26 Mar Sharing ideas for better practice
This week we share some innovative ideas that helped Sheinaz Stansfield and her practice, Oxford Terrace and Rawling Road Medical Group, improve the efficiency, access and care for patients with long term conditions. Next week we will share some more innovations for dementia care.
Start with the review of your practice…
We embarked on a project to improve both acute access and chronic disease management. Initially we found that most mornings by 8.30 all routine appointments were taken, leaving both patients and the receptionists irate and unhappy.
On review of our appointment system we found that it was set up to deliver 9.5 appointments per patient per year (double the national average). A further audit indicated that we were actually delivering 5.4 appointments per patient per year (exactly the national average).
GPs undertook a retrospective review of their surgeries and found that a third of the patients they were consulting could be seen by a nurse. A similar review of nurse appointments showed that they had 27% self-blocks and 22% of their appointments were not used.
Clearly there was a lot of waste in our system with approximately 49% of the nurse appointments were wasted. Nurses had no access to clinical supervision and they were reactive in most of their interventions, they were not undertaking work commensurate with their clinical grading. There was variation in timings for clinical tasks and clinical recording. Although we were high achievers of QOF, our patients were attending A&E and being admitted for conditions that could be better managed if patients engaged in self-care up stream. Review of our A&E attendances and admissions indicated that frail elderly patients with UTIs, upper respiratory conditions and Asthma were frequent flyers.
Nurses became actively involved in improving the system. We used some of the tools of LEAN methodology to observe and measure the tasks undertook.
What we did:
- The appointment system was changed;
- Time undertaken to do clinical tasks reduced – e.g smears from 20 minutes to 15 minutes (observation had indicated that the majority of smears were completed and recorded in 12 minutes);
- Review of call and recall systems, and delegation to admin team;
- Six weekly clinical supervision and performance review, and;
- Review of all clinics.
A national review indicated that there was no national clinical competency framework for practices nurses, there was no standard job description or clinical supervision process that we could draw upon. The job descriptions were redrafted using the agenda for change competencies and a clinical supervision policy and processes were put in place.
Within 10 weeks of starting this work our nurses became more effective, efficient and productive. In addition, we were able to free them to become involved in developing a tool for risk stratification and undertake proactive management of patients with COPD.
Despite two nurses leaving the practice we were able to free up 280 nurse appointments per week. These two positions were not replaced, and resulted in a saving of £54,000. The waste stripped out of nurse appointments equated to one WTE GP providing 8 sessions of 10 minute appointments per week, which made a significant difference to our GP appointment availability. This enabled us to improve access to GP appointments and free-up GP time to undertake ward rounds in four nursing homes.
In effect, we were doing more work with reduced workforce.
We used some aspects of LEAN and PDSA’s as our quality improvement tools. These have enabled us to track changes and engage the whole practice team in a culture of continuous quality improvement.
Using the risk stratification tools enabled us to identify patients who were at high risk of admission. Proactive case management of theses patients through integrated working with our community matrons, self-care, and referral to pulmonary rehab enabled us to make a significant reduction in both attendances and admissions to hospital for patients with chest conditions. In addition, we were able to achieve further reductions in attendances and admission to A&E for frail elderly patients in nursing homes, through care planning and proactive case management of those patients and better palliative care and end of life planning.
This innovation has enabled us to strengthen the nursing team with the right skills. In addition, it has enabled us to move towards more patient centred, care planning approach to managing patients with long term conditions. In April we are moving to the House of Care approach to the management of long term conditions. This will further remove waste from our system by reducing the number of appointments patients need to management of more than one long term condition. It will also enable us to engage patients more actively in self-management/self-care.
Sheinaz Stansfield is a practice manager with over 30 years’ experience in the NHS. She initially trained as a nurse and health visitor, and then worked in commissioning at PCT and strategic health authority level, concerned mostly with developing services outside hospital, for example, integrated primary and community services, integrated nursing teams and services in GP practices. She has also worked for a Primary Care Group as a primary care development and commissioning/contracting manager and helped set up clinical commissioning in Gateshead. She is an elected locality manager for Gateshead Clinical Commissioning Group, practice representative on the Gateshead Newcastle CCG Governing Body and the practice manager representative on the RCGP Northern Faculty Board.