PATIENT FOCUSSED BOOKING IMPLEMENTATION GUIDE

Transcription

1 PATIENT FOCUSSED BOOKING IMPLEMENTATION GUIDE

2 PATIENT FOCUSSED BOOKING IMPLEMENTATION GUIDE Scottish Executive, Edinburgh 2006

3 Crown copyright 2006 ISBN: X Scottish Executive St Andrew s House Edinburgh EH1 3DG Produced for the Scottish Executive by Astron B Published by the Scottish Executive, May 2006 Further copies are available from Blackwell s Bookshop 53 South Bridge Edinburgh EH1 1YS The text pages of this document are printed on recycled paper and are 100% recyclable

4 CONTENTS Patient Focussed Booking Implementation Guide: ii-iii Page ACKNOWLEDGEMENTS iv 1. INTRODUCTION 1 Purpose of Guide 2 Who Should use this Guide? 2 What is Patient Focussed Booking? 2 Why Should You Implement PFB? 3 2. PLANNING STAGE 6 Involving Stakeholders 8 Resources 9 Information 13 Policies 15 PFB Adaptation IMPLEMENTATION STAGE 17 Prior to Implementation 18 Going Live 19 Following Implementation 20 PFB for Return Outpatients 21 PFB for Diagnostics, Inpatients and Day Cases HELP AND GUIDANCE 24

5 This Guide has been written by: Stewart Cully Marilyn Horne Linda McAllister Sylvia Moran Max Brown Dan Isaac Acknowledgements Thanks go to all of the project managers and their teams involved in the implementation of Patient Focussed Booking in Outpatient Departments across NHSScotland. Not only have they provided excellent accounts of their experiences but their dedication and ability to drive through change has improved the outpatient booking process throughout Scotland, benefiting hundreds of thousands of patients. The Guide draws heavily on A Guide to Good Practice Elective Services, produced by the National Leadership and Innovation Agency for Healthcare in NHS Wales. Sincere thanks go to the editor, Allan Cumming, for kindly giving permission to use material from the document and for providing invaluable advice and guidance on the development of Patient Focussed Booking in Scotland. MARCH 2006 NHSSCOTLAND HAS EMBRACED THIS NEW WAY OF BOOKING OUTPATIENT APPOINTMENTS AND PATIENTS ARE NOW OFFERED REAL CHOICE. THIS, COUPLED WITH CREATING MORE EFFICIENT MANAGEMENT OF WAITING LISTS, HAS HELPED DRIVE DOWN WAITING TIMES. THE HEALTH DEPARTMENT WILL CONTINUE TO SUPPORT THE DEVELOPMENT AND ROLL OUT OF PFB THROUGH FUTURE PROGRAMMES OF WORK, TO ENSURE THAT SIMILAR BENEFITS CAN BE REALISED IN OTHER PARTS OF THE NHS. Kevin Woods Chief Executive, NHSScotland

6 CHAPTER ONE INTRODUCTION

7 PATIENT FOCUSSED BOOKING IS A PRACTICAL WAY OF OFFERING PATIENTS A CHOICE OF OUTPATIENT APPOINTMENT AND ADHERING TO NEW WAYS GUIDANCE. Dr Harry Burns Chief Medical Officer PURPOSE OF GUIDE This Guide explains the principles behind Patient Focussed Booking (PFB), provides examples of why it is an improvement on traditional booking processes, and outlines a step-by-step approach to implementation. It highlights experiences from staff involved in the implementation of outpatient booking in NHS Scotland and incorporates lessons learned from their experiences. The Guide also considers issues which have arisen during implementation in outpatients, including situations where the process may need to be adapted or where more attention may be required to ensure equality of access for all patients. WHO SHOULD USE THIS GUIDE? This Guide has been produced to support anyone involved in implementing Patient Focussed Booking. The Guide will be relevant to Service and Planning Managers in illustrating the case for PFB, whilst the detailed implementation sections will be of more value to project managers, medical records staff and others involved in changing the booking process. That said, the Guide should provide useful reference material for Community Health Partnerships, GPs, hospital clinicians, allied health professionals and administrative and clerical staff in primary and secondary care settings. WHAT IS PATIENT FOCUSSED BOOKING? Very simply, Patient Focussed Booking (PFB) puts patients at the heart of the booking process by engaging them in a dialogue about their appointment. Previously, patients would be sent an appointment letter, with the date and time of their appointment, no matter how far ahead in time that may have been. There was little certainty that the clinic would not be cancelled or that the patient would attend. With PFB, patients are sent a referral acknowledgment letter, which confirms that they are on a waiting list and that their wait will be no longer than the national standard. The letter explains that the patient will be contacted again nearer the time they are due to attend to arrange their appointment. It may also indicate the likely wait for their appointment, should this be much shorter than the guaranteed maximum. Urgent patients are clinically prioritised to by-pass this process and will always be seen first. Approximately six weeks before they are due to attend, the patient receives the second letter inviting them to telephone to arrange an appointment. When the patient phones, the call operator offers a choice of dates and times and the patient chooses the most convenient to them. If the patient fails to phone, contact details are checked and a reminder letter is sent. If there is still no response, a further letter is sent to the patient and their GP, explaining that the patient has been removed from the waiting list. From a hospital perspective, PFB is about creating a good appointments system, whereas for patients it is about better information and being involved in choosing a convenient appointment. PFB can be introduced wherever an appointment/treatment is booked from a waiting list that has a maximum wait of at least six weeks.

8 Patient Focussed Booking Implementation Guide: 2-3 WHY SHOULD YOU IMPLEMENT PFB? 1. Patients should be listed according to date of referral, so letters are always sent to the longest waiting routine patients, ensuring that they are invited to phone in order (clinically prioritised patients are always seen first). 2. No action is taken to allocate resources to the patient s care until they have contacted the appointment centre to confirm attendance, at which time contact details can also be updated. Therefore, PFB is often referred to as self validating and, assuming waiting times are less than six months, validation should not be necessary once PFB is in place. 3. Patients like it! In September 2005, patients attending dermatology outpatient clinics across Scotland were asked to feedback on the PFB process. There were over 700 responses to the Centre for Change and Innovation survey, revealing that 98% of patients were happy to telephone to arrange their appointment and 97% were happy with the appointment they received. A typical comment reads for someone travelling from the north, it was a lot more convenient being able to make an appointment around work and family commitments and not having to set off too early. 4. The quality of patient information and communication is improved. PFB encourages a dialogue between the hospital and the patient around choosing an appropriate date and time of appointment, thereby directly involving the patient. Before they contact the appointment centre, following referral, the patient receives a letter explaining that they are on a waiting list and are sent a PFB leaflet to explain the process. This is an improvement on the previous booking approach. On receiving an acknowledgement letter, a dermatology patient in Ayrshire & Arran phoned the Booking Centre to say what a good idea it was because at least she knew that her GP referral letter had been received by the hospital. (Having past experience of long waiting times and no contact until the appointment letter was sent out.) This graph shows how waiting times can be dramatically improved by seeing patients in order of referral. NHS Dumfries & Galloway analysed the outpatient waiting list for ophthalmology in September 2004 and found that had the queue been managed by booking routine appointments in turn, the maximum wait could have been reduced from 44 to 21 weeks. One of the fundamentals of PFB is that routine patients are seen in order, so where this was not practised before, the immediate effect on maximum waits can be dramatic. NHS Dumfries & Galloway has fully implemented PFB for new and return outpatients. Actual Outpatient Waiting List Booked in Turn Ophthalmology Sept 2004: Outpatient Waiting List vs List for patients booked in turn Number Wait (weeks)

9 5. Patients have a choice. With PFB, the patient instigates the dialogue about their appointment more suited to their lifestyle. The data collected demonstrates that patients are far more likely to attend as a result. 6. PFB makes the booking and waiting list management process more open and transparent. Waiting lists become visible when linked to PFB and patients are much more aware of how long their wait is likely to be. 7. Interim guidance on New Ways of Defining and Measuring Waiting Times, distributed to NHS Board chief executives in March 2005 by the Scottish Executive Health Department set out the choice agenda to be in place by the end of Included within the guidance is a statement on what is considered to be a reasonable offer of an appointment/admission. This is described as regardless of method of offer (written/verbal/combination) the patient should be offered a minimum of three dates all of which should be at least three weeks in advance. Whilst acknowledging that there will always be situations where short notice is given, the guidance clearly advocates a patient focussed booking approach. Indeed, it would be difficult to comply with New Ways without PFB, due to inevitable delays where letters are going backwards and forwards. 8. Building a Health Service Fit for the Future (2005) recommends that we should learn from some of the successes in Scotland and elsewhere building, for example, on the impact of patient focussed booking when considering how to ensure access to quicker treatment. Delivering for Health (2005), the long-term plan for the NHS in Scotland, says that Referral management and Booking Services will help to ensure that the patient is seen by an appropriate practitioner, in an appropriate setting, in the shortest possible time. 9. In February 2006, Audit Scotland published Tackling Waiting Times in the NHS in Scotland and noted that Improving the efficiency of existing services will help to reduce waiting times but other changes are also required (including) using processes such as patient focussed booking. In response to the report, the Minister for Health and Community Care drew attention to the substantial progress in tackling the longest waits. The Minister went on to outline ways that NHSScotland should go further and this included involving patients in decisions on where and when they get treated, saying there is a need for NHS boards to publicise the range of choice more widely, and through initiatives such as our Patient Focussed Booking programme, we are working to make convenient booking easier for everyone. This graph clearly shows the effect that PFB has on patient DNA (non attendance) rates. Yorkhill Sick Children s Hospital in Glasgow began PFB implementation in December 2003 and completed roll out to all appropriate specialties in July This stepped implementation led to a steadily reducing DNA rate, falling from 17% to 11% over the period Percentage of new outpatient DNAs, all specialties, Yorkhill PFB Implemented DNA rate (overall) DNA rate (no PFB) DNA rate (PFB) Further analysis undertaken at the end of 2005, shows that the DNA rate for PFB-only patients (normally routines) is lower still, hovering around 6% Apr-03 May-03 Jun-03 Jul-03 Aug-03 Sep-03 Oct-03 Nov-03 Dec-03 Jan-04 Feb-04 Mar-04 Apr-04 May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct-04 Nov-04 Dec-04 Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05

10 Patient Focussed Booking Implementation Guide: Less administrative staff time is spent cancelling and rearranging appointments Percentage of return outpatient DNAs, all specialties, Yorkhill and Dumfries & Galloway PFB Implemented PFB Implemented Yorkhill D&G A combination of a six-week clinic cancellation policy and the PFB rule of never booking patients more than six weeks ahead can have a dramatic effect on the number of clinics cancelled by the hospital. In NHS Argyll & Clyde, hospital cancellation rates for new and return outpatient appointments were cut from 3.6% in April 2004 (when PFB implementation began) to 1.5% in December This equates to 6,000 fewer appointments needing to be re-arranged per year Cancellation policies should apply to all staff whose absence would reduce capacity and should insist on at least six weeks notification of leave and other absences. Apr-03 May-03 Jun-03 Jul-03 Aug-03 Sep-03 Oct-03 Nov-03 Dec-03 Jan-04 Feb-04 Mar-04 Apr-04 May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct-04 Nov-04 Dec-04 Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 SINCE THE INTRODUCTION OF PATIENT FOCUSSED BOOKING OUR ROLE HAS EVOLVED EVEN FURTHER AND WE MAINTAIN THE OUTPATIENT WAITING LISTS FOR SPECIFIC SPECIALTIES. WE OVERSEE THE PATIENTS JOURNEY FROM REFERRAL THROUGH TO CLINIC ATTENDANCE, KEEPING THE WAITING LIST UP TO DATE, SEEING THE WAITING TIME DECREASE AND IMPROVING THE UTILISATION OF THE SLOTS THROUGH VALIDATION. WE ALSO RECEIVE THE POSITIVE FEEDBACK FROM PATIENTS WHO FEEL THEY ARE INCLUDED IN THE PROCESS AND CAN PLAN THEIR FAMILY COMMITMENTS AT THE SAME TIME. WE ARE HAPPY WITH THE PART WE PLAY IN THE OUTPATIENT ARENA AND SEE PFB AS A POSITIVE STEP FORWARD IN APPOINTMENT BOOKING FOR BOTH STAFF AND PATIENTS ALIKE. Gillian and Elizabeth Clinic Coordinators, Stobhill Hospital, NHS Greater Glasgow

11 CHAPTER TWO PLANNING STAGE

12 Patient Focussed Booking Implementation Guide: 6-7 BE PREPARED TO BE FLEXIBLE AND ADAPTABLE. PLANS WILL CHANGE AND YOU NEED TO BE ABLE TO ADJUST AND DEVELOP AN ALTERNATIVE APPROACH SHOULD BARRIERS STAND IN YOUR WAY. Marilyn Horne, Medical Records Manager, Yorkhill Planning the implementation of a completely new booking process can seem like a daunting prospect. However, by setting aside sufficient time at the start to plan carefully and by following this Guide, the transition should be much smoother. A definite starting point is to seek out those who have already been involved with PFB implementation. The process has been introduced across most outpatient specialties in NHSScotland and a list of local project managers involved is included in the Help and Guidance chapter at the end of the Guide. A number of processes, practices and policies will need to be in place in order to ensure that PFB implementation is successful. These are discussed on the following pages. Based on the experiences of local project managers who implemented PFB for outpatients, this should provide a useful overview of how to effectively plan PFB implementation. Starting small allows you to get a feel for PFB. Most projects in outpatients started with three specialties and then moved on to others. It also helps to start where there is the greatest support for PFB and these staff can help to spread the word as implementation is extended. The majority of projects went live with PFB, whilst traditionally-booked patients were still in the system. Feedback from project sites supports this approach but it should be noted that it becomes more difficult to show PFB impact due to the time it takes for the traditionally-booked patients to go through the system. However, it prevented a large administrative and public relations exercise, explaining to patients (who had been offered an appointment) why this no longer stood. NHS Fife adopted a half-way house approach when going live with PFB in outpatients in August Medical Records Manager, Valerie Anderson, explains ALL TRADITIONALLY-BOOKED PATIENTS DUE TO BE SEEN BEFORE THE END OF DECEMBER 2005 REMAINED IN THE SYSTEM, WHILST THOSE BOOKED IN 2006 WERE UN-BOOKED AND RECEIVED DETAILS OF HOW THE PFB SYSTEM HAD BEEN INTRODUCED TO PROVIDE GREATER CHOICE. IT TURNED OUT THAT THESE PATIENTS WERE ACTUALLY SEEN MORE QUICKLY THAN HAD THEY KEPT THEIR ORIGINAL APPOINTMENTS.

13 INVOLVING STAKEHOLDERS Senior managerial leadership and support When Patient Focussed Booking was launched as part of the CCI Outpatient Programme, an executive lead was assigned to have board level responsibility for the project at each site. This was important in order to ensure good communication channels between the project team (implementing PFB on the ground) and senior management. Whilst senior managers may not need to be aware of day-to-day progress and issues, there will inevitably be times when those implementing PFB will encounter problems that may need senior manager support to resolve. Communication works both ways and the lead executive will be able to keep the project team updated on policy issues that may effect implementation. Clinical leadership, support and engagement Clinicians in primary and secondary care need to be engaged in the PFB process and may need some convincing that this new approach is better than the one they are used to. The current booking process may be undertaken by medical secretaries, where centralised booking systems are not set up, and there may be a reluctance to give up this booking autonomy. Identifying clinical leaders who can talk honestly with their colleagues about the advantages of PFB will be helpful and combining this with robust data showing PFB impact (perhaps improved outpatient DNA rates) will usually achieve majority support. Ideally, clinical leads should be enthusiastic and proactive, command respect amongst their peers and have access to good networks and communication channels to spread the word. A staff survey conducted in the summer of 2005 revealed that a minority of clinical staff had a negative view of PFB but analysis of comments revealed that concerns were often misplaced or linked to other issues. This is why communication is vital and where there are genuine issues, it is important to listen and try and find a solution that is mutually agreeable. Medical Directors In NHS Scotland are supportive of further PFB implementation and reaffirmed this when the impact data collected was presented to them at a meeting in February Patient and public involvement It would be hypocritical to call a process Patient Focussed without involving patients at all stages of implementation. Alongside managerial and clinical support, patient and public involvement in PFB should be a priority when planning the change to the booking process. Involving patients and the public at an early stage should include eliciting their views on the current booking service, i.e. prior to implementation. Do patients want a choice of appointment? By conducting a patient survey before PFB is introduced, it is possible to directly compare patient satisfaction with the old and the new method of booking (repeating the survey following implementation). Careful attention should be given to question selection, to ensure comparability. PFB should benefit all patients and it is important that special attention is given to patients with communication needs to ensure that the booking process is equally accessible. As with arranging an appointment to see a GP, PFB promotes booking appointments by telephone and similar challenges need to be faced to ensure equity of access to services. Suggested approaches could include undertaking a demographic/language profile of the local population to assess communication needs and to ensure that resources exist for communication in the majority of community languages. Patient information sheets/booklets should also be available for the main community languages identified by the needs assessment, as well as providing versions suitable for patients with learning disabilities. Ideally, appointment centre staff should be multilingual or telephone interpreting services should be available. In addition, feedback should be actively sought from minority groups on the PFB process through questionnaires, telephone interview or focus groups. Further guidance and advice on developing an equality and diversity approach should be available within your NHS system, where a supportive policy will be in place. In addition, you can contact the SEHD to find out more about the Equality and Diversity Impact Assessment Toolkit at

14 Patient Focussed Booking Implementation Guide: 8-9 PFB HAS RESULTED IN MARKED IMPROVEMENTS IN THE MANAGEMENT OF OUTPATIENTS ACROSS NORTH GLASGOW BOTH FOR PATIENTS AND STAFF. THE IMPORTANCE OF ENGAGING WITH ALL KEY STAKEHOLDERS AT AN EARLY STAGE CANNOT BE OVER-EMPHASISED. TOGETHER, WE DEVELOPED A ROBUST CHANGE AND COMMUNICATION PLAN, WHICH ENABLED THE IMPLEMENTATION PROCESS TO CONTINUALLY EVOLVE TO MEET SERVICE NEEDS OVER TIME. Linda McAllister - Health Records Manager, North Glasgow There is less potential for confusion amongst staff if PFB is introduced specialty by specialty, rather than consultant by consultant. This means that medical records staff do not have to decide whether a referral has to go to the new or the old process. The intention should be to streamline processes and have PFB as the single, standard approach for all routine appointments. RESOURCES IT system capable of operating PFB In theory, PFB can be introduced without the support of an IT system but in practice it is a fairly essential requirement. Manual checking of records and appointing patients is cumbersome, resource intensive and prone to error and although one project successfully implemented PFB for outpatients using this approach, the Medical Records Manager involved agrees that an IT solution is preferable. Dedicated project management for implementation process PFB implementation needs to be carefully planned and communication with all stakeholders is a time-consuming, but very necessary, part of this. It follows that a project manager should be appointed to take on the responsibility for implementation and become the expert on all issues relating to PFB. They should be responsible for submitting any bids for funding, developing project implementation plans, overseeing the change in booking processes, collecting information and reporting progress to all stakeholders. This should be a dedicated role (not shared with other responsibilities) though whether full or part time will depend on the scale of implementation and the stage in the process. Project managers should be supported by a project team, including medical records and information staff, who will meet regularly to consider day-to-day issues. TEAM-WORKING AND NETWORKING, BOTH LOCALLY AND NATIONALLY, HAVE PROVIDED THE CATALYST TO CHANGE A SYSTEM WHERE PATIENTS PREVIOUSLY HAD MINIMAL INVOLVEMENT IN THE SCHEDULING OF THEIR APPOINTMENTS. Sylvia Moran Head of IM&T, Lomond & Argyll

15 Although PFB can be implemented using numerous points of contact, experience from outpatients shows that having a centralised booking process is beneficial. North Glasgow University Hospitals Division set up a single booking centre covering the three main acute sites. Linda McAllister says SIGNIFICANT ADVANTAGES IN TAKING THIS APPROACH INCLUDE THAT PATIENTS CAN BE OFFERED CHOICE BETWEEN HOSPITALS. ALSO, ECONOMIES OF SCALE HAVE ALLOWED US TO GENERATE A WIDER SKILLS BASE AND PROVIDE GREATER FLEXIBILITY IN STAFFING HOURS AND APPOINTMENT CENTRE OPENING TIMES. Appointment Centre The heart of the PFB system is an efficient appointment centre, dependent on a dedicated team of staff who can accept calls and make appointments. The Appointment Centre must be somewhere where external and internal mail is delivered several times a day. While in theory it is possible to site the centre anywhere, proximity to the hospital will make communications simpler. For most people, the appointment centre will be the first point of contact with a hospital staff member so it is worthwhile putting time and energy into the public relations skills of the Appointment Centre staff. By monitoring the volume of calls throughout the week, appointment centre hours can be adjusted accordingly and staffing flexed to focus on peak times. Many patients will phone on a Monday morning (after the weekend post), so consider sending more letters at the start of the week to counter this. Ongoing staffing of appointment centre/medical records Though this may appear to be an obvious consideration, it is important to match staffing to extent of PFB implementation, i.e. volume of calls received. As more specialties go live with the new system, so the number of calls will increase, thus demanding more staff time. It may be necessary to increase appointment centre hours or flex appointment centre staffing to meet peak call demand and staff should be employed on contracts allowing shifts to cover these times. By arranging a course on Effective communication on the telephone, NHS Lanarkshire ensured that all staff were appropriately trained to handle calls from patients. Outpatient Project Manager, Joyce Galloway, says THE COURSE INCLUDED SOME BASICS IN GOOD TELEPHONE MANNER AS WELL AS HOW TO COMMUNICATE POSITIVELY AND DEAL WITH PROBLEM CALLERS. A CHECKLIST OF THINGS TO REMEMBER AND TO AVOID WHEN DEALING WITH DIFFICULT CALLS SERVES AS A USEFUL AIDE-MEMOIRE TO STAFF.

16 Patient Focussed Booking Implementation Guide: Call volumes should be monitored over a period to know peak call times and adjust staffing levels as appropriate. Training of all staff in the new process and any associated systems is important and experienced staff may need to be drafted into these posts, backfilling with new staff. A staff training plan should be developed outlining the training requirements for staff in both PFB and customer care (telephone skills). Effective telephone system providing accessible service to patients Many hospital telephone systems are outdated and cannot easily manage large volumes of calls. Prior to implementation, it is essential that this part of the project is fully scoped and advice is sought from appropriate IT and telecommunications experts. To operate PFB, dedicated telephone lines are required with a single number for the public to call feeding into multiple operator lines. Consideration should be given to introducing specialist equipment including call distribution software (randomly allocating calls to operators), headsets (allowing hands-free operation) and telephones which allow staff to complete transactions on their computers before accepting another call. In addition, an answer-phone, for when lines are busy, allows the patient to record a message leaving their contact details so that someone can call them back. Talkative callers tend to be the greatest challenge for appointment centre staff, particularly when they may have another caller waiting. Whilst you are trying to systematically gather information from the patient, they are going off on a tangent. It is important not to show boredom or interrupt. Instead, listen for a gap in the conversation to get back to the point, ask direct, closed questions and summarise the relevant points. NHS Dumfries & Galloway undertook a patient survey and, whilst very positive about the new booking process, many patients commented that they had experienced problems getting through on the telephone. Information Manager, Stewart Cully, explains A THOROUGH ANALYSIS OF CALL VOLUMES AND ENGAGED CALLS WAS INITIATED AND IDENTIFIED THAT SOME PATIENTS WERE FAILING TO GET THROUGH FIRST TIME. STAFFING WAS FLEXED TO DEAL WITH THE MONDAY MORNING RUSH AND INNOVATIVE BOOKING APPROACHES ARE BEING CONSIDERED TO COMPLEMENT PFB AND TAKE THE PRESSURE OFF THE HOSPITAL TELEPHONE NETWORK.

17 Stationery and postage Stationery and postage costs will need to be identified, based on an increase in correspondence with patients. However, this will vary depending how quickly the patient responds to the initial letter inviting them to contact the booking centre, i.e. whether reminder letters are needed. Some medical records departments have invested in letter folding machines to free up staff time from what is a relatively mundane but time consuming task. Some NHS organisations elsewhere in the UK have further reduced costs by forming a partnership arrangement with outside contractors to print and process letters. This approach involves sending letters electronically to a print bureau, who sort the electronic file by postcode, print and despatch the letters. As a result, less space and expenditure is needed for printers and letter folding machines and, by sorting files, organisations can take advantage of Royal Mail discounts on postage. However, the cost effectiveness of this would need to be carefully considered before embarking on this arrangement. Appointment Reminder and confirmation systems Further work has been undertaken throughout NHSScotland to improve attendance rates. Text messaging has proved popular and early results from automated booking reminder systems have been encouraging. However, such systems will not have the added benefits of improving queue management, as with PFB, and should only be introduced once PFB has been established. NHS Dumfries & Galloway has piloted an automated booking reminder and confirmation system in outpatients. In October 2005, they teamed up with a commercial company, who offered the ability to issue reminders via , text messaging and Interactive Voice Response (IVR). IVR involves the patient responding to a series of recorded messages via the telephone keypad. All acute outpatients booked beyond seven days and aged 75 or under, were offered the option of receiving an appointment reminder and 94% of patients opted in. Initial results involved almost 3,000 patient appointments in a six-week period. Over the period, 24 patients used the system to cancel their appointment and another 45 chose to rearrange their appointment to a more suitable time. So long as sufficient notice is given to reallocate the appointment slot, this equates to 200 more patients being seen each year. DNA rates for patients receiving a reminder reduced to 2.5% across all age groups, though these were most effective in the under 55s. The cost of this service is 15,500 per annum, resulting in an increased use of 1,450 existing outpatient slots per year (including 270 new attendances). The cost of putting on extra clinics to see this number of patients would be up to 30,000. Other savings are made in reducing waiting times and administrative time spent on writing to patients who have failed to attend, creating further appointments, pulling case notes, etc. Stewart Cully says DESPITE ALREADY HAVING A RELATIVELY LOW DNA RATE IN DUMFRIES & GALLOWAY, THE SERVICE HAS PROVED TO BE A COST-EFFECTIVE METHOD OF REDUCING THIS RATE SIGNIFICANTLY AND INCREASING OVERALL CLINIC EFFICIENCY AND WE PLAN TO GO AHEAD WITH THE SERVICE ON A PERMANENT BASIS.

18 Patient Focussed Booking Implementation Guide: INFORMATION Know your service In order to measure the impact of PFB on your booking processes and management of waiting lists, it is important to understand where you are starting from and how you will measure the impact of any changes. A process mapping exercise will help to understand the current booking process and identify where bottlenecks and constraints are found. This will map out the patient journey, e.g. from GP visit to first outpatient appointment and should include all steps in between. From this, the focus should shift to ensure that the constraint is maximised and bottlenecks are reduced to improve flow. This Guide does not consider the tools and techniques for understanding the service and managing projects but an excellent source of reference is Chapter 5 of the National Leadership and Innovation Agency for Healthcare s A Guide to Good Practice Elective Services (2005). Once you have a sound understanding of the current service/system, including problem areas, information is needed to substantiate this. Experience shows that, whilst it is often true that much information is collected, this is not always relevant to show the impact of service change and careful consideration should be given at the planning stage to ensure that information requirements are adequately met. Clear, informative patient information Communication plans, identifying how key stakeholders will be informed of the new process and kept up to date on progress, should be developed at an early stage. All appropriate staff and patients will require informative and concise literature, which should be regularly updated as the implementation process moves forward. Staff can be updated through briefing sessions, newsletters or making PFB Steering Group minutes/actions available to all staff. It is important to keep colleagues in primary care updated, particularly regarding implementation status. Patients will receive a series of letters from the appointment centre, explaining where they are in the process and detailing any actions they need to take. The referral acknowledgment letter (for outpatients) represents the first contact with the patient and is an opportunity to set a good tone and include any information leaflets on PFB. Demand, Capacity, Activity and Queue Management In waiting list management, the queue is often perceived as the problem but can often be overlooked when looking for solutions by increasing capacity and activity. However, queues need to be managed and there are a number of simple approaches that will help to keep the maximum waiting time as short as demand allows. The following will help to manage the queue effectively: Referrals sent to a service rather than a named consultant; Implement referral management services; Pooling lists combine a number of consultant lists into one; Minimise slot types, e.g. musculoskeletal slots instead of hand or back slots; Reduce the number of slot types to urgent and routine; See routine patients in turn. PFB implementation will have a positive effect on both the queue and activity, through improved validation, treating patients in turn and reducing cancellations and DNAs. It is important to measure this impact and understand how this inter-relates with capacity and demand.

19 Data set to measure impact In order to measure PFB impact, a number of key performance indicators should be routinely collected before, during and after PFB implementation. In addition, systems should be able to separate data between patients who have telephoned to arrange their appointment and those who have been booked through traditional methods. Often, this means comparing routine patients with those who have been clinically prioritised to be seen sooner. The following list has been compiled, based on the outpatient PFB experience: Patient attendances (activity) the number of patients attending a clinic/service; Patient DNAs the number of patients who fail to attend without prior warning; Patient cancellations (CNAs) the number of patients who have contacted the hospital prior to their appointment to inform that they are unable to attend. It is worth distinguishing between short notice and sufficient notice CNAs i.e. those patients who have provided enough notice of nonattendance for the slot to be allocated to another patient; Patient removals the number of patients removed from the waiting list as a result of patient instruction; Hospital removals the number of patients removed from the waiting list following noncontact from patients; Hospital cancellations the number of patients whose appointment has been cancelled or re-arranged by the hospital; Primary targeting lists are patients being booked in turn? Prospective waits this information is important when communicating with the patient re: how long they are likely to wait to access the service; New to return ratios for outpatients, a useful indicator to show trends in new and return patient activity; Conversion rates (outpatient to day case/inpatient) the rate of outpatients who go on to day case/inpatient treatment; Call volumes and successful connection rates critical telecommunications information to assess peak call times and whether patients are being connected in a timely manner; Complaints (from patients and staff) comparing the number of complaints before, during and after PFB implementation will give an indication of whether the new service is working well; Satisfaction (from survey questionnaires) a key tool to understand patient and staff perceptions of the new service and to make any necessary refinements to the process; Letter response rates the number of patients responding to first/second/third invitation-to-phone letters against the numbers sent; Stationery/postage costs linked to the above, these costs should be measured to monitor the effectiveness of the process; Savings any changes to working practices, staffing or stationery costs, as a result of PFB implementation should be identified and measured. As well as improved validation, reduced cancellations and fewer patient DNAs, this may include less medical secretary/reception time spent arranging and re-arranging appointments and less wasted consultant time. These savings can be difficult to measure and specifically attribute to the introduction of PFB. However, accurately identifying and quantifying savings will help in evaluating the success of the redesigned booking function and planning ongoing workforce requirements. Whilst PFB ensures that routine patients are invited to phone-in in turn, patients will respond out-of-turn. This can cause problems where waiting times are close to the maximum guarantee and appointment slots for potential breaches may be given to other patients.

20 Patient Focussed Booking Implementation Guide: When New Ways is introduced, a patient will be unavailable and suspended from the list from the date of a reminder letter (two weeks after the invitation to phone letter) until the patient contacts the booking centre. This will help to tackle the issue of how to manage patients who choose to delay making contact with the hospital, which is working to meet challenging waiting times guarantees. In the interim, measures should be taken to improve the management of non-responders, e.g. reinforcing the need for a prompt response through invitation-to-phone letters, telephoning slow-responding patients or reducing the time period between invitation and removal letters. POLICIES Robust clinic cancellation/staff leave and patient non-attendance policies These policies are critical to the success of PFB. The clinic cancellation policy should be based on providing six weeks notice of a need to cancel a clinic, e.g. consultant annual leave/study leave. Without agreement from consultant staff that they will not cancel clinics at short notice, it is not possible to give any certainty to patients who phone in that their appointment will go ahead. Most consultants will already be working to a six-week rule following the introduction of PFB in outpatients and therefore this should not be a major obstacle to overcome. Notification of unavailability should apply not only to consultants but to all staff whose absence would lead to a cancellation or reduction in size of a clinic. Once notification of leave is given, it is vital to act on this quickly. Clear leave approval procedures will ensure that clinics are able to be closed off within a few days of the leave being requested. If not, clinical staff adhering to the policy may still see clinics cancelled but for purely administrative reasons. A clear, robust policy backed up by prompt procedures will make this process work. Patient non-attendance policies should also be well developed but may need updating. Interim New Ways guidance states that if a patient does not attend their appointment/treatment, with no prior notification, they should be removed from the waiting list and returned to GP care (unless clinically inappropriate). Policies should be agreed and signed-off by senior clinicians and the Senior Management Team to ensure effective buy-in. One reason for short notice of cancellation by junior doctor staff is that leave is applied for in another department/hospital and then arrive in a new department with pre-approved leave. All induction material sent to new staff must include details of the six-week leave policy. BECAUSE WE ARE ONLY BOOKING SIX WEEKS AHEAD, WE CAN ACCOMMODATE CHANGES IN CLINIC SCHEDULES MORE READILY. Linda McAllister Health Records Manager, North Glasgow

21 PFB ADAPTATION Acknowledging circumstances where PFB may need to be adapted There are circumstances where the introduction of PFB could complicate the booking process. That is not to say that PFB implementation should not be considered but that the process may need adaptation to incorporate patient choice. In addition, every effort must be made to ensure that specific patient groups, e.g. those with communication needs, are accommodated and receive the same choice as other patients. The outpatients experience identified the following circumstances where PFB may need adaptation: Waiting times are less than six weeks; Patients need to be seen within six weeks; Clinics are arranged with less than six weeks notice; On surveying patients, NHS Dumfries & Galloway discovered that those with hearing difficulties found the booking process very difficult to use, due to the dependence on voice contact. As a result, they invested 1,000 in a Minicom system to extend the service to these patients. NHS Fife experienced delays in implementing PFB in outpatients due to the prolonged development of a new hospital IT system. However, the chief executive of the acute operating division became directly involved in the process, which enabled medical records staff to resolve any problems very quickly. The project was soon back on course and PFB was implemented in all appropriate specialties in two acute hospitals within five months of going live! Very specific appointment dates need to be arranged, e.g. obstetrics; Multiple appointments with set times need to be arranged, e.g. ophthalmology.

22 Patient Focussed Booking Implementation Guide: CHAPTER THREE IMPLEMENTATION STAGE

23 PRIOR TO IMPLEMENTATION Meet with medical staff If possible, approach each consultant individually. A group meeting with the consultants in a specialty may be an alternative but ensure that a follow-up meeting is arranged with any staff not present. Avoid working solely through third parties, such as the Clinical Director. After meeting with medical staff, send a letter to each consultant thanking them for their time, reconfirming the six-week rule, the commitment to review the clinic profiles (with a date for the first draft) and a date by which the clinic should be operating fully. Meet with other clinic staff Before working on profiles, it is useful to meet with the nursing and clerical staff for the specialty to explain the new booking system and get any information they may have on quirks of the clinics. Stressing how the new system will resolve current problems should generate enthusiasm in support of the changes. Dissatisfied staff in the clinic can do a lot to sway the consultant staff against change and staff who are on board will help with minor problems that could arise during implementation. In any organisation, staff will be happy to discuss current problems, so use this to your advantage and show how PFB will improve matters. For example, with traditional booking processes, staff will often field many complaints from patients following the cancellation of their appointment by the hospital. Show staff what has happened elsewhere in Scotland with cancellation rates before and after PFB implementation. Then discuss what effect PFB could have on your local data. Review and prepare clinic profiles Evidence has shown that PFB leads to significant reductions in DNA rates. As many consultants will have taken DNA rates into account when calculating clinic sizes, an important step in introducing PFB is to review clinic profiles. With consultants, determine how many slots need to be reserved for urgent patients. Are clinics made up of new and return patients or are there separate clinics for each? Analysis of the clinics for the past few months should give a good starting point for this information. Determine both the average and the maximum in any particular clinic to identify whether there is much variability in the types of referral or whether the referral rates are predictable. Try to minimise allocating too many slot types and consider whether the soon category can be withdrawn. Once the new booking rules are drafted, based on this information, confirm them with both the consultant and the clinic staff as being workable. Also check that the number of new referral slots will allow the service to see the number of patients referred. Be careful of allowing clinic numbers to drop significantly unless there are clear reasons why the clinics were previously overbooked. It is important not to create a problem of reduced capacity through this process. Finally, set up the new profiles on the system to start from the date that all previously booked patients will have been seen. When reviewing profiles, start with the existing lists of actual attendances in clinic and not the clinic profiles on the system, which often bear little resemblance to the actual booking rules. PFB HAS LED TO A MAJOR CHANGE IN WORKING PRACTICE THAT STAFF HAVE WELCOMED AS THEY CAN SEE THAT THEIR HARD WORK AND ENTHUSIASM HAS IMPROVED THE SERVICE TO PATIENTS. COMMUNICATION IS THE KEY TO STIMULATING MAJOR CHANGE. Sylvia Moran Head of IM&T, Lomond & Argyll

24 Patient Focussed Booking Implementation Guide: BY ANALYSING CAPACITY AND DEMAND DATA AND REVIEWING CLINIC PROFILES IN ENT, WE WERE ABLE TO CONVERT URGENT AND REVIEW SLOTS TO NEW ROUTINE SLOTS, ENABLING MORE LONG WAITERS TO BE SEEN, THUS REDUCING WAITING TIMES. Carol Golding, Assistant General Manager, NHS Ayrshire & Arran Clean and validate waiting lists A list of patients, ordered by clinical priority and then according to the date of referral is required for PFB to operate. Ideally, this waiting list should have been validated to confirm that it is a true list of patients waiting for consultation/tests/treatment, although patient details will be validated at the point the patient contacts the appointment centre or when contact is not forthcoming. Stop booking Prior to going live with PFB you need to stop booking using the traditional approach. Although this may seem obvious, it is probably the most important part of implementation because all systems and staff will switch to the new way of working at this point. GOING LIVE PATIENTS ATTENDING A FIRST APPOINTMENT PFB works by acknowledging the referral when it is received and then sending a further letter to the patient, usually four to six weeks before they need to attend, asking them to phone and make an appointment. Generating the Pick List Each week, staff look at clinics for six weeks ahead. For each clinic they calculate how many patients will be needed to fill the clinic and select those patients from the top of a pick list. The pick list is always sorted first by priority order, then referral date order. Most outpatient IT systems in NHSScotland have been developed to undertake this automatically. The Phone letter The picked patients are each sent a letter, which asks them to phone the Appointment Centre as soon as possible to arrange a suitable date and time for their appointment. When they phone, an appointment is made on the hospital information system and a confirmation letter is printed and sent. Self-balancing system If too few patients phone in any week, extra letters can be generated the following week. Likewise, if more patients phone, bookings can be made into weeks five and six and correspondingly, fewer patients picked the following week. The acknowledgment letter As a patient is registered and prioritised, a letter is generated telling them the approximate wait and that they should expect another letter closer to the time. An explanatory leaflet on the process could be enclosed with this letter. If the patient is to be seen within six weeks, they are asked to phone straight away and make an appointment.

25 NHS Tayside employs a member of staff to work for 2 or 3 hrs beyond the appointment centre opening hours to undertake numerous tasks. PFB Project Manager, Sandra Cassidy, says THE POST HAS BEEN INVALUABLE BECAUSE THE MEMBER OF STAFF HAS TIME TO PHONE PATIENTS BACK, CONTACT NON-RESPONDERS AND CONFIRM URGENT APPOINTMENTS. What if the patient fails to phone? A reminder letter is generated automatically for those patients who do not respond to the invitation letter. If they do not respond to this reminder within two weeks, the referral is automatically closed and a letter is sent to the GP as well as the patient. FOLLOWING IMPLEMENTATION Review the booking rules Once PFB is implemented, and several clinics have run where ALL patients have been booked through the new system, go back and meet with the staff again to determine whether any changes need to be made to the booking rules. It is quite possible that there are perceived problems that have led to under booking, or that insufficient slots were removed to allow for the reduction in DNAs. Diary dates for regular review Things change. Don t assume that getting things right the first time will mean that the booking rules are set in stone. All clinic profiles should be reviewed at least annually. This review should include start and finish times, the number of new and return slots and the timings of appointments. The review should be conducted as part of the process of balancing annual capacity and demand, so that an increase or decrease in demand over the year can also be addressed. Patient and staff feedback Do patients like the new booking process? Do they feel that they are getting choice? Is the information they have received clear and informative? Soliciting the views of patients is an important ongoing process once PFB has been introduced. The easiest way to gain information is through the patient survey, which can be repeated at regular intervals to show trends in perception of the service change. This is also a particularly useful way of pinpointing problems, which when addressed should show an improvement in responses thereafter. In NHS Ayrshire & Arran, a number of slots are reserved for urgent referrals until one week before the clinic date. The ENT consultants have agreed that any urgent slot that has not been filled can automatically be converted to a routine slot. The appointments staff then call patients that have agreed they can be contacted at short notice and offer to bring their appointment forward. On phoning to arrange an appointment with the Booking Centre, one patient confirmed that he was able to accept an appointment at short notice (as he was between jobs) and gave a mobile telephone number. Carol Golding explains ON THIS OCCASION, THE PATIENT WAS DELIGHTED AS, IN THE MEANTIME, HE HAD ACCEPTED A NEW JOB WHICH STARTED IN TWO WEEKS TIME. BY ACCEPTING AN EARLIER APPOINTMENT, HE DID NOT NEED TO TAKE TIME OFF WORK TO ATTEND.