Aims and objectives:
The increase in the proportion of patients treated as day cases and the re-allocation of short notice cancellations of day case slots has improved the utilisation of day case lists. This, combined with a reduction in re-admissions and a hugely improved pre-operative assessment process helps the Trust to keep costs under tariff in Payment by Results.
The Surgical Care Practitioner role has supported improved teaching and training of junior doctors, enabling the Trust to achieve the European Working Times Directive.
New ways of working has reduced variation in clinical practice in respect of information giving, premature admissions to wards, length of stay on wards and To Take Out (TTO) prescriptions. This contributes to making the hospital a more attractive option under Patient Choice and keeps costs under tariff.
Support for the change:
The Project Executive was a very influential executive director and the clinical lead the Clinical Director of general surgery, which provided clinical leadership throughout and senior support in difficult times. Early on in the project a multi-disciplinary re-design day was held with the whole specialty team present. During the project a lot of one to one coaching took place within the team. The Nottingham LIS Programme’s Change Management Framework has been used for the basis of the benefits analysis and business case.
Patient and public influence:
Specialty staff held semi-structured interviews with patients in November 03 and again in September 04 to evaluated the impact of the changes. A patient tracking study was conducted in outpatients and pre-operative assessment clinics in February 04. The findings of these studies and direct patient feedback to the surgical care practitioners through the telephone follow-up audit were incorporated into the work of the project.
Impact on the workforce:
The Surgical Care Practitioner role has offered development for senior nursing and operating department practitioners, while enabling a co-ordinated approach to patient care.
The teaching and training of junior doctors is now more flexible and the consultants and the surgical care practitioners can provide higher quality learning experiences to the junior doctors.
The Pre-operative assessment nurse role is currently being developed, offering outpatients nurses more opportunities to do clinical work.
Measuring the results:
The measures were a combination of nationally set ones by the Action On programme and locally developed indicators. These were baselined and re-measured after implementation.
Comparisons with other organisation were mainly done through Royal College guidelines and comparisons with other members of the IPH and Action On networks.
The key stakeholders in this project were patients, GPs, PCTs, Trust Programme board, consultant surgeons, junior doctors, SCPs, nurses, medical secretaries and outpatient staff. A variety of communication and involvement methods were used throughout the project, which were co-ordinated through a communication plan.
A key tool used in the evaluation was benefits interviews held with staff from across the patient process.
Improved performance:
The number of outpatients waiting over 13 weeks has reduced from between 166 and 213 (March 03 to January 04) to 0 in September 04.
The new pre-operative assessment process has reduced the staff pay cost element from £ 60 to £ 34 per patient, while quality measures such as process duration have been slashed from 210 to 20 minutes, the ’non-value-added’ time for patients reduced from 121 to 8 minutes.
Daycase rates for hernias have been raised across the specialty from 56 % in October 03 to over 70 % in August 04, and for laparoscopic cholecystectomies from 2% to 17%, with substantial cost savings for the Trust under Payment by results.
The average length of stay on wards for cholecystectomies patients has been reduced from 1.9 days in 2003 to 1.5 in 2004 and for hernia patients from 1.64 to 1.5 days. In both patient groups the variation between consultants has also shrunk.
The new short notice re-allocation system of cancelled daycase slots saves 110 slots per year.
Through the use of telephone follow-up by the surgical care practitioners the percentage of hernia patients being followed-up in outpatients has been reduced from 5 % to 1 % and in cholecystectomy patients from 100% to 9%.
Re-admissions to wards have been reduced from 5.4% in 03 to 2% in summer 04.
Both staff surveys and patient interviews have demonstrated high satisfaction with the new process.
Reflecting diversity:
While the core patient process is streamlined, it offers a more supportive service to individual needs, continuity of care by the surgical care practitioners and telephone support service.
Sharing the learning:
The results of the projects have been reported through the Action On programme on a monthly basis, been displayed on the TIN website and several presentations have been made to different NHS conferences. Several articles have been published in Trust and GP newsletters and the Nottingham Evening Post.
Outstanding features:
The patient-focused re-design of the main patient process has cut out many inefficiencies and made the patient journey a much better experience for staff and patients. Freeing up medical staff time has enabled a much more flexible service to be delivered. Among the individual steps of the process, the new pre-operative assessment process has demonstrated the greatest scope for impact in terms of efficiency.
