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ENT Express:
Improving the Patient Journey through the Royal Newcastle
Centre Ear, Nose and Throat Clinics
Anthony Larkins & Judith Swan, Hunter New England Local Health Network
Introduction
The Ear, Nose & Throat (ENT) Clinics at the
Royal Newcastle Centre (RNC) deliver a
significant ambulatory care service to around
4,500 patients annually. The service was
experiencing complex problems including:
• long waiting lists to get an appointment for new
non urgent patients;
• long wait times upon arrival in the clinic;
• overbooking of clinics;
• staff frustration; &
• patients complaints.
Aim
The purpose of the project was to make
recommendations that will ensure a patient
centred ENT ambulatory care service that meets
the needs of the community.
The Patient Experience: Jo’s Story
Key Issues
“I went to my GP because I had a discharge
from my ear. I waited for 3 months for an
appointment [at the ENT Clinic]. On the day of
my appointment I waited for 2 hours to be seen.
I returned 6 weeks later for another appointment
and went through the same procedure. I had a
total of 5-6 appointments each about six weeks
apart. I was very frustrated in that I saw a
different doctor each time. I arrived for an
appointment and had to repeat my story from
the start every time. I only saw the specialist
twice in 12 months. I felt…rushed after waiting
for 2 hours to be seen. When I complained I
was told that 3 patients can be booked into one
appointment time.”
• There is variation in internal processes for
bookings and internal flows.
• There is minimal capacity for non urgent new
patients to be seen in the ENT service leading
to long waiting lists.
• There are no clear pathways and criteria
articulated to transfer patient care both into the
ENT Ambulatory Care service and back to their
GP.
Objectives
•
•
•
•
Method
The NSW Health Clinical Redesign
methodology was used to conduct the project
as shown below.
Project Timeline
1
2
August
3
4
5
i. Project
Initiation & Start-up
The solutions fall into six clear categories:
Specialists
GPs
Emergency
Department
Referral pathways &
management guidelines
available to GP’s
Define the ENT service aligned
with HNE Health Ambulatory
Care Guiding Principles.
September
6
7
8
9
ii. Diagnostic Phase
10
October
11
12
13
14
November
15
iii. Solution Design Phase
20/9/2010 – 25/10/2010
16
17
18
December
19
20
iv. Implementation, Planning
Leave planned and centrally
coordinated
Results from the 2009 NSW Health Patient Survey for
Outpatients in the RNC found that patients:
• ranked the courtesy of the staff very highly.
• felt the health workers worked well together
and felt they had enough time with the person.
• felt they waited too long in the waiting room
and the reason for the delay was not explained.
• were not able to get an appointment when
wanted.
As of 31 August 2010
there were 1,867
patients waiting for
an appointment at
the ENT Clinic. The
majority of these
patients (75%) were
triaged as non urgent
to be seen within 365
days.
Number of Occasions
• Staff interviews
6
• Attendance at Visiting Medical Officer Meeting
2
• Process Mapping Sessions
2
• Patient Interviews
10
• Staff Surveyed
8
• Patients Surveyed (Patient Experience Trackers)
54
• Tagalongs
3
• Internal Reports Reviewed
3
• External Reports Reviewed
4
• Data Analysis – iPMs, IIMS
Clinics booked to 75%
capacity
21
A variety of activities were utilised to diagnose
key issues and identify solutions. Stakeholders
were consulted and patient experience was
central to the approach. A literature search was
undertaken and leanings were shared with staff
from The Alfred Hospital Ambulatory Care
service in Melbourne.
Activities Performed
Findings
1/7/2010 – 31/8/2010
The following guiding principles (written by
HNE Health clinicians) for the development of
non-inpatient services in HNE Health
underpinned the solution design phase:
• Services are delivered as close to home as
possible in a caring, efficient and timely way;
• Care is evidence-based and continuously
improving;
• The elements of care are integrated and
coordinated;
• Care is supported by appropriate technology;
• There is a focus on preventative healthcare;
• Resources are used wisely;
• There is strong leadership;
• There is support for staff and their ongoing
education and training.
Processes are
complex. There are
14 major steps (first 5
shown here), just to
go from referral to
patient arrival in the
waiting room. Each
step has numerous
associated detailed
processes and tasks
(shown as “+”).
Source: University of
Western Sydney,
Visual Analytics
Project
Acknowledgements
Tracey McCosker, Director Clinical Operations (Executive Sponsor)
Dr Kelvin Kong, VMO, Ear Nose & Throat
Professor Nikolai Bogduk, Director Clinical Research, RNC
Todd McEwan, General Manager, Greater Newcastle Acute Network
Sue Waters, Service Manager/DON Royal Newcastle Centre
Wendy Pudney, Operations Manager, Ambulatory Care Centre, Royal Newcastle Centre
Julie Tait, Service Manager, Division of Surgery John Hunter Hospital
Jane Gray, Director Innovation Support
A/Professor Terry Sloane, University Western Sydney
Cathy Grahame, Nurse Unit Manager Paediatric Ambulatory Care John Hunter Children’s
Hospital
Staff from the RNC Ambulatory Care Service & the Referral Management Centre
A/Professor Anneke Fitzgerald, University of Western Sydney (Visual Analytics Project)
Dr Joanne Curry & research team, University of Western Sydney (Visual Analytics Project)
Management
of Referral
Referral template with
specific key information
Triaging
Agreed standardised
approach to triage.
Referral quality checked
prior to triaging
Waiting
List
Review Clinic templates
based clinic utilisation data
i.e. measure time taken to
see different patients
ENT Clinic
Pathways
Patient
Arrives in
Clinic
Patients information available
to clinicians e.g. history,
investigations, results
Patient Seen
in Clinic
Equipment available e.g.
microscopes and endoscopes
Clinics set up cards
Dual computer screens in
clinic rooms for better access
to patient information
Coding system to know what
patients are arriving for.
Reorganise clinics to meet
patient needs e.g. Audiology,
Head & Neck clinics, Registrar
Clinics & Nurse led clinics for
identified patient groups.
Improved
Internal
Flows
Clinic
Structure
Waitlist regularly
reviewed, measured,
monitored and process in
place for action and
accountability.
RACGP Extended Skills
Training Program.
Diploma in ENT for GP’s
Scheduling
Improve patient satisfaction.
Reduce the number of patient complaints.
Reduce the number of patients on the waitlist.
Improve staff satisfaction
July
Key Opportunities for Improvement
Improving the
Patient Journey
and
Staff Experiences
Scheduling /
Waitlist
Follow up or
Transfer Out
Criteria for transfer of
care back to GP
Training and
Education
Electronic discharge
summaries
Measure and
Monitor
Outcomes
The key solutions are:
1. Patient Centred Services
• Referral pathways for high volume patient
groups with pre defined management and
investigations where appropriate. Standardised
referral template for GPs.
• Criteria for transfer of care back to GPs.
• Electronic discharge summaries.
• Information about ENT services are available on
website.
2. Clinic Structure
• Equipment and resources available
• Reorganise clinics to meet patient demand
• Nurse led clinics
3. Scheduling / Waitlist
• Implement clinic template booking to 75%
capacity to allow for urgent reviews and post
operative appointments. Monitor compliance of
bookings to template.
• Waitlist to be regularly reviewed, measured,
monitored and processes for action and
accountability to be put into place.
• Minimise number of cancelled clinics.
The associated UWS visual analytics project will
develop a range of recommendations for
improved processes.
To implement these solutions a range of enablers
will need to be considered including training &
education and the development of ambulatory
care performance indicators and an associated
coding system.
Conclusion
This ENT project has been important to RNC
Ambulatory Care services as it provides a key set
of leanings that may be applicable for other
ambulatory services.
The guiding principles have been integral to the
project and were well accepted by the clinicians,
managers and staff involved.
Contact Details
Anthony Larkins. Email: [email protected]
Judith Swan. Email: [email protected]