The Welsh Audit report in 2015 encourages clinicians to challenge assumptions on outpatient referral habits and supports clinical leadership in taking managed risks to ensure that patients at greatest clinical need are seen quickly whilst avoiding unnecessary appointments for those who can be managed elsewhere.
We sought to implement a service improvement, guided by these prudent healthcare principles with a referral prioritisation project to improve the capacity/ demand gaps and reduce waiting times for our patients. Our prioritisation service aligns with NICE guidance for the management of rheumatoid arthritis in adults (CG79), particularly recommendations in section 1.1 of the guidance for referral, diagnosis and investigations. The service also aligns with Quality Statements of QS33.
As a direct result of this project, we have been able to provide timely appointments for all new patients requiring early rheumatology review as endorsed by the British Society for Rheumatology. We have also made enormous improvements in managing our existing patients with inflammatory conditions by reducing our follow-up not booked caseload.
Aims & Objectives
Our specific aims were to:
- Reduce waiting times for all new outpatient appointment to under 26 weeks, and
- Reduce the number of patients waiting in excess of expected times for a follow up appointment
The British Society for Rheumatology and NICE guidance CG79 and QS33 emphasise the importance of early referral to specialist services for people with suspected inflammatory joint disease, to support prompt intervention and minimise joint damage.
In April 2014, our service in Abertawe Bro Morgannwg University (ABMU) did not deliver this and as clinicians we knew our waiting times were unacceptable with 13% of patients waiting for over 26 weeks (Welsh Assembly Government Target) for a new outpatient appointment. We also had a large number of follow-up patients (1624) waiting longer than their target date for review.
The Welsh Audit report in 2015 encourages clinicians to challenge assumptions on outpatient referral habits and supports clinical leadership in taking managed risks to ensure that patients at greatest clinical need are seen quickly whilst avoiding unnecessary appointments for those who can be managed elsewhere. We sought to implement a service improvement, guided by these prudent healthcare principles with a referral prioritisation project to improve the capacity/ demand gaps and reduce waiting times for our patients.
Our improvement project involved the multidisciplinary team, including our service manager who played a key role. The first steps, taken in March 2014 involved a process mapping discussion of the referral pathway. The change we focused on was the referral prioritisation.
This remains an activity traditionally performed by numerous clinicians in a service, using no agreed clinical criteria, often at the end of a busy outpatient clinic or as part of administration duties. The issues raised were: inconsistencies in approach, delays in the process, the number of different people involved in the process and inappropriate referrals.
The change we made was that 2 designated consultants in the East and West of the Trust would take responsibility for assessment of each referral, examination of relevant test results and cross referencing with our electronic rheumatology database. These consultants would test the change on top of their clinical workload.
We developed agreed criteria for offering new patient appointments in line with national guidelines defining the appropriate case mix for rheumatology clinics. Referrals could be:
- redirected, if appropriate, to other services such as the Musculosketal Clinical Assessment Service (MCAS) or chronic pain teams
- returned to the referring clinician (primary or secondary care) with tailored investigation/ management plans.
Letters were sent directly to patients, explaining the rationale behind this decision. We obtained support from Shared Services and refined the process, testing and developing the criteria all the time.
Weekly records were kept of all referrals received/ redirected/ returned and we updated the wider team at our bimonthly departmental meetings. This work was presented as a Plan, Do, Study, Act (PDSA) cycle by our service manager in November 2015 to the ABMU Managing to deliver programme, with excellent feedback and subsequent requests to share this work with other clinical teams.
We did encounter some obstacles along the way. These were mainly administrative and included the need to ensure all referrals were sent to the clinician involved, by informing all involved staff across the 4 hospitals served; improving the efficiency of communicating urgent appointment requests etc. via the booking office. These were overcome gradually, as problems or inefficiencies were encountered, the clinician and manager leading the project would discuss solutions with the required staff.
Results and evaluation
At 6 months, we reviewed the results so far obtained and whilst improvements had been made, (new patient waiting times had fallen to 10 weeks at Princess of Wales Hospital/ Neath Port Talbot Hospital and 22 weeks in Swansea), it was felt that there was scope for further reductions to be achieved.
The decision was made to appoint a single consultant (author) to prioritise all referrals across the Trust. To incorporate this activity (approx 75 referrals weekly), my job plan was reduced by one new patient clinic session weekly. This arrangement would be open to review depending on the success of the project.
Following the introduction of a single consultant prioritising all referrals, the waiting times fell to 4-6 weeks across all sites by March 2015. The graph shows the number of new patient appointments across the rheumatology department, reflecting the reduced number of appointments required following redirection of referrals at the prioritisation stage. We strive to provide timely and clear communication to all patients whose referrals have been redirected, so that they are aware of the rationale behind this decision.
We are pleased to report that since the project commenced, only one patient has expressed reservations at this decision. They were offered an appointment for review at which time an explanation was provided regarding appropriate management in primary care. Following the success of the referral prioritisation on our new patient waiting times, we looked to convert new patient clinics to follow up activity in order to reduce the follow-up not booked (FUNB) caseload. This has resulted in the reduction of the number of patients waiting longer than their target date from 1624 in March 2014 to 253 in Jan 2016 (see graph in the supporting material).
Key learning points
- While the involvement of a single clinician in this work has resulted in a consistent approach to the prioritisation principles adopted there are issues when this clinician is away. Thought needs to be given to cross cover in support of the validation process and encouraging team working.
- We have recently begun electronic referral prioritisation which supports rapid referral assessment and direct electronic communication with the referrer. This process is being gradually rolled out across specialties within ABMU and across Wales. This process should be integrated at the outset into any prioritisation projects to facilitate effective and timely communication with primary care referrers.
- This project relied on the close collaboration and partnership between our service manager and senior clinicians, with regular updates on outcomes and feedback to the wider team on progress. This is integral to the success of our service change and has resulted in the work involved being shared with both managerial and clinical staff, and subsequent interest by a number of clinical teams looking to adopt this strategy to address their outpatient capacity challenges.