AHP Out-Patient Services Capacity and Demand Management Masterclass

1. AHP Out-Patient Services Capacity and Demand ManagementMasterclass Robert Jones Fiona Jenkins 3rd June 2011

2. Objectives • Reasons for considering new approaches to AHP booking systems • The concepts of backlog, capacity and demand modelling in relation to out-patient appointments systems, using data to inform decision-making • Familiarisation with a system for managing and reducing waiting lists and DNA • Sustainability of a new system • Impact of reduced delays on AHP pathways • Concepts of service re-design to be able to implement and sustain change • National reporting

3. Before break • Why waiting list management ? • Concepts of capacity and demand • IM&T • Managing change- taking staff with you

4. Your Expectations?

5. Jargon Buster Demand - what we should be doing Activity - what we are doing Capacity - what we could be doing Backlog - what we should have done but haven’t Carve out- sub-dividing service into specialties

6. Who has a Waiting List?

8. Physio Out patient longest waits

9. How do you calculate your waits? • When do you count the start of the wait? • When do you count the end of the wait? • Does the way that patient access your service influence the wait time?

10. The DH waiting time definition The time between: the date that a referral is received and the date the patient istreated.

11. What are you aiming for? • What has worked previously? • Was it sustainable? • Who pays for your service(s)..what difference does this make? • Are you needing to scrutinise costs? • Contestability...is this coming? • What do your patients think? • What do your referrers think? • What do your commissioners think?

12. Consider • Do your patients and referrers want shorter waits? • What facilities have you got • Staff specialism • Skill mix profile – is it optimal? • Staff profile, activity and service costs • Infrastructure – admin, data collection, phones • How long per appointment • How many contacts per episode • Are you ready to pass control over to patients? • Is your service ready to re-design?

13. Validating waiting lists – have you tried it? • Validation is checking to see that the patients require appointment • Has their condition improved so they no longer require the appointment? • Do by sending letters or telephoning • …especially if you have a long waiting list • Gives you a clearer understanding of 'real' demand in the system.

14. Wasted Slots • Don’t confuse your DNAs and UTAs • How to calculate? • Liberate capacity

15. Data and Information • What is data? • What is information? • What have you got? • How do you collect it? • How do you use it ? • What do you need ?

16. Benefits • Information for: • Management • clinical • finance • workforce

17. Pay and Non Pay Overheads Capital charges Other Largest element for AHPs is staff costs Costs of your service

18. Planning staff involvement

19. R

20. A Framework for the Management of Change Moving From the Current to the desired - triggers for change Essential Actions Skills for Success Evaluation Learning Points F

22. Questions so far?

23. THE FINANCIAL CONTEXT - Extraordinary Public Sector Debt - Public Sector Funding Restricted (Zero Growth) - Higher Inflation and Downward Pay Pressure - Tariff reduced by 1.5% - 2% per annum -Population Increase (elderly, LTC) -Medical and Drug Advances (Technology) - Shift from Secondary to Primary Care - Expensive Infrastructure - Financial Deficits in Organisations

24. THE NEXT FIVE YEARS • Continuing Tariff Reduction • At least 2.5% inflation • Cost Pressures • Organisations with Recurring Deficits • Efficiency Requirement • Less Money to do More Activity or Work differently • Activity Volumes too High to be affordable • Insufficient Community and Primary Care Infrastructure • Variation in Length of Stay • Too many Follow-ups and too many DNAs • Too Many Staff and too Many Beds!

25. SOME SHORT AND LONG TERM STRATEGIES • Improved Effectiveness and Efficiency • Organisation Development Structure • Patient Level Costing Driving Strategy (SLR) • Improved Productivity • Vertical Integration, e.g (Stroke, COPD, Hospital at Home • Horizontal Integration (e.g Path, Backroom) • Quality, Patient Safety Initiatives • Reduced Activity • Disease Management - Self Care) • Effective, Lean ( Programme Management) • Less Money, therefore Less Beds, Less Staff • Less expensive Management Structures • Tendering • Any Willing Provider?

26. Have you thought of Benchmarking? • Valuable tool to determine how your service compares • Requires collection and interpretation of data • Can be wide-ranging or very focussed • Can speak louder than your single voice • ….or identify where efficiencies can be made

27. Edited by Robert Jones and Fiona Jenkins Foreword by Karen Middleton The Jigsaw of Reform: Pushing the Parameters Money, Money, Money: Fundamentals of Finance Commissioning for Health Improvement: Policy and Practice Striking the Agreement: Business Case and SLAs   Thriving In the Cash Strapped Organisation   Information is Power - Measure it, Manage it Information Management for Healthcare Professionals Allied Health Records in the Electronic Age Data ‘Sanity’: Reducing Variation   Outcome Measurement in Clinical Practice Improving Access to Services: demand and capacity to support service re-design   Benchmarking AHP Services    Management Quality and Operational Excellence Evaluating Management Quality in the Allied Health Professions Evaluating Clinical Performance in Healthcare Services  Project Management for Allied Health Professionals with Real Jobs Marketing for AHPs Effective Report Writing   Demonstrating Worth: Marketing and Impact Measurement Self – Referral  

28. Do you have a waiting list? What is the size of the list? Is it a problem? What is your target? Are you meeting it? What have you tried before to manage it? What size what it last year? ..and the year before? How many waiting lists do you have? Do you carve out? How do you prioritise? Who puts patients on the waiting list? Do you have referral criteria? Any Patients Waiting?

29. Questions • What is you waiting time? • What is your DNA rate? • Do you have carve out? • What are the causes of waits? • Does it fluctuate? • Why does it fluctuate? • How do you currently manage waiting lists? • What info systems do you have? • Do staff accurately input data? • Do you make full use of it? • Does Choose and Book impact?

30. How referrals are handled affects waits

31. Because demand exceeds capacity? Mismatch between demand and capacity? We want queues to keep us busy? Variation in demand + variation in capacity = queue Occasionally demand > capacity Why do queues form?

32. Managing Flow NHSI No delays achiever

33. How to Measure Capacity • Understand how you use time, patient and non patient contact time • Expertise available, staff hours in WTE and grade, and hours the service is open for • If equipment or facilities are an essential element, their availability need calculating.

34. How to Measure Demand • Understand your referral patterns and type • Multiply the number of patients referred from all sources by the time it takes to complete a patient episode • Measure true demand- are there some not accessing your service that should be?

35. Patient Flow • In healthcare flow is the movement of patients, information or equipment between departments, staff groups or organisation as part of a patients care pathway. Three options • Manage flow • Create flow • Increase responsiveness

36. How to Measure the Backlog • Multiply the number of patients waiting by the time it takes to complete the patient episode. • For example, 100 patients on the waiting list x 30 minute treatment time each = 50 hours backlog. • If you are working towards a 6 week wait, and have 16 weeks on your waiting list, backlog = 10 weeks • Need to consider the number of patients waiting and the time that represents

37. Planning to Match Capacity and Demand • If services are planned so that average capacity is higher than average demand, waiting lists rarely build up and should decrease ;as long as the capacity is used. • The level to aim for is to set capacity higher than the average demand.

38. The famous have said: • “You will never solve the problem with the mindset that created it” Albert Einstein • “Every system is perfectly designed to achieve the results it gets”Don Berwick

39. Where do we get extra capacity from? • New Money ££££££££££! • Map process • re-design process • measure bottleneck • demand/capacity/activity/backlog • analyse data :- reduce variation • continue to measure and analyse

40. Activity • What do staff do with their time? • How much of each activity • Who does it • Where it happens • Methodology to ascertain accurate picture of what staff are doing with their time • Ability to drill down

41. Why do we need to know this? • Development of staffing profiles • Case load management • Skill mix management • Evidence-based staff deployment • Clinical issues • Audit and R&D

42. Why do we need to know this? • Clinical governance • Effectiveness and quality • Evidence-base for service development • Business environment and strategy • Service and workforce planning • Service re-design “tool” • Capacity and demand management

43. Paediatrics and long term disability management • Traditionally heavy caseloads and long waits • Even more important to undertake capacity/demand management • Do you want to see the patient? • Or do they need to see you? • Episodes of care philosophy • Patient self-referral • Caseload management tools • Regular review • Skill mix

44. Staff Activity • What do staff do with their time? • Patient related • Non patient related • Leave patterns • Maternity leave • Seasonal variation • Daily variations • Carve out • Savings requirements

45. Activity Sample: Methodology • Development and prototyping • Snapshot of activity on a regular basis • Data collection form • Staff involvement • Computer software • Reporting methods • Use

46. Face to face contact -individual Face to face contact – group Telephone contact with patient or carer Activity Sample Form Direct Patient Contact

47. Ward rounds Case conferences Administration- patient related Home assessment visits Patient Related Activity Sample Form

48. Study leave In-service training Other CPD activity Teaching Supervision Liaison with other services Administration Management duties Travel Staff/team meetings Other Activity Sample Form Non patient related

49. Date of activity sample Site Location Clinician code Band Post name/rotation Absence? Reason Your contracted working hours today Your actual working hours today Number of group sessions you have done today Number of home assessment visits you have done today Number of patients on your caseload today Activity Sample Form Other

50. Examples of analysis • Percentage of time spent in different categories by: • Whole service • Team • Individual band • Individual staff member • Location • Profession comparison