Protecting urgent patients
01/09/2014by Rob Findlay
Although everyone agrees that cancer and other urgent patients should have shorter waits than non-urgent ‘routine’ patients, we don’t always see this happening in practice. Yet this is a clinical safety issue – patients may come to harm or even die if we get it wrong. Can it really be so difficult?
Unfortunately, as so often in healthcare, there is a lot more to this than meets the eye. The difficulty varies from service to service, and it turns out that the most common scenario is also the most complex.
Let’s take the simplest scenarios first.
If urgent patients are fairly rare in your service, then you can rely on the time-honoured NHS technique of just squeezing them in.
Or if you work in a huge teaching hospital, where some consultants only see urgent patients and others only see routines, then your work is already carved out for you. The all-urgent services run with very short total waiting times, almost like an emergency service; and the all-routine services can simply treat everybody in roughly date order.
But the vast middle ground between these two extremes is more common and more difficult. Significant numbers of urgent patients are passing through the same clinic and theatre sessions as all the routine patients, and you somehow have to get the urgents in quickly with minimum disruption to everything else. How?
Maximum flexibility (for the provider)
If you only ever booked your sessions a week or so in advance, then you would have maximum flexibility. No matter how many urgent patients needed to be booked, you would always be able to fit them in. Then you could just fill up the rest of the session with routines (all picked nicely in date order, of course).
This would be highly convenient for the provider, but not for the poor routine patients. They would find themselves waiting for ages without a booking, and then be expected to drop everything and come in next week. Happily, you can do a lot better than this.
Carving out urgent slots
Instead of keeping the whole session empty until short notice, you can just keep part of it empty and fill the rest with routine patients. After all, not every patient is urgent. That way the routine patients have plenty of notice of their bookings, but you still reserve enough empty session time for urgent patients who will arrive at short notice. So the next question is: how much?
Let’s say you reserve enough session time to cope with the average number of urgent patients. The actual numbers will of course vary from week to week. Sometimes you’ll have fewer urgents and some of the time you reserved will be left idle – in other words, wasted. Other times you’ll have more urgents than average, and then (if there is no standard process for dealing with them) the situation will escalate into a crisis for senior managers to resolve.
Whenever there is a crisis, the natural desire will be to increase the time being reserved for urgents so that the crisis is less likely to recur. Then you end up with even more idle time. Idle time attracts fewer complaints all round, but it is a waste of expensive capacity and means your waiting list will be progressively bigger than it should be.
But we’re working along the right lines, so let’s see if we can improve on this and deal with those crises and all that waste.
Processes not crises
Let’s take a closer look at those crises. The problem is that you have clinically urgent patients who need an appointment sharpish, but there is no empty session time to book them into.
You could impose on the goodwill of staff by asking them to stay late and extend the session, but this is no basis for a long term arrangement; either that extra time is available regularly or it isn’t.
You could seek a flexible arrangement with staff that any extended sessions will be repaid with some shorter sessions on another day. If urgent patients are few and far between then this can work, but in most services the numbers and variability are too large and any reasonable degree of flexibility is quickly exhausted.
Or you could lay on a whole extra session. But this isn’t easy or cheap at short notice, it takes a fair bit of a senior manager’s time, and more seriously your urgent patients can end up being delayed while the arrangements are made. There is a broader point too: repeated calls for extra sessions mean that either your baseline capacity or your patient booking processes, or both, are inadequate.
So if extra session time is ruled out of your regular processes, then the only way to find time for an urgent patient is by displacing somebody else. In other words, by cancelling whichever booked patient will be least inconvenienced. Which gives rise to the next question: how do you rebook them? This is going to happen fairly often, so again you need a standard process that booking staff can follow without needing to seek further permission.
It turns out that the best approach depends on whether you are running a fully-booked service (where patients are given appointments immediately, which is typical of outpatients), or a partially-booked service (where bookings are only issued a few weeks in advance, which is typical of theatres). For a fully-booked service it is better to rebook cancelled patients into urgent slots so that they aren’t sent right to the back of the queue, and increase the number of urgent slots to allow for this. For partial booking there is little to be gained from doing that so the next available routine slot can be used.
What we’re reaching is a solution that has to strike a careful balance between several kinds of undesirable event: cancelling a patient, making a patient wait longer, and asking a patient to come in at very short notice. Also we need to achieve all this without wasting session time.
It means having the right capacity to keep up with demand and meet your other objectives, reserving the right amount of time for urgent patients, and having the right standard booking processes to cover every common event safely and immediately. Those processes need to allow enough interplay between urgent and routine capacity to avoid the waste that stems from rigid capacity carve-outs.
To cut a very long story short it took a great deal of computer modelling to get the balance just right, but the good news is that the solution can be expressed fairly simply. The amount of session time you need for urgent and routine patients can be worked out automatically by software, and the booking processes can be boiled down into five straightforward rules.
So it is possible to ensure that cancer and other urgent patients are always protected, without compromising on efficiency. If urgent patients are (rightly) jumping the queue, then of course routine patients must wait longer, but that is all quantifiable and can readily be built into capacity plans to achieve 18 weeks.
In short, the concerns rightly expressed by the Royal College of Surgeons can all be addressed. Shall we get cracking?Return to Post Index