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No Bones About It

The Children's Hospital at Westmead
Project Added:
26 April 2016
Last updated:
28 April 2016

No Bones About It


This project decreased unnecessary time spent in orthopaedic clinics, reduced the number of patients per clinic to a safe and manageable level and standardised follow-up pathways for orthopaedic patients.

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

No Bones About It poster


To decrease patient episode time at The Children’s Hospital Westmead (CHW) Orthopaedic Outpatient Clinic from 108 minutes to 60 minutes by April 2016; reduce the average number of patients in two clinics from 40 to 35 patients by February 2016; and improve patient satisfaction with the service from a baseline of 61% by February 2016.


  • Improves health outcomes for orthopaedic patients.
  • Decreases episode time for patients and carers.
  • Improves staff and patient satisfaction and experience.
  • Reduces unnecessary follow-up appointments and x-rays.


The number of patients in the Orthopaedic Outpatient Clinic at the CHW has increased by 10% each year from 2005 to 2015. In 2015, the clinic treated 20% of all outpatients at the CHW. On average, there are 13 different half-day orthopaedic clinics per week at the CHW. Prior to the project, the average time a patient spent with the doctor was 12 minutes with a wait time of 107 minutes. This led to significant patient and carer dissatisfaction, as well as staff stress and burnout, evidenced by carer complaints and staff stress leave.

To reduce the pressure on staff and provide a better experience for patients and carers, the CHW required a new referral pathway for orthopaedic services. It was anticipated that this would reduce average wait times, reduce the number of patients in each clinic and improve overall satisfaction with the service.


Outpatient clinic

1. Testing phase: 1 October 2015 to 17 December 2015

Two clinics piloted the implementation of solutions over a six-week period. Fortnightly reviews and modifications were undertaken, to identify and resolve all issues prior to rolling the solutions out across all clinics.

2. Implementation phase: February 2016 to July 2016

Implementation of solutions is underway for all orthopaedic clinics, with a target of 90% implementation by July 2016.


  • Patients are scheduled for an appointment according to their clinical requirements, via an animal coding system:
    • dingo means only see the doctor
    • possum means see physiotherapist for cast removal, then see the doctor
    • parrot means see physiotherapist for cast removal, get an x-ray, then see the doctor
    • roo means have an x-ray, then see the doctor
    • ibis means imaging other than an x-ray, then see the doctor
    • koala means the patient needs a consultant review.
  • Arrival times for patients are staggered, with 10 patients seen every 30 minutes. Appointments comprise a mixture of animal types, so that radiology, physiotherapy and clinicians have a steady stream of patients without long waiting times.
  • Standardised follow-up guidelines were developed for common fracture types, to reduce unnecessary follow-up appointments and x-rays.

Emergency department

A pathway for presentations to the emergency department was developed to identify injuries, such as soft tissue injuries and simple fractures, that are suitable for review by a general practitioner (GP). GP consultation occurred through Wentwest Primary Health Network and standard letters to GPs were developed, along with patient fact sheets.

Project status

  • Sustained - the initiative has been implemented and sustained in standard business.

Key dates

  • Project start: 31 March 2015
  • Project finish: June 2016

Implementation sites

  • Orthopaedic Outpatient Clinic, The Children’s Hospital Westmead



  • The average episode time per patient reduced from 107 minutes in June 2015 to 64 minutes in March 2016.
  • Patient experience results demonstrated improved patient satisfaction from 61% in June 2015 to 71% in March 2016, with patients identifying the wait time in orthopaedic clinics as suitable.
  • Feedback forms identified positive comments, including:
    • ‘less crowded in the waiting room’
    • ‘changing the system is the best thing ever!’
    • ‘quick, friendly and professional’.
  • Staff surveys showed improved satisfaction. Results were as follows:
    • ‘there was enough staff for the patient load at any time’ – from 0% to 70%
    • ‘overall I had a positive experience in the clinic today’ – 25% to 50% agree
    • ‘patients did not complain about the wait’ – 50% to 80% agree.
  • An audit completed in the emergency department showed that 33 splints were used appropriately.
  • No patients returned to the emergency department for review, however three patients returned or phoned to request information on purchasing a second splint.

Lessons learnt

  • Problems exist for a long time before something is done.
  • People are positive about change if they can see the benefit to patients.
  • It can be difficult to engage with GPs due to their availability.
  • It is best to plan for delays as there will be unforeseeable obstacles.

Further reading


Melissa Potts
Project Manager
The Children’s Hospital Westmead
The Sydney Children’s Hospital Network
Phone:  02 9845 2725

Dr Varun Sahni
Project Manager
The Children’s Hospital Westmead
The Sydney Children’s Hospital Network
Phone: 0432 434 219

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