The BONE Project: Building Orthopaedic Network Excellence

Benefits

• Improved clinical safety and sustainability.
• Upskilling of staff and realignment of existing clinical services.
• Improved patient and staff experience.
• Reduced waste and organisational costs through digital enablement.
• Increased patient choice in access to services.
• Reduced out of pocket expenses for patients.
• Improved clinic flow with reduced clinic time per patient.
• Positive reputation for clinics and organization.
• Reduced overtime for organization.
• Close the gap initiatives with involvement of ALOs during clinics. Future benefit: Increased capacity for primary care general practitioners and Kempsey workforce.
• Future benefit: Increased capacity for primary care general practitioners and Kempsey workforce.

Program status

Program dates

• November 2018 – started planning
• February 2019 – initiation commenced
• March 2019 – commenced diagnostics
• May 2019 – solution development
• June 2019– commencement of phase one of implementation
• December 2019 – solution one implementation complete and commencement of phase 2
• 2020 – phase two, three and four implementation role out and evaluation
• 2021 ongoing – implementation and plan-do-study-act cycle continues

Status

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

Background

The Fracture Clinic redesign project commenced to meet the needs of the rapidly growing orthopaedic outpatient service at Port Macquarie Base Hospital.

Since commencement in 2003, the demand for clinics has increased by 500% with no formal review or resource enhancement. There is a significant shortfall in the budget and staff are being pulled from other services.

Patient and staff experience is low with a 4/10 rating on the experience tracker.

Clinics have inconsistent flow and bottlenecks which are driving the high unproductive waiting times of up to 90% and an ACT per person of 130 minutes.

The last 12 months have seen a 200% increase in staff overtime and consumer complaints.

Implementation

• Application of the Clinical Redesign Methodology; initiation, diagnostics, solutions, implementation, monitoring.
• Diagnostics including: process mapping with the multidisciplinary team from referral to clinics to transfer of care from clinics, time in motion observations with 10 patients, focus groups with staff and patients, staff survey, recording check in and check out time (providing baseline ACT per patient), recording productive time and unproductive time, engagement of a LEAN expert to observe clinic flow, involvement of a consumer on the project team, consultation with Aboriginal community and completion of Aboriginal impact statement.
• 130 issues were identified, with the root cause identified, themed and prioritised.
• Solutions were generated using a variety of tools including: brainstorming sessions, radical triangle model, impact and feasibility scoring matrix and team voting.
• Quick wins were established including the purchase of IT equipment and an automatic door for the waiting room and trial of an answering machine for patient bookings.
• Solutions were strengthened using patient personas and feedback from consumer groups representative of social and cultural groups.
• An Aboriginal health impact statement was completed to identify opportunities.
• A solution ‘owner’ was identified for three primary solutions; digital enablement, medical imaging, orthopaedic pathways. Small working groups were established to design and pilot the solutions. Secondary solutions and quick wins have continued throughout the implementation phase in line with plan-do-study-act cycles.
• An Orthopaedic Steering Committee was established as a decision making committee with terms of reference and minutes and chaired by the executive manager of community and allied health (also the project sponsor). Meetings were held every six weeks and will continue as business as usual.
• Project scope, risks and issues and communication plans were actively managed throughout the project.

Implementation sites

Orthopaedic Outpatient Fracture Clinics, Hastings Macleay Clinical Network at Port Macquarie Base Hospital and Kempsey District Memorial Hospital, Mid North Coast Local Health District.

Partnerships

• Centre for Healthcare Redesign
• University of Tasmania
• North Coast Primary Health Network
• IMED
• Justice Health NSW

Results

Quick wins

• Establishment of the orthopaedic Steering Committee.
• New workstation on wheels.
• New automatic door for wait room.
• Refurbishment of clinic space.
• Approval for all clinic expenditure to be aligned in fracture clinic cost centre.
• Answering machine for patient appointments.

Solutions

• The clinic is now 100% digital.
• Orthopaedic Clinical Pathway endorsement from Steering Committee (regular review required).
• Elective wounds seen in community wound clinic around the clinical network (73 elective patients in last 12 weeks seen in community wound clinics as opposed to fracture clinics. No scheduled appointments missed, seen close to home less than 15 minutes travel time and 5 minutes waiting time to see clinician, 100% satisfaction).
• Medical imaging is now available at three different sites in the network providing more choice for patients.

Results October 2020

1. By December 2020, increase patient and staff experience from 40% to 80%.
   Result: Patient experience 88%, staff 75%.
2. By December 2020, decrease the Average Clinic Time (ACT) per patient from 130 to 90 minutes.
   Result: 67 minutes. Non-productive time was 85 minutes, now it is 35 minutes.
3. By December 2020, increase awareness of the clinic budget from low to high (then using this information to build a sustainable budget long term).
   Result: Previous budget 2019-20 was at $52,000. Current 2020-21 budget is at $170,288.

Staff feedback

Dr N: “70% of paper referrals were incomplete impacting on clinic efficiency. The new electronic referral form with mandatory fields is a really positive change and safer for the patient”.

“Clinics no longer run over time, in fact there is no overtime now!”

“Less angry patients as the waiting times have improved significantly”

“Thanks to redesign team for making clinics better”.

Patient feedback

“Streamlined service”.

“Friendly, helpful, courteous and caring staff”.

“Clinic is easy to access and well organised”.

Lessons learnt

• Establishment of a steering committee with the key players was fundamental.
• Strong leadership from project sponsor.
• Identification of solution owners and ongoing support for them.
• Timing and climate are essential.
• Staged approach, build momentum and celebrate wins.
• Manage resistance and keep a focus on scope, risks and issues and communication plans.
• True implementation and sustainability takes careful planning, perseverance and hard work!

Contacts