Abstract
Introduction: Widespread public demand for improved access, political pressure for shorter wait times, a stretched workforce challenge healthcare leaders to adopt new management approaches1. The healthcare service used to implement this initiative is a community-based primary care physiotherapy service providing care to a population of 118,542 (2011 census). In 2015, the physiotherapy service had a 29.3% increase in demand over 2013 level leading to 990 patients on the waiting list and the number of patients waiting longer than 12 weeks for the first appointment increasing to 45%, and the average wait time at 53 weeks and longest wait time at 78 weeks. There was no addition to the staffing resources to cope with this increased demand.
A. Cause & Effect Analysis of the problem highlighted the constraints to patient flow identified the key stakeholders whose actions or inactions contributed to the problem.
a. Management/Leadership
Need to:
i. Clarify vision for the service
ii. Link service delivery to organisational goals
iii. Develop mechanism to evaluate performance
iv. Acknowledge high performance
b. Organisational Structures
i. Structural Issues
- Infrastructural deficiencies (clinic space, IT, equipment etc)
- Staffing deficit
- Inadequate service delivery model
ii. Process Issues
- Poorly optimised work systems
- Poorly established links with community groups / local authorities
c. Staff
i. Cultural Issues
- 'Cherry-picking' of patients on the waiting list
- Traditional 1-to-1 service delivery model
- Underbooking of appointments
d. Referrers
i. Appropriateness of referrals & data quality
ii. Poor communication links
e. Patient
i. Non-attendance at appointments
ii. Changing patient profile
iii. Changing patient expectations of the service
f. Unique Demographic Factors
i. Extensive geographical area
ii. No acute hospital outpatient support
iii. High comparative deprivation index
iv. Increased service demand
Short description of practice change implemented:
The initiatives implemented include:
i. Negotiated and increased staff performance targets for new patient appointments from 1.2 per staff day present in 2013 to 1.7 in 2016
ii. Developed and implemented Group Physiotherapy Service targeted at patient groups with similar diagnosis or referral reason
iii. Streamlined and optimised clerical support role to physiotherapy service
iv. Optimised time spent by physiotherapists on patient contacts and documentation
v. Introduced text message reminder for follow-up patient appointments
vi. Engaged with referrers on appropriateness of referrals
HSE Change Model and IHI Model for Improvement (PDSA Cycle) were used to implement the initiatives
Aim & Theory of Change: The objectives of the initiatives implemented are by the end of December 2016:
(1) Reduce the percentage of patient waiting over 12 weeks to 35% and the longest wait time for physiotherapy appointment to 39 weeks
(2) Evaluate staff effectiveness and efficiency
(3) Evaluate patient satisfaction with the service
(4) Evaluate impact on organisational goals
The Psychology Theory of Behavioural Change and the Organisational Development Theory of Constraints underpinned the implementation of the change initiatives.
Targeted Population & Stakeholders: The targeted population is as described in the Introduction above:
Stakeholders include:
a. Management/Leadership
b. Staff (Physiotherapy, Clerical, MDT)
c. Referral Sources (GPs, Consultants, PHNs, HSCPs etc)
d. Patient
e. Local Authorities
Timeline: The implementation of the change initiatives first began in July 2014 and have continued into 2016 with more initiatives introduced as the PDSA cycle was used to test and re-test the changes. Data monitoring and analysis started in Jan 2015
Highlights (innovation, impact & outcome): The data for quantitative and qualitative outcomes were obtained from: (a) Staff Monthly Metrics Return; (b) Review of staff attendance and WTE and time allocation for patient contact and (c) Evaluation of feedback questionnaires.
As a result of the above change actions and initiatives:
By the end of 2016:
1. We had optimized the clinic hours' utilization rate for patient contact by 17.6% since 2013 (from 64.2% to 81.8%)
2. New patient appointments had increased by 53.1% above 2013 level (2804 appts in 2013 and 4293 appts in 2016), and 7.6% more than expected target for 2016
3. Patients waiting over 12 weeks for appointment had reduced marginally from a peak of 45% to 42%
4. The longest waiting time had reduced significantly to 38 weeks from 78 weeks.
5. 2016 Patient Experience Survey of 105 patients who responded showed that:
a. 90.5% of the patients reported that the service met their need and expectation
b. 96% of the patients were satisfied with the service. Even though 42% of them remained dis-satisfied with wait time, it still represented a 20% improvement over 2015 evaluation.
Comments on Sustainability: The initiatives have been integrated into our work processes and staff performance review
Comments on Transferability: The learning and outcomes from the initiatives have been shared with other physiotherapy managers in the area who have adopted them in their locations
Conclusions, Discussions & Lessons Learned: The outcome of these initiatives indicate that extended wait times are not always due to demand, but may be attributable to capacity under-utilization. The implementation of the initiatives, particularly the Group Physiotherapy Service has the potential to develop into a service delivery model with the capacity to facilitate the delivery and attainment of key organisational service goals in the areas of integrated care. The outcomes indicate that the change initiatives require sustained action and continued monitoring.
Reference:
1. Patrick, J., & Puterman, M. L. Reducing Wait Times through Operations Research: Optimizing the Use of Surge Capacity. Healthcare Policy, 2008;3(3):75–88.
