Know Before You Go: Transforming Surgical Access

Improving the pre-admissions process for elective joint replacement patients

South Eastern Sydney Local Health District

Published 28 October 2022. Last updated 24 November 2022.

This project is improving the pre-admissions clinic (PAC) process for elective joint replacement patients at The Sutherland Hospital (TSH). The perioperative process optimises the surgical journey for every patient by collating, analysing and integrating information from multiple sources. The aim is to make each individual patient’s experience safe, appropriate, effective, efficient and positive.

View a poster from the Centre from Healthcare Redesign graduation November 2022.

Know before you go poster


  • Reduce the average monthly time elective joint replacement patients spend in the PAC by 40% (4 hours to 2.5 hours) at TSH by March 2023.
  • Reduce the number of joint replacement patient-related operating theatre cancellations from 4% (monthly average) to less than 2% at TSH by March 2023.
  • Increase the number of joint replacement patients scheduled for their PAC appointment, within six to eight weeks, prior to day of surgery from 20% in June 2022 to 80% in March 2023.
  • Increase the number of vulnerable patients identified prior to the PAC visit (managed in accordance with the TSH Clinical Business Rule CLIN559) from 33% in June 2022 to 100% by March 2023.1


  • Enhanced collaboration and more effective knowledge sharing between the key members of the multidisciplinary perioperative team for patient cantered care.
  • Reduced waiting time for patients in the PAC.
  • Improved patient experience by seeing clinicians at the right time, the first time.
  • Early identification of patient conditions and vulnerable patients, allowing for clinicians to optimise patients for surgery.
  • Reduced number of patient-related operating theatre cancellations for elective joint replacement patients, complying with Ministry of Health targets and key performance indicators.2
  • Improved clinician efficiency and satisfaction with the PAC process.


The main functions of a perioperative service are to ensure that:

  • the patient and carer are optimally prepared for their complete surgical journey
  • the surgical journey occurs in a safe, efficient and patient-centred manner.

A number of ineffective and inefficient aspects of the current elective joint replacement patient’s journey at TSH’s PAC have been identified from both patients and families and members of the perioperative services multidisciplinary team.

  • Majority of the patients are currently waiting on average four to six hours (benchmark two and half hours) in the PAC to complete the required tasks, resulting in poor patient experience and inefficient use of resources.
  • 80% of the PAC visits are currently occurring two to three weeks prior to the day of surgery, rather than the optimal schedule of six to eight weeks prior to the day of surgery.
  • A 2020 root cause analysis, performed following a fatal outcome of a vulnerable patient, identified several system improvement opportunities for the PAC. Only 33% of vulnerable patients are identified at the most appropriate stage in the PAC process in accordance with TSH Clinical Business Rule CLIN559, to allow for a multidisciplinary management plan.1
  • 79% of the recommendation for admission forms are sent to the PAC incomplete. This results in significant time by the PAC staff chasing up vital patient and surgery information, which leads to delays in the PAC process and unnecessary cancellations.

In addition to these issues, there has been an increase in the number of joint replacement patients attending the PAC over the past three years (average 30 per month in 2019 to 80 per month in 2021). This increase, along with COVID-19-related stopping of elective surgery, has resulted in long surgical waiting times for the patients.

TSH is also undertaking a two-phase redevelopment of the operating theatre complex, which will result in an additional two operating theatres and two procedure rooms to be completed in 2023. This redevelopment will result in an increase in the number of surgeries and patients attending the PAC. This increased capacity prompted a review of the surgical services at TSH to meet the patients’ needs and improve patients’ pre-admission journey prior to elective surgery.3


Diagnostic process

  • Pre-admission process mapping with the perioperative multidisciplinary team
  • Patient interviews to understand the patient experience, gaps and co-design with solutions
  • Focus group sessions to further issue identification and prioritisation
  • Extensive data collection of objective data, as well as productivity, efficiency, safety and clinical outcome key performance indicators.
  • Performance metrics were reviewed to identify any significant gaps in the system requiring further investigation. Peer hospital benchmarking and reconciliation with the Ministry of Health key performance indicators was also conducted.1
  • Real time mapping of PAC appointments for patients attending PAC via virtual care and in person.
  • Root cause analysis (5 Whys) was performed on priority issues and then validated with key stakeholder.


A collaborative and co-design approach, including multiple focus group sessions with the perioperative services multidisciplinary team and patient interviews, resulted in six solutions and two quick wins to be implemented.

Quick win 1: Patient reminder

Test a reminder to the patients one week prior to their pre-admission appointment to remind them what documentation to bring to avoid unnecessary surgery delays or cancellations.

This has been evaluated by weekly patient surveys and successfully implemented.

Quick win 2: Information video

Play an information video in the PAC waiting room to better inform the patients on how to prepare for their upcoming surgery and what to expect post-operatively.

This has been evaluated through weekly patient surveys and successfully implemented.

Solution 1: Referral for admission checklist

Attach a checklist to the referral for admission form, with simple instructions to enable full completion of the form by the surgeon and patient.

Solution 2: Orthopaedic medical roster

Create an orthopaedic medical roster to schedule mandatory attendance times in the PAC to reduce waiting times for patients.

Solutions 3: Pathology request form

A pathology request form is given to the patient during the initial consultation so that patients can attend an initial screening blood test for early identification of risk factors.

Solution 4: Better integration of programs

Better PAC integration with the Osteoarthritis Chronic Care Program and coordination with the orthopaedic clinical nurse consultant for potential Advanced Recovery Orthopaedic Program admission. Currently these services run independently of each other. Collaboration between services will provide a more comprehensive, multidisciplinary perioperative approach for the patients.

Solution 5: Pre-admission blood test

Patients to have pre-admission blood test one week prior to PAC visit to have results ready for review during PAC visit. This minimises the walking distances for patients and the changes of missing the medical teams, which lead to PAC delays and late identification of medical risks.

Solution 6: Screening of referral for admission forms

A qualified registered nurse will screen all referral for admission forms within three days of submission to surgical bookings to identify missing information, potential health issues and vulnerable patients. The nurse will liaise with the patients, PAC anesthetist and medical specialist to develop a management plan.


Implementation – The project is ready for implementation or is currently being implemented, piloted or tested.


The project started in August 2021. The project was then put on hold due to COVID-19 restrictions and restarted in March 2022.

Implementation sites

  • Surgical Bookings, The Sutherland Hospital
  • Pre- Admission Clinic, The Sutherland Hospital


Centre for Healthcare Redesign


The objectives and solutions are being measured through a formalised data collection plan which includes performance, efficiency, safety and outcome data along with weekly patient surveys, interviews and staff feedback.

The quick wins and solutions 1 and 2 have started implementation and currently on track in accordance with our implementation plan and strategy.

Lessons learnt

  • Trust the methodology, it is in very in depth and each phase feels overwhelming but the skills you learn are invaluable.
  • Be flexible with your consultation approach.
  • Time management and delegation of tasks will assist you in meeting your deliverable timeframes.
  • Communication is key!


  1. NSW Ministry of Health and South Eastern Sydney Local Health District. Service Agreement 2022-23. Sydney: South Eastern Sydney LHD; 2022 [cited 26 Oct 2022].
  2. The Sutherland Hospital & Community Health Services. Clinical Business Rule: Highly Vulnerable Patients – Ward Management of (CLIN559). Sydney: South Eastern Sydney LHD; November 2021 [cited 26 Oct 2022].
  3. South Eastern Sydney Local Health District. Health Plans. Sydney: South Eastern Sydney LHD; 2022 [cited 26 Oct 2022].

Further reading

  • Emanuel A, Macpherson R. The Anaesthetic Pre-Admission Clinic is Effective in Minimising Surgical Cancellation Rates. Anaesthesia and Intensive Care. 2013 Jan;41(1):90-4.
  • He J, Gallego B, Stubbs C, et al. Improving patient flow and satisfaction: An evidence-based pre-admission clinic and transfer of care pathway for elective surgery patients. Collegian. 2018 Apr;25(2):149-56.
  • Alsher P. Use Heat Mapping to Drive Better Project Decision Making. Lakewood, CO USA: Implementation Management Associates; 2018.
  • Carlucci D, Schiuma G. Assessing and Managing Organizational Climate in Healthcare Organizations: An Intellectual Capital Based Perspective. Int J Inf Syst. 2012 Oct;4(4):49-61.


Sara Hogan
A/Nurse Manager Perioperative Services
The Sutherland Hospital
Phone: 02 9540 7600
South Eastern Sydney Local Health District


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