Microsoft PowerPoint Graham Mercer Hip Knee Arthroplasty by lindayy

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									Hip & Knee Arthroplasty Outpatient
        Service Redesign

  Repatriation General Hospital SA

Dr Graham Mercer
Head, Orthopaedic Unit
Repatriation G
R                 l Hospital
     t i ti General H   it l


Christine Doerr
Project Manager
Arthroplasty Demand and Allocation Management




       OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
                 Background Information

Evolution Of Arthroplasty Services at RGH, Sth. Aust.


 Rationalisation of Orthopaedic Services in Southern Region, SA, 2005
  Fragmented   IT

                         system active
 Outdated prioritisation system-active management minimal

 Increasing prevalence of OA in ageing population

 E t d d waiting times result in worsening disability, social
 Extended  iti ti          lt i        i di bilit         i l
                    and psychological health



            OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
                                       Patients ‘Waiting to Wait’ !!

                 Quality of Life Scale                                                        Depression Scale

            10                                                                        20




            8
                                                                                      15




                                                                          Frequency
  equency




            6
                                                                                      10
Fre




                                                                          F
            4

                                                                                      5


            2
                                                                                                                                                16.50
                                                                                                                                        Mean = 16 50
                                                                                                                                        Std. Dev. = 11.24525
                                                    Mean = 0.3779                     0                                                 N = 80
                                                    Std. Dev. = 0.27398
                                                                                       0.00   10.00   20.00     30.00   40.00   50.00
            0                                       N = 81
                                                                                                              CESD
                 0.00   0.20   0.40   0.60   0.80
                               AQOL




                                      OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
                                 Background Information

    Hip & Knee Arthroplasty Outpatient Service Redesign

       Part of a Continuum of Care
      From GP referral

Waiting list              OPD                         Operative              Ward               Summary
                          clinic                      Services
     Priority tool                          Report       Op info                          Follow-up
                                  Billing   writing                  Path‐        Audit
                     Bookings                                        ways
                                            Research                 Composite 
Referrals
  d
Audit  QOL                       W/L 
                                 W/L                    Resourcing   Functions
                                                                     F ti                      QOL
                                 mapping




                                Management of Patients with Arthritis

                          OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
       Why is the Waiting List So Long???



Pt.
with       GP                   OPD                /
                                                  W/L                Surgery
                                                                        g y
OA       R f    l
         Referral               Appt
                                A t


           Expected pathway to surgery

          Potential barriers to pathway




         OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
  Why Shorten Ortho OPD Review Time?

        Diagnosis      Orthopaedic-
 Missed Diagnosis- not Orthopaedic ?? Malignancy

 May not need review by an Orthopaedic Surgeon

 Undetected & Unmanaged Depression

I       ibl D     i    i i Q li        f Lif
Irreversible Deterioration in Quality of Life

           bottleneck
Contrived ‘bottleneck’ for Waiting List Management




     OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
    The Problem
    18 month wait for Outpatient Appointment
    - 850 Clients

    24 month wait for surgery once on the waiting List
                               g p                  /
    - 500 Clients- annual throughput 275 TJR -1st on/ 1st off

     Currently
    6-12    k ‘ i iti d’      it f Outpatient Appointment
    6 12 week ‘prioritised’ wait for O t ti t A   i t   t
    - 120 new referrals per month

    Up to 8 month wait for surgery once on the waiting list
    - annual throughput 540 ‘prioritised’ TJR

M    i    t tl h           i i       d ti t j
More importantly, however, is improved patient journey
             OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
The Process:-
1. Draw a ‘li i th sand’
1 D       ‘line in the d’

2. Contact all clients waiting for OPD appointments
     labor intensive BUT 30% will no longer want appointment

       pp                      prioritisation q
3. No appointment until return p              questionnaire
   we use MAPT (multi-attribute prioritisation tool)

4. Develop dedicated ARACs
  (multi D Arthritis Review and Assessment Clinics)


5.
5 Communicate with ALL Stakeholders

6. Ensure CEO’s , Bureaucrats, Surgeons, on side


            OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
                                      MAPT
                         (Multi-Attribute Prioritization Tool)

  Developed by the Victorian Department of Human Services in conjunction with
Melbourne Health and the University of Melbourne

  Introduced to MAPT through 2005/6 AMQuIP Study




              OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
                          MAPT
           (Multi-Attribute Prioritization T l)
           (M lti Att ib t P i iti ti Tool)

Is not an exclusion tool      - acts as a guide only


Is not used in isolation     - clinical judgment will always override


If referral from a GP       - part of a referral guide
                                  Algorithm
                                     f    l    l
                                  Referral Template
                                  Management Guidelines
                                  Pt & GP Resource Locator

No OPD appointment until MAPT returned from patient




        OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
                                                                                             Interaction of MAPT and BLIS
                                             Waiting List Category One Patients MAPT Score
                80.00
                80 00
                70.00
                60.00
                50.00
        Score




                40.00
                30.00
                20.00
                10.00
                 0.00
                                         1                2                 3               4                     5                   6                   7

                                                                                                                                                                      First MAPT Scores
                                                                                         Patients
                                             Waiting List Category Two Patients MAPT Score

        100.00

           80.00

           60.00
                                                                                                                                                                         June 2006
Score
S




           40.00
           40 00

           20.00

                0.00
                           1         3   5     7      911 13 15 17 19 21 23 25 27 29 31 33 35 37 39
                                                                      Patients
                                             Waiting List Category Three Patients MAPT Score
    100.00
        90.00
        80.00
        70.00
        60.00
Score




        50.00
        40.00
        30.00
        20.00
        10.00
          0.00
                  1    7   13   19   25 31 37 43 49
                                                              OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
                                                      55 61 67 73   79 85 91 97 103 109 115 121 127 133 139 145 151 157 163 169 175 181 187 193 199 205 211 217 223
                                                                      Patients
                                                     Waiting List Category One Patients MAPT Score
             100.00
              90.00
              90 00
              80.00
              70.00
MAPT Score


              60.00
              50.00
              40.00
              30.00
              20.00
              10.00
               0.00
                                                                                                1
                                                                                            Patients
                                                     Waiting List Category Two Patients MAPT Score
        100.00


                                                                                                                                                                            l
                                                                                                                                                                        Total MAPT Scores
         90.00
         90 00
         80.00
         70.00
MAPT Score




         60.00
         50.00
         40.00                                                                                                                                                          2 Quarters Later
         30.00
         20.00
         10.00
          0.00
                          1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73
                                               Waiting List Category Three Patients MAPT Score
                                                                         Patients
             100.00
              90.00
              80.00
MAPT Score




              70.00
              60.00
              50.00
              40.00
              30.00
              20.00
              10.00
               0.00
                      1    11   21   31   41   51   61   71   81   91   101 111 121 131 141 151 161 171   181 191 201 211 221 231 241 251 261 271 281 291 301 311 321
                                                                                            Patients

                                               OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
       Structure of OPD Clinics


        0-20
MAPT 0 20
- referred back to GP with suggestions for further
     management- unless triager is concerned

 MAPT 20-40
   Multi D
 - Multi-D ARAC


 MAPT 60+
- Referral to Arthroplasty OPD



   OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
             q                       g
Initial Consequences of Service Realignment


   Early   i ii     f        j k !!!
   E l acquisition of a FLAK jacket!!!

                    temporarily blows out’!!!!
   W/L for surgery ‘temporarily’ ‘blows out !!!!


   OPD Service for the State!!


              g                  p          p
   ‘Interesting’ variations of Hip and Knee pain




        OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
           Is the System easy to Set Up?
                          Barriers T Service
                          B i      To S  i

Development:-

        H   it l B
        Hospital Bureaucracy                    Reluctance t change
                                               -R l t      to h
        Lack of Funds for Infrastructure          - Esp. Staff & IT
          pp              p                         g
        Support for Development of Business & Strategic Plans

Maintenance:-

       Access to GPs
       Exposure of True W/L
       Evolution of IT
       Ability to expand Infrastructure as required
       Revenue Neutral



            OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
            Enablers To The Service
Recognition of the Need for the Service:-
                      - finite Resource
                      - burgeoning TJR Numbers
                      - cost of ‘Burden of Disease’

Enthusiasm of Community Services to Support Service

Committee of Stakeholders

Dedicated ‘front-line' drivers

Pilot feasibility Study-       - AMQuIP

                                      Specialists
Cooperation of Consultant Orthopaedic Specialists- Communal W/L

+ve Feedback from pts.




     OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
              Summary of Benefits
Patients:-
  Transparency of Waiting List- OPD and Surgery
  - equitable delivery of Health Services
  S      ti    lf
  Support in self management t
  Monitoring of Disease Burden

Surgeons:-
Surgeons:
  Less manipulation of Waiting and Operating Lists
  More deserving pts are prioritized

Managers/ Musculo-skeletal Coordinator:-
  Coordinated treatment options for management OA
                            GPs
  More logical Rapport with GPs, Politicians
  Less pt. complaints
  Involvement in Education Modules
  More logical triaging


      OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
  Yes, it works!


6 12       prioritised
6-12 week ‘prioritised’ wait for Outpatient Appointment
- 120 new referrals per month

                ait fo surgery            aiting
Up to 8 month wait for s ge once on the waiting list
- annual throughput 540 ‘prioritised’ TJR


System now being run out Statewide in South Australia
        under Arthroplasty Clinical Networks




        OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
     You can’t run a functional and timely
Arthroplasty Waiting List Management Program
    without the supportive management of
p                              general Community
patients with arthritis in the g               y




        OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
    Wider Outreach

          2 Key Projects




OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
Joint Replacement Waiting List
      Referral G id Pilot
      R f    l Guide Pil t
  July 2007-September 2008
   OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
                         History


 End Point of Victorian OWL Stakeholder Consultation
 Final Report commissioned by DoHA and conducted
by the Centre for Rheumatic Diseases at Melbourne
University i collaboration with the RACGPs.
U i     it in ll b ti       ith th RACGP

RGH Orthopaedic Unit chosen for Pilot as it has
demonstrated a longstanding commitment to service
redesign in the area of Arthroplasty of the Hip and
Knee




       OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
                         Objectives




To determine extent to which GPs could be engaged to
develop strategies to optimise conservative management
 o pat e ts t osteoarthritis of the p and ee
for patients with osteoa t t s o t e hip a d knee




          OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
whilst at the same time evaluating a Referral Guide 
which had been developed to support timely and 
                     p        pp         y
appropriate referral for joint replacement




         OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
                         Imperatives



It was deemed crucial to engagement to support GP’s with
  appropriate tools and resources to enable them to make
  decisions about management and referral within the
  time constraints of a consultation.




           OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
                          Conclusions


• Demonstrated high level of engagement is encouraging
  for wider implementation


• Evaluation process identified significant benefits for both
                                    p         y          g
  cohort GP’s and the RGH service particularly with regard
  to guiding GP’s on when to refer patients and also in
  improved triaging through information received via the
  standardised referral template leading to more timely
  and informed assessment.


            OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
                     ADAM


Arthroplasty Demand and Allocation 
        Management Project




    OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
Project developed under the auspices of the 
Project developed under the auspices of the
    Arthroplasty Sub Committee of the (SA) 
  Statewide Orthopaedic Clinical network to 
  Statewide Orthopaedic Clinical network to
 formulate processes that will address service 
  inequities statewide and ensure that those
  inequities statewide and ensure that those 
 patients with the highest degree of disability 
      are treated first wherever possible
      are treated first wherever possible



       OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
       f h                 f h G S i
Many of the components of the RGH Service 
redesign are being incorporated into ADAM’s 
            i l          i    l
            implementation plan 




       OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
                 QUESTIONS


How did we measure and monitor
     improved outcomes?
        p

Do our stakeholders believe that all of
Do our stakeholders believe that  all of 
  this work  has been translated into 
       better patient outcomes?
       better patient outcomes?



     OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
        Measuring and Monitoring



  Collection d      l i f       i i        d ll        f
• C ll i and analysis of statistics around all stages of
  the patient journey redesign shows positive outcomes

• Surveys of patient satisfaction with OPD assessment

• Feedback from stakeholders




        OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
OPD Survey Results Immediately Post Visit


Agree and strongly agree categories
• 98.8% understood why they were being assessed
• 86.3% believed that they received clear explanations
• 85.2% felt that they were listened to
• 97% felt that the assessment time (including wait for
  appt) was acceptable




           OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
         Survey 2 Months Post Review




• 88.2 % had begun conservative management measures 
  suggested by OPD/GP’s
    gg       y    /

• 73% believed that their hip and/or knee needs were being 
  met




           OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
                     Patient “Voices”




• “I was not just a number”
          treated ith        t d     listened t and f lt
• “ I was t t d with respect and was li t   d to d felt
  that I was important to you”
  “The         li t     t d          ith      i
• “Th personal interest and care with compassion was
  very reassuring, friendly and professional”




           OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
                        GP “Voices”



  “Excellent example of Best Practice.”
• “E ll           l fB       P    i ”
• “Greatly improved communication between GP and
  H    it l”
  Hospital”
• “Great value in standardised referral tool “
• “MAPT tool provides excellent indication of where patient
  is on disease journey”




          OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM
    QUESTIONS


OUTPATIENTS – Beating the Waiting Game - Cairns September 2009 GEM

								
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