an appointment compared with 4,143 in August 2000. In March this year, only 996 patients were waiting more than 13 weeks.
The non-attendance of non urgent patients was reduced from 16 per cent to 5 per cent.
Patient data was continually validated.
Patients liked to be involved in agreeing their appointment date.
The number of hospital-cancelled appointments was reduced because clinics were not booked more than six weeks ahead.
In the traditional booking system, patients were sent an appointment and if they failed to attend, other patients waited longer for an appointment.
In spring 2001, an integrated partial booking module was installed in the hospital information system and this allowed the trust to plan the rollout of partial booking to the majority of specialties in October 2001.
The appointment centre has been extended and more staff appointed following a review of the clinic-clerk function. The scheme now covers all specialists in the trust.
Staff in the trust were invited to express an interest in transferring to the appointment centre and we were surprised to find we had too many applicants. It was agreed with Unison that, subject to their suitability, staff would be offered posts on the basis of length of service.
Staff have revised their views about the appointment centre because they have seen that it works and realised it was a new department with high specification computers, flexible working and patient contact.We have also retained the majority of the staff we employed at the outset.
In total, 13 whole-time equivalent staff work in the centre, processing around 62,000 new outpatient appointments per year.
The trust achieved the agreed targets through a combination of waiting-list initiative clinics, validation and partial booking.
Sustaining the improvements
The performance management team monitors outpatient performance against trust targets on a fortnightly basis and corrective action is taken when necessary.The appointment centre uses a computer-generated waiting list produced weekly by the information department to ensure that patients are offered appointments in strict chronological order, taking account of clinical priority. Patients are advised in their invitation letter that if they refuse to accept a choice of appointment dates over a four-week period, they will be discharged back to their GP.
The availability of appointments in clinics is constantly monitored.
Patients on the waiting list are contacted at short notice if appointments arise as a result of cancellations.Continual data validation ensures that only patients who require appointments are on the outpatient waiting list.
Clinic templates are 'flexed', so where follow-up slots are vacant these may be converted into first appointments.Non-attendance continues to fall.
Two specialties have agreed to grade urgent or routine referral letters, which has helped average waiting times.
This will be rolled out to other specialties during the course of the year. Partial booking has made a major contribution to sustaining a reduction in waiting times for non-urgent outpatient appointments.We have found that establishing an appointments centre has been a key factor in meeting outpatient appointment targets.
But it is also essential that waiting lists are monitored continually and immediate action is taken when problems arise.
A trust which was failing to meet the national standards on outpatient performance in 2000 met the targets in 2001 by reviewing waiting lists and setting up a call centre to manage outpatient appointments.
Non-attendance has been reduced from 16 per cent to 5 per cent.
Staff were recruited from outside the trust for the call centre.
Patients are given a choice of outpatient appointments over a fourweek period. If they refuse they are discharged back to their GP.
The appointment centre employs 13 staff and processes 62,000 outpatient appointments.
1A Step by Step Guide to Improving Outpatient Services. Department of Health National Patients Access Team, July 2000.
Elaine Scarborough is patient access manager, University Hospital Aintree, Liverpool.