Meridian has engaged with the trust on 3 previous occasions working within Theatres, Radiology and the Outpatients department. Following on from the success of these projects, Meridian were commissioned to undertake a further analysis across the entire Medical workforce.
As part of the national requirement of the NHS to save £20bn over 4 years, the trust had a target Cost Improvement Programme (CIP) of £22m for 2015/16, representing 6% of total spend.
Meridian conducted an analysis over a 3 week period consisting of:
- Consolidation of 180 consultant job plans into one central database, allowing analysis of the 5,569 PAs that dictated consultant capacity with the ability to compare cross-specialty and cross consultant.
- Review of the status of the job plans and identify those with errors, omissions, conflicts or those that were overdue a review
- Review of sessional commitments and whether they were in line with the expectations of the Trust.
- Analysis of past sessional fulfilment, and planned verses actual activity levels of consultant clinics, incorporating quantification of the volume of extra Waiting List Initiatives (WLIs) that had been carried out.
Based on the findings, Meridian proposed a programme consisting of the following:
- Moving activity carried out in WLIs back into core capacity, avoiding extra costs.
- Installing controls over fulfilment of clinics to meet the expectations in individual consultant job plans.
- Maximising outpatient capacity through the expansion of outpatient clinic templates to align with job plans.
- Increase in booking utilisation through the installation of booking controls & tools for identifying unfilled slots.
Meridian embarked on a 14 week program to improve the utilisation of clinics by working with the six Outpatient booking teams and maximising overall consultant capacity through management of job plans across the 8 directorates:
- Surgery
- Specialist Medicine
- Critical Care
- Trauma and Orthopaedics
- Head and Neck
- Women’s Health
- Paediatric Health
- Oncology
A new management control system was developed and installed across the directorates through workshops and 1:1 coaching. These sessions were carried out across all of the various tiers of management to ensure consistency in understanding and practice across the hierarchy.
The Trust had a technical solution already in place to highlight unbooked capacity in Outpatients. However, there was a misconception amongst management that this tool was fully utilised. This misconception led to a lack of follow-up and variance checking and a subsequent drop in performance. Meridian set about creating a behavioural shift in the usage of the system. Firstly, the negative opinions that people had of the system were challenged, and where valid, rectified. Secondly, the operation of the system was enhanced by increasing the frequency of update of the information, thereby making it much more accurate for users. Thirdly, a clear and defined process for its daily usage was developed and agreed.
For the first time there was a structured daily review process within the Booking teams that systematically picked up clinic slots that would have otherwise perished. Another process was implemented to identify and challenge unclear and unspecific reasoning behind ‘blocked’ slots. Prior to the project, these slots had been removed from all review processes, masking the enormity of the capacity reduction. 320 of these slots were found in an average week, equating to approximately £32k of lost income per week. They were identified as a product of historic booking practice and so a robust perpetual review was installed to either rationalise or clear these blocked slots to ensure optimum availability of capacity.
Developing a central job plan database allowed the directorates to keep track of the status of their consultant contracts. Finally having this information highlighted overdue reviews and allowed the Trust to target all job plans outdated by more than 2 years. The analytical output of this database assisted General Managers in the job planning process, by providing time-based fact which was easily comparable to the demand on the individual services. Ultimately, this meant a simple solution to putting the right medical capacity in the right place at the right time, thereby getting best value from the consultant job plans.
The system also highlighted variances between outpatient clinic templates and consultants’ job planned programmed activities (PAs). Using the information, Clinical Directors and Managers took steps (facilitated by Meridian) to rectify these variances to either gain further outpatient capacity or reduce the capacity within the Medical workforce through closure of PAs.
Historically there had been no way in the Trust’s clinical systems to differentiate between core and WLI sessions. A flag was established for this and configured in the system to allow reporting of standard rate and premium rate sessions electronically.
A tool was developed with the Information Department that allowed management to track consultant sessional fulfilment – a key metric that had never before been reviewed. Targets were set by directorate for the number of sessions expected by consultant per year. Using this ongoing tracking of capacity attainment, a simple process was installed to disallow any premium rate sessions from being approved where sessional fulfilment had not met sufficient tolerance during the course of the year.
All of these controls combined ensured that the Trust was obtaining the best possible value from the most expensive resource it had.
The installed system provided rigorous control over the job planning process, sessional fulfilment and improved booking utilisation. The ‘way of working’ changed so that management in the outpatient department fixed the root causes of variances, rather than continually fire-fighting them.
The improvement can be summarised by the following:
- With an average weekly realised improvement of £12k, annualising to over £622k, the project paid for itself before its completion with a return on investment of approximately 6:1.
- An increase of 0.25 patients attending for every clinic held.
- Approximately 3,500 more patients were seen across the Outpatients Department during the project lifetime than in the same period of the previous year.
- Identified 126 hours per week of misalignment between job plans and existing outpatient clinic templates across the Trust. At the time of project completion, the management team had reclaimed more than 3 PAs, and gained an extra 36 new patient slots per week. The combined improvement equated to an additional £137,327 annually.