A Joint Effort: patient centred redesign in rheumatology outpatients

Published 24 April 2019. Last updated 9 May 2019.

This project aims to implement a sustainable and patient centred service for patients attending the rheumatology outpatient clinics at Royal Prince Alfred Hospital (RPA).

View a poster from the Centre for Healthcare Redesign graduation May 2019.


To provide sustainable, patient-centred outpatient clinics within the rheumatology service at RPA by August 2019.


For the patient

  • Timely access to the rheumatology service for new patients
  • Reduction of clinical complications
  • Reduced time spent in the outpatient clinic
  • Improved communication channels for patients
  • Increased positive experience with the rheumatology clinic.

For staff

  • Improved communication between the staff in the rheumatology department
  • Efficient and consistent processes
  • Increase in job satisfaction as a result of the improved service.

For the healthcare system

  • Increased productivity resulting in increased revenue
  • Decreased ‘no show’ rates, resulting in more efficient use of resources.


There is an increasing demand on the services of the rheumatology department at RPA.

Occasions of service increased 12% in the 2016-17 financial year, compared to the 2015-16 financial year.1 The service is burdened by this demand, delivering 102 hours of care within 65 hours of allocated clinic time per week.1 Staff and patient surveys show the demand has created issues within the clinics. For example, 61% of patients wait more than 30 minutes to be seen for their scheduled appointments. Whereas 64% of new patient referrals wait more than six weeks for their first appointment.2

Patients and staff identified five key focus areas affecting the patient journey in the rheumatology outpatient service.

  1. Communication regarding clinic processes and delays
  2. Intradepartmental communication
  3. Ad hoc clinic structures and processes
  4. Length of time between referral to clinic and appointment
  5. Waiting times for scheduled appointments in clinic.


A total of nine solutions were developed in consultation with staff and patients. Implementation of the following solutions will take place from February 2019 to June 2019.

  1. Department meetings and education sessions
  2. Scheduling and clinic restructure
  3. Clinic huddles
  4. Waiting room refresh
  5. Communication with patients about possible delays
  6. eReferrals
  7. Establishment of new patient clinic with rapid access slots
  8. Nurse led education and monitoring clinic and clinical hotline
  9. Administrative staff- increased full time equivalnet staff numbers and role definitions.


Implementation - The initiative is ready for implementation, is currently being implemented, piloted or tested.


February 2018 to August 2019

Implementation site

Royal Prince Alfred Hospital Rheumatology Outpatient Services



A comprehensive evaluation will be undertaken in August 2019 with periodic monitoring occurring in April and May 2019 to identify whether the project objectives have been achieved. These evaluations include:

  • patient survey (with comparison to baseline results) about their satisfaction with clinic experiences
  • staff survey (with comparison to baseline results) regarding their workplace satisfaction
  • data analysis of scheduling and NSW Health activity based management portal to review occasions of service, no shows, clinic utilisation and cancellations
  • eReferral report to analyse how long patients are waiting to be seen for a new appointment
  • clinic time and motion review to determine how long patients are waiting for their scheduled appointment

Informal feedback provided by patients and staff external to these evaluation methods will also be taken into consideration.

Lessons learnt

  • While the overall patient and staff satisfaction rates with the rheumatology outpatient service are high, there is still room for improvement.
  • We have identified nine strategies to facilitate the development of efficient and more patient (and staff) centered rheumatology outpatient service at RPA.
  • Access to ongoing resources, patient and staff feedback, sponsor support and ensuring key stakeholder buy will be crucial to implementing and sustaining change.


  1. Data obtained from outpatient scheduling reports.
  2. Data obtained during diagnostic phase.

Further reading

  • Hardy KJ, O’Brien SV, Furlong NJ. Information Given to Patients Before Appointments and its effect on Non-attendance Rates. BMJ. 2001;323:1298-300
  • Tseng Ann. Huddling Up: Expanding Clinic Huddles. Ann Fam Med. 2017;15:584
  • Royal College of Physicians NHS. Improving teams in healthcare – team communication. London: RCP; 2017.
  • Godley M, Jenkin JB. Decreasing Wait Times and Increasing Patient Satisfaction. A Lean Six Sigma Approach. JNurs Care Qual. 2019 Jan/Mar;34(1):61-5.
  • Scheibe MM, Imboden JB, Schmajuk G, et al. Efficiency Gains for Rheumatology Consultation Using a Novel Electronic Referral System in a Safety-Net Health Setting. Arthritis Care & Research. 2015 Aug;67(8):1158-63.
  • Larsson I, Bergman S, Fridlund B, Arvidsson B. Patients’ experiences of a nurse-led rheumatology clinic in Sweden: A qualitative study. Nursing & Health Sciences. 2012;14(4):501-7.
  • Ndosi M, Lewis M, Hale C, et al. ‘Outcomes and cost effectiveness of nurse led care in RA’, Ann RheumDis. 2014;73:1975-82.
  • Larsson I, Fridlund B, Arvidsson B, et al. A nurse-led rheumatology clinic versus rheumatologist-led clinic in monitoring of patients with chronic inflammatory arthritis undergoing biological therapy: a cost comparison study in a randomised controlled trial. BMC Musculoskeletal Disorders. 2015;16:354-63.


Dorothy Fowler
Clinical Nurse Consultant
Rheumatology Department
Royal Prince Alfred Hospital
Sydney Local Health District
Phone: 02 9515 9337


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