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Pre Admission Clinic Managing Attendance Numbers (PACMAN)

Concord Repatriation General Hospital
Project Added:
4 December 2014
Last updated:
8 December 2014

Pre Admission Clinic Managing Attendance Numbers (PACMAN)

Concord Repatriation General Hospital,  Sydney Local Health District 

Summary

Pre Admission Clinic Managing Attendance Numbers (PACMAN) is a clinical redesign project being undertaken at Concord Repatriation General Hospital that is focused on improving the patient journey for elective surgery patients by reducing delays in the Pre Admission Clinic and reducing cancellations on the day of surgery. 

Download a poster about this project from the Centre for Healthcare Redesign graduation, December 2014. 

Aim

This project aims to improve the elective surgery patient journey by reducing the number of patients that need to attend the Pre Admission Clinic by ensuring appropriate referral, reducing the time spent in the Pre Admission Clinic, improving communication between the Hospital and the patient prior to the day of surgery and thereby reducing cancellations on the day of surgery.

Benefits

Patient benefits

  • The creation of a pathway/protocol for determining if patients need to attend the Pre Admission Clinic will reduce the overall number of presentations. Subsequently, the time patients will spend in the clinic is reduced, due to reduced patient numbers.
  • Communication with patients prior to surgery is improved.
  • Cancellations on the day of surgery are reduced, meaning our patients will only need to take time of work and make arrangements for their surgery once, they will only need to fast once and they will only need to prepare themselves for surgery once.

Health system benefits

  • Reduced cancellations on the day of surgery increase Key Performance Indicator (KPI) compliance.
  • Improved Operating Theatre Efficiency 
  • Reduced costs associated with cancellations.

Staff benefits

  • Increased staff satisfaction and reduced stress due to better organisation within the Pre Admission Clinic and earlier finalisation of operating theatre lists.

Background

Concord Hospital provides 11,000 surgical procedures per year. Seventy five percent of procedures are elective surgery, of which over 90% are admitted on the scheduled day of surgery. 

Preparedness for admission is monitored through NSW Health peri-operative key performance indicators, which include rates of cancellation on the day of surgery, utilisation of scheduled theatre time, a timely start to the working day, and timely discharge of patients from hospital. 

The Hospital has consistently been unable to meet NSW Health targets for cancellations on the day of surgery. Local data suggest that around 40% of cancellations might be avoided by better preparation and co-ordination. (Davidson, file audits over several years). 

It is also acknowledged that patients can spend excessive time in the Pre Admission Clinic. It has been estimated that 20% of patients could be appropriately assessed without attending a preadmission clinic (S Cameron, personal communication).

In 2013, 266 elective surgery patients were cancelled on the day of surgery. On average, five cases are performed in a theatre session, equating to 53 sessions with no patients or one week with ten empty theatres. Based on an average staffing mix this equates to $334,131.92 of paid operating staff time, in which no procedure was performed. 

The vast majority of patients are required to attend the Pre Admission Clinic, they may not have completed all of the required documentation or maybe scheduled to attend at the same time as a large number of other patients and are likely to spend an extended time waiting, with limited information about delays.

They may be cancelled on the day of surgery because the list was overbooked, patients were not prepared for surgery or due to a pre-existing medical condition. Meaning, patients and/or a family member or friend arranged to have time off work, patients may have fasted and prepared themselves for a surgery that did not occur. 

Implementation

  1. Development of an agreed pathway or protocol (with the right of veto) to assist in determining if patients need or do not need to attend the Pre Admission Clinic. 
  2. Inform patients of delays in the Pre Admission Clinic and the Day of Surgery Admission Clinic (DOSAC).
  3. Implement a revised scheduling system in the Pre Admission clinic, which allocates time based appointments.
  4. Development of a business case for the creation of a Co-ordinator /Triage nurse for the Pre Admission Clinic.
  5. Revised structure for the submission of the final operating theatre lists, with all lists to be submitted by 9am on the day prior to surgery.
  6. Implementation of a telephone queuing system in DOSAC, which allows for patients to be placed in a queue and informs them of the importance of their call and the number of callers before them.
  7. Development of a generic SMS reminder to be sent three days prior to surgery, to confirm surgery and remind patients to contact the hospital.
  8. Development of a business case for 0.5 full time equivalent (FTE) pharmacist Grade 1 for a 6-12 month trial working 4.5 hours per day, to be responsible for medication reconciliation in the Pre Admission Clinic.
  9. Development of the ability to electronically submit documentation for the Pre Admission Clinic and an electronic check-in option.
  10. Use Surginet to build operating theatre lists based on individual surgeon’s historical averages for each procedure.
  11. Collaborate with the Inner West Medicare Local to facilitate patient document preparation.

Evaluation

A method of evaluation has been identified for each of the proposed solutions and will be undertaken once they have been fully implemented. The following outcomes are hoped to be achieved as a result of the project:

  1. 20% reduction in inappropriate referrals to the Pre Admission Clinic
  2. 90% of non- complex patients to be seen within 90 minutes and 90% of complex patients to be seen within 3 hours in the Pre Admission Clinic (this is total time spent in the Clinic, not waiting time)
  3. All patients are kept informed of delays within the Pre Admission Clinic and DOSAC
  4. Compliance with the cancellations on day of surgery key performance indicator of less than 2%.

Partnerships

The project was undertaken via the Agency for Clinical Innovation’s Centre for Healthcare Redesign program.

Lessons Learnt 

  • Work with stakeholders, accept small gains and build a positive platform for change
  • Be persistent and remain patient
  • Keep stakeholders involved and informed
  • Strict scope management
  • Risk and issues management 
  • Communication, collaboration and cooperation
  • Project planning is key - set strict deadlines and to stick to them

Acknowledgements

Acknowledgements to Pre admission staff at Sydney Adventist Hospital. Bankstown Hospital Pre admission, DOSAC and admissions staff. 

Contacts 

Leo George
Nurse Unit Manager
Concord Repatriation General Hospital
Sydney Local Health District
Phone: 02 9767 5427
Email: leo.george@sswahs.nsw.gov.au

Hannah Storey
Operational Support Manager, Executive Unit
Concord Repatriation General Hospital
Sydney Local Health District
Phone: 02 9767 7867
Email: Hannah.Storey@sswahs.nsw.gov.au

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