a practical example of dcaq

A PRACTICAL EXAMPLE OF DCAQDr Gerry BeattieClinical Lead, NHS Lothian18th November, 2009

DCAQ Gynaecology - backgroundWhy is the out-patient waiting time 16-18 weeks ?What are the consultant staff doing ?Why are we losing capacity and how can we stop it ?What are we going to do about the next round of job planning ?

DCAQ Gynaecology UNDELIVIERED ACTIVITY the waiting list, service entry points, primary care interface.

DELIVERED ACTIVITY productivity, rotas, inappropriate activity, templates.

LOST CAPACITY leave, compensatory rest, short notice cancellations

DCAQ GynaecologyDEMAND

CAPACITY

ACTIVITY

QUEUES

Two important points to remember Its just good housekeeping, its not rocket science !

Just because its aye been done this way doesnt mean there isnt a better way of doing it !

Demand the problemsUnclear as to what the demand was in terms of numbersNo idea as to the case mix out there6 entry points into the system NRIE, WGH, SJH, LCTC, Roodlands, Liberton.Little dialogue between primary care and the acute sector

Demand some solutionsCentralised Booking set up for Lothian bringing all referrals to one central point in the NRIE and now moving to e referral and e-triage

Outcoming from triage recorded to inform the size and location of service queues and what needs to be in place where

Exploring electronic GP helplines to prevent patients becoming referrals

Another important point -Demand is not a given, it can be influenced in your favour

The 3 Ds Driving Down Demand !

A thought -What if referrals were not referrals and simply requests for advice ?

Capacity the problemsDifficult to define

Difficult to measure

Lost capacity

Reliant on Consultant job plans

What is capacity ?Templated capacity (52 weeks)

Adjusted capacity (42 weeks)

Delivered capacity (about 36 weeks)

What is capacity ?Capacity is a dynamic concept that is constantly changing

It is not a straight line or a box with rigid sides

Capacity ModellingReal time job plans can help measure capacityConvert weekly job plans into at least 4 weekly spreadsheets to overview capacity and identify peaks and troughsA real need for dynamic prospective capacity modelling

Capacity some solutionsCentralised booking has allowed capacity measurement across Lothian and respond to service pressuresReal time job plan mappingSanitisation of clinic templatesStandardisation of clinic templatesFlexibility of consultant workforce

Activity the problemsLots of it but not accurately recordedCoding issuesInappropriate activityClinic templates new/return ratiosOutreach clinicsConsultant productivityRole of senior trainees

Activity some solutionsAccurate recording and coding, with medical input into codingMinimum standards for clinic templatesNew/return ratios revised in the light of speciality developmentThe ring pessary challengeUtilisation of senior traineesKeep the mavericks in the building

Queues the problemsThere was a big one and lots of little ones

There was no idea of how wide the pathway had to be to accommodate the queues

Chaos reigned !

Queues some solutionsCentralised booking has streamlined, quantified and reduced the queues

Patients now seen by the most appropriate clinician at the most appropriate site

Waiting time across Lothian now 6 weeks and falling !

Question - DCAQ where did we start ?

Answer - Job planning

The 2004 Consultant ContractFull time commitment of 10 programmed activities (PAs) per week 4 hour sessionsDirect clinical care (DCC), Supporting professional activities (SPA), additional/external duties7.5 PAs DCC / 2.5 PAs SPA (Plans for 9+1)Flexibility depending on commitments eg Clinical Governance leads etcEPAs separate contract, no obligation

Job PlanningThe process is individual but collectively job plans must reflect the over all needs of the serviceProvides the capacity to meet the demand on the service

Job planning the issuesPlan the service to meet the demandConsultant productivity 42 wks if not, why not ?Notify, control, monitor and restrict leave and learn to say NO !Get service into PAs and use EPAs for reward eg cross cover / additional activity

Job planning the issuesRota management to reduce impact of compensatory rest lost capacityAllow flexibility in the job planning processPlay to individual strengthsNeed all consultants look the same ?

Consultant engagementProtected time gives recognition to the importance of the work

Sell the carrot, not the stick

Get one of their own doing the work

A disease analogySymptoms of reluctance to change, reluctance to engage and inefficiency

Syndrome of weve aye done it this way

The challenge - Physicians of the utmost fameWere called at once, but when they cameThey muttered as they took their feesThere is no cure for this disease

Hilaire Belloc

Any questions ?