[music]
As a unit we had noticed the demand just kept going and our capacity or our staff was static
and we were always finishing late, always doing overtime, having our patients wait too
long, feeling like we weren't spending enough time with the patients we had in front of
us when there was still another one in the waiting room. So, particularly the junior
staff were feeling very stressed because that is not an easy way to do a good job. So we
felt we had to change.
I think the team has long recognised that we are unable to meet the current demands
that we are facing, and that the system does need to be improved.
The main drivers for change were long waiting times in our clinics, and I guess the need
for us to see not only the urgent patients but also the patients that we don't actually
see as urgent but have also got pressing needs for them, in a timely fashion.
We had an increasing number of patients who couldn't get a clinic appointment. The list
was growing. We had over three thousand patients that haven't been able to get a clinic appointment
for more than several years.
The three drivers for change were the patient, the services and the staff.
For the neonatal service the main driver was that we were undertaking roughly seventy per
cent more outpatient attendances that we were funded for and that raised questions of whether
that was sustainable.
We ran into significant resource pressures. We are a mind driven service and as a public
service to southern Adelaide health region. We have had to respond to the number of referrals
sent to us by the GPs in our region but we have reached capacity.
So for all of our patients access to timely, patient focused care is really important to
us. No matter whether we send them into the private sector or into the public hospital
outpatients department. So re-orientation of the outpatient services is really important
to us on behalf of our patients.
It's really refreshing to take time out and actually review your processes and your systems
because ultimately you can't take those things for granted. The era of being a clinician
where you turned up and you delivered clinical care is gone. To be an effective clinician
now you actually have to understand your service. You have to want to know how to deliver it
better and how to improve it continuously.
In terms of our core business, it is really about thinking about what are the things that
our services are needed for and are there things that we are doing at the moment that
can be done as effectively and efficiently by someone else. For instance, can the same
things be done in general practice.
We are the only publicly funded paediatric and neonatal service from Cross Roads to our
north as far as Mount Gambier in the south. There is nothing else. So, we had to determine
what other services patients could have access to within our region. Such as management
of attention deficit hyperactivity disorder, which
could be managed, for the most part, by the GPs with only an annual review here. Whereas
a number of patients were being followed three monthly here by their paediatrician. So those
have been triaged back to the GPs to manage that process.
So from a neonatal perspective we've been seeing a number of cumulative paediatric patients
over many years and we've come to the conclusion in reality that is not our core business.
Our core business is a co-op of patients who have graduated from the Neonatal Unit and
try and transfer them back to the care of paediatricians or general practitioners as soon as possible
There are a group of patients that are inappropriate for a tertiary hospital to see and it is really
hard, one of the hardest things, we will say no, we are not seeing this patient because
we're the dermatologists and we are really careful about putting the bar up before they
get to us. New patients we have to be very careful that we don't just keep them out of
habit. We actually discharge those back because they might not be needed to be seen in a tertiary hospital.
Two of the big changes across the network have been the re-stratification matrix that
we've developed across each sector. The second major change has been a real culture
shift for the network. Here at Flinders, at the Repat, Noarlunga Hospital and Primary
Care Services, really trying to look at matching the patient need with patient services and
aligning with specialist services that are available at each site.
We measured that we have emergencies. So we could say yes we need this many slots. Otherwise,
we were always asking our guys to see one more emergency, which you are never going
to not do. Clinicians each let the clinic staff know
six weeks in advance if they are going to be away. If they can't let them know in a
timely way then they need to arrange for some cover for them, so the clients that are coming
are still able to be seen.
There are ways of getting more use out of equipment if we change the way we process
them, because the way we are currently doing it, it is taking 30 minutes to disinfect the
equipment that we need, where if there is a way of doing it in five minutes.
One interesting one is that I do a Wednesday clinic and it is always late finishing but
I worked out I could actually start my clinic at a different time and somehow bring the
day forward. Yet, for years and years, I would always start at a certain time. It seemed
quite dramatic to move your staff forward but, you know, it's simple. Trying to get a one
to two old review as a gold standard but when we started we were one to six and I think
that reflected that we were just too busy. We were not discharging. We've got down
to one to four most months but I can't say all the time and we have been able to do that
based on talking about it. It is totally high profile and I do almost jokingly say, guys
how are we getting on, are we actually remembering to discharge people.
One of the things that we put into place in our clinics was that we mandated a review by
consultant. So, once a registrar saw the patient twice there is a mandated consultant review
to ensure that the patient still needs to be in the clinic and in many cases they don't.
One of the processes that was really pivotal to us being able to look appropriate care
and appropriate setting was to make sure we were all talking about the same language.
So, defining what risk was and working out for each organisation what that actually meant
for us.
We drew up guidelines for most of the common gastroenterological problems for general practitioners
to use and essentially we've made the process so that they were obliged to follow the guidelines
up to a certain point, which if the patient or the client then had not responded, then
the patient should be referred to a specialist outpatient department.
Transparency in waiting times is not just important to me as the coordinator of that
patients care but also really important to the patient, to meet their expectations about
when they are going to be able to be seen in the outpatient department, that if it is
in two weeks' time that is great but if we find out that it's four months or six months
because it is not a critically important problem that needs to be seen urgently. Then we can
manage that patient in the meantime using those management guidelines.
The main challenge is the initial amount of work required to provide the information for
our medical colleagues. The modification of the triage criteria, the letters to the GPs
for interim management are going to need to be drafted and will obviously require quite
heavy clinician input.
The difficulties are telling GPs or families that we are not going to be able to fulfil
the request for an appointment. Usually that's not a problem because if we can explain that
we cannot diagnose auditory processing disorder, for example. That is done by other people;
the GP can make a direct referral to those people. Similarly major behavioural difficulties,
if there is not a question of is this caused by medical problem, thyroid problem or particular
diagnosis that requires a paediatrician then the GP can make a direct referral to a clinical
psychologist. They don't need a paediatrician to do that. The GP can do a mental health
care plan under Medicare and skip the unnecessary intermediate step with the paediatrician.
Trying to get people to change their ways because when you have been doing it a certain
way for many years it is very hard to change. To do that you need to show people data, that
there is a better way of doing this. We provided the same amount of care, even a better level
of care. There are always some costs associated with change but I think in the long term this
will actually result in savings.
Sharing with my consultants the fact that there are some interesting patients they will
be giving up and some interesting aspects of medicine that they are going to have to
say well I haven't got the time to do that anymore. That is a small challenge and by
and large it is a challenge they can see as something which is understandable. Therefore,
the problem is relatively small in implementing it.
My advice for other areas looking to undergo this change is that although the initial work
may be very heavy and frustrating that I think the benefits by far outweigh those.
Make sure that you know what you want to achieve, what your outcomes need to be. Make sure that
you communicate effectively with everyone at every step. It has to be a team approach.
There are other people involved in the process of getting the patients through the clinic
efficiently and effectively. You need to involve admin staff. You need to involve nursing staff.
You need to involve the patients in your discussions when redesigning your system and you need
to involve your other customers which may be the referrers which could be internal or
external.
Building relationships takes time and there has to be a lot of trust and to a large extent
it's not about just talking about the strengths, it's about exposing some of your vulnerabilities.
There needs to be a willingness to share information and share resources and if you are able to
then pull that information together and move forward.
I find the rapid improvement program very useful and I think you should use the resources
that you have currently in the system. Use the skilled people who can help you with change
and reform.
So it is very important that once you have completed the process that you go back and
assess what effects these changes that you have made have had in terms of your clinic.
Do some measurements and see if the changes that you have put in place have had the desired
effect.
I think the key approach one has to take when one's initiating change is to ensure that
the people it is going to affect understand the reasons why the change is being initiated.
They understand the options that are ahead and that they play a role in some way shape
or form in choosing those options. Then they own both the problem and the solution and
if they own the solution, they will implement it.
For us it has been worthwhile. We were on a road to nowhere. We had tried the more staff
option but I guess the clinical practice improvement course said to us, forget the more staff option,
you are not going to have it, so, what else are you going to do? And that's when we really
moved into getting interested in redesign because we thought well that is a pretty true
statement. Us and every other unit wants more staff.
One of the roles we have in general practice is shared care of patients, especially those
with chronic diseases or complicated problems that with the right advice from our specialist
colleagues we are very capable of managing those patients in a shared care model.
I think, what we want to do is we want to deliver a service that's of an excellent standard
for our patients. That's really the key and the outcome we would really like to achieve.
What I would hope is that in the next year or two that Southern Adelaide Local Health
Network will be known as the premiere network for managing its outpatient services and that
the community and the staff would both be praising us for a job well done.