Scottish Government Health Directorates: Delivery

St Andrew’s House, Regent Road, Edinburgh EH1 3DG www.scotland.gov.uk abcde abc a

Scottish Government Health Directorates: Delivery Directorate Access Support Team Division

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CEL 36 (2010) Date 18-10-10

Dear Colleague Achieving the 18 Week Referral to Treatment Standard in Orthopaedic Services Summary This letter is to provide Boards with the Orthopaedic Services Task and Finish Group Interim Output Report and to commend action in the key areas detailed below. Interim Output Report The report is intended to support you in a detailed assessment of your service and as a guide to intensive action where required. A primary aim of the report is to support opportunities to streamline services, ensuring the patient’s interest are right at the centre of any redesign. We recognise that achieving the 18 Weeks RTT standard will require whole systems ownership and strong organisational leadership (both clinical and managerial) in order to embed and operationlise change on a sustainable basis. Key Areas Commended for Action The key areas commended to Health Communities and NHS Boards for action are:

1. Use the ‘Check List for Boards’ box in each section of the report to identify the priority areas for change which apply to your service, and work with stakeholders and change champions to drive their implementation, making full use of the extensive range of tools and techniques available through the Improvement and Support Team.

2. Use available information, local knowledge and analysis of ‘what if?’ scenarios to identify key areas for urgent change and drill into the processes which will ‘unlock’ bottlenecks and remove non-value adding steps (See section 3.2 for commended actions).

3. Evaluate the findings from the audits of Arthroscopy, Carpal Tunnel Syndrome and Hip and Knee Arthroplasty Pathways to identify improvement opportunities, remove variation and enhance your action plans (See section 3.5 for commended actions and link to website for audit reports).

4. Ensure that your Board has fully engaged with the Enhanced Recovery Programme (see Section 3.5.3).

Addressees For action Chief Executives (NHS Boards) Medical Directors (NHS Boards) Chief Executives (Operating Divisions) Medical Directors (Operating Divisions) Enquires to: Kate James – Project Manager Access Support Team St Andrew’s House Regent Road Edinburgh EH1 3DG Tel: 0131-244 5211 E-mail: [email protected]

mailto:[email protected]


5. Undertake the appropriate level of Demand, Capacity, Activity, Queue analysis [DCAQ] at sub-specialty level to understand your service. Set monthly (or shorter time period) targets for capacity utilisation and queue size based on realistic projections for variation in demand. Proactively mange services against your plan. Where pathway redesign and/or LEAN methodologies are applied enusre appropriate measures are applied and managed. Ensure that Waiting List Initiatives [WLI’s] and the private sector are only used for one-off backlog removal and that reliance on ongoing WLI’s and the private sector are removed.

6. If resource gaps in capacity are identified, consider options for using your workforce differently and maximising the use of skills across clinicians, specialist nurses, AHPs, GPwSI and admin and clerical staff. If additional resource is definitely required, back-up the case with robust DCAQ analysis.

7. Ensure your Board’s submission to the monthly MSK Audit Demand and Activity sheet is accurate and that the information is used to identify improvement opportunities for your Board.

8. Ensure learning is shared across Scotland. Use the appendix of case studies to identify improvement opportunities and projects in other Boards to learn from. Use the attached blank case study template to enhance this resource by adding additional case studies for your Board.

9. Reinforce continuous focus on all dimensions of quality in line with the NHS Scotland Quality Strategy.

Boards should develop their local Orthopaedic Services Action Plan to ensure the nine commendations are covered. We are providing a facility for Boards to share their Orthopaedic Action Plans so that we can jointly share examples of good practice and identify solutions to common challenges. The sharing of ‘action plans’ will be on a collaborative basis to support problem solving and will not in any way be used for performance management. Kate and colleagues are available to provide advice on the content of plans but there is no central prescription on content, the aim is to share what is useful to clinical services. These enhanced plans should be submitted to [email protected] or [email protected] by Friday 17th December 2010. The Task and Finish Group and the Scottish Committee for Orthopaedics and Trauma are keen to learn from best practice at Boards and to offer support where required. Boards can request a visit from a combination of clinicians, managers and information, modelling or improvement specialists. Any Board wishing to arrange visits should email [email protected] with their requirements. Each Board’s progress in achieving 18 Weeks RTT for Orthopaedic Services will be linked to the Scottish Government’s support and escalation process and may be reviewed at the Chief Executives’ meetings and individual mid-year reviews.

Any Board who believes that they are at risk of failing to achieve the 18 Weeks RTT Standard for Orthopaedic Services is encouraged to request a ‘Safe Space’ discussion with Access Support Team. Tailored support may then be provided.





I look forward to hearing of your success in implementing improvements in Orthopaedic Services. Yours sincerely

Mike Lyon Deputy Director, Health Delivery Directorate Enclosure –

Achieving the 18 Weeks Referral to Treatment Standard in Orthopaedic Services - Task & Finish Group Interim Output Report

CEL 36 (2010) 18 weeks Service Redesign and Transformation Programme Sharing Good Practice Blank Case Study Templates Template – Narrative

CEL2010_36CaseNarrative.doc

Template - Data

CEL2010_36CaseData.doc

http://www.sehd.scot.nhs.uk/mels/CEL2010_36CaseNarrative.doc

http://www.sehd.scot.nhs.uk/mels/CEL2010_36CaseData.doc

Scottish Government Health Directorates Directorate of Delivery Orthopaedic Task & Finish Group

F3130196 Page 1 of 63 October 2010

Achieving the 18 Weeks Referral to Treatment Standard in Orthopaedic Services

Task & Finish Group Interim Output Report

October 2010



Contents Page No. Foreword 3 Chair’s Reflections 4 1 Introduction .................................................................................................................................................................................................. 6

1.1 The 18 Weeks Referral to Treatment Standard and Programme Structure.................................................................................... 6 1.2 Task & Finish Groups......................................................................................................................................................................... 6 1.3 Orthopaedic Services Facts and Figures ......................................................................................................................................... 7

2 Orthopaedic Services Task & Finish Group .......................................................................................................................................... 17 2.1 18 Week RTT Risks to Delivery........................................................................................................................................................ 18 2.2 Priority Task & Finish Group Improvement Actions...................................................................................................................... 18

3 Task & Finish Group Outputs ................................................................................................................................................................. 19 3.1 Measurement and Definitions.......................................................................................................................................................... 21 3.2 Demand/Capacity/Activity/Queue (DCAQ) Analysis ...................................................................................................................... 22 3.3 Primary Care Solutions .................................................................................................................................................................... 27 3.4 Performance Management ............................................................................................................................................................... 30 3.5 Service Redesign and Transformation ........................................................................................................................................... 31 3.6 Cultural / Change .............................................................................................................................................................................. 42 3.7 Making the Most of Your Workforce................................................................................................................................................ 42 3.8 Communication................................................................................................................................................................................. 44

4 Catalysts for Change ............................................................................................................................................................................... 45 Appendices - Appendix A – Task & Finish Group Membership 47 Appendix B – MSK Audit Monthly Demand & Activity Data 48 Appendix C – Orthopaedic Case Studies 49



Foreword – by Robert Calderwood, Chair of the 18 Weeks Operational Delivery Team The work of the Orthopaedic Services Task and Finish Group was sponsored by the Operational Delivery Team within the Scottish Government’s 18 Week Referral to Treatment programme. The group includes NHS clinicians, managers and GPs. The contents of this Interim Output Report is commended to you by the Operational Delivery Team to support detailed assessment of your service and intensive action where required. It is essential that all opportunities for streamlined service management and ongoing improvement and transformation are optimised, with the patient’s interest’s right at the centre. Delivery and improvement will require whole systems ownership and strong organisational leadership (both clinical and managerial) in order to embed and operationalise change on a sustainable basis. The core elements commended to Health Communities and NHS Boards for action are:

1. Use the ‘Check List for Boards’ box in each section of this report to identify the priority areas for change that apply to your service, and work with stakeholders and change champions to drive their implementation, making full use of the extensive range of tools and techniques available through the Improvement and Support Team.

(See http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/Pages/About.aspx).

2. Use available information, local knowledge and analysis of ‘what if?’ scenarios to identify key areas for urgent change and drill into the processes which will ‘unlock’ bottlenecks and remove non-value adding steps (See section 3.2).

3. Evaluate the findings from the audits of Arthroscopy, Carpal Tunnel Syndrome and Hip and Knee Arthroplasty pathways to identify improvement opportunities, remove variation and to enhance your action plans (See section 3.5 for commended actions and http://www.18weeks.scot.nhs.uk/how-to-achieve-and-maintain-18-weeks/task-and-finish-groups/orthopaedics/ for the audit reports).

4. Ensure that your Board has fully engaged with the Enhanced Recovery Programme (see Section 3.5.3).

5. Undertake comprehensive Demand, Capacity, Activity, Queue analysis [DCAQ] at sub-specialty level to understand your service and proactively manage your demand/capacity balance. Ensure that Waiting List Initiatives [WLI’s] and the private sector are only used for one-off backlog removal and that reliance on ongoing WLI’s and the private sector are removed.

6. If resource gaps in capacity are identified, consider options for using your workforce differently and maximising the use of skills across clinicians, specialist nurses, AHPs, GPwSI and admin and clerical staff. If additional resource is definitely required, back-up the case with robust DCAQ analysis.

http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/Pages/About.aspx

http://www.18weeks.scot.nhs.uk/how-to-achieve-and-maintain-18-weeks/task-and-finish-groups/orthopaedics/

Or

Scottish Government Health Directorates Directorate of Delivery

thopaedic Task & Finish Group


7. Ensure your Board’s submission to the monthly MSK Audit Demand and Activity sheet is accurate and that the information is used to identify improvement opportunities for your Board.

8. Ensure learning is shared across Scotland. Use the appendix of case studies to identify improvement opportunities and projects in other Boards to learn from. Use the attached blank case study template to enhance this resource by adding additional case studies for your Board.

9. Reinforce continuous focus on all dimensions of quality in line with the NHS Scotland Quality Strategy.

It is expected that Boards will continue to develop their local Orthopaedic Services Action Plan. The Task and Finish Group and Improvement Support Team will continue to provide implementation support to ensure Boards achieve the 18 Weeks RTT Standard. Should 18 Weeks RTT performance in this specialty prove unsatisfactory, the escalation process could include further action planning with the Access Support Team, more detailed tailored support, intervention as needed and submission of detailed recovery plans. Boards’ progress on implementation will be reviewed at the Chief Executives’ meeting and individual mid-year reviews.

Chair’s Reflections – by Prof. Jimmy Hutchison – Chair of the Orthopaedic Services Task and Finish Group I was delighted to be invited to chair the Task and Finish Group for Orthopaedic Services as the 18 Weeks Referral to Treatment [RTT] standard is fundamentally all about good medicine. A risk analysis identified Orthopaedic Services as one of the specialties most likely to need additional support to achieve 18 Weeks RTT, largely due to the shear volume of referrals. We are the ‘elephant in the room’ (in the nicest possible sense) – and to some extent, a Cinderella. Orthopaedic disease is often not life-threatening, but it is ‘quality-of-life threatening’ and our treatments can transform patients’ lives.



The Orthopaedic Task and Finish Group was established in January 2009 and harnesses expertise from across NHSScotland to consider the existing evidence base for delivery of timely treatment for Orthopaedic patients. The purpose is to encourage best practice across NHSScotland and support Boards in the use of tools and techniques to make service improvements. A comprehensive engagement strategy was adopted that included Service Manager Workshops, an Enhanced Recovery event in March 2010 and two national events in November 2009 and June 2010. A significant amount of our work has involved identifying and validating the critical data that describe a service and inform planning decisions. This Interim Output Report recognises that one size does not fit all and the ‘Checklist for Boards’ box in each section offers a range of improvement actions that encompass enhancing primary and secondary care relationships, getting patients on the right pathways, standardising and improving pathways, improving access, managing waiting lists, balancing Demand, Capacity and Activity, maximising the value of information, ensuring timely diagnostics, making the most of your workforce and equality of access, quality and safety. Through engagement with patients throughout the redesign process, these improvement actions will place the patient at the centre of the planning and design of services. Providing improved access to high quality care by designing out unnecessary waits and delays that add no value to the patient will improve the patient experience. In essence, striving to ensure the patient is seen by the right person, at the right time and in the right place, i.e. simply good medicine. The improvement resources should enable Clinicians, Service Managers, members of Multi-Disciplinary Teams and 18 Weeks Teams to drive their local improvement strategy to deliver the 18 Weeks RTT Standard for December 2011, provide a platform to support the improvements necessary to deliver the NHS Quality Strategy and ultimately to improve services for patients. I believe that the Task and Finish Group has created a momentum for change within Orthopaedic Services. Achieving a full referral To Treatment Standard of 18 Weeks by December 2011, however, will be a considerable challenge for Orthopaedic Services, and there is a real concern amongst clinicians that it may be impossible within current resource. They will require repeated reassurance that attempts to achieve this will not prejudice priorities of clinical care. Evidence from work around the country suggests that it is achievable, and information within this Interim Output Report can help in that goal. I wish you every success as you move forward in developing your service, and the Task and Finish Group will continue work to support you in this.



1 Introduction 1.1 The 18 Weeks Referral to Treatment Standard and Programme Structure The 18 Weeks Referral to Treatment [RTT] Standard builds on the considerable improvements Boards have made in recent years to patient waiting times for first outpatient appointment, access to eight key diagnostic tests and inpatient/daycase treatment. From December 2011, 18 weeks will become the maximum wait from referral to treatment for non-urgent patients. The 18 Weeks RTT Standard shifts concentration on managing waiting times for each stage of treatment to whole pathways of care. The 18 Weeks RTT Programme is designed to support NHS Boards in transforming the whole patient journey including early diagnosis, treatment and patient experience. The Programme Board has four Delivery teams reporting to it; the Operational Delivery Team, the Information Delivery Team, the Diagnostic Steering Group and the Emergency Access Delivery Team. These teams all have members from NHS Boards and the Scottish Government. Within the Scottish Government’s Delivery Directorate the Improvement and Support Team [IST] and the Access Support Team [AST] are also focussing on 18 Weeks RTT. To ensure absolute focus on achieving the 18 Weeks RTT and managing associated risks to delivery, these teams link closely with each Board’s 18 Week team to ensure progress on all work-strands. 1.2 Task & Finish Groups At the start of the programme, the Operational Delivery Team undertook analysis to identify the specialties most likely to need additional support to achieve the 18 Weeks RTT Standard. Orthopaedic Services was identified as one of six such specialties. This decision was on the basis of the high level of demand for Orthopaedic services, the need to embed sustainable change, to support a move away from reliance on waiting list initiatives and to develop whole system working with quality and safety as a central tenet (See NHS Scotland Quality Strategy http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/NHSQuality ). In addition to the specialty based Task and Finish Groups, two cross-cutting groups have been formed to address Diagnostics and Capacity Demand Management.

http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/NHSQuality



1.3 Orthopaedic Services Facts and Figures Significant improvements in orthopaedic services have been achieved in the last decade, at the same time as balancing changes in workforce brought about by the European Working Time Directive, Junior Doctors Working Hours and Hospitals at Night policies.

• Boards have made significant progress in improving waits for Orthopaedic Services. The March 2010 ‘Stage of Treatment’ target of no more than a 12 week wait for the first Outpatient appointment and 12 weeks for Inpatients/Day Case (All Boards opted to work to a target of 9 weeks for Inpatient/Day Case) were achieved.

• There has been an increase in complex cases, such as hip and knee replacement (approximately doubled in the last 10 years) and shoulder surgery (a 27% increase in the last 10 years).

• There has been a reduction in length of stay (7 days down to 6 days in the last 10 years) and in same day surgery (50% increase in last ten years).

• The percentage of hip fractures operated on within 24 safe operating hours increased from 80% in April ’06 to 98% in Dec. ’08. • There has also been an increase in the provision of community-based services to reduce unnecessary hospital appointments.

Max. waiting18 months

Overall guarantee


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1 April 1997

31 December 2003

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Max. waiting15 weeks OP/IP6 weeks Diag.

The 20 Year Journey

Max. waiting12 weeks OP/IP

(all source)

31 March 2010

This diagram represents targets that have been consistently met over the last 20 years.



The following charts can be used at national level and Board level to understand Demand for Orthopaedic Services.

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Actual Trends - New Outpatients - NHS Scotland - Trauma & Orthopaedic Surgery This graph shows demand coming from GPs, A&E, Consultant to Consultant and ‘Other’. It demonstrates the significant degree of seasonal variation in demand. (N.B. only those referrals where the patient was given an appointment are included. The date is the date the referral was received.)

At Board level the percentage of demand from different sources varies significantly e.g. one Board has as big a percentage from A & E as it does from GPs. Boards need to understand the patterns for their own Board for pro-active demand management.

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Arthroscopy Foot ProceduresHip Replacement Knee ReplacementCarpal Tunnel Release

Source: SMR01

IP/DC Activity - NHS Scotland - Orthopaedics - Principle Procedures

This graph shows the increase in principal procedures between 2003 and 2009. (N.B. Some additional Carpal Tunnel Releases are undertaken in other specialties e.g. plastic surgery and neurosurgery).



Acceleration & Deceleration in Increase in ReferralsOrthopaedics - NHS Scotland Patients given New OP appointments

(consultant-led service) dated from date of referral

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This graph shows the acceleration and deceleration in the increase in referrals to Orthopaedics since 2006. The percentage shown at each quarter end compares the year back from that quarter end with the year prior to that. This method removes the effect of seasonality from the calculation of the overall increase in referrals. During 2008 the increase accelerated and remained high in early 2009. By the second quarter of 2009, however, the increase was decelerating and has continued to do so for the next three quarters.



Quarterly Change in Referrals patients given new OP appointments

Orthopaedics - NHS Scotland

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This graph shows the effect of seasonality in Orthopaedics. Between 13% and 16% more referrals were received in April – June in each of the last four years than in the period January to March. The effect of seasonality on referral rates is predictable. Capacity planning must be flexed to account for the variation.



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Conversion Rate - NHS Scotland - Trauma & Orthopaedic Surgery

Conversion Rate - NHS Scotland - Trauma & O th di S

Source: SMR00, SMR01 and New Ways Data Wareho se

This graph shows the conversion rate (black line) from New Outpatients Seen (red line) to Additions to List (blue line).

Ideally, conversion rates should not be affected by a seasonal rise and fall in demand. Boards should review this graph for their own Board to assess the degree of seasonal variation in conversion rates. If there is a variation, Boards should consider whether the rate is influenced by a seasonal increase in referrals where an Orthopaedic consultant is not necessarily the most appropriate professional to see these patients as a lower percentage convert to surgery or if there is a lowering or raising of the criteria for surgery at certain times of year.

In terms of the overall trend in conversion rates over several years, Boards should consider whether community and primary care projects are having a positive effect on conversion rates.



The following graphs can be used at national and Board level to understand how waiting lists are being managed.

1 . T o ta l n u m b e r o f p a t ie n ts o n th e w a it in g lis t a t m o n th e n d (c e n s u s ) N e w O u t p a t ie n t s - N H S S c o t la n d - T r a u m a & O r th o p a e d ic

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J a n F e b M a r A p r M a y Ju n J u l A u g S e p O c t N o v D e c

2 0 0 8 2 0 0 9 2 0 1 0S o u r c e :N e w W a y s d a ta , a s a t 3 0 Ju n 2 0 1 0

1 . T o t a l n u m b e r o f p a t ie n t s o n t h e w a it in g lis t a t m o n t h e n d ( c e n s u s ) In p a t ie n t s - N H S S c o t la n d - T r a u m a & O r t h o p a e d ic

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These graphs show the size of the Inpatient, Outpatient and Day Case waiting lists in ‘08/’09/’10. They show a seasonal variation in waiting list sizes.

The Inpatient graph shows a steady reduction in numbers waiting over the two and a half year timescale.

For Outpatients the reduction in 2009 was significant but unfortunately the 2010 pattern shows a steep increase in the late spring to levels almost as high as those in 2008.

The Day Case graph shows a big increase between ’08 and ’09, possibly due to a shift in practice from Inpatients to Day Case but without the availability of sufficient Day Case capacity. The start of ’10 shows a promising reduction but since April, levels have risen higher than in either of the previous two years for the early summer months.

1 . T o ta l n u m b e r o f p a t ie n ts o n th e w a it in g lis t a t m o n th e n d (c e n s u s ) D a y C a s e s - N H S S c o t la n d - T r a u m a & O r th o p a e d ic

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3. Waiting List Activity - Additions to list & removals from list within month

Inpatients - NHS Scotland - Trauma & Orthopaedic

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Gap betw een additions/removals Additions to list Removals to listSource:New Ways data, as at 31 Mar 2010

This graph shows that in March ’10 the Stage of Treatment Target of no more than 9 weeks wait for Inpatients treatment was being achieved. It also shows the variation in ‘shape’ of waiting lists between different Boards. The ‘shape’ of Board B’s waiting list is not sustainable as the service is extremely vulnerable to the impact of any increase in demand or decrease in available capacity.

Inatients waiting in one week time bands as % of total waiting lists - Trauma Orthopaedic - New ways data, March 2010

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This graph shows seasonal variation in additions and removals from the waiting list. It highlights months where removals did not balance additions and waiting lists grew.

It is essential for Boards to understand their own variation and to plan sustainable capacity accordingly.



Outpatient appointments

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The graphs show Additional Activity as a percentage of all activity (scheduled and unscheduled), April ’09 to March 2010.



Risk Assessment- Outpatients (All Sources of Referrals)

Trauma & Orthopaedic, New Ways Jun-10

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Bubble Area proprtional to number waitng > 9 weeks (all source of referrals)

1037

373

664

41

166

Risk Assessment- Day Cases Trauma & Orthopaedic, New Ways Jun-10

Borders

GG & C

D & G Fife

FV

Grampian

Lanarks

Lothian

A & A

TaysideHighland

0

5

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15

-10% -5% 0% 5% 10%% change in monthly queue size (averaged over the year ending Jun-10)

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Bubble Area proportional to number waiting > 6 weeks

434

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17

69

These graphs show the balance of three risk factors: • The size of the ‘bubble’ is in relation to the number of patients on the

waiting list. • The vertical height of the ‘bubble’ is in relation to the estimated

number of weeks required to clear the waiting list based on recent activity.

• The horizontal position of the ‘bubble’ is in relation to the monthly increase/decrease in waiting list size

Activity figures include waiting list initiatives as well as core activity. If the number of weeks required to clear is relatively low this does not guarantee there is no risk – for example, activity could be being increased by unsustainable waiting list initiatives.

It is important for Boards to understand the level of activity required for ‘business as usual’, i.e. to meet appropriate demand as opposed to the one-off activity required for ‘back-log clearance’.


F3130196 Page of 63 October 2010

All the graphs on the previous pages have been for stages of treatment and they can be used to measure performance and identify and monitor improvement opportunities. In order to be sure that Boards are meeting milestones towards achieving the 18 Weeks RTT standard by December 2011 it is essential that full RTT patient journeys are being accurately measured. Boards have been asked to submit their journey measurement ‘completeness’ figures on a monthly basis.

Trauma & Orthopaedic Admitted Completeness

0

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Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10

% C

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Trauma & Orthopaedic Non Admitted Completeness

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Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10

% C

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Boards have been anonomised on these graphs. The graphs show that most Boards need a significant improvement in journey measurement before 18 Weeks performance can be assessed. Admitted completeness is relatively high at some Boards but there is little sign of significant measurement improvements over time.

Non Admitted completeness is very low in a number of Boards and being erratically reported in other Boards.



2 Orthopaedic Services Task & Finish Group

The Orthopaedic Services Task and Finish Group was set up in January ’09 and includes Service Managers, Orthopaedic Consultants, Anaesthetists, Extended Scope Physios, GPs and Scottish Government members (see Appendix A for full membership). The group have focussed their actions so far in the following work-streams; Measurement and Definitions; Demand / Capacity / Activity / Queue (DCAQ); Primary Care Solutions; Performance Management; Service Redesign and Transformation; Cultural; Workforce and Communication. From the outset the Orthopaedics Task and Finish Group aimed to support clinically appropriate and evidence based sustainable improvements and to support a reduction in reliance on Waiting List Initiatives [WLI’s] and the private sector. The following chart shows a ‘Glenday Sieve’ analysis of the volume of activity by procedure. Just nine Orthopaedic procedures (4%) account for 50% of activity. This has provided a clear focus for national work to support improvements in pathway management that will have the highest impact across NHSScotland. The Task and Finish Group is running projects to support improvements for the following pathways:

• Enhanced Recovery – Total Hip and Total Knee Replacement • Suspected Carpal Tunnel • Arthroscopy

In addition, a Spinal Pathway project and a Community MSK Pathway project are in progress.

Glenday sieve analaysis of St Elsewhere Trauma and Orthopaedic Inpatient/Day-case activity 2007/8

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

1 7 13 19 25 31 37 43 49 55 61 67 73 79 85 91 97 103

109

115

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127

133

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145

151

157

163

169

175

181

187

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211

procedure number

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ostic)


F3 2010

130196 Page 18 of 63 October

2.1 18 Week RTT Risks to Delivery Through consultation with Boards, the following risks to delivery in Orthopaedic Services were identified from the outset:

• Significant variation by Board and sub-specialty in terms of the time it takes from referral to treatment. For example, the gaps between the ‘value-adding’ steps of the pathway and the number of ‘non-value-adding’ steps included.

• Difficulties in measuring performance and improvement due to non-integrated and disparate IT systems. • Significant variation in patient experience of access to services and the pathways they follow. • Significant variation in the service provided for patients living in Boards with a regional centre and those without. • Pathways with ‘hand-offs’ to other departments, particularly diagnostic tests, prosthetics, orthotics and consultant to consultant

referrals in other specialties or Boards. • Difficulties in measuring Demand and Capacity to identify whether a service is ‘in balance’. • Unsustainable reliance on WLI’s and the private sector.

2.2 Priority Task & Finish Group Improvement Actions The following priority actions for the group to support NHS Boards mitigate delivery risks and develop sustainable solutions were identified:

• To augment available data by creating a data set to support service planning and improvements.

• To ensure boards are using available data and tools to understand areas for improvement and manage demand and capacity.

• To gain an understanding of the Demand and Capacity balance and Queue Size and Shape through collection and analysis of comparable information for Orthopaedic Services across Scotland.

• To drill down into available information to identify local, regional and national planning and training requirements, risk areas, high impact changes, improvement opportunities, benchmarking and the identification of best practice.

• To undertake individual projects for high volume pathways – Arthroscopy, Suspected Carpal Tunnel Syndrome, Enhanced Recovery for Total Hip and Knee Replacement Surgery and the Spinal problems Pathway.

• To identify ways to reduce the number of outpatient appointments required with consultants in secondary care by ensuring patients access care at the most appropriate place e.g. community MSK assessment services.

• To share good practice for adoption and spread through national events managed by the Improvement and Support Team.



3 Task & Finish Group Outputs

The following is a summary of the Orthopaedic Services Task and Finish Group outputs achieved so far. Items are then described more fully in the following sections.

Workstream Completed In Progress 1 Measurement &

Definitions • Input to national Principles & Definitions. • Encouragement of Clinical Outcoming in Orthopaedic

clinics.

• Encouragement of improvements in 18 Weeks Completeness and Performance reporting (particularly for Non-Admitted pathway).

• Analysis of clinical outcome data to highlight further opportunities for service redesign including return appointments and onward referrals to other specialities.

2 Demand/Capacity/

Activity/Queue • Monthly Demand and Activity MSK Audit data being

used for identification of improvement opportunities (now on HEAT website – see Section 3.2.1).

• Audit of Referral to Diagnosis Pathways & Additional Capacity Used 08/09.

• Information for Improvement Letter sent to Exec Leads encouraging use of IST tools & all available data.

• Pilot DCAQ project with NHS Lothian to proactively plan capacity.

• Health Intelligence Group analysing all available data sources (e.g. MSK Audit data, New Ways/QueSSTCap data) to identify risks and inform performance and improve action planning.

3 Primary Care Solutions

• Community based MSK Pathway project (pilot in Lanarkshire). Assessment and triaging of back pain patients.

• Clarification of referral criteria e.g. spinal pathways, carpal tunnel.

• Link with Demand Management Group focusing on Orthopaedics.

• Identification of best practice clinical guidance intranets and collaboration between primary and secondary care.



4 Performance

Management • New Ways / QueSSTCap data used to identify trends

and risk areas. • Support of good Waiting List management principles

and reduction of reliance on WLIs.

• Work with Boards on specific areas identified by the data.

• ‘Safe Space Risk Assessment’ with specific Boards.

5 Service Redesign and Transformation

• Focus on improvement opportunities for high volume pathways through re-design of:

o Suspected Carpal Tunnel Syndrome pathway (including role and provision of Nerve Conduction Studies)

o Arthroscopy/Knee Pain Pathway o Total Hip & Total Knee Replacement through

participation in Enhanced Recovery Programme.

• Spinal Pathways collaboration between Neurosurgery and Orthopaedics. Agreement of protocols for which patients should be seen by which professionals locally and regionally.

6 Cultural • Encouragement of full completion of Monthly MSK Audit Demand and Activity data as gaps from individual hospitals or Boards reduce the value of the rest of the data for comparison purposes and national analysis.

• Presentations at Scottish Orthopaedic Club ’09 & ’10.

• Consideration of an Orthopaedic Supportive Visits Programme (with Scottish Committee for Orthopaedics & Trauma).

• Implementation of Enhanced Recovery Programme to further develop multi-disciplinary team working in Orthopaedics.

7 Workforce • Input to Workforce Solutions Event.

• Update of SWISS Workforce database (via SCOT). • Identification of best practice and pilots with

opportunities for changing clinical roles (e.g. extended role practitioners).

8 Communication • National Orthopaedic Events (Nov ’09 & June ‘10) to demonstrate best practice and take re-design projects forward.

• Orthopaedic Managers & Lead Clinicians events held (May & July ’09). Presentations to Scottish Committee for Orthopaedics & Trauma.

• Identification and roll out of best practice.



3.1 Measurement and Definitions 3.1.1 Definitions

The application of common definitions is fundamental to the accurate measurement of waiting times. The generic clock start / clock stop definitions apply as set out in ‘18 Weeks: The Referral to Treatment Standard – Principles & Definitions’ (issue 2.0, January 2009. See http://www.18weeks.scot.nhs.uk/how-to-measure-and-monitor-performance/principles-and-definitions/ N.B. The Information Delivery Team advise that the document is currently being revised. For further information please contact [email protected] .

Check List for Boards: o Ensure that all staff involved in recording clock starts / clock stops, understand and apply the definitions uniformly. This includes the

understanding and application of New Ways Rules to support the recording of periods of patient unavailability.

3.1.2 Measurement Stage of Treatment measurement has been undertaken for many years. Boards are now required to undertake 18 Weeks measurement.

Check List for Boards: o Ensure robust and fit for purpose management information. Embed use of the data into operational management to support delivery of

18 Weeks and highlight opportunities for improvement. Use data to drill into problem areas and to inform next steps, including opportunities for the development of models of care in community settings.

o Ensure 18 Weeks reporting of Completeness and Performance and work towards improving these on a monthly basis (particularly Non-Admitted Completeness). Are your systems 18 Weeks and New Ways compliant in terms of recording and correctly taking account of periods of patient unavailability for reporting purposes. Do all relevant staff understand the rules and how to apply them?

o Review the recording of the Unique Care Pathway Number [UCPN] at each stage of each patient’s 18 Week Journey, including for Onward Referrals. Automate wherever possible.

o Review recording of Clinical Outcomes at all new and return appointments and remove paper recording where possible. Make sure all clinical staff and administrators understand which codes should be used in which circumstances. If a ‘clock stopping’ code is being used, has the 18 Week journey been correctly stopped so that the patient will not be counted in any reports as having an ongoing wait?

http://www.18weeks.scot.nhs.uk/how-to-measure-and-monitor-performance/principles-and-definitions/


O


rthopaedic Task & Finish Group


o Evaluate where treatment is occurring, for example with AHPs, and ensure all staff understand the importance of ‘stopping the clock’. o Ensure that reports and systems designed to link elements of patient pathways are used to identify bottlenecks, unnecessary waits and

improvement opportunities as well as individual patients about to breach. (See ‘Patient Journey Analyser’ http://www.improvingnhsscotland.scot.nhs.uk/tools/Pages/Search.aspx )

3.2 Demand/Capacity/Activity/Queue (DCAQ) Analysis Maintaining a balance between demand, capacity and activity, to ensure an efficient service where queues do not develop, requires robust information. It also requires a detailed understanding of the parameters and the impact that a change in any of the parameters has on the others. For example, demand can vary weekly or seasonally and can increase or decrease gradually over-time. Actions can be taken to influence a decrease in demand for secondary care appointments. Efficiencies can be gained through management and redesign that optimise capacity utilisation or some demand can be redirected to other professionals. Accurate data input and capture from systems is integral to undertaking robust DCAQ analysis to underpin the management of variation, to support service planning and inform service redesign and transformation. 3.2.1 Information for Improvement – Maximising the Value of Information The following information, tools and support are available to Boards: MSK Audit The MSK Audit team are funded by the Access Support Team and harness the expertise from the Hip Fracture Audit, a highly successful vehicle to develop clinically credible data to improve timeliness of patient care. The MSK Audit is run by ISD and provides resource for each NHS Board to employ an MSK Audit Coordinator. The Audit has two elements:

• Monthly management information on Demand and Activity by site. Aggregated to national level and ‘real time’ feedback to managers and clinicians (See Appendix B).

• A series of sprint audits to support pathway redesign (see section 3.5 – Service Redesign and Transformation). The MSK management information has been collected since March 2009. There has been considerable investment to improve the coverage and quality of the data, and support offered for NHS Managers to use this as part of a suite of information (see Tools and Support section below), to enable them to more effectively manage capacity, demand and backlog clearance.

http://www.improvingnhsscotland.scot.nhs.uk/tools/Pages/Search.aspx



The development of the MSK data pre-dated the comprehensive availability of QueSSTCap data derived from the National New Ways Data Warehouse. The intent is to rationalise the MSK management information data set and data sources. This includes work to understand the differences between NHS Boards in the way they collect and use this information, which often results as a consequence of different service models. Importantly, the MSK Audit data adds the following value:

• All referrals are counted, not just those referrals added to list, enabling full quantification of referrals and those not added to list. • Level of Additional Activity e.g. waiting list initiatives, GJNH and private sector is quantified. This enables core capacity vs.

capacity to manage current backlog clearance to be assessed. • It counts elective procedures actually undertaken (rather than admissions). • Non Consultant-led AHP activity is quantified.

New Ways Data and QueSSTCap Analysis Boards submit data to the national New Ways data warehouse which is then analysed by ISD. A set of charts have been developed to enable easy analysis for performance management and improvement purposes. This is referred to as QueSSTCap analysis (Queue Size, Shape and Trend and Capacity analysis). Some of these graphs have been include in Section 1.3 Orthopaedic Facts and Figures. Boards can access the information at Board level on the HEAT website (Call 0131 275 7777 or email [email protected] if you do not currently have access). The aim is to ensure that this information is fully utilised as a key tool for operational management, with data systematically derived and used at local level. Additional Data, Tools and Support Better Quality Better Value Indicators (such as Length of Stay, DNA rates, etc.) are useful to benchmark your hospitals against other hospitals. (Link http://www.bqbvindicators.scot.nhs.uk/ ). DCAQ training sessions are provided by the Improvement and Support Team [IST] and incorporate the principles of capacity planning, good waiting list management and demonstrate how the principles of LEAN methodologies might be applied in practical settings. Practical tools to support prospective DCAQ and waiting list management are available at http://www.improvingnhsscotland.scot.nhs.uk/tools/Pages/Search.aspx . Bespoke support is also available to Boards as needed, to ensure detailed understanding of demand and capacity (email [email protected] ).


http://www.bqbvindicators.scot.nhs.uk/

http://www.improvingnhsscotland.scot.nhs.uk/tools/Pages/Search.aspx




‘What If…’ Scenario Analysis Boards are commended to undertake ‘What If…’ scenario analysis to explore what impact an improvement in one or more parameters could have on the demand, capacity and activity balance. A number of parameters are detailed below but Boards are encouraged to consider others. Analysis at sub-specialty level (e.g. shoulders, knees, foot and ankle, etc.) is important to identify variation and improvement opportunities. See Appendix C for case studies of work already undertaken at Boards.

What if… GP referral patterns could be influenced so that all referrals meet clearly defined and jointly agreed pathway criteria and unexplained variation is reduced? This analysis could lead to a GP/Consultant engagement and education action plan. Boards can use the Locally Enhanced Services process to improve working between primary and secondary care. What if… New Outpatient Appointments could be reduced by X% and the conversion rate to surgery therefore increased to Y% This analysis could lead to a Community MSK project – see Section 3.3 Primary Care Solutions. What if… Procedure X or Diagnostic Test Y was undertaken at the median rate per 100,000 of population? This analysis could lead to a review of referral criteria and a reduction in variation. What if… the New to Return appointment ratios were optimised? New attendances could potentially increase if return appointment slots were freed-up. Could AHPs (e.g. physios or OTs) in primary or secondary care see some return patients? Allow for differences in new to return ratios between sub-specialties. What if… all scheduled clinics went ahead and all slots at scheduled clinics were utilised? Analysis may show a significant number of ‘gaps’ in clinics that actually occur. Clinics may be cancelled for valid reasons but not reinstated if the reason changes. Analysis may also show a significant variation in the number of patients seen each week at each clinic. This offers the opportunity to improve capacity utilisation. Templates and staffing may also need to be clarified. Consider reducing infrequent sub-specialty clinics and/or ensure empty slots are filled with general patients at an agreed timescale prior to the clinic. What if… all new appointments were allocated X minutes & follow-ups were Y minutes and all clinics ran for at least 4 hours? This analysis may identify potential for additional clinic slots. The amount of time allocated will need to vary by sub-specialty and for more complex cases. There may be significant variation in the length of scheduled clinic times. There may be historic reasons for this. Where possible these clinic profiles should be re-negotiated as it is likely that a minimum of 4 hours is more efficient use of the time for all the staff involved.



What if… some clinics ran for more than 42 weeks a year? This scenario is only relevant where space is a rate limiting factor rather than consultant availability. This may be relevant at some Boards where other consultants can use the space for clinics in the weeks where the normal clinic is not running. What if …. Pre-op length of stay could be reduced to achieve upper quartile in Better Quality Better Value Indicators? Analysis may identify opportunities to reduce pro-operative stay potentially releasing beds days and increasing productivity. What if …. Average length of stay could be reduced to achieve upper quartile in Better Quality Better Value Indicators? Analysis may identify opportunities to reduced average length of stay potentially releasing bed days and increasing productivity. Implementation of Enhanced Recovery should be considered to support the reduction in average length of stay (See Section 3.5.3). What if … Same Day Surgery Rates were optimised? Analysis of BADS directory of procedures or Better Quality Better Value Indicators may highlight opportunities to increase day surgery rates and improve efficiency of pathways. (See http://www.bads.co.uk or http://www.bqbvindicators.scot.nhs.uk/ ). What if … Administration delays were eliminated from pathways? Analysis of MSK Carpal Tunnel and Arthroscopy Audits, as well as 18 weeks Readiness Assessment (See http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/Pages/Resources.aspx) may highlight opportunities for improvement of pathways through reduction in administration delays (See Section 3.5). What if … Theatre utilisation was optimised? Analysis of data collected through the National Theatres Benchmarking Project may identify opportunities to improve theatre efficiencies. (See http://www.isdscotland.org/isd/6321.html ). What if… Capacity matched Demand! Demand and its seasonal variation can be predicted through statistical modelling. Analysis of demand data (SMR00) over the last four years has shown an average of a 13% increase in demand in April-June of each year compared with Jan-March. Proactive capacity planning needs to be in place to increase capacity to meet this demand. Capacity needs to be flexed seasonally to meet demand and prevent queues building up (this will probably require changes to annual leave policy and job plans.) What if the backlog was removed once? Would queues build up again or would capacity and demand be ‘in balance’?

http://www.bads.co.uk/


http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/Pages/Resources.aspx

http://www.isdscotland.org/isd/6321.html



Check List for Boards: o Ensure you regularly access the MSK Audit and QueSSTCap information available on the HEAT system, make full use of IST support

and tools and the Better Quality Better Value Indicators (see links given earlier in this section). o Undertake robust Demand, Capacity, Activity, Queue analysis to understand whether your service is ‘in balance’. Understand source of

demand, case mix, conversion rates from outpatient appointments to listing for surgery, queue sizes and shapes. o Develop and manage your Capacity Plan, including scheduling, managing variation, improving and optimising use of available capacity,

and where appropriate, one-off backlog removal to ensure a sustainable service. o Understand Seasonality. Ensure leave is managed to match demand peaks and troughs. Once a service’s DCAQ information is

routinely shared with consultants they understand the need for a leave policy to be enforced, swift vetting, focus on capacity utilisation, and improvements in clinical administration.

o Following identification and implementation of improvement opportunities, identify if a gap exists between capacity and predicted demand. If there is a gap, produce a business case for additional staff that demonstrates full understanding of DCAQ to ensure a sustainable service without an ongoing requirement for WLIs or the private sector.

o Assess the DCAQ balance between sites. Is there inequity in terms of patients experiencing longer waits in some locations? o Proactively plan your Board’s use of the GJNH. A quantity of work negotiated with the GJNH over several years will be significantly

cheaper than resorting to the private sector at short notice. o Consider options for regional working for some sub-specialties. o Undertake ‘What If…’ scenario analysis at sub-specialty and consultant level to identify variation and improvement opportunities.

Ensure you develop an Action Plan of improvements. See Appendix C for case studies of work already undertaken at Boards. o Consider best practice capacity planning guidelines of ensuring that available capacity can cope with at least 80% of the variation in

demand to ensure that queues do not build up. o If you are concerned by your Board’s ability to balance capacity and demand for Orthopaedic services and meet the 18 Weeks RTT

without reliance on WLIs and the private sector then contact AST for ‘Safe Space’ discussion. (Contact [email protected]).




3.3 Primary Care Solutions The Task and Finish Group consider that there is significant scope for elements of Orthopaedic care currently undertaken in secondary care to move to primary care. There is also scope for streamlining pathways into secondary care to ensure patients get onto the right pathway, first time. 3.3.1 Community-based MSK Pathway Project This project is being led by the AHP and Healthcare Sciences Branch of the Scottish Government. Pilot projects are currently being run in Lothian and Lanarkshire health board areas. For the pilots, back pain MSK services have been redesigned to test the national model as follows:

• Standardise self-referral through NHS24. • Incorporate work status within assessments and outcomes. • Shift ESP (advanced practitioner) capability into the community, allowing earlier assessment and triage. • Standardise criteria for when MRI should be used. • Standardise criteria for referrals to Orthopaedics, thus reducing outpatient appointments and increasing conversion rates for surgery. • Develop protocols for all ‘exit routes’ to appropriate professionals.

The following measures of success are in place:

• Increase % of patients accessing physio via self referral. • The National AHP dataset includes patient outcomes through their journey which will enable economic evaluation. • Reduce volume of MRI investigations. • Increase conversion rate to surgery in Orthopaedics.

The following patient benefits and staff / organisational benefits have been identified:

• Rapid access to community services for patients. • Equitable access to services. • Fewer hand-offs between different professionals and services throughout the patient’s journey. • Cost savings. • Increased ability to meet the 18 Week RTT standard as consultant’s time is freed-up from outpatient appointments.



The next steps for the project are to: • Establish a national steering group and a project steering group in each NHS Board. • Ensure spread and adoption across Scotland. • Establish a community of practice within the Rehabilitation Framework MKN hosted by NES.

Check List for Boards: o Scope current MSK service provision with Orthopaedic and AHP managers. o Link with National Lead to assist with service re-design (Contact [email protected] ). o Agree measurable outcomes to assess impact of service redesign.

3.3.2 GP Guidance It is important that GPs have access to user-friendly information to support decisions regarding appropriate treatments, pathways, protocols, straight-to-test options, ‘advice only’ routes, etc. Improving GP guidance ensures patients get on the right pathways to see the most appropriate professional first time. Check List for Boards: o Consider potential approaches to demand management for Orthopaedic services across the health community (N.B. The Demand

Management Group are focussing on Orthopaedics. Contact Alan Kerr [email protected]). o Explore the potential for the development of community-based solutions. o Reduce variation in referral patterns and ensure referrals meet clearly defined pathway criteria. Analyse GP referral profiles and

develop a programme to address issues e.g. educational sessions for GPs and consultants. Encourage GPs to use the analysis to benchmark themselves.

o Ensure patients get on the right pathway - Evaluate how easy it is for GPs to navigate your board’s intranet. How easy is it to find Orthopaedic Services information on: treatment advice that might prevent or delay a referral being necessary, services provided, referral criteria, standardised pathways, bespoke protocols etc. NHS Forth Valley’s Service Information Directory, Lothian’s RefHelp and Grampian’s Clinical Guidance Intranet are good examples (Contact [email protected] at Grampian).






o Consider whether seasonality of demand could be influenced? o Enable ‘Advice Only’ referrals - Take advantage of existing SCI Gateway functionality and implement an ‘advice only’ channel for GPs.

Boards need to develop links with their referral management solutions and ensure a clear process is understood (in the meantime, ask your e-health department to ‘turn on’ the sending GP’s email address on all referrals so that it is visible to the receiver). Add the ‘Advice Only’ channel into your referrals management process. Measure the volume of ‘advice only’ referrals where the advice received delays or prevents a full referral being necessary. Stress the benefits to GPs, including reassurance for patients that advice has been sought from a specialist. Other specialties have implemented successful ‘advice’ channels e.g. NHS Forth Valley rheumatology.

o Effective e-referrals - Ensure the way your Orthopaedic Services are structured within SCI Gateway enables GPs to navigate to select the most appropriate service to make a referral to (the index can be restructured to enable GPs to select sub-specialty first and then locality).

o Consider bespoke SCI Gateway forms for high volume sub-specialties (e.g. Suspected CTS–Contact [email protected] ) and ensure they clarify the criteria for acceptance of a patient onto the specific pathway. Questions asked should provide information to allow allocation to the most appropriate professional / clinic or straight-to-test route at the vetting stage.

o Evaluate ways to clarify referral protocols from A & E. o Consider mechanisms for reducing referral variation. Tayside, Highland, Dumfries and Galloway and Borders are using ‘Closer Working

Monies’ to profile referral patterns. Forth Valley is also reviewing practice profiles (See Appendix C for Case Studies).




3.4 Performance Management Boards have been working to reduce the backlog of long waiters across their Orthopaedic service, and to reduce the time taken for each of the component stages of the overall journey to support the delivery of 18 Weeks RTT. Underpinning this approach, the application of good waiting list management principles remains a fundamental element in the successful delivery of reduced waiting times – in particular:

o Minimise the number of separate queues i.e. pool lists where appropriate; o Streamline systems and processes for administering waiting lists; o Ensure scheduling and booking follows established good practice; o Apply ‘Treat in Turn’ to manage the ‘shape’ of the list and reduce ‘tails’ of long waiters; o Validate and clean lists to ensure their ongoing currency/accuracy; o Reduce DNA/CNAs; o Implement New Ways Rules (e.g. Reasonable Offer and Periods of Unavailability).

Ongoing risk management to drive delivery remains of central importance. The monthly Stage of Treatment and 18 Week reports are important for management purposes at service level and Board level, as well as at national level. The onus remains on Boards’ information and performance teams to develop their systems and processes and to integrate these within existing organisational structures, to ensure that fit for purpose waiting times intelligence is available.

Check List for Boards: o Continue to ensure you are meeting Stage of Treatment standards every month during the transition to 18 Weeks pathway management. o Ensure you have set and are meeting 18 Weeks milestones. Focus specific performance improvements and use a robust understanding

of DCAQ to support the setting of realistic milestones right through to December 2011. Continue service redesign and transformation efforts to ensure your DCAQ is in balance.

o Undertake ongoing risk assessment and prioritisation of mitigating actions to ensure milestones are met. o Continue to adhere to the principles of good waiting list and queue management to facilitate delivery. Focus on the longest waiters and

‘treat-in-turn’ principles to ensure a small number of long waiters are not extending your maximum wait figures unnecessarily. NHS Ayrshire and Arran have worked in a number of specialties to develop daily reports that demonstrate the benefits of good waiting list management (contact Stewart Cardwell [email protected] Service Improvement Lead for further information). NHS Grampian has also worked on ‘booking in turn’ (contact Gillian Evans [email protected] ).





3.5 Service Redesign and Transformation Continuous improvement is an important part of the 18 Weeks Service Redesign and Transformation Programme and is central to the work of the Task and Finish Group. A critical aspect of 18 Weeks RTT delivery for Orthopaedics is the promotion of improvement work in all Board areas to improve systems and processes, share good practice and embed sustainable change. Learning and development opportunities in redesign and improvement have been offered to Service Managers to help focus their local redesign work. National events have provided an opportunity to share case study examples and to identify scope for further pilots/small cycle change. See Appendix C for Case Studies. Boards are asked to continue to identify specific risks to delivery and to develop bespoke action plans to mitigate these risks. Service improvement support is available from the regional teams of the 18 Weeks Service Redesign and Transformation Programme, and given identified risks relating to Orthopaedics, local 18 Weeks Teams also have this as one of their priority workstrands. The Task and Finish Group are running a number of projects to support improvements in high volume or complex pathways:

o Improving the Arthroscopy Pathway o Improving the Suspected Carpal Tunnel Syndrome Pathway o Enhanced Recovery for Primary Hip and Primary Knee Replacement o Improving Spinal Pathways

3.5.1 Improving the Arthroscopy Pathway An audit of Arthroscopy patients was undertaken by the MSK Audit team and the report released in February 2010. The audit tracked journey times, including waits between episodes of care and profiles, for example MRIs undertaken by age. The report identifies significant and largely inexplicable variation in practice, for example Arthroscopy rates per head of population, day case rates, use of arthroscopy for diagnostic purposes, and ‘debridement’. Large variations exist between hospitals in the time from referral to treatment and between episodes of care due to admin delays. Approximately 30% of the patient journeys are currently completed within 18 weeks. There is no correlation between access to MRI, arthroscopy rate or operation type suggesting that there is no consistency in service delivery. The following patient benefits and staff / organisational benefits have been identified:

• Reduced waits for patients and an achievement of 18 Weeks RTT. • Appropriate use of arthroscopy for treatment and diagnosis. • Appropriate use of MRI. • A quality service across Scotland with equity of treatment for patients.



The next steps for the Improving the Arthroscopy Pathway project is to work with the Scottish Committee for Orthopaedics and Trauma [SCOT] to:

• Organise a knee surgeons’ workshop to agree guidelines to standardise practice including the development of a knee pain pathway (conservative and surgical treatment) across Scotland from referral to treatment.

• Clarify Referral Criteria and enhance GP Guidance. • Encourage a reduction in variation of service delivery e.g. Arthroscopy and MRI rates. This may increase activity in some areas. • Prepare a proposal for a study of Patient Reported Outcome Measures and other measures (e.g. number of arthroscopies and MRI

scans). Measure standardised pain and / or disability scores before and after surgery to ensure service provision is justified by results and patient satisfaction. There is currently no evidence that low rates or high rates of arthroscopy produce better outcomes for patients or that the provision of universal MRI access is essential. This study will help to engage with clinicians and influence change.

Check List for Boards: o Benchmark the hospitals within your Board against other hospitals and use the Audit report to identify improvement opportunities (See

http://www.18weeks.scot.nhs.uk/how-to-achieve-and-maintain-18-weeks/task-and-finish-groups/orthopaedics/ ) o Quantify and remove pathway delays e.g.:

• Vetting process.

• Process from first outpatient appointment to diagnostics and review prior to listing for surgery.

• Percentage of patients not operated on at first theatre date booked. o Use outcome data to encourage clinician engagement and change. o Apply ‘what if’ scenarios to each pathway (see section 3.2.1).




3.5.2 Improving the Suspected Carpal Tunnel Syndrome Pathway Two workshops have been held with Scottish Hand Surgeons to identify ways to reduce variation in pathways for patients with suspected Carpel Tunnel Syndrome [CTS]. A draft pathway has been developed and compared with the recently released British Society for Surgery of the Hand Guideline to ensure it is in-line. An audit, run by the MSK Audit team, commenced in January 2010. All patients undergoing Carpal Tunnel Decompression were audited. In addition, patients referred to secondary care with suspected CTS were flagged to enable analysis in Autumn 2010 of the pathways they subsequently followed and to focus improvement efforts on both conservative and surgical management. The report provides opportunities for standardisation and improvement. It shows that currently approximately 28% of patients are treated within 18 weeks from referral to treatment. Significant pathway delays are evident, for example, it is taking a mean of 0.7 of a week or greater for vetting in one third of hospitals and in more than half of all hospitals greater than 10% of patients are not operated on at the first theatre booked date. There is a significant risk to 18 Weeks RTT posed by the length of wait in some areas for Nerve Conduction Studies [NCS]. There is also significant variation in the percentage of patients with suspected CTS who are sent for NCS. In December 2009, the Extended Diagnostics MMI identified that over 3600 patients in Scotland had waited more than four weeks for NCS. The three main NHS Boards that provide these tests were asked to provide a further breakdown including; the distribution of the wait, differentiation between waiting times for consultant and technician test and the board of residence of the patient waiting. Since December 2009 significant improvements can be seen in the figures, with a reduction from 3,600 to 2,500 patients waiting over four weeks. Work is ongoing to reduce the waiting lists further. See Appendix C for case studies. The following patient and staff / organisational benefits of the project to improve the Suspected Carpal Tunnel Syndrome Pathway have been identified:

• A reduced wait for patients and appropriate conservative or surgical treatment. • Equity of treatment, for example whether NCS are undertaken. • Achievement of 18 Weeks RTT and the provision of a quality service.



Next steps for the Suspected Carpal Tunnel Syndrome Pathway project are to: • Finalise the Suspected CTS pathway. • Identify ways to share best practice and reduce variation. • Develop standardised referral criteria for CTS and NCS and improve GP Guidance. • Monitor improvements in NCS waits.

• Support tertiary Boards and their NCS referring Boards in agreeing service level agreements and standardised NCS referral criteria.

• Audit all flagged Carpal Tunnel Syndrome referrals in Autumn 2010 to identify the pathways they have followed and identify improvement opportunities.

Check List for Boards: o Benchmark the hospitals within your Board against other hospitals and use the Audit report to identify improvement opportunities (See

http://www.18weeks.scot.nhs.uk/how-to-achieve-and-maintain-18-weeks/task-and-finish-groups/orthopaedics/ ). o Use the ‘Suspected Carpal Tunnel Pathway’ (available on the link above by end of October 2010) to improve GP guidance of who to refer

and when and to identify opportunities to improve the pathway within secondary care. o Evaluate use of SCI Gateway standardised Carpal Tunnel and Nerve Conduction Studies forms-Contact [email protected] o Write a case study of best practice in your Board and see what can be learnt from case studies from other Boards (See Appendix C). o Quantify and remove pathway delays. o Use clinical outcome data to model the pathway. o Apply ‘what if’ scenarios to each segment of the pathway (see section 3.2.1). o Review referral pathways into tertiary sites (Contact [email protected] for Lothian [email protected] for GG&C).







3.5.3 Enhanced Recovery for Primary Hip and Primary Knee Replacement

The Orthopaedic Task and Finish Group are sponsoring an Enhanced Recovery project that supports the implementation of evidence based clinical interventions at key stages of the primary hip and knee replacement pathways. Lothian and the GJNH are taking part in a Department of Health project and David McDonald (Extended Scope Physio from GJNH) is being funded to support other Boards in implementation. The concept of Enhanced Recovery has evolved in recent years as a multidisciplinary programme that aims to accelerate patient rehabilitation and reduce peri-operative morbidity thereby safely reducing hospital length of stay. The main principle is to reorganise the existing infrastructure of a hospital service with no significant additional finance or investment being necessary. In fact, cost savings should out-weigh any additional costs. Enhanced Recovery principles for lower limb arthroplasty follow the patient from primary care, referral to secondary care, pre-operative assessment, through admission and surgery until discharge. The project aims to utilise evidence based good practice and spread it across Scotland to provide an equitable experience of patient care to all patients undergoing primary arthroplasty. The project is engaging with NHS Boards to understand their current pathways and then support implementation and improvements by utilising the principles of Enhanced Recovery. Successful implementation requires a number of factors; changing clinical interventions, changing care systems and processes, creating a team to work across the patient pathway and technical and behavioural change management. The project aims to measure:

• Improved quality of patient care. • Improve quality of patient experience. • Improve efficiency, through increasing patient throughput.

The following measures were ‘base-lined’ in May to July 2010 and will be measured again in January to March 2011:

• Audit – The MSK Audit Team started an audit of all patients undergoing a primary hip or knee replacement across Scotland in May 2010. The report will be available by November 2010. This will provide a baseline measure of current practice and will be repeated six months later to measure improvements made by Boards in the patient pathway.

• Enhanced Recovery Pathway Maps – Each NHS Board has been asked to map which Enhanced Recovery principles they currently have in place, those that they are working on implementing and those where they need additional support to implement. They have also been asked to record the number and role of Arthroplasty Practitioners.

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• Real Time Audit and ‘Critical Friend’ Support – David McDonald is ‘walking the patient journey’ at Boards and updating the Pathway Maps. Boards are being encouraged to utilise these maps and the Department of Health document ‘Delivering Enhanced Recovery’ to map out current processes of care and costing to understand where benefits may be achieved.

• Length of Stay – The Scottish Arthroplasty Project measures Length of Stay. From this, cost saving (avoidance) in reduced bed days delivered as productivity gains can be calculated.

• Patient Experience and Outcome – Boards are being encouraged to ensure a minimum set of questions are included in a patient questionnaire (quantitative data). Boards may also organise Focus Groups (qualitative data).

• Reduced waiting times due to greater capacity for throughput – This will be evidenced by sustainable delivery of 18 Weeks RTT.

• Complication / Re-admission rates - With a reduction in Length of Stay it is vital the impact of change is measured to ensure no negative consequences. The Scottish Arthroplasty Project measures some outcomes to ensure the impact is monitored.

Enhanced Recovery is a multidisciplinary approach with the following benefits:

• It is hoped that the project will improve patient care throughout Scotland by improving quality and sharing of good practice. A significant number of studies have demonstrated reductions in morbidity and improved patient satisfaction with the use of Enhanced Recovery principles.

• By reviewing current practice and aiming to reduce variation within and between individual units it is hoped the project will reduce variability and empower staff to provide a high standard of evidence based patient care to all patients within their arthroplasty service.

• Through streamlining of patient pathways and process it is hoped that this will enable patients to have reduced time within hospital and improve capacity within the individual departments. It is not expected large scale investment will be required, rather a transformational change of current practice should enable implementation with little financial impact or even cost savings.

Next Steps for the project:

• Continue to engage with Boards through discussion of the Audit results and by organising events to enable sharing of best practice.

• Use bespoke support from GJNH (David McDonald and colleagues) to engage with members of each Board’s multidisciplinary team to gain an understanding of current practice and develop areas of local sustainable improvement along the six points of the pathway.

• Develop a cost benefit analysis with individual Boards to evaluate areas where additional costs can be balanced by productivity and efficiency saving opportunities.



Check List for Boards: o Benchmark the hospitals within your Board against other hospitals e.g. on Average Length of Stay and Pre-operative Length of Stay. Use

the Scottish Arthoplasty Project data on Length of Stay, Revisions and Complications (Link - http://www.arthro.scot.nhs.uk/ ) and ‘Better Quality Better Value’ Indicators to identify improvement opportunities (Link http://www.bqbvindicators.scot.nhs.uk/ ).

o Ensure you have completed an ER Pathway Map involving members of the multi-disciplinary team and that it is up-to-date with those elements that are in place and those you are currently implementing.

o Arrange a visit to GJNH to see how the model has had a positive impact on their patient care. Ensure a multi-disciplinary team is involved (orthopaedic surgeon, anaesthetist, Physio, nursing staff, etc). Learn from implementation of elements of Enhanced Recovery at other hospitals (Contact David McDonald [email protected] ).

o Utilise available support (David McDonald and members of the Enhanced Recovery steering group) to develop and deliver local solutions to patient pathways. Produce a cost benefit evaluation for your Board based on an available template.

o Once the Audit report is available, review the results and enhance your local Action Plan to improve patient outcomes. It will be sent to all Boards and be available at http://www.18weeks.scot.nhs.uk/how-to-achieve-and-maintain-18-weeks/task-and-finish-groups/orthopaedics/

o Early results from the report indicate many areas with improvement opportunities:

• Pre-operative setting of patient and carer expectations by provision of written information including from physios and OTs.

• Day of surgery admission and reducing the length of time prior to surgery that fasting and stopping of clear oral fluids is required.

• Types of pre-medication, anaesthesia, intra-operative IV fluids given and pre-operative serum creatinine and haemoglobin levels.

• The timing of administering of anti-emetics, reduction in the requirement for post-operative IV fluids and pre-, intra- and post-op catheterisation and blood transfusion.

• Types of post-operative analgesia prescribed, early discontinuation of IV fluids and early recommencement of normal diet.

• Early post-operative mobilisation, reduction in post-operative length of stay and reduction in post-discharge physiotherapy.

• Undertake route-cause analysis of reasons for delayed discharge and LoS >7days, such as OT issues and non-standard OT and Physio discharge criteria.

• Length of time from referral to surgery (e.g. administrative delays, hospital and patient cancellations and failed pre-assessment).

http://www.arthro.scot.nhs.uk/






3.5.4 Improving Spinal Pathways The Orthopaedic Task and Finish Group recognise that for spinal problems the pathway to the right professional is often unclear. Patients are sent to Orthopaedics, Neurosurgery, Physios, Chronic Pain services, etc. and may then get passed on to another professional before treatment. Some examples of good practice exist, for example the Glasgow Back-pain service and the recently started pilot in Lanarkshire for Community MSK assessment (see Section 3.3.1). It is important to ensure equity of access and treatment across Scotland. Demand is increasing and consultants and theatre time are scarce resources. A Spinal Pathways project has been set up with the following actions planned to ensure equity of access and treatment for all patients:

• An Audit run by the MSK Audit team will run from Sept ’10 to Dec ’10. It will provide an overview of spinal services provided by each Board, all entry points for patients to these services and pathways that patients then follow. The audit will include all specialties involved not just Orthopaedics. The audit will then review outcomes from first outpatient appointments to identify proportions of patients following different pathways.

• An initial ‘Spinal Collaboration’ meeting between Orthopaedics and Neurosurgery was held in September 2010. This group will ensure that all strands (e.g. Scoliosis Review, Spinal Injuries Unit, West of Scotland review of services, etc.) are taken into account.

• Demand and Capacity analysis will be undertaken to establish which elements of spinal pathways are ‘in balance’ and where the biggest gaps are.

• Referral Criteria and GP Guidance for the entry points into these services will be developed. • Evidence based care pathways with updated guidelines for surgery vs. conservative treatment will also be developed. • Service Maps (local, regional and national) will be developed to identify who should be treated where.

Check List for Boards: o Review your service provision and Spinal pathways using the Readiness Assessment tool and identify improvement opportunities (See

http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/Pages/Resources.aspx). o Use clinical outcome data to model pathways and quantify and remove delays and apply ‘what if’ scenarios to each pathway (see section

3.2.1). o Consider community MSK assessment options (See Section 3.3.1). o Review referral pathways into tertiary sites and discuss regional pathway opportunities with regional planning. o Input to the work of the Spinal Collaboration Group (Contact [email protected] ).





3.5.5 General Service Redesign and Transformation Opportunities The following table gives general ideas for service redesign and transformation. Each Board is commended to review these and build those that are appropriate to local circumstances into their Action Plan:

Check List for Boards: o Review pathways, including paediatric pathways, using 18 Weeks ‘Readiness Assessment’ tool to highlight opportunities for

improvement (See http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/Pages/Resources.aspx). o Draw on Better Quality Better Value Indicators, MSK Audits, local Outcoming data etc to identify opportunities for improvement and

measure their impact (See Section 3.2.1). o Consider further opportunities for community-based approaches. o Review pathways and protocols to ensure removal of non-value adding steps and smoothing of hand-offs. Waste can take many forms

e.g. waiting, over authorisation, checking and amending errors, duplication of effort, unnecessary appointments, too many hand-offs between one segment of the pathway and the next etc.

o Evaluate your pathways against Centre for Change and Innovation [CCI] pathways (N.B. several of these, such as Carpal Tunnel Syndrome, are being updated and will be hosted on the 18 Weeks website. In the longer term it is hoped QIS will take on the updating and verification process).

o Assess the ‘gaps’ between episodes of care as this is where you are most likely to find ‘waste’, delay and significant variation for individual patients e.g. can your admin and secretarial processes be streamlined? Could return appointments be booked based on the estimated date of availability of test results?

o Identify improvement opportunities in Referral Management. Electronic vetting removes delays and adds the ability to monitor and quantify demand and timeliness.

o Encourage staff (e.g. secretaries) to use the SCI Gateway Onward Referral template rather than letters as a means of making consultant to consultant referrals. This will ensure they are instantly received and flow smoothly into the receiving department’s electronic referral management process. Ensure that all staff understand the difference between the forwarding of an existing referral for the same condition (i.e. patient already on an 18 week journey with a Unique Care Pathway Number already assigned) and the generation of a new referral for a new condition.


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o Consider ways to reduce DNA and CNA rates (significantly higher in some hospitals than others – See Appendix B – MSK Audit Demand & Activity Monthly data):

• For example, ‘partial booking’ where patients are sent a letter detailing the timeframe their appointment will be within but that they should contact the service to book an actual appointment slot. Patients are more likely to attend as they have had some choice in the timing of the slot. Those that do not respond to the initial letter can be followed up and some will turn out not to require the appointment anymore (N.B. Additional admin support required must be compared with the benefits of DNA reduction).

• Ensure the appointment letter provides a prompt for patients to let you know if the appointment is no longer required. Consider reminder options such as telephone and SMS.

• Consider making it easy for patients e.g. by providing a link to public transport travel line information. • Consider collaboration with GPs to ensure patients are ‘prepared’ for their appointment.

o Implement an efficient vetting process: • Evaluate the benefits of e-vetting, identify a vetting team, agree a daily rota and ensure a consistent approach. • Encourage appropriate ‘advice only’ response where the referrer can be advised to try a particular treatment or further

investigation that might prevent or delay an appointment being necessary. Send back referrals using personalised standard paragraphs to explain why and with advice regarding treatment or further investigations. A reduction in referrals may be experienced as GPs become familiar with the responses. This mechanism could also be used to return referrals with insufficient information to enable an informed decision of how to proceed.

• Consider improvements to referrals from A & E and how to ensure sufficient information is captured and that patients get on the right pathway.

• Agree options and criteria for vetting straight-to-test. • Consider conversion rates e.g. by agreeing options for vetting straight to other professionals such as physios or orthotics.

o Maintain a ‘short-notice’ list so that all unused slots can be filled X days before a scheduled clinic. This involves managing patients’ expectations in terms of being willing to attend at short-notice.

o Review access to tests and protocol criteria: • Ensure criteria are followed for what tests should be undertaken in which circumstances. • Evaluate the interface between your department and departments undertaking tests. Could the process for making requests and

receiving results back be improved e.g. by use of SCI Gateway to send test requests? o Understand roles and competencies of the full multi-disciplinary team e.g. nurse specialists and AHPs. Ensure they are used to their full

potential.



o Consider managing return appointments differently: • Assess if all current return appointments are necessary, e.g. two and five years after surgery. • Could a ‘self-referral’ system be implemented instead? In some cases, information and advice could be provided over the

telephone rather than an appointment being necessary. • Could ESPs, as part of defined team, do some returns appointment? • Are all follow-up appointments to discuss test results necessary?

o Evaluate Theatre Utilisation and Cancellations and benchmark with other Boards. 1 in 10 scheduled procedures are classified as ‘no longer required’. Can improvement opportunities be identified?

o Identify further opportunities for increased Day Case rates. Look at ways to enhance community support and facilities. o Assess improvements for Pre-Operative Assessment and a reduction in cancelled operations. Is there any active management of

waiting patients to avoid deterioration? o Understand Demand and Capacity for Scheduled & Unscheduled patients and flows through your hospitals. Ensure beds are matched to

meet the respective demand and capacity fluctuations to ensure optimal use of beds. Consider pros/cons of protecting Orthopaedic beds.

o Make best use of the available accommodation and ensure its use is optimised. o Evaluate improvement opportunities in onward referral routes including podiatry and orthotics. o Involve Patients in redesign. Ensure the voice of the patient is included in your redesign process. o Link to Quality and Safety Standards. Reinforce the message that access to, and speed of delivery of a service are key elements of

quality. (See NHS Scotland Quality Strategy http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/NHSQuality ). o Share learning through completion of case studies to assist in the spread of good practice examples, and lessons learnt from service

changes. (See http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Search.aspx and email ideas for new case studies to [email protected] ).

o Where required, seek additional advice or tailored support from your local 18 weeks Programme Team and your Regional Improvement and Support Team. (Contact using email address above).

http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/NHSQuality

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Search.aspx




3.6 Cultural / Change Improvement projects require cultural and behavioural change as well as physical process or clinical change to lead to successful sustainable change. High level leadership is an important factor underpinning successful delivery. The Task and Finish Group have engaged with the Scottish Committee for Orthopaedics and Trauma [SCOT] to encourage the benefits of 18 Weeks for patients and staff to be embraced.

Check List for Boards: o Ensure clinical and managerial leadership are identified to lead service improvement. o Include key stakeholders in pathway redesign to ensure cultural resistance to change is minimised and opportunities for improvement are

maximised.

3.7 Making the Most of Your Workforce Great progress has been made in terms of the development of multidisciplinary teams including extended scope physios and GPwSI. Discussions continue regarding workforce capacity, competencies, training programmes and the impact of the ‘Agenda for Change’. Boards are encouraged to review their workforce competency profile, with a view to strengthening roles and responsibilities of different contributors, to ensure that each task is undertaken by the most appropriate person. 3.7.1 Workforce Database The Orthopaedic Task and Finish Group identified the need for an accurate Orthopaedic Workforce Database. The Group asked SCOT to collate the following information:

• Consultants – whole time equivalents, sub-specialty, year aged 60 • Trainees - training programme, year of CCT, intended sub-specialty • Other Medical Staff - SAS, ‘Trust doctors’, Clinical Fellows, etc.



The database was then compared with the SWISS database maintained by the Scottish Government from information supplied by each Health Board. Significant inaccuracies were found in some Boards and SCOT are in the process of writing to HR Directors to ensure the errors are rectified in the source information. Next Steps –

• Use of the database for regional planning for sub-specialties e.g. spinal surgery • Collation of AHP / ESP information. • Review workforce templates across boards to understand reasons for variation.

3.7.2 Orthopaedic Services Workforce

It is up to each Board to determine how they can achieve a sustainable balance between demand, activity and capacity. The improvement opportunities identified will support Boards in making significant progress towards achieving a balance. The Task and Finish Group recognise that some Boards may undertake detailed DCAQ analysis and improvement projects and identify that a gap still exists between available capacity and predicted demand. This resource gap may be best met with a combination of additional clinicians, specialist nurses, AHPs, GPwSIs or admin and clerical staff. Any planning of additional resource should take full account of the scope for extended roles and competencies. Boards should benchmark themselves against other Boards to consider best ways to deliver services.

Work is underway to map sub-specialisation and evaluate options for regional working. There may also be considerable unmet need in the provision of Orthopaedics services (evidenced for instance in social inequalities in rates of referral). The introduction of the 18 Week RTT Standard may encourage GPs to refer patients to secondary care where they had previously been managed in primary care. In addition, demographic change will create further demand on Orthopaedics services. Additional Orthopaedics workforce is likely to be required and consideration should be given to this in Workforce Planning, both within Boards, in NES and in the Scottish Government. The Task and Finish Group has an ambition to commission a national Musculoskeletal and Orthopaedic ‘Needs Assessment’.

It will be important to match an increase in capacity to quantified need not infinite demand. As demand increases it will become increasingly important to identify which patients would benefit most from specialist consultant or AHP input and who could be cared for by other professionals in primary and secondary care.



Check List for Boards: o Check the accuracy of your Board’s submission of workforce figures to the SWISS database and rectify any errors. o Evaluate the roles, competencies and skill mix of your multi-disciplinary team and ensure the mix matches demand at sub-specialty level

and your Board’s ability to deliver a sustainable service throughout the year. o Explore the scope for extended roles and working differently within your service, along with increased use of GPwSI and / or AHPs. o Use the Workforce ‘Six Steps’ model for integrated workforce planning.

http://www.healthcareworkforce.nhs.uk/index.php?option=com_docman&task=doc_download&gid=1902&Itemid=697 o Engage in regional workforce planning. o Liaise with NES regarding training of Extended Scope Physios. o Refocus admin resource on managing pathways and free up time for clinical staff. o If it is identified that additional staff are required, make sure the business case is backed up by robust DCAQ and service redesign and

transformation work.

3.8 Communication Three national Orthopaedic events (in July 2009, November 2009 and June 2010) have been held. These events have provided opportunities for shared learning and action planning for Boards (The following link has the presentations and webcast http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/Pages/Past_Events.aspx ). SCOT has been helpful in promoting and debating delivery principles and their practical application.

Check List for Boards: o Continue to use national forums to debate and drive delivery challenges. o Use the template provided to submit additional Case Studies to enable shared learning. o Submit articles for the 18 Weeks Newsletter to [email protected]

http://www.healthcareworkforce.nhs.uk/index.php?option=com_docman&task=doc_download&gid=1902&Itemid=697

http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/Pages/Past_Events.aspx



4 Catalysts for Change

Significant work is underway nationally and in Boards to understand and manage risks to 18 Weeks RTT delivery. The Task and Finish Group, Access Support Team and Improvement and Support Team will continue to work with key stakeholders and individual Boards to improve performance and to implement service redesign and transformation. National ‘Stage of Treatment’ targets must continue to be met as we work towards the measurement of whole pathways and achievement of 18 Weeks RTT. The use of robust management information, strong organisational leadership, understanding of capacity and demand, the proactive application of good waiting list management principles and the application of tools and techniques to embed service redesign and transformation, will all support steady and sustainable performance and service improvement. This will build on recent significant achievements and ongoing work across this service. The focus of further national and local actions must be where they are most needed and Boards must ensure that improvement actions are being taken in all key areas for maximum gain. The Task and Finish Group believe that there is a momentum for change within Orthopaedic Services. The group commend to all 18 Weeks teams, service managers and clinicians that there should be a continuing focussed improvement effort on Orthopaedic services. Boards are commended to implement improvements which ensure effective use of capacity and decrease demand for secondary care appointments. This will reduce queues and improve the quality of Orthopaedic services and access to them along a referral to treatment pathway. Relatively small changes to a service can make it more effective and more responsive to the needs of patients. Working in partnership and ensuring the right person with the right skills is available to help an individual at the right time provides tangible benefits for the patient. The Task and Finish Group recognise that not all ideas will be relevant to all Boards. Boards should, however, be encouraged to consider all suggested actions to develop their own improvement strategy. Service redesign and transformation, ongoing assessment of best practice and ongoing use of information to manage the service are all critical to success. In particular, whole system working across primary and secondary care is essential. Quality and Safety standards should of course be improved upon in parallel.



Summary of Check List for Boards: o Continue to develop and ensure timely and robust 18 Week measurement and reporting. o Ensure that health intelligence from local and national sources such as the HEAT website (see Section 3.2) is used to drive performance,

management and improvement. o Enhance your detailed local Action Plan with ideas from each ‘Check List’ section of this report. Manage performance and minimise risk. o Undertake robust DCAQ analysis and use the results for planning proposes. o Review primary care solutions and information at GPs finger-tips to support informed decision making regarding criteria and appropriate

pathways for patients. o Assess implementation of a Community-based MSK pathway project as described in Section 3.3.1. o Review high volume pathways using 18 weeks ‘Readiness Assessment’ tool to highlight opportunities for service improvement. o Ensure that all processes and pathways are reviewed to reduce duplication, waste and unnecessary steps and tasks. In particular, review

Referral Management, Vetting, Arthroscopy, Carpal Tunnel Syndrome, Enhanced Recovery for Primary Hip and Knee and your Spinal pathways as described in Section 3.5.

o Review workforce roles, competencies and skill matrix to ensure optimum use of resources both locally and regionally. o Communicate with other Boards and share learning by submitting case studies, writing articles and speaking at national events. We hope that this report supports your local Action Planning process to drive delivery of the 18 Weeks RTT in Orthopaedics in your board - Over to you!



Appendices Appendix A – Task & Finish Group Membership

Member Board E-mail Prof James D Hutchison Orthopaedic Surgeon Grampian [email protected]

Colin Howie Orthopaedic Surgeon Lothian [email protected]

Lech Rymaszewski Orthopaedic Surgeon GG & C [email protected]

Ian McLean Orthopaedic Surgeon D & G [email protected]

Debbie Kirk Service Manager A & A [email protected]

Jamie Hogg GPwSI Grampian [email protected]

Sarah Mitchell Nat. Rehab Coordinator & Physio [email protected]

David Wylie Head of Podiatric Services G G & C [email protected]

Judith Reid Extended Scope Physio A & A [email protected]

Ian Johnston Anaesthetist Highland [email protected]

Jane Todd Service Manager Lothian [email protected]

Laura Jones 18 Wks Programme Manager Scottish Government [email protected]

June Watters 18 Wks Regional Mgr Scottish Government [email protected]

Kate James Project Manager Scottish Government [email protected]

Andy Kinninmonth Orthopaedic Surgeon Golden Jubilee [email protected] Jane Campbell Audit Project Manager MSK Audit [email protected]

John Nugent 18 Week Primary Care Advisor G G & C [email protected]

Mike Lyon Head of Access Support Team Scottish Government [email protected]

Mick McMenemy Community MSK Assessment Project [email protected]

David McDonald Extended Scope Physio GJNH [email protected]

William Leach Orthopaedic Surgeon GG&C [email protected]






















Appendix B – MSK Audit Monthly Demand and Activity Sheet Month: May 2010 Referrals Number of new outpatients seen

Operations

Hospital

Number of scheduled

referrals received

"Scheduled care" new outpatients

seen

"Unscheduled care" new outpatients

seen

"Additional Activity"

used

New Outpatient

seen Total

DNA N/R

CNA N/R

"Scheduled care"

daycases

Scheduled care

Inpatients

Unscheduled care patients

"Additional Activity"

used

Operation total

A & A 994 665 661 40 1366 - - 150 65 135 64 414 Ayr 329 166 197 29 392 - - 55 32 64 17 168

Crosshouse 665 499 464 11 974 - - 95 33 71 47 246 Borders 256 293 115 0 408 29/50 61/67 29 37 61 18 145

BGH 256 293 115 0 408 29/50 61/67 29 37 61 18 145

D & G 515 439 215 29 683 30 2 77 42 87 16 222

DGRI 515 439 215 29 683 30 2 77 42 87 16 222

Fife 1571 770 433 88 1291 125/286 125/236 211 127 163 15 516

QMH 741 354 195 77 626 64/131 72/110 124 23 162 12 321

Victoria 721 324 238 11 573 56/128 45/111 87 104 1 3 195

Peripherals 109 92 0 0 92 5/27 8/15 0 0 0 0 0

FVAH 703 435 358 20 813 25/98 0/0 145 47 103 127 422

Grampian 1279 945 - 0 - 63/263 64/317 280 282 278 21 861 ARI/

Woodend 914 637 354 0 991 44/200 45/262 251 228 210 21 710 RACH 70 65 65 0 130 5/14 5/3 4 6 19 0 29 Other

peripherals 0 41 0 0 41 0/2 0/3 0 0 0 0 0 Dr Grays 295 202 - 0 - 14/47 14/49 25 48 49 0 122 GG&C 3769 2314 1696 585 4595 485/1316 234/595 393 571 533 217 1714 SGH 346 263 277 34 574 62/183 88/269 1 73 41 15 130

VI 318 359 55 14 428 56/138 69/156 100 48 80 28 256 GRI 932 605 578 18 1201 135/375 57/129 108 144 134 0 386

WIG 826 419 185 200 804 81/210 20/31 81 125 88 50 344

IRH 489 293a 235 53 581 47/179 0/4 35 53 57 35 180

RAH 603 307 298 92 697 63/162 0/4 38 109 133 66 346

VOL 255 68 68 174 310 41/69 0/2 30 19 0 23 72



GJNHb 39(268) 29(451) NA NA 29(451) 0/36 1/27 22 201 5c

NA 228

Highland 814 422 221 36 679 20/58 30/115 88 104 182 0 374

Raigmore 721 287 185 36 508 17/51 25/103 88 104 182 0 374

Peripherals 93 135 36 0 171 3/7 5/12 0 0 0 0 0 Lanarkshir

e 1791 1370 810 119 2299 204/427 192/370 253 143 400 49 845

Hairmyres 534 373 250 0 623 48/120 54/167 128 56 129 - - Monklands 562 537 246 36 819 75/183 68/111 79 49 125 - -

Wishaw 695 460 314 83 857 81/124 70/92 46 38 146 - -

Lothian 2340 1451 845 23 2319 227/573 131/398 231 338 321 77 967d

RIE 92 639 672 0 1311 158/401 63/209 179 284 257 77 797 Lauriston Building 1483 339 NA 0 339 23/69 30/102 NA NA NA NA NA

Roodlands 167 122 NA 18 140 7/9 7/17 NA NA NA NA NA

St John's 396 213 79 5 297 25/48 23/36 38 18 1 0 57

RHSC 202 138 94 0 232 14/46 8/34 14 36 63 0 113

Tayside 1254 - - 43 - - - 204 334 240 95 778f

PRI 337 485e - 41 526 15/75 - 60 116 70 12 246f

Ninewellsg 634 - - 2 - - - 44 150 170 47 364f

Stracathro 283 211 62 0 273 20/27 - 100 68 0 36 168f

-' = Data unavailable 'NA' = Not applicable

aIncludes patients seen at a combined rheumatology/orthopaedic clinic bAll figures in brackets indicate patients referred to GJNH by other hospitals - i.e. inter hospital referrals cThese are patients that have been re-admitted - GJNH does not have a trauma dept dThis figure includes all unscheduled ADMISSIONS not just operations eUnable to breakdown Perth figures into scheduled and unscheduled f95 WLI patients duplicate counted in scheduled care daycase or inpatient operation figures gNinewells outpatient data not submitted in time for inclusion



Appendix C – Orthopaedic Case Studies

1. What if… GP referral patterns could be influenced so that all referrals meet clearly defined and jointly agreed pathway criteria and unexplained variation is reduced? This could lead to a GP/Consultant engagement and education action plan. NHS Boards could then use the Locally Enhanced Services process to improve working between primary and secondary care.

NHS Forth Valley recognised that they would benefit from developing a broader project to engage primary care with the wider redesign and major strategic changes happening within their Board area. After initial discussion between the CHP Clinical Leads, General Managers and the GMS Enhanced Services Group it was decided to use funding as an incentive for practices to take forward work within 3 priority areas:

• Patients’ journeys relating to emergency admissions • Exploring and understanding the factors around Referral Variability (Orthopaedics) • Prescribing- linked to national priorities around antimicrobials and antidepressants

To read more please visit: http://www.18weeks.scot.nhs.uk/how-to-achieve-and-maintain-18-weeks/task-and-finish-groups/orthopaedics/ NHS Forth Valley introduced an ESP-led community screening service for GPs to refer directly to ESP in primary care in 2009. This has reduced the number of referrals to the Orthopaedic outpatient clinic and allowed the patient to be managed in a primary care setting. In a sample of 213 referrals, ESPs were able to manage (or further refer within primary care) 72% of referrals, with only 18% requiring orthopaedic consultant outpatient appointment. For more information please contact Lesley Dawson, ESP, [email protected] NHS Grampian has identified Orthopaedics as a priority speciality and a test bed for their Hub improvement approach. This allowed protected time to study the patient journey and interaction of disciplines, focusing on the first stages of the patient journey, including AHP pathways as well as secondary care referrals. Led by the Better Care Without Delay (BCWD) Team, this work was undertaken over a six week period. Referrals received into Orthopaedics were examined and the triage decisions recorded by Orthopaedic consultants and invited GPs. Patient pathways were mapped out using Visio software and important issues logged. Interviews were semi-structured but allowed to range over any relevant topics that the combined team were interested to pursue. Colleagues from Physiotherapy, Podiatry, Radiology and Rheumatology participated. The physical location of all GPwSI, Radiology facilities and AHPs were also mapped to understand the potential for MSK community based services across Grampian.





There was also involvement and input from e-health analysts to understand the administrative, IT and clinical pathways with a view to transforming the whole process from ‘stage of treatment’ management to an 18 week pathway. This in-depth work on the administrative and IT pathways was part of the ground work for NHS Grampian’s 18 week RTT measurement and tracking system. The Orthopaedic department identified an opportunity to improve administrative and booking processes through the development of a centralised booking office. This has led to the consistent management of waiting lists, equitable access for patients and efficient use of theatres. Staff were given refresher courses for the main systems in operation to ensure data was accurately collected. The triage process was improved to ensure consistency of decision making. Physiotherapists and GPwSI are also now involved in vetting so patients can be appropriately directed to the right healthcare professional. For more information please contact Aileen MacVinish, 18 Weeks Programme Manager: [email protected] .

2. What if… New Outpatient Appointments could be reduced by X% and the conversion rate to surgery therefore increased to Y% This analysis could lead to a Community MSK project – see Section 3.3 Primary Care Solutions.

NHS Dumfries and Galloway found that Lower Back Pain (LBP) was a challenge, accounting for approximately 15-20% of all orthopaedic referrals. Working with the Orthopaedic team the 18 Week Project Team developed a new patient pathway for all LBP referrals. An ESP was appointed to join the Orthopaedic team. A SCI referral protocol has been created and development sessions with GPs to support implementation have been arranged. The ESP triages all direct referrals along with LBP referrals to the consultant team with the exception of Cauda Equina. Appointments are managed as part of the orthopaedic service through Patient Focussed Booking and a significant number are followed up by telephone. Protocols have been agreed with the radiology department to allow ESP to refer for MRI. The introduction of this service has supported the achievement of reduced waiting times for consultant led Orthopaedic clinics. To read the full case study please visit: http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Improving_Management_of_Low_Back_Pain.aspx


http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Improving_Management_of_Low_Back_Pain.aspx



3. What if… Procedure X or Diagnostic Test Y was undertaken at the median rate per 100,000 of population? This analysis could lead to a review of referral criteria and a reduction in variation.

NHS Borders looked at their booking process for Physiological measurement and identified that moving from a paper based to electronic booking system would reduce the workload of the administrative staff and reduce the need to involve clinical staff in the booking process. To read the full case study please visit: http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/implementing_electronic_booking_for_physiological_measures.aspx NHS Lothian had a 45 week wait for Nerve Conduction Studies in November 2009. To tackle this, an initial scoping exercise was undertaken which included data analysis, stakeholder interviews, process mapping and clinic observations. A one-day workout was held for all staff to identify the issues and an action plan was developed and implemented. Some of the changes included patient focussed booking, improved patient information, waiting list validation, increasing capacity by altering templates and the implementation of physiologist reporting. A meeting was also held with regional referrers to the service and actions included agreeing a clear referral pathway, referral guidelines for non-consultant referrals, SCI referral form and improved communication between the department and referrers. Capacity for physiologist led nerve conduction studies increased from 12 slots per week to 21 and waiting times reduced to 6 weeks for physiologist led test and 12 weeks for consultant led tests. DNA rates were also reduced from 15% to 2%. To read the full case study please visit: http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Nerve_Conduction_Studies.aspx NHS Lanarkshire looked at patients referred for a brain CT scan and identified that unnecessary delays were being caused, because patients had to attend a consultant-led Neurology outpatient clinic which had a 17 weeks wait to then get referred for a scan which had a further six week wait. A straight-to-test referral protocol for open access to CT was drawn up and agreed in consultation with local GP representatives. This was then communicated to all GPs in NHS Lanarkshire. Since the introduction of direct GP referral to CT, the waiting time has been reduced to three weeks for a CT scan. To read the full case study please visit: http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/straight_to_test_protocols_for_brain_scans.aspx NHS Tayside undertook a 6 months pilot of direct access to MRI Lumber spine in April 2009. Alan Cook spoke about this work at the ‘Diagnostics – An integral part of 18 week patient pathways’ event on the 31 March 2010. To view the presentation please visit: http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/Pages/31March2010-Diagnostics–Anintegralpartof18weekpatientpathways.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/implementing_electronic_booking_for_physiological_measures.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/implementing_electronic_booking_for_physiological_measures.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Nerve_Conduction_Studies.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/straight_to_test_protocols_for_brain_scans.aspx

http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/Pages/31March2010-Diagnostics%E2%80%93Anintegralpartof18weekpatientpathways.aspx

http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/Pages/31March2010-Diagnostics%E2%80%93Anintegralpartof18weekpatientpathways.aspx



4. What if… the New to Return appointment ratio were optimised? New attendances could potentially increase if return appointment slots were freed-up. Could AHPs (e.g. Physiotherapists, Occupational Therapists) in primary or secondary care see some return patients? Allow for differences in new to return ratios between sub-specialties.

NHS Dumfries and Galloway is piloting different approaches to communicate test results to patients and GPs without the need to arrange follow up appointments. This is either in the form of telephone or written commutation, and is supported by advancing technology to track test requests and receipts. For more information please contact Nicole Connell, 18 Weeks Programme Manager: [email protected]. NHS Fife found that there were an increasing number of patients presenting to Orthopaedic clinics with shoulder problems and the resultant impact on follow up activity. Analysis of patients highlighted that most post-operative shoulder surgery follow up is routine and could be undertaken by an ESP. It was agreed the ESP would follow up post-surgery patients. Initially this was undertaken at a mixed clinic and latterly at a specific ESP shoulder follow-up clinic. A five week shadowing process was undertaken to ensure the quality of the patient pathway. To read the full case study please visit: http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Providing_Orthopaedic_Follow-ups_in_the_Correct_Care_Setting.aspx

5. What if… all scheduled clinics went ahead and all slots at scheduled clinics were utilised? Analysis may show a significant number of ‘gaps’ in the clinics that actually occur. Clinics may be cancelled for valid reasons but not reinstated if the reason changes. Analysis may also show a significant variation in the number of patients seen each week at each clinic. This offers the opportunity to improve capacity utilisation. Templates and staffing may also need to be clarified. Consider reducing infrequent sub-specialty clinics and/or ensure empty slots are filled with general patients at an agreed timescale prior to the clinic.

NHS Fife looked at ways they could reduce their Rheumatology waiting times to achieve the guarantee of nine weeks by March 2010. The service was already achieving the current waiting time guarantee of 12 weeks. NHS Fife invited the Improvement and Support Team (IST) to conduct an initial service assessment, including data collection and analysis, provision of external models of care and to provide recommendations on how to take the service forward. For more information about the recommendations that NHS Fife implemented, please contact Helen Woodburn, 18 Weeks Programme Manager: [email protected].


http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Providing_Orthopaedic_Follow-ups_in_the_Correct_Care_Setting.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Providing_Orthopaedic_Follow-ups_in_the_Correct_Care_Setting.aspx




6. What if… all new appointments were allocated X minutes & follow-ups were Y minutes and all clinics ran for at least four hours? This analysis may identify potential for additional clinic slots. The amount of time allocated will need to vary by sub-specialty and for more complex cases. There may be significant variation in the length of scheduled clinic times. There may be historic reasons for this. Where possible these clinic profiles should be re-negotiated as it is likely that a minimum of four hours is more efficient use of the time for all the staff involved.

NHS Dumfries and Galloway recently reviewed all Orthopaedic outpatient clinic profiles to set them all at the same duration and with the same number of return and new slots. This will enable the team to plan available capacity better. For more information please contact Nicole Connell, 18 Weeks Programme Manager: [email protected]. NHS Fife identified that patients were waiting too long in the Orthopaedic outpatient clinic. A computer simulation, built on information from process mapping and patient tracking, was used to test potential improvements to the clinic. One of the objectives of the simulation was to improve the experience for patients and staff who attended the clinics. After simulating the impact of small, incremental changes to the clinic, the clinical director moved small fracture appointment slots away from the start of the orthopaedic clinic and negotiated all of the small tissue patients to be reviewed in A&E where they had previously been followed up. The outcome was an improvement in the running of the general clinic; it became less busy and less fractious. Anecdotally, patients appeared to be waiting significantly less time to be seen. A further patient tracking exercise will be undertaken in the New Year to quantify the impact of the changes to the pathway. To read the full case study please visit: http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/simulation_modelling_of_an_orthopaedic_clinic.aspx

7. What if… some clinics ran for more than 42 weeks a year? This scenario is only relevant where space is a rate limiting factor rather than consultant availability. This may be relevant at some Boards where other consultants can use the space for clinics in the weeks where the normal clinic is not running.

NHS Dumfries and Galloway has reviewed consultant job plans to ensure they accurately reflect service demands. An Associate Specialist also provides cover for consultant clinics allowing for capacity to be available for approximately 48 weeks a year. For more information please contact Nicole Connell, 18 Weeks Programme Manager: [email protected]


http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/simulation_modelling_of_an_orthopaedic_clinic.aspx




8. What if …. Pre-op length of stay could be reduced to achieve upper quartile in Better Quality Better Value Indicators? Analysis may identify opportunities to reduce pre-operative stay potentially releasing beds days and increasing productivity.

NHS Borders introduced a new structure for day surgery shoulder care. Criteria were developed for pre-assessment. Patients who met the criteria at the pre-assessment service were added directly to the day surgery list instead of previously being added to the inpatients waiting list. A liaison nurse was employed for six months to deliver home care on these patients' first day post operative. To read the full case study please visit: http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/changing_in-patient_surgery.aspx NHS Dumfries and Galloway has developed a comprehensive pre-operative assessment service across the region for both inpatients and day surgery services. This links with a co-ordinated approach to booking orthopaedic waiting lists which has seen the pre-op length of stay for the speciality reduce from 0.71 in 2007/2008 to currently 0.2. To read the full case study please visit http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/pre-operative_assessment_service.aspx NHS Lanarkshire has established a single system of pre-admission assessment for all planned surgical procedures. This facilitates consistent, standardised assessment and preparation at each of the acute hospital sites. This includes consistent pre admission pathways, standardised clinical protocols and documentation and equity of resources in terms of staffing, equipment and physical environment. This forms the building blocks for the 18 weeks programme. NHS Lanarkshire achieved 100% pre–admission assessment for all elective surgical patients at August 2009, increased % of day case rates across all specialties and day of surgery admissions. There is also further development of one-stop clinics where patients come directly to pre-admission assessment from the outpatient clinic. To read a poster with more information please visit: http://www.18weeks.scot.nhs.uk/how-to-achieve-and-maintain-18-weeks/task-and-finish-groups/orthopaedics/

NHS Lothian identified that all Orthopaedic patients were admitted to an inpatient bed the day prior to their operation even though most patients had no therapeutic input on this day so the admission process was reviewed. Using Lean techniques the patient pathway was process mapped and all non-value adding steps were identified at a workshop involving multidisciplinary groups of staff. The pathway was streamlined to allow patients to come in on the day of surgery, an exclusion criteria was agreed for patients who would require day before admission. The Day of Surgery Admission unit (DOSA) opened in the Royal Infirmary in January 2008 and is housed alongside the

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/changing_in-patient_surgery.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/pre-operative_assessment_service.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/pre-operative_assessment_service.aspx




pre-assessment clinics. All patients (excluding the agreed criteria) are admitted directly to this unit, being reviewed by the surgeon and anaesthetist and going straight to their operation. To read the full case study please visit: http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/day_of_surgery_orthopaedic_admissions.aspx NHS Grampian was scheduling pre-assessment appointments late in the patient pathway. This meant that if patients failed then theatre slots were cancelled at last minute. Due to a lack of a consistent process patients were spending up to three hours in pre-assessment with only half of this time spent in clinical contact. A Value Stream Analysis of the Orthopaedic pathway identified a number of areas that would benefit from further analysis and improvement work. Improvements to the whole pre-assessment process were seen as a priority for patient experience and efficient use of departmental resources. A Rapid Improvement Event (RIE) was set up involving GPs, Consultants, nursing, AHP and administrative staff. The current state of the pre-assessment pathway was mapped and staff had the opportunity to add comments and issues. The RIE examined patient flow, administrative flow, staff flow and scheduling. Some of the implemented improvements included quick health screen at outpatients for all patients going for surgery, set criteria for all patients requiring full assessment on medical grounds and relating to proposed procedure, pre-assessment appointments given to patient before leaving outpatient department, patient information given to patient before pre-assessment, pre-assessment brought forward in the pathway to approx 6 weeks in advance of surgery, number of pre-assessment slots increased from 48 to 70, pre-assessment clinic flow re-organised with appointments introduced, to reduce time patients are in attendance and new clinic flow allows doctors, AHPs to attend at fixed intervals thereby reducing time they are in attendance and paperwork reviewed to avoid duplication. To read the full case study please visit: http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Improving_Orthopaedics_Pre-assessment_in_NHSGrampian.aspx

9. What if …. Average length of stay could be reduced to achieve upper quartile in Better Quality Better Value Indicators? Analysis may identify opportunities to reduced average length of stay potentially releasing bed days and increasing productivity. Implementation of Enhanced Recovery should be considered to support the reduction in average length of stay. (See Section 3.5.3)

Golden Jubilee National Hospital (GJNH) found that patients undergoing total knee replacements (TKR) suffer from significant pain which resultantly slows down their rehabilitation and therefore increases length of stay. Numerous methods had been used to help alleviate pain but resulted in patients still being in hospital on average for over one week. Through a visit to Copenhagen to look at their technique to reduce pain whilst shortening length of stay, GJNH developed a new Enhanced Recovery approach which was piloted and then spread across the

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/day_of_surgery_orthopaedic_admissions.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/day_of_surgery_orthopaedic_admissions.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Improving_Orthopaedics_Pre-assessment_in_NHSGrampian.aspx



whole department which was named the CALEDonian Technique which stands for Clinical Attitudes Leading to Early Discharge. No patient is excluded from the pathway and it has been expanded to include all orthopaedic patients within the GJNH. Along with lower average length of stay and satisfactory pain scores, GJNH staff have managed to reduce the time required for routine observations and have been freed up to spend more time caring for the patients. To read the full case study please visit: http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Improved_Patient_Pathway_Enhanced_Recovery_Programme.aspx NHS Borders has an increasing reliance on outsourcing orthopaedic work due to a lack of capacity. They wish to treat all patients locally and will need to manage a potential 20% increase in activity. After looking at data from a bed modelling tool and national audits it was identified that the average length of stay for fractured neck of femur (FNOF) patients for the past three years was 16-21 days. A multi-disciplinary team agreed that this could be reduced to five days. The current patient flow was mapped and changes included categorising patients by complexity at the beginning of their journey and preparing for discharge or further rehabilitation within five days. In six months the length of stay reduced from 16 to 10 days and is still reducing. To read the full case study please visit: http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/reducing_length_of_stay_for_fractured_neck_of_femur_patients.aspx NHS Fife reduced the average length of stay for hip replacement patients by improving pre-assessment. The improvement of this service enabled staff to improve the management of patient and carer expectations. An improvement in pain management protocols on the ward was also implemented. Improvements ensured patients did not remain in hospital unnecessarily. The average length of stay reduced from approximately ten to seven days. To read the full case study please visit: http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/reducing_length_of_stay_for_hip_surgery.aspx NHS Forth Valley found that the length of stay for elective total hip replacement (THR) and TKR varied across their NHS Board. To address this data was collected per procedure, consultant and by day of surgery and an audit of delayed discharges on an elective Orthopaedics ward was undertaken by a physiotherapist. Now, an agreed standard length of stay for elective THR and TKR is four days is in place. To read the full case study please visit: http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/managing_length_of_stay_for_hip_and_knee_replacement.aspx NHS Greater Glasgow and Clyde was placing shoulder surgery patients on an inpatient waiting list; this increased the waiting time for surgery and the length of stay in hospital. A new structure for day shoulder surgery was developed for patients that met the criteria at the pre-assessment service. A liaison nurse was also employed for six months to deliver home care for these patients’ first post operative day. To read the full case study please visit: http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/changing_in-patient_surgery.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Improved_Patient_Pathway_Enhanced_Recovery_Programme.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/reducing_length_of_stay_for_fractured_neck_of_femur_patients.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/reducing_length_of_stay_for_fractured_neck_of_femur_patients.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/reducing_length_of_stay_for_hip_surgery.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/reducing_length_of_stay_for_hip_surgery.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/managing_length_of_stay_for_hip_and_knee_replacement.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/managing_length_of_stay_for_hip_and_knee_replacement.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/changing_in-patient_surgery.aspx



10. What if … Same Day Surgery Rates were optimised? Analysis of British Association of Day Surgery (BADS) directory of procedures and Better Quality Better Value Indicators may highlight opportunities to increase day surgery rates and improve efficiency of pathways. See http://www.bads.co.uk and http://www.bqbvindicators.scot.nhs.uk/ for more information.

NHS Forth Valley developed day surgery pathways for foot and shoulder patients and are in the upper quartile in Scotland for day surgery rates overall. For more information please contact Alison Easson, Service Improvement Manager: [email protected] NHS Lanarkshire reviewed their practices and processes within their Day Surgery Units to improve patient journeys. Pre-assessment criteria for day case surgery were revised to ensure consistency of patients treated as day case. A protocol was introduced for managing patients that do not fit the day case criteria. Nurse led discharge, unless special arrangements had been made, and a post Anaesthesia Discharge Scoring System was introduced in the day surgery units. A review of admission times for day case patients was undertaken and a protocol implemented whereby patients on afternoon only theatre lists are now admitted no earlier than 12.00 noon on the day of surgery. To read a poster more with more information about this work, the discharge protocol for day surgery patients and protocol for overnight admissions following day surgery please visit: http://www.18weeks.scot.nhs.uk/how-to-achieve-and-maintain-18-weeks/task-and-finish-groups/orthopaedics/ NHS Tayside analysed patient activity for April – June 2009. Procedures with high volumes of patients which were performing below the day surgery target were identified and further analysis undertaken. Thirteen procedures in Orthopaedics, Gynaecology and ENT were identified. Graphs were produced to illustrate actual performance of each procedure against their BADS target. Improvement trajectories were included to highlight month on month performance required to reach individual targets by March 2010. In July 2010 the same day surgery rate was 76.5% which meets the end March 2011 target. To read the full case study please visit: http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Treat_Day_Surgery_As_The_Norm.aspx




http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Treat_Day_Surgery_As_The_Norm.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Treat_Day_Surgery_As_The_Norm.aspx

http://www.bads.co.uk/




11. What if … Administrative delays were eliminated from pathways? Analysis of MSK Carpal Tunnel and Arthroscopy Audits, as well as 18 weeks Readiness Assessment (See Section 3.5 http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/Pages/Resources.aspx) may highlight opportunities to improve pathways through reduction in administrative delays.

NHS Forth Valley has undertaken work to streamline the elective booking process for patients to eliminate unnecessary delays. This has included improving processes between out patient’s clerks, waiting list clerks and pre operative assessment. For more information please contact Amanda Forbes, NHS Forth Valley 18 Weeks Programme Manager: [email protected] NHS Lanarkshire identified the administrative and clerical staff as being essential to the delivery of 18 weeks RTT and redesigned the roles of the Orthopaedic secretarial team in partnership with staff to reduce variation and streamline processes. For more information please contact Cathy Dunn, 18 Weeks Programme Manager: [email protected]

12. What if … Theatre utilisation was optimised? Analysis of data collected through the National Theatres Benchmarking Project may identify opportunities to improve theatre efficiencies (see http://www.isdscotland.org/isd/6321.html).

NHS Borders applied LEAN methodology to improve theatre utilisation and increase patient throughput by streamlining processes. Actions included value stream mapping of the patient journey, staff and patient observations and a one week RIE. Outcomes of the work have produced earlier surgical start times and quicker patient turnaround times, improved theatre throughput managing three major cases/list. Improved processes delivered 16 additional minor cases per month, improved compliance with patient safety checks, reduction in list over runs in theatre and an increase in staff morale. For more information on this work please contact Irene Gourlay, 18 Weeks Programme Manager: [email protected].





http://www.isdscotland.org/isd/6321.html



NHS Lanarkshire increased effectiveness of theatres through the use of lean methodology. NHS Lanarkshire presented at the ‘Improving the Safety, Reliability and Efficiency of Theatres - An Integrated Approach to Improvement’ event on the 14 June 2010. To view the presentation please visit: http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/Pages/14June2010%20-%20Improving%20the%20Safety,%20Reliability%20and%20Efficiency%20of%20Theatres%20-%20An%20Integrated%20Approach%20to%20Improvement.aspx

13. What if … e-referrals from GP’s were optimised? Analysis of % of electronic referrals may identify opportunities to improve referral rate and also to highlight opportunities to reduce variation in referral rates.

NHS Ayrshire and Arran receives 98% of GP referrals via SCI gateway. Electronic referral management is being rolled out across all specialties and 55% of referrals are now managed electronically. Orthopaedics at Crosshouse Hospital now manages all referrals electronically with Extended Scope Physiotherapists triaging all referrals and allocating to the most appropriate service. Time taken to vet referrals and appoint patients has dropped from an average of 8 -14 days and a maximum of 56 days, to an average of 3 – 7 days and a maximum of 14 days. Electronic management of referrals was rolled out to the Ayr Hospital site by the end of September 2010. Analysis of the electronic referrals has highlighted a difference in waiting times for triage for referrals to named Consultants. GPs have now been advised that referrals should be made to the specialty rather than to named individuals. For more information on this work, please contact Joan McGhee, 18 Weeks Programme Manager: [email protected] NHS Forth Valley receives 98% of referrals via SCI Gateway. Orthopaedic referrals are classified by body part and the ESP Physiotherapist triages the referrals electronically. A pathway was agreed for referrals for Orthotics to be vetted and triaged directly to Orthotics. This avoids any avoid unnecessary delay and removes the requirement for an outpatient consultation with an Orthopaedic consultant. For more information please contact Alison Easson, Service Improvement Manager: [email protected]

http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/Pages/14June2010%20-%20Improving%20the%20Safety,%20Reliability%20and%20Efficiency%20of%20Theatres%20-%20An%20Integrated%20Approach%20to%20Improvement.aspx







14. What if … all outpatient new and return patients were outcomed? Analysis of outcome data may identify opportunities for further redesign and transformation.

NHS Forth Valley is recording clinic outcomes for all new and return outpatient clinics. In August 2010, Orthopaedic clinics had 93% clinic outcomes recorded. For more information please contact Amanda Forbes, 18 Weeks Programme Manager: [email protected] NHS Greater Glasgow and Clyde undertook an evaluation of clinic outcome data captured across their eight sites within the Board. This found inconsistent practice and variance across sites. A pilot was set up to test a new version of the outcome form. Following feedback from the pilot, guidance tools were developed and the outcome form revised. The redesigned outcome form was implemented for all outpatient appointments. Weekly compliance reports are produced from IT and shared with the service. Support is provided to the service through Service Improvement Managers and webnet to encourage correct completion of outcome forms. NHS Greater Glasgow and Clyde presented this work at the ‘18 Weeks Event for Administrative Services Staff’ on the 25 February 2010. To view the presentation please visit: http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/Pages/25%20February%202010%20-%2018%20Weeks%20Event%20for%20Administrativeistrative%20Services%20Staff.aspx NHS Lanarkshire increased the amount of clinical outcomes recorded and electronic management of referrals through good communications across their NHS Board. NHS Lanarkshire presented this work at the ‘18 Weeks Event for Administrative Services Staff’ on the 25 February 2010. To view the presentation please visit: http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/Pages/25%20February%202010%20-%2018%20Weeks%20Event%20for%20Administrativeistrative%20Services%20Staff.aspx


http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/Pages/25%20February%202010%20-%2018%20Weeks%20Event%20for%20Administrative%20Services%20Staff.aspx





October 2010

15. What if … referral and diagnostic pathways were improved? Analysis of referral and diagnostic pathways may identify opportunities to reduce variation.

NHS Ayrshire and Arran identified that there was variation in treatment for non-arthritic knee pain across the Board. In addition, a number of patients referred into Orthopaedic Consultants were unsuitable for surgery which resulted in wasted clinical and patient time. Analysis of case records revealed differences in treatment and routes of referral. A multi-disciplinary group including Primary Care representatives’ process mapped the current pathway and identified areas for improvement. Agreement was reached on referral criteria and subsequent investigation and treatment plans. NHS Ayrshire and Arran are now involved in planning, developing and piloting a new MSK triage and treat service with joint involvement of Orthopaedic and Physiotherapy services. To read the full case study please visit – http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Non_Arthritic_Knee_Pathway_in_Ayrshire_%20and_Arran.aspx NHS Dumfries and Galloway has commenced work on the management of return patients, working with local GPs and extending the roles of Allied Health Professionals (AHPs) and Specialist Nurses. A new role has been developed within the AHP team to receive direct referrals for certain conditions. A team of Extended Scope Practitioners (ESP) triage all referrals to remove those suitable for AHP review with the remainder being sent for consultant vetting. This will have a significant impact on demand for consultant-led clinics. For more information please contact Nicole Connell, 18 Weeks Programme Manager: [email protected]. NHS Dumfries and Galloway: Go to Question 2 to see how NHS Dumfries and Galloway have improved the management of Lower Back Pain patients NHS Fife is reviewing the service offered to patients with musculoskeletal (MSK) referrals. Triage hubs are being developed; the hubs will be established outside of the acute sector and in the Community Health Partnerships (CHPs). Triage hubs are multi-disciplinary and will predominantly be led by AHPs and closely supported by consultants and GPs with Specialist Interests (GPwSI). The purpose is to be a central point for MSK referrals. The team of MSK professionals will triage patients onto the most appropriate pathway. For more information please contact Helen Woodburn, 18 Weeks Programme Manager, [email protected]

F3130196 Page 62 of 63

NHS Highland has introduced triage of Orthopaedic referrals by Physiotherapy. To read the full case study, please visit http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Triage_of_orthopaedic_ref.aspx.

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Non_Arthritic_Knee_Pathway_in_Ayrshire_%20and_Arran.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Non_Arthritic_Knee_Pathway_in_Ayrshire_%20and_Arran.aspx



http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Triage_of_orthopaedic_ref.aspx



NHS Lanarkshire: Go to Question 3 to see how NHS Lanarkshire have introduced direct access GP access to CT. NHS Orkney identified that there was an unsustainable number of new cases being seen by the visiting consultant service. After looking at the activity data it was identified that not all referrals required the input from the Orthopaedic surgical service. A Physiotherapy-led triage system was introduced to identify appropriate patients for physiotherapy input and treatment, a Physiotherapist was also employed to develop a referral protocol. Average waiting times for the visiting Orthopaedic consultant service reduced from 11 weeks in March 2008 to 4.5 weeks in March 2010. To read the full case study please visit: http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Triage_of_Referrals_Prioir_to_Seeing_a_Consultant.aspx NHS Tayside aimed to improve the 18 week Referral to Treatment pathways for Orthopaedics, improve access to the service and reducing inequalities. This was achieved through bringing all stakeholders together to discuss opportunities for improvement. Benefit realisation templates were completed. Following the event the service improvement team and senior managers collated the information and produced an action plan. To read the full case study please visit: http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/end_to_end_orthopaedic_pathways.aspx Go to Question 3 to see how NHS Tayside have piloted direct access for MRI Lumber spine and NHS Lanarkshire have introduced direct access GP access to CT.

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Triage_of_Referrals_Prioir_to_Seeing_a_Consultant.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/Pages/Triage_of_Referrals_Prioir_to_Seeing_a_Consultant.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/end_to_end_orthopaedic_pathways.aspx

http://www.improvingnhsscotland.scot.nhs.uk/case-studies/pages/end_to_end_orthopaedic_pathways.aspx

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Scottish Government Health Directorates: Delivery