NHS Board
NHS Shetland
Contact
Linda Halcrow
Email
linda.halcrow@nhs.net
Title
Current Pathway for Pre-Operative Assessment for Surgeries Off
Island (Orthopaedic)
Category
Whole System Patient Flow
Background/
context
The NHS Board’s corporate objectives are to provide quality,
effective and safe services, delivered in the most appropriate
setting for the patient. Several NHS Shetland pathways were
identified as potentially having challenges and variation within
them with pre-operative assessment for off island procedures
being identified as one of the priorities. It was therefore this
pathway that was chosen as a project to identify the current state
so the challenges could be identified from within it.
Problem
The main problem was that the staff members working within this
pathway were voicing confusion and finding it stressful working
within the current system. Initial conversations with staff
members revealed variation, duplication and ambiguity and it was
decided to map the current state so the problem could be
identified and future recommendations suggested.
Aim
The aim over a four month period was to identify the current
pathway for patients and their clinical information for preassessment for planned hip and knee joint replacements off
island. This would take into account both the staff and patient
experience.
By the end of the four months, the current pathway would be
identified and shared with the staff members (on Shetland, Elgin
and Aberdeen) involved. On island, Shetland staff members will
be aware of their own and each other’s roles within the current
system and future recommendations will be made.
Action taken
Initially a project initiation document, contract, charter and driver
diagram were drawn up. Then, interviews were held with staff
members involved in the current system (10 members of staff on
island) and telephone/email conversations with staff members off
island (five in Elgin, six in Woodend) and the current system was
drawn up as a process map. This map was sense checked with all
staff members to ensure it was accurate. Data was collected to
find out how many patients went through the system. Patient
stories were collected using emotional touch points.
Following collection of this information, a facilitated discussion
was held on Shetland with the NHS Shetland staff members
involved. During this session staff members measured their
understanding of each other’s roles at the beginning and end of
the session on a scale 1-10 (1 being they do not understand the
role at all, 10 being full understanding of the role). The beginning
of the day saw scores varying from 1-10, the end showing
variation of 8-10. This session also allowed future
recommendations to be set.
During the project, there were several risks identified that were
resolved. Procedural errors were highlighted where staff were
unaware around policy sharing and this was addressed
immediately. There was also ambiguity of words on documents
being shared with across NHS Boards which was highlighted and
changed. It was highlighted that there was variation in how
patient information was being sent to the mainland (posted
recorded delivery and scanned and emailed) and this was
streamlined to be the same system for all hospitals.
Results
Attached at the end of the report are three figures which show
the pathways for Shetland, Elgin and Aberdeen as they currently
stand.
This work benefits patients as staff are now aware of the current
process they follow so can better inform them of their journey
which leads to less confusion. Staff members appear happier in
their work and have a clearer understanding of their role and each
other’s, thus enhancing working relationships. This work has
raised the profile of NHS Shetland within mainland NHS Boards,
organisationally staff are compliant with policies within the
pathway and variation has been reduced thus reducing associated
costs.
Efficiency savings
and productive
gains
Productivity has been improved because staff are now fully aware
of the system they work within, they are able to provide the same
service within existing budget but are able to inform the patients
better around their journey. Costs have been lowered by scanning
and emailing pre assessment pack to the mainland rather than
sending recorded delivery which has led to a more efficient and
cost effective means of producing the same results with less
input.
The future recommendations this project has identified will
further add to the efficiency and productive gains by further
reducing variation and streamlining the system to ensure faster
throughput of patients.
Sustainability
A local working orthopaedic group has been established on island
to take forward to recommendations from this project. All key
stakeholders have been identified and invited. This will ensure
regular and effective communication links are maintained
between key staff members, which will also ensure sustainability
of the current changes.
Lessons learned
The main lesson learned from this work was the time it took to
extract the information from all stakeholders and the complexity
of working across NHS Boards. It highlighted the importance of
having a clear working pathway which everyone is aware of and
understands. Challenging assumptions was another learning
point, as often these assumptions are not factual and can further
lead to confusion. The local orthopaedic working group will take
forward the recommendations which have been identified by
completing this work. Others looking to map similar pathways
could use this as a means of demonstrating the benefits of this
type of analysis – without mapping these pathways, it would have
been impossible to find where the variation and ambiguity was
and therefore, how to find solutions.
Figure 1 – Shetland pathway
Figure 2 – Elgin Pathway
The Pathway for Patients and Their Clinical Information For
Planned Hip/Knee Replacements – Elgin
Receives letter from
Shetland orthopaedic
secretary regarding
patient
All patients out with
waiting time guarantee
– phone patient and
offer operation
elsewhere sooner
Patient wishes to be
seen elsewhere –
Amanda informs her
supervisor
Patient details added to CWTT
spreadsheet and sent to CWTT
on Friday. Details sent to
CWTT: patient name, CHI,
waiting list details and
highlight it is a Shetland Mr
Anderson patient.
Patient requests Dr
Gray, Elgin. Receives
POA pack via e-mail
from Shetland PFB
Team (Hannah)
Receives POA
pack and checks
everything
there
Receives POA
pack from
Shetland PFB
Team (Hannah)
Orthopaedic secretary
will print POA pack and
give to nurse
If patient rejected
elsewhere or wish to
come back to CWTT
email back with POA
If anything
missing contact
Shetland POA
nurses
Pack passed to
anaesthetist for
reviewing POA
pack. Patient
passed or failed.
Letter sent to
patient with
date and details
of travel
Key:
Orthopaedic Secretary – BLACK
Medical Secretary Supervisor/Trainer – GREY
Pre assessment Nurse – RED
Anaesthetist – BROWN
Other - GREEN
Notes and POA
pack arranged
for admission
Patient
admitted day
before surgery.
Checked in by
ward staff.
Abbreviations:
CWTT – Central Waiting Times Team
POA – Pre operative assessment
PFB – Patient Focussed Booking
Surgery
CWTT
Figure 3 – Aberdeen Pathway