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My Check-in For Surgery: Elective Surgery Pre-admission Project

Project Added:
2 December 2016
Last updated:
16 December 2016

My Check-in For Surgery: Elective Surgery Pre-admission Project

Summary

Canterbury Hospital implemented measures to improve patient and clinician satisfaction and hospital efficiency, by enhancing elective surgical pre-admission processes. These included a review of communication, screening and assessment tools, booking processes, roles and responsibilities, accountability and escalation processes.

View a poster from the Centre for Healthcare Redesign graduation, December 2016.

Aim

To improve patient and clinician satisfaction with pre-admission processes, by reducing the average time spent in the Pre-admission Clinic to less than 2.4 hours; reducing the proportion of low-risk patients required to attend a full Pre-admission Clinic to 66.75%; and reducing patient related day of surgery cancellations to less than 2%, by April 2017.

Benefits

  • Improves patient and clinician satisfaction with preoperative care.
  • Enhances preadmission risk screening and triage to appropriate type of clinic.
  • Reduces wait time for patients in the Pre-admission Clinic.
  • Optimises the use of staff, interpreters and clinic sessions.
  • Reduces the number of patients who do not attend their Pre-admission Clinic appointment.
  • Increases efficiency in preparing patients for surgery.
  • Reduces hospital and patient related day of surgery cancellations.
  • Improves operating theatre utilisation rates

Background

Prior to the project, clinicians in the Pre-admission Clinic at Canterbury Hospital reported patient dissatisfaction about clinic waiting times. Data revealed that 27 patients spent over five hours in the clinic during April 2016, with an average wait time of three hours. While patients were satisfied with the care they received, the lengthy wait time had a negative impact on their experience.

Clinicians also expressed concern about the efficiency of some pre-admission assessment and triage processes. The majority (80%) of patients were sent to the full Pre-admission Clinic, where the patient was reviewed by a nurse, anaesthetist and junior medical officer. This process was very resource intensive and may not have been necessary for low-risk patients, who could be reviewed by a nurse in person or via a phone clinic assessment.

There were also high rates of patient related day of surgery cancellations, with a monthly average of 3.28% in 2015 (the Ministry of Health target is 2%). This may have been related to patients not being adequately prepared for surgery. These delays and cancellations also contributed to operating theatre utilisation rates that were lower than Ministry of Health targets.

Additionally, interpreters were not always available and few patient information brochures were available in languages other than English. Written communication to patients was confusing and sometimes not distributed at the best time in the patient journey.

Other areas identified for improvement included timely access to external patient history and medical reports, communication between departments, patient clinic booking systems and the definition of roles and responsibilities in the pre-admission pathway.

Implementation

  1. Communication with general practitioners (GPs) was improved and input was obtained earlier in the patient journey. This was achieved by revising the ‘GP Supplementary Medical History’ form, to obtain sufficient medical history prior to submission of the Request for Admission form. A letter to update GPs when required, following the patient’s assessment in the Pre-admission Clinic, was also developed. In phase three of the project (2017) a HealthPathway will be developed.
  2. Communication was improved between the Admissions Office, Pre-admission Clinic and Day Surgery Unit. This was achieved via regular meetings with key staff from these areas. Improved processes were established, to ensure there is a shared understanding of the patient’s status and risks, with processes to initiate timely actions so late surgery deferral or patient related cancellations can be avoided.
  3. Health literacy was improved by revising the written communication materials distributed to patients, ensuring they cater to the culturally diverse community. The materials aim to make patients aware of the steps in their journey and their role in preparing for surgery.
  4. The roles of staff in the Pre-admission Clinic were reviewed and defined, to reduce duplication, improve efficiency and enhance patient and clinician satisfaction.  
  5. Risk screening tools and processes were improved, so patients can be directed to the most appropriate type of pre-admission review (phone or clinic) and prepared for surgery in the most efficient way possible.
  6. Guidelines are being developed to prepare urology patients for surgery, to improve understanding of pre-admission requirements and streamline the process.
  7. A process of accountability for identified patient risks was developed, to ensure patients are followed up and any risks are addressed by the most appropriate staff member.
  8. Data collection processes were improved, to support timely and effective management of Pre-admission Clinic activities. This allows staff to electronically check patients out of the clinic and export reports to Excel spreadsheets.
  9. Resource requirements will be reviewed in phase two of the project, once previous solutions have been implemented.
  10. An improved booking process will be developed in phase two of the project. This will allocate patient bookings to the most appropriate time and date, so hospital resources are matched to the needs of the patient.
  11. The booking process for interpreters will be reviewed in phase two of the project, to reduce delays and improve efficiency.

Project status

Implementation - the initiative is currently being implemented

Project dates

March 2016 – April 2017

Implementation site

Canterbury Hospital, Sydney Local Health District

Partnerships

Evaluation

A full evaluation of the project will be undertaken in April 2017, with results compared to baseline data collected in April 2016. This evaluation will measure the following objectives:

  • patient satisfaction, using the outcomes of patient and carer experience interviews
  • the average time spent in the full Pre-admission Clinic
  • the proportion of patients required to attend the full Pre-admission Clinic
  • the proportion of patient related day of surgery cancellations.

Additional measures will monitor the progress of solutions, with results shared in steering committee meetings. These include:

  • patient medical history available at pre-admission triage
  • patient results and documentation available at the Day Surgery Unit
  • number of late patient related surgical deferrals
  • patient understanding of pre-operative instructions
  • number of patients waiting over one hour to see a doctor
  • percentage of patients who did not attend their Pre-admission Clinic appointment
  • number of patients who attend the Pre-admission Clinic and require an interpreter, but there is no interpreter available
  • percentage of patients who are electronically checked out of the clinic.

The average time spent in the full Pre-admission Clinic was reduced from over three hours in April 2016 to the target of 2.4 hours in June 2016. The percentage of patients electronically checked out of the clinic was also a quick win for the project, with 90% of patients electronically checked out in May 2016, compared to 0% in March 2016. Patient related day of surgery cancellations met the Ministry of Health target of 2% in October 2016.

Lessons learnt

  • Early involvement of key stakeholders and ongoing communication is important to avoid surprises down the track.
  • Identification and support from clinical leads and champions is required to successfully involve various departments.
  • Recognising the competing demands and identifying the right time for implementing change is important to gain support.
  • Focus groups with representatives from various areas can lead to a shared understanding of the issues and need for change.
  • Aligning with related projects can improve sustainability of the project.
  • Be resilient and trust the clinical redesign methodology.
  • Awareness and management of scope, risks and issues is important.

Related reading

  • DeMarco J, Nystrom M. The importance of health literacy in patient education. Journal of Consumer Health on the Internet 2010; 14(3): 294-301.
  • NHS Institute for Innovation and Improvement (NHSIII). Quality and service improvement tools: patient information. United Kingdom: The National Archives; 2008.
  • Protheroe J, Nutbeam N, Rowlands G. Health literacy: a necessity for increasing participation in health care. British Journal of General Practice 2009; 59(567): 721-723.
  • Ross J. Preoperative assessment and teaching of postoperative discharge instructions: the importance of understanding health literacy. Journal of Perianaesthesia Nursing 2013; 28(5): 318-320.
  • ACI Perioperative Toolkit (Consultation Draft) 2016.

Contact

Judy McGlynn
Complex Care Clinical Nurse Consultant
Canterbury Hospital
Sydney Local Health District
Phone: 02 9787 0254
Judy.McGlynn@sswahs.nsw.gov.au

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