Chapter 1 Introduction
This publication is a compendium of the improvement work undertaken by local teams from across NHSScotland under the auspices of the Planned Care Improvement Programme ( PCIP). These case studies and improvement stories represent a huge amount of work and effort, and we would like to take this opportunity to thank those that undertook to deliver these valuable improvements to the healthcare system in Scotland.
The programme was tasked with supporting local teams to deliver improvements in line with the five high impact changes noted below. These changes provide the bedrock on which an 18 week referral to treatment target will have to be built upon. Much of the work that is contained within this document is in the very early stages and will continue after March, providing the basis for improvement towards 18 weeks.
The five high impact changes are:
1. Treat day surgery (rather than inpatient surgery) as the norm for planned procedures;
2. Improve referral and diagnostic pathways;
3. Actively manage admissions to hospital;
4. Actively manage discharge and length of stay;
5. Actively manage follow up.
These represent each stage of a patient's journey along the elective care pathway and provide a focus for improvement work. Some NHS Boards have chosen to take a single specialty and progress changes for all or some of the changes, others have taken pressure points in isolation from a number of specialties.
Change 1: Treat day surgery (rather than inpatient surgery) as the norm for planned procedures
For a number of years it has been recognised that converting clinically appropriate procedures from an inpatient to a day case or outpatient setting is good practice. Evidence from across the UK demonstrates that this shift generates numerous benefits for the overall system, clinical outcomes and for patient experience.
Improvement Focus
- Hospital systems should be organised on the basis that day surgery is the norm for the majority of elective procedures;
- Adopt a day case strategy and address operational issues such as the admission of patients the night before or patients being kept in overnight for non-clinical reasons;
- Ensure that patients are coded correctly and inpatients with a zero length of stay are recorded as day surgery patients;
- Ensure evidence based patient focussed pathways are in place;
- Aim to raise performance to the best through benchmarking performance and sharing good practice with other NHS Boards.
Change 2: Improve referral and diagnostic pathways
Referral from GP practices to secondary care represents the patient's first step along their acute care journey. In process terms this is one of the most complicated steps and one that is undergoing the greatest evolution. Patients can be referred through numerous channels and mediums and need to be sorted so the patient is booked to see the most appropriate clinician with the shortest waiting times.
Evidence shows that there are benefits for both patients and the system if referral routes can be standardised and a common process put in place.
Improvement Focus
- Creation of standardised protocols and pathways between primary and secondary care;
- Establish referral protocols to clearly identify how and where patients are managed;
- Feedback to GPs information on referral and admission rates;
- Introduce Patient Focussed Booking and referral management systems to ensure that the patient gets choice and certainty of appointment date and time.
Change 3: Actively manage admissions to hospital
Pre-assessment is key to the reliable admission of patients for surgery, and the balancing of the emergency and planned flow is key to ensuring good utilisation of hospital resources. Much of the work looking at the balancing of emergency and planned flows was undertaken by the Unscheduled Care Collaborative.
Improvement Focus
- Put in place nurse led pre-admission services for surgery with support from anaesthetic services, ensuring the process is 'decide to admit' not 'admit to decide';
- Measure and analyse elective and emergency demand by day of the week and hour of the day;
- Utilise referral management and booking services to provide co-ordinated centralised admissions services;
- Eliminate the non-clinical cancellation of operations.
Change 4: Actively manage discharge and length of stay
Traditionally it has been assumed that the relationship between planned and emergency admission patterns caused the greatest variation in patient journeys. However, on closer analysis, it is the discharge process. It is therefore important to start the planning of a patient's date of discharge as early on in the process as possible.
Benchmarking exercises have demonstrated significant differences in the length of time that patients with similar clinical requirements stay in hospital. Patients who are admitted on a Friday will often spend longer in hospital than those admitted on a Tuesday.
Improvement Focus
- Analyse inpatient stays to identify where improvements will have the greatest impact;
- Ensure seven day working applies to admissions and discharges;
- Plan day of discharge at admission or pre-admission;
- Ensure that the most appropriate healthcare professional is able to discharge patients;
- Benchmark against other NHS Boards and raise the standards to the best.
Change 5: Actively manage follow-ups
Return outpatient appointments represent a huge amount of the activity undertaken by the NHS. Traditionally patients have been routinely given appointments rather than it being based on either clinical need or patient request. Consultants often undertake these clinics, where as evidence shows, that in many cases these can be led by a nurse or an Allied Health Professional ( AHP). By offering return appointments to only those patients with a clinical need or whom have requested it, and making sure that the most appropriate healthcare professional undertakes the assessment, we are able to free up resource to treat more new patients, reducing overall waiting times for patients and improving efficiency.
Improvement Focus
- Make sure follow ups are planned at the front end of the patient journey and are offered for a specific clinical or patient led reason;
- Redesign so all relevant tests are planned and booked to occur in one visit;
- Redesign services to provide patients with the most appropriate healthcare professional for their condition;
- Train clinical nurse specialists to handle appropriate follow-up appointments;
- Introduce non face-to-face follow-up where clinically appropriate.