By: 1 March 2010

Clinicians at the Nottingham Treatment Centre's busy Orthopaedics gateway in the UK were regularly faced with overbooked clinics. Under Clinical Lead Tony Westbrook, they developed new ways of working that allowed them to handle a 12% increase in patient appointments (and a 10% rise in daycase procedures) without any risk to patients. How did they do it?

Nations Healthcare's Nottingham site handles some 200,000 patient visits a year. Patient satisfaction approaches 100% and its new MRSA infection rate is zero. Performance data showed its 1,500+ professionals delivering efficiency and productivity gains averaging 20.2% for daycase surgery and 15.1% for outpatient visits during 2009 - and a major contributor to those increases was the Orthopaedics speciality under Tony Westbrook and Nicholas Downing.

The speciality was characterised by large follow-up lists and a complex patient pathway - leading to overbooked clinics for its consultants. According to Gateway Co-ordinator Laura Baines, the operational changes were in three areas: focussing clinic types, enabling nurse-led clinics, and making effective use of an additional clinician.

The Special Situation in Orthopaedics
For patients needing a high number of follow-up appointments over extended periods - hip replacement patients, for example, are on a pathway that includes five- and ten-year checks - efficient scheduling is hard. Combined with the speciality's diversity of conditions (multiple parts of the body and the need for diagnostic imaging) this was leading to an uncomfortable volume of overbookings. Although clinics were already specialised by patient condition, it was decided to specialise further, by first or follow-up.

For example, Nicholas Downing (the Clinical Lead for Hands) now sees only follow-up patients in his Thursday morning clinic - with new outpatients in an evening session. This helps him see up to 20 follow-up patients in a clinic, an increase on before.

Nicholas explains, “This 'smart scheduling' lets me see more patients than might otherwise be possible during a clinic - while letting me focus entirely on new patients in separate clinics.”

This made the most of the existing specialisation of clinics. In Nottingham, Orthopaedics is divided into subspecialities (with Hip & Knee, Foot & Ankle, and Sports Injury clinics grouped together) while Hands have clinics of their own (and their own Clinical Lead in Nicholas Downing). Since each subspeciality has distinct “patterns” of first and follow-up patients, organising clinics around these differences reduced the tendency for follow-ups to “crowd out” first outpatients. And with around twice as many follow-ups as first outpatient visits each month, it made a big difference.

Nurse-led Clinics: Piloted by Hands
The work of wound-checking and dressings in follow-up appointments is vital - but doesn't always need a consultant's experience. At the Nottingham Centre, clinicians decided to instigate nurse-led clinics, where a nursing professional handles a list of 12-14 patients. (A consultant, of course, is always available if needed).

After a pilot in Hands increased throughput further, Nurse-led clinics have since been explored for Hip & Knee clinics too.

Academic Results: Bringing in a Fellow
In addition, a Research Fellow from the neighbouring Queen's Medical Centre site of Nottingham University Hospitals NHS Trust (where many staff at the Centre are seconded from) has joined the department to handle a list of 20-25 patients each week, relieving pressure on overbooking further.

Tony Westbrook, Clinical Lead (Orthopaedics) said, “The patient experience can be improved by such rationalisations - including reduced waiting times, shorter patient pathways, and more effective use of a clinician's time. We're pleased with the results so far.”

Delivering a 12% Improvement
Across the speciality as a whole, the total number of patients seen each month has risen by 12% over the five months measured (July to October 2009) - without any subsequent dropoff, confirming the improvement was no quick fix.

The rise in first outpatient numbers has also had an effect in daycase for orthopaedics, where productivity for the speciality has risen 10%. The experience of the Orthopaedics speciality in Nottingham seems to demonstrate that empowering frontline staff can have a transformative impact.