- Email: [email protected]
Redesigning an orthopaedic pre-assessment clinic
Journal of Orthopaedic Nursing (2004) 8, 77–82
Journal of Orthopaedic Nursing
www.elsevierhealth.com/journals/joon
Redesigning an orthopaedic pre-assessment clinic Louise Lowry, RN, BSc(Hons)*, Vivien Lewis, RN, BSc(Hons) Orthopaedic Pre-assessment Unit, The Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
KEYWORDS
Summary This article describes the change process involved in redesigning the orthopaedic pre-assessment services within the Leeds Hospital Trust. The orthopaedic pre-assessment service is a crucial stage in the patient’s journey and therefore it was vital to create an environment that encouraged the development of partnerships with other clinicians and managers to enable the realisation of a “gold standard service”. In respect to this, development needed to be in the following areas: • Patient centred care measures as part of performance management and the UK Clinical Governance agenda. • Leadership based on personal growth and development. • New clinical career and competency framework for nursing staff. c 2004 Elsevier Ltd. All rights reserved.
Change management; Best practice; Bench marking pre-assessment services; Orthopaedic
Editor’s comment Examples of local initiatives are often far from perfect but very effective and useful in helping others undertaking similar work. This article describes how nurses have taken national directives and used them to energise local changes. Readers might like to look at the UK NHS Modernisation Agency for other examples of similar initiatives, www.modern.nhs.uk. PD
Introduction The UK NHS plan (DoH, 2000) talks of blurring the boundaries of the professions and of nurses having more autonomy and new innovative roles. It describes “nurses working across the whole patient pathway providing ambulatory patients with real continuity of care from admission to discharge”. It also talks of NHS employers empowering the appropriate qualified nurse to undertake a larger range of clinical tasks, which include the making and receiving of referrals. These recommendations are supported by the UK Chief Nursing Officers 10 key roles for nurses. *
Corresponding author. Tel.: +44-113-2065999; fax: +44-1132065346. E-mail address: [email protected] (L. Lowry).
The UK government targets have undoubtedly improved the service for many patients, but for the patient who wants a specific consultant who may have a long waiting list there is little choice but to wait. The complexity of how and why some consultants have long waits is something that the patient in the UK is not privy to nor should they be affected by it. However, this is inevitable when demand outweighs capacity. It will be seen from this article that our plan complements the government’s agendas. The Trust and the government have shown their commitment by the development of a Diagnostic and Treatment Centre (DTC) which will provide the patients of Leeds with elective orthopaedic services on one site. With a vision and a change management model a benchmark is also needed to work with. However, it must also be remembered that improving a service is
1361-3111/$ - see front matter c 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.joon.2004.03.003
78
L. Lowry, V. Lewis
not about changing all practices but evaluating practices and identifying the best practice with the aid of benchmarking. For the team to accomplish this, all the team attended a best practice/benchmarking study day. Areas were identified that needed improvement. Staff attended the national pre-assessment learning set meetings held in Manchester. Ideas and problems were shared and links formed with other teams. This will be our next step in order to assess what we have achieved and where we need to go next. Involving the patients in any further change or evaluation of our services would be the ideal and something we would like to attempt.
Local situation Prior to amalgamation the orthopaedic pre-assessment services varied considerably across the city (Table 1). The service was split between the two main hospital sites – Leeds General Infirmary (LGI) and St. James University Hospital (SJUH). Additional work was also undertaken at two peripheral sites. The introduction of the Elective Orthopaedic and Plastic Co-ordinator for the Trust has seen the evolution of the service over the last two years. The aim has been to draw the services together and establish a more robust patient focused service. To make changes an optimistic and energised team is needed. Hiatt (1995) stipulated that to create something we must be something; a strong team cannot be built if there are no strong team players. Another component of success is the core values of the team (Lucas, 2002): • Commitment to our patients – development of patient centred services. • Commitment to professional development Staff.
Table 1
• Commitment to the team. • Commitment to the Trust. The next phase was to look at the service development underpinning the government’s agenda; “The NHS plan” (2000). In the plan some of the core principles include the provision of a universal service for all based on clinical need and provision of a comprehensive range of services. Also mentioned in the NHS Plan (2000) is the shaping of services around the patient’s predilection and family network. It stresses the point of continuously working to improve services and curtailment of errors. Whilst these principles are not new to nurses or indeed the NHS as a whole, they are a good basis from which to develop.
The changes Our own internal triggers for development have coincided with the government’s agenda. The amalgamation of the two main pre-assessment services led to the introduction of a new post; the elective orthopaedic and plastic co-ordinator. The nursing and medical team met regularly to decide future developments and discuss their implementation. A model was needed to guide the staff and change management models from business organisations were adapted for use in a NHS setting. Cole (1996) identified key stages of organisational development. The stages will be discussed in the context of our own pre-assessment units’ development.
Analysis and diagnosis An analysis was performed by the coordinator through monitoring the work of staff over a four-
Pre-assessment services prior to amalgamation
Service 1 LGI
Service 2 SJUH
Established 1992 One full time Nurse “G” grade Home visits Telephone screening and post-discharge ‘phone calls’ Bone donation Only joint replacement patients seen, then given admission date X-ray clinics (1, 5, 10 and 15 years) 1996 Advice line set up
Established 1995 One part time Nurse “G” grade Clinic appointments Telephone screening Bone donation All orthopaedic patients seen in clinic, admission date known by patient prior to attending clinic
Redesigning an orthopaedic pre-assessment clinic week period. This involved not only the preassessment aspect but also the work done on the waiting list. The following findings were made and actions taken: Findings • Further members of staff were required. • Limited accommodation reduced the potential for expansion of services. • Lack of a recognised pre-assessment programme. • Resources such as computers, ECG and phlebotomy facilities were needed. • More effective communication with consultants was required. • Need for multidisciplinary team collaboration. • Need to forge links with the primary care teams. • Need for the development of patient information booklets.
Actions • New staff appointed to establish three teams headed by a G grade elective orthopaedic nurse practitioner followed by F grade sisters and staff nurses resulting in all the pre-assessment staff being experienced nursing staff. • Each team took on the responsibility of working with between 1 and 3 consultants depending upon the length of their waiting list. This was to allow closer monitoring of the active waiting list and suspension list. • Short-term occupation of accommodation was negotiated on both sides of the city. • Collaboration with the professional development department of the Trust, which resulted in the production of a draft document of competencies for nursing staff. • The introduction of additional clerical staff to provide the clerical cover needed for the increased work required. • Establishment of a monthly multidisciplinary team meeting. • Collaboration with the primary care teams to develop contact with the patient. • Set up a working group to look at patient information.
Evaluation and review This stage is important for the team to monitor progress and it gives opportunities to clarify any unclear aims and objectives. Monthly meetings
79 were held for the pre-assessment team on their own and with the multidisciplinary teams. However the overall change is still in its infancy and there will be a lot of amendments until the vision is realised. Three systems will now be described and an evaluation of the benefits of each. System 1 This is the traditional method of pre-assessment where a patient is listed for surgery and then sent for screening. Unless the patient has voiced specific requests regarding dates, this system offers little flexibility. The pressure is also severe when pre-assessment uncovers problems that will prevent the admission in that a replacement has to be found at short notice. The pre-assessment nurse would then liaise with the relevant health care professional to promote the optimum patient fitness for surgery and make the consultant aware of when fitness has been achieved. The nurse also suspends the patient from the waiting list system and takes responsibility for their management whilst in suspension. In elective services this is still the predominant system. System 2 This system uses the reverse procedure. Patients are listed in clinic for surgery. The pre-assessment nurses are informed of all listings and call these patients forward in a chronological or clinical order for assessment. Once all tests and documents have been returned and passed as satisfactory, the patient is then put forward as “fit” for surgery and given a date. This is all nurse led and the nurse has responsibility to waiting-list manage the patient. Patients are asked at the time of listing for specific dates that would prevent their admission and efforts are made to accommodate their needs. This system gives a very low cancellation rate for surgery, as all problems should have been dealt with prior to dating for theatre. This system has remained unchanged, but the coordinator managed to gain additional funding to increase the hours of the nursing input to full-time in an appreciation of the workload to manage the whole list in this way. System 3 The patients are called to a “one-stop shop” preassessment. They are listed in clinic and the nurse informed. That nurse then organises their attendance to pre-assessment clinic. Here, a nurse will see the patient and all investigations ordered. The consultant will also see them and take consent. The occupational therapist is “on-call” to assess any problems that the nurse has highlighted. Finally,
80 the anaesthetist sees all the patients who have passed through these stages. If all professionals and the patient are happy, the consultant will agree a date with the patient, so the patient leaves with their date for surgery. This gives a very low problem rate and a high patient satisfaction rate. This system has been unchanged since the introduction of the co-ordinator, but an appreciation of workload ensured increased staffing levels for those clinics and clerical support to arrange the clinics. The nurse also manages those patients before pre-assessment, in that while they wait the nurse is their point of contact for any problems that need dealing with prior to surgery. She acts, as coordinator in terms of patients with specific requirements or date needs.
Effects for patients Having one named nurse working with a consultant provides the patient with a defined point of contact. This is particularly beneficial to the patient with co-morbidity and awaiting complex surgery. The need to understand what is happening at all times is very important. Written information can support this process but the value of having an identified point of contact is significant. A dedicated telephone advice line provides this for the patient. If the individual nurse is unavailable then a message can be left or they can speak to any of the other nurses for immediate advice. The relationship that develops with the patient puts them central. The aim is to keep the patient in control and to try to avoid the feeling of having “things done to them”. The decision on surgery should be a joint choice between patient and consultant. This could improve post-operative outcomes as the patient feels autonomous and takes a certain degree of responsibility for their rehabilitation. The benefits of traditional pre-assessment in terms of postoperative outcomes have been well documented (Janke et al., 2002), hence the wide adoption of the principles of pre-assessment. Having a nurse as a link can reaffirm this approach at all times, especially in interpreting the true meaning of surgery on the patient’s future lifestyle choices. The “one-stop shop” style of pre-assessment clearly demonstrates how comprehensive pre-assessment can be. This style of clinic is moving a lot closer to the booked admissions system that the government is recommending (Modernisation Agency, 2002). As the clinic presently runs, the patient will leave with a date for surgery that has been mutually agreed between patient and con-
L. Lowry, V. Lewis sultant. However, the current wait from being listed to the agreed date is approximately 6–9 months. The pre-assessment nurse has a list of patients waiting and a very basic health questionnaire is completed at the time of listing so that any major problems can be dealt while they wait. The patients waiting on the “screen then date” list have the advantage of being on a very short waiting list. It is therefore possible to be screened on the day of listing and potentially be given a date within the next three months. The relatively short wait is very advantageous. This method provides the patient with a clear knowledge of their progress through the system. It also allows the patient to work with the health professional regarding the most appropriate time for their surgery. However, this system does mean that a large proportion of the waiting list could be in suspension at any one time. This unfortunately goes against the Trust’s waiting list management policy that no more than 5% of the list should be in suspension at a time. That the patient is fit for surgery prior to dating means that cancellations are rare. Awareness of the problem of extreme length of wait for surgery was highlighted from when nursing staff took responsibility for the waiting lists and this has led to the trial of the scoring system described later.
Effects for nursing staff The changing role of the nurse is the subject of many published articles (NHS, 2000). Nursing staff are driving the change that they feel is beneficial to the patient but also beneficial professionally. Indeed, many of the intended future changes are natural progressions rather than re-defining a role. To include waiting list management and put it at the centre of the job is appropriate for nurses. The proposed inclusion of many skills such as listening to basic heart sounds and chest auscultation is being service driven as the pre-assessment nurse has responsibility to ensure measures of health are reported to the appropriate health professional such as the anaesthetist. The teaching of these skills and competencies could be provided through the local university.
Effects for medical staff The consultant surgeons have benefited tremendously from this new way of working. A strong working relationship has developed between con-
Redesigning an orthopaedic pre-assessment clinic sultant and nurse. Patient problems and needs can be discussed in a clinical manner, but with the patient as the focus. The consistency of this relationship is the key to the success. Apart from the secretary, the consultant has no consistent colleagues due to the rotational nature of all medical posts. The appointment of the co-ordinator provided a change agent in a senior position whom was able to promote the virtues of having this system across a city.
Pilot scoring system To attempt to monitor the waiting list more thoroughly a pilot system was introduced and one consultant is currently piloting it. The patient’s journey starts at the out patient clinic if a decision for surgery has been made (Fig. 1). First, a health screen is performed on the patient. If the patient has no obvious medical problems that would preclude surgery, then they will be placed on the waiting list. However, if problems are identified
81 such as blood pressure, cardiac or respiratory conditions that need reviewing, then the patient will not be placed on the waiting list until they are reviewed and deemed fit to proceed. The patient is made aware of this. The system is divided into three equal parts. The score in each section is from 1 to 10. The sections are: (i) patient scores themselves by use of a questionnaire on their functional abilities, (ii) the consultant makes decision on clinical urgency and (iii) the length of time on the waiting list (Table 2). The higher the overall score the greater the need for earlier admission for surgery, maximum 30. All the details of the patients’ scores are entered into a database, which produces reports of patients’ total scores in descending order. If any patient on the list of the consultant using this score contacts the pre-assessment sister and informs her of their deterioration, another questionnaire is sent to the patient for completion. On receipt of the questionnaire the patient’s records are obtained and the case discussed with the consultant.
Clinic review by Consultant / Elective Orthopaedic Nurse Practitioner
Decision of need for surgery made
Score according to clinical urgency, disability and waiting list time
Patient assessed by pre-assessment sister
Patient fit for surgery:
Patient unfit for surgery:
? given date in clinic or placed
assessed by pre-assessment Sister
on waiting list
and referred to appropriate professional by medical team
Figure 1
Pilot system.
82
L. Lowry, V. Lewis
Table 2
Scoring patients at entry to waiting list
Urgency
Disability
Waiting list priority
Decided by consultant
Using Oxford score; given by patient, verified by sister Maximum 10
By length of time on list
<2 yr ¼ 2 <1 yr ¼ 4 <6/12 ¼ 6 <3/12 ¼ 8 <1/12 ¼ 10
The result may be an increase in the total score or it may remain the same. The advantages of the score system may be considered as: • • • • • • • •
Patient centred service. Appropriate listing of patients. Patients have an identified point of contact. Patients receive appropriate information early in the process. Patients’ records up-dated with regard to health status and demographic details. Further reduction of cancellations and wasted theatre time. Patients admitted at short notice. Allows identification of the percentage of patients that will not have surgery within the government targets.
This system is in its infancy. There are questions about the equality of the system, as some may suggest that patients may manipulate the score to their advantage, or that the consultant may be subjective in his opinion of clinical urgency. Both the patient and the consultant opinion should be respected. In the initial phase the consultant and the Sister using the system feel it is beneficial to the patients as it is making the clinical decision more objective. However there is continued pressure with regard to the waiting times set by government.
Discussion The merging of the two hospitals’ pre-assessment units has not been an easy task and in many re-
Months on list 1¼1 6¼6 2¼2 7¼7 3¼3 8¼8 4¼4 9¼9 5 ¼ 5 10 ¼ 10
spects is a long road that will never end until the two orthopaedic units come together as one in the new DTC. The nurses’ roles have and are still evolving in pre-assessment as the government targets are moving so swiftly (Lucas, 2002). We still have to complete the “days work” as well as develop the unit. This is believed to be part of the reason that change is so slow with regard to multidisciplinary working. This is part of modern working life in the new NHS. The main criticism of our merging is the continued running of three different systems of working. As demonstrated, each has their own particular merits, but in order to offer consistency and equity to patients one system should be developed. This would consist of the merits of each system merged into one. The plan is to achieve this on moving to one central site, where both nursing and medical staff should be working to the same system.
References Cole, G.A., 1996. Management: Theory & Practice, fifth ed. Letts Educational. Hiatt, J., 1995. Winning with Quality. Addison-Wesley Longman. Janke, E. et al., 2002. Pre-Operative Assessment. Setting a Standard Through Learning. Southampton University, Southampton. Lucas, Brian, 2002. Developing the role of the nurse in the orthopaedic outpatient and pre admission assessment settings: a change management project. Journal of Orthopaedic Nursing 10 (6), 153–160. Modernisation Agency, 2002. Improving Orthopaedic Services: A Guide for Clinicians, Managers and Service Commissioners. DoH London. DoH, 2000. The NHS Plan. The Stationary Office Ltd, London.
Journal of Orthopaedic Nursing
www.elsevierhealth.com/journals/joon
Redesigning an orthopaedic pre-assessment clinic Louise Lowry, RN, BSc(Hons)*, Vivien Lewis, RN, BSc(Hons) Orthopaedic Pre-assessment Unit, The Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
KEYWORDS
Summary This article describes the change process involved in redesigning the orthopaedic pre-assessment services within the Leeds Hospital Trust. The orthopaedic pre-assessment service is a crucial stage in the patient’s journey and therefore it was vital to create an environment that encouraged the development of partnerships with other clinicians and managers to enable the realisation of a “gold standard service”. In respect to this, development needed to be in the following areas: • Patient centred care measures as part of performance management and the UK Clinical Governance agenda. • Leadership based on personal growth and development. • New clinical career and competency framework for nursing staff. c 2004 Elsevier Ltd. All rights reserved.
Change management; Best practice; Bench marking pre-assessment services; Orthopaedic
Editor’s comment Examples of local initiatives are often far from perfect but very effective and useful in helping others undertaking similar work. This article describes how nurses have taken national directives and used them to energise local changes. Readers might like to look at the UK NHS Modernisation Agency for other examples of similar initiatives, www.modern.nhs.uk. PD
Introduction The UK NHS plan (DoH, 2000) talks of blurring the boundaries of the professions and of nurses having more autonomy and new innovative roles. It describes “nurses working across the whole patient pathway providing ambulatory patients with real continuity of care from admission to discharge”. It also talks of NHS employers empowering the appropriate qualified nurse to undertake a larger range of clinical tasks, which include the making and receiving of referrals. These recommendations are supported by the UK Chief Nursing Officers 10 key roles for nurses. *
Corresponding author. Tel.: +44-113-2065999; fax: +44-1132065346. E-mail address: [email protected] (L. Lowry).
The UK government targets have undoubtedly improved the service for many patients, but for the patient who wants a specific consultant who may have a long waiting list there is little choice but to wait. The complexity of how and why some consultants have long waits is something that the patient in the UK is not privy to nor should they be affected by it. However, this is inevitable when demand outweighs capacity. It will be seen from this article that our plan complements the government’s agendas. The Trust and the government have shown their commitment by the development of a Diagnostic and Treatment Centre (DTC) which will provide the patients of Leeds with elective orthopaedic services on one site. With a vision and a change management model a benchmark is also needed to work with. However, it must also be remembered that improving a service is
1361-3111/$ - see front matter c 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.joon.2004.03.003
78
L. Lowry, V. Lewis
not about changing all practices but evaluating practices and identifying the best practice with the aid of benchmarking. For the team to accomplish this, all the team attended a best practice/benchmarking study day. Areas were identified that needed improvement. Staff attended the national pre-assessment learning set meetings held in Manchester. Ideas and problems were shared and links formed with other teams. This will be our next step in order to assess what we have achieved and where we need to go next. Involving the patients in any further change or evaluation of our services would be the ideal and something we would like to attempt.
Local situation Prior to amalgamation the orthopaedic pre-assessment services varied considerably across the city (Table 1). The service was split between the two main hospital sites – Leeds General Infirmary (LGI) and St. James University Hospital (SJUH). Additional work was also undertaken at two peripheral sites. The introduction of the Elective Orthopaedic and Plastic Co-ordinator for the Trust has seen the evolution of the service over the last two years. The aim has been to draw the services together and establish a more robust patient focused service. To make changes an optimistic and energised team is needed. Hiatt (1995) stipulated that to create something we must be something; a strong team cannot be built if there are no strong team players. Another component of success is the core values of the team (Lucas, 2002): • Commitment to our patients – development of patient centred services. • Commitment to professional development Staff.
Table 1
• Commitment to the team. • Commitment to the Trust. The next phase was to look at the service development underpinning the government’s agenda; “The NHS plan” (2000). In the plan some of the core principles include the provision of a universal service for all based on clinical need and provision of a comprehensive range of services. Also mentioned in the NHS Plan (2000) is the shaping of services around the patient’s predilection and family network. It stresses the point of continuously working to improve services and curtailment of errors. Whilst these principles are not new to nurses or indeed the NHS as a whole, they are a good basis from which to develop.
The changes Our own internal triggers for development have coincided with the government’s agenda. The amalgamation of the two main pre-assessment services led to the introduction of a new post; the elective orthopaedic and plastic co-ordinator. The nursing and medical team met regularly to decide future developments and discuss their implementation. A model was needed to guide the staff and change management models from business organisations were adapted for use in a NHS setting. Cole (1996) identified key stages of organisational development. The stages will be discussed in the context of our own pre-assessment units’ development.
Analysis and diagnosis An analysis was performed by the coordinator through monitoring the work of staff over a four-
Pre-assessment services prior to amalgamation
Service 1 LGI
Service 2 SJUH
Established 1992 One full time Nurse “G” grade Home visits Telephone screening and post-discharge ‘phone calls’ Bone donation Only joint replacement patients seen, then given admission date X-ray clinics (1, 5, 10 and 15 years) 1996 Advice line set up
Established 1995 One part time Nurse “G” grade Clinic appointments Telephone screening Bone donation All orthopaedic patients seen in clinic, admission date known by patient prior to attending clinic
Redesigning an orthopaedic pre-assessment clinic week period. This involved not only the preassessment aspect but also the work done on the waiting list. The following findings were made and actions taken: Findings • Further members of staff were required. • Limited accommodation reduced the potential for expansion of services. • Lack of a recognised pre-assessment programme. • Resources such as computers, ECG and phlebotomy facilities were needed. • More effective communication with consultants was required. • Need for multidisciplinary team collaboration. • Need to forge links with the primary care teams. • Need for the development of patient information booklets.
Actions • New staff appointed to establish three teams headed by a G grade elective orthopaedic nurse practitioner followed by F grade sisters and staff nurses resulting in all the pre-assessment staff being experienced nursing staff. • Each team took on the responsibility of working with between 1 and 3 consultants depending upon the length of their waiting list. This was to allow closer monitoring of the active waiting list and suspension list. • Short-term occupation of accommodation was negotiated on both sides of the city. • Collaboration with the professional development department of the Trust, which resulted in the production of a draft document of competencies for nursing staff. • The introduction of additional clerical staff to provide the clerical cover needed for the increased work required. • Establishment of a monthly multidisciplinary team meeting. • Collaboration with the primary care teams to develop contact with the patient. • Set up a working group to look at patient information.
Evaluation and review This stage is important for the team to monitor progress and it gives opportunities to clarify any unclear aims and objectives. Monthly meetings
79 were held for the pre-assessment team on their own and with the multidisciplinary teams. However the overall change is still in its infancy and there will be a lot of amendments until the vision is realised. Three systems will now be described and an evaluation of the benefits of each. System 1 This is the traditional method of pre-assessment where a patient is listed for surgery and then sent for screening. Unless the patient has voiced specific requests regarding dates, this system offers little flexibility. The pressure is also severe when pre-assessment uncovers problems that will prevent the admission in that a replacement has to be found at short notice. The pre-assessment nurse would then liaise with the relevant health care professional to promote the optimum patient fitness for surgery and make the consultant aware of when fitness has been achieved. The nurse also suspends the patient from the waiting list system and takes responsibility for their management whilst in suspension. In elective services this is still the predominant system. System 2 This system uses the reverse procedure. Patients are listed in clinic for surgery. The pre-assessment nurses are informed of all listings and call these patients forward in a chronological or clinical order for assessment. Once all tests and documents have been returned and passed as satisfactory, the patient is then put forward as “fit” for surgery and given a date. This is all nurse led and the nurse has responsibility to waiting-list manage the patient. Patients are asked at the time of listing for specific dates that would prevent their admission and efforts are made to accommodate their needs. This system gives a very low cancellation rate for surgery, as all problems should have been dealt with prior to dating for theatre. This system has remained unchanged, but the coordinator managed to gain additional funding to increase the hours of the nursing input to full-time in an appreciation of the workload to manage the whole list in this way. System 3 The patients are called to a “one-stop shop” preassessment. They are listed in clinic and the nurse informed. That nurse then organises their attendance to pre-assessment clinic. Here, a nurse will see the patient and all investigations ordered. The consultant will also see them and take consent. The occupational therapist is “on-call” to assess any problems that the nurse has highlighted. Finally,
80 the anaesthetist sees all the patients who have passed through these stages. If all professionals and the patient are happy, the consultant will agree a date with the patient, so the patient leaves with their date for surgery. This gives a very low problem rate and a high patient satisfaction rate. This system has been unchanged since the introduction of the co-ordinator, but an appreciation of workload ensured increased staffing levels for those clinics and clerical support to arrange the clinics. The nurse also manages those patients before pre-assessment, in that while they wait the nurse is their point of contact for any problems that need dealing with prior to surgery. She acts, as coordinator in terms of patients with specific requirements or date needs.
Effects for patients Having one named nurse working with a consultant provides the patient with a defined point of contact. This is particularly beneficial to the patient with co-morbidity and awaiting complex surgery. The need to understand what is happening at all times is very important. Written information can support this process but the value of having an identified point of contact is significant. A dedicated telephone advice line provides this for the patient. If the individual nurse is unavailable then a message can be left or they can speak to any of the other nurses for immediate advice. The relationship that develops with the patient puts them central. The aim is to keep the patient in control and to try to avoid the feeling of having “things done to them”. The decision on surgery should be a joint choice between patient and consultant. This could improve post-operative outcomes as the patient feels autonomous and takes a certain degree of responsibility for their rehabilitation. The benefits of traditional pre-assessment in terms of postoperative outcomes have been well documented (Janke et al., 2002), hence the wide adoption of the principles of pre-assessment. Having a nurse as a link can reaffirm this approach at all times, especially in interpreting the true meaning of surgery on the patient’s future lifestyle choices. The “one-stop shop” style of pre-assessment clearly demonstrates how comprehensive pre-assessment can be. This style of clinic is moving a lot closer to the booked admissions system that the government is recommending (Modernisation Agency, 2002). As the clinic presently runs, the patient will leave with a date for surgery that has been mutually agreed between patient and con-
L. Lowry, V. Lewis sultant. However, the current wait from being listed to the agreed date is approximately 6–9 months. The pre-assessment nurse has a list of patients waiting and a very basic health questionnaire is completed at the time of listing so that any major problems can be dealt while they wait. The patients waiting on the “screen then date” list have the advantage of being on a very short waiting list. It is therefore possible to be screened on the day of listing and potentially be given a date within the next three months. The relatively short wait is very advantageous. This method provides the patient with a clear knowledge of their progress through the system. It also allows the patient to work with the health professional regarding the most appropriate time for their surgery. However, this system does mean that a large proportion of the waiting list could be in suspension at any one time. This unfortunately goes against the Trust’s waiting list management policy that no more than 5% of the list should be in suspension at a time. That the patient is fit for surgery prior to dating means that cancellations are rare. Awareness of the problem of extreme length of wait for surgery was highlighted from when nursing staff took responsibility for the waiting lists and this has led to the trial of the scoring system described later.
Effects for nursing staff The changing role of the nurse is the subject of many published articles (NHS, 2000). Nursing staff are driving the change that they feel is beneficial to the patient but also beneficial professionally. Indeed, many of the intended future changes are natural progressions rather than re-defining a role. To include waiting list management and put it at the centre of the job is appropriate for nurses. The proposed inclusion of many skills such as listening to basic heart sounds and chest auscultation is being service driven as the pre-assessment nurse has responsibility to ensure measures of health are reported to the appropriate health professional such as the anaesthetist. The teaching of these skills and competencies could be provided through the local university.
Effects for medical staff The consultant surgeons have benefited tremendously from this new way of working. A strong working relationship has developed between con-
Redesigning an orthopaedic pre-assessment clinic sultant and nurse. Patient problems and needs can be discussed in a clinical manner, but with the patient as the focus. The consistency of this relationship is the key to the success. Apart from the secretary, the consultant has no consistent colleagues due to the rotational nature of all medical posts. The appointment of the co-ordinator provided a change agent in a senior position whom was able to promote the virtues of having this system across a city.
Pilot scoring system To attempt to monitor the waiting list more thoroughly a pilot system was introduced and one consultant is currently piloting it. The patient’s journey starts at the out patient clinic if a decision for surgery has been made (Fig. 1). First, a health screen is performed on the patient. If the patient has no obvious medical problems that would preclude surgery, then they will be placed on the waiting list. However, if problems are identified
81 such as blood pressure, cardiac or respiratory conditions that need reviewing, then the patient will not be placed on the waiting list until they are reviewed and deemed fit to proceed. The patient is made aware of this. The system is divided into three equal parts. The score in each section is from 1 to 10. The sections are: (i) patient scores themselves by use of a questionnaire on their functional abilities, (ii) the consultant makes decision on clinical urgency and (iii) the length of time on the waiting list (Table 2). The higher the overall score the greater the need for earlier admission for surgery, maximum 30. All the details of the patients’ scores are entered into a database, which produces reports of patients’ total scores in descending order. If any patient on the list of the consultant using this score contacts the pre-assessment sister and informs her of their deterioration, another questionnaire is sent to the patient for completion. On receipt of the questionnaire the patient’s records are obtained and the case discussed with the consultant.
Clinic review by Consultant / Elective Orthopaedic Nurse Practitioner
Decision of need for surgery made
Score according to clinical urgency, disability and waiting list time
Patient assessed by pre-assessment sister
Patient fit for surgery:
Patient unfit for surgery:
? given date in clinic or placed
assessed by pre-assessment Sister
on waiting list
and referred to appropriate professional by medical team
Figure 1
Pilot system.
82
L. Lowry, V. Lewis
Table 2
Scoring patients at entry to waiting list
Urgency
Disability
Waiting list priority
Decided by consultant
Using Oxford score; given by patient, verified by sister Maximum 10
By length of time on list
<2 yr ¼ 2 <1 yr ¼ 4 <6/12 ¼ 6 <3/12 ¼ 8 <1/12 ¼ 10
The result may be an increase in the total score or it may remain the same. The advantages of the score system may be considered as: • • • • • • • •
Patient centred service. Appropriate listing of patients. Patients have an identified point of contact. Patients receive appropriate information early in the process. Patients’ records up-dated with regard to health status and demographic details. Further reduction of cancellations and wasted theatre time. Patients admitted at short notice. Allows identification of the percentage of patients that will not have surgery within the government targets.
This system is in its infancy. There are questions about the equality of the system, as some may suggest that patients may manipulate the score to their advantage, or that the consultant may be subjective in his opinion of clinical urgency. Both the patient and the consultant opinion should be respected. In the initial phase the consultant and the Sister using the system feel it is beneficial to the patients as it is making the clinical decision more objective. However there is continued pressure with regard to the waiting times set by government.
Discussion The merging of the two hospitals’ pre-assessment units has not been an easy task and in many re-
Months on list 1¼1 6¼6 2¼2 7¼7 3¼3 8¼8 4¼4 9¼9 5 ¼ 5 10 ¼ 10
spects is a long road that will never end until the two orthopaedic units come together as one in the new DTC. The nurses’ roles have and are still evolving in pre-assessment as the government targets are moving so swiftly (Lucas, 2002). We still have to complete the “days work” as well as develop the unit. This is believed to be part of the reason that change is so slow with regard to multidisciplinary working. This is part of modern working life in the new NHS. The main criticism of our merging is the continued running of three different systems of working. As demonstrated, each has their own particular merits, but in order to offer consistency and equity to patients one system should be developed. This would consist of the merits of each system merged into one. The plan is to achieve this on moving to one central site, where both nursing and medical staff should be working to the same system.
References Cole, G.A., 1996. Management: Theory & Practice, fifth ed. Letts Educational. Hiatt, J., 1995. Winning with Quality. Addison-Wesley Longman. Janke, E. et al., 2002. Pre-Operative Assessment. Setting a Standard Through Learning. Southampton University, Southampton. Lucas, Brian, 2002. Developing the role of the nurse in the orthopaedic outpatient and pre admission assessment settings: a change management project. Journal of Orthopaedic Nursing 10 (6), 153–160. Modernisation Agency, 2002. Improving Orthopaedic Services: A Guide for Clinicians, Managers and Service Commissioners. DoH London. DoH, 2000. The NHS Plan. The Stationary Office Ltd, London.