The vast majority of patients are required to attend

the Pre Admission Clinic (PAC) prior to their surgery.

They do not always completed all of the required

documentation. They are likely to be scheduled to

attend PAC at the same time as a large number of

other patients and are likely to spend an extended

time waiting, with limited information provided

regarding any delays.

In 2013 266 patients were cancelled on the day of

surgery. On average 5 cases are performed in a

theatre session, equating to 53 sessions with no

patients or one week with ten empty theatres. Based

on an average staffing mix this equates to

$334,131.92 of paid operating staff time, in which no

procedure was performed.

Patients may be cancelled on the day of surgery

because the list was overbooked, they were not

prepared for surgery or due to a pre existing medical

condition. Meaning, they or a family member or friend

arranged to have time off work, they fasted and

prepared themselves for a surgery that did not occur.

To reduce delays in the Pre Admission Clinic and

reduce cancellations on the day of surgery for elective

surgery patients at Concord Repatriation General

Hospital.

• Reduce elective surgery cancellations on day of

surgery by 30% by December 2014 and 50% by

July 2015 from a baseline of 266 patients

• Achieve the Ministry of Health target of <2% of

patient cancelled on the day of surgery by July

2015 from a baseline of 2.8%.

• Reduce the number of patients required to attend

the Pre Admissions Clinic (inappropriate

attendances) by 10% by December 2014 and 20%

by July 2015.

• Reduce the amount of time patients are required

to spend in the Pre Admissions Clinic with 90% of

overnight and day only patients to be finished

within 90 minutes and 90% of complex patients to

be seen within 3 hours by July 2015 from a

baseline of 54% and 82% respectively.

The project utilised the Agency for Clinical Innovation

Clinical Redesign Methodology. Each phase of the

project has defined activities and deliverables

requiring approval by the project Steering Committee,

Project Sponsor and Chief Executive.

The above graph illustrates the positive and negative responses received in relation to

the 8 Picker dimensions of care. In all bar one of the dimensions the majority of

comments received were positive, with Physical Comfort receiving an equal number of

positive and negative comments. The negative comments related to factors such as

being cold, requiring additional blankets and being uncomfortable on the hospital beds /

trolleys.

Access to Care received only positive comments, with patients commenting that their

referral to health care professionals throughout their journey was reassuring,

comforting & made them feel safe.

The above Statistical Process Control (SPC) charts highlight the common and special

case variation that has occurred in relation to cancellations on the day of surgery, since

January 2006. The graphs highlight that all special cause variation within the upper limit

occurred between 2006 to 2009, while all special cause variation within the lower limit

occurred in 2012 and 2013. This highlights a downward trend in the Hospital’s

performance in relation to cancellations and that the Hospital has been unable to

consistently meet the required target.

Hannah Storey, A/Operational Support Manager & Leo George, Nurse Unit Manager, Concord Repatriation General Hospital, Sydney Local Health District

• The Executive Steering Committee will continue to

provide governance and sponsorship for the project.

• System and process changes with be supported

through the development of policies and procedures

and ongoing staff training, as required.

• Ongoing monitoring and reporting of improved

performance against Key Performance Indicators.

Lessons learnt by the project team in relation to project

management and the Redesign Methodology can be

transferred and applied to other projects and settings,

including:

• The support of sponsors, the Involvement of key

stakeholders and clinician engagement from the

commencement of the project is crucial to its success

and sustainability.

• Accessibility to accurate and complete data is crucial

to making informed decisions and presenting the

case for change.

• Project planning and the tracking of required

activities and tasks against timeframes is vital.

• We are all here for our patients. Presenting their

experiences and stories gives projects meaning and

relevance.

A number of the solutions identified as part of this

project could potentially be transferred and

implemented in a number of different services and

settings. Although, full implementation and evaluation

would need to occur prior to this happening.

• Consumers, carers and staff who participated and

assisted in the project

• Dr Teresa Anderson, Chief Executive, SLHD

• Project sponsors Dr Tim Sinclair, General Manager,

CRGH and Geraldine Antonio, Operational Nurse

Manager, CRGH

• Members of the Executive Steering Committee

• Barbye Castillo, Performance and Clinical Redesign

Program Manager, SLHD

• Centre for Healthcare Redesign staff and fellow

course members

Hannah Storey, A/Operational Support Manager

Hannah.Storey@sswahs.nsw.gov.au, 02 9767 7867

6 4 2 0 2 4 6 8 10 12

Access to Care

Respect for patients

Coordination and integration of care

Information and education

Transition and continuity

Physical comfort

Emotional support

Involvement of family and friends

number of interviewees

Positive and negative aspect of patient experience, findings from 10 interviews.

Negative/ Disagree Positive/ Agree

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

0

50

100

150

200

250

Cu

mu

lati

ve

%

Rea

so

n T

ota

l

Reasons for Cancellation on Day of Surgery

Total by Reason Cumulative % Cut off 80%

A root cause analysis

session was undertaken

to understand the root

causes behind the

problems associated

with processes/delays in

the Pre Admissions

Clinic.

Solution Tracking

Develop an agreed pathway/protocol (with the right of veto) for appropriate

referral to the Pre Admissions Clinic

Develop a script & process to ensure that Patients are kept informed of

delays

Review current scheduling system & implement a revised system, which

allocates time based appointments

Develop a business case for the creation of a Co-ordinator /Triage nurse

for the Pre Admissions Clinic

Develop a Business Case for 0.5 FTE pharmacist responsible for

Medication Reconciliation in the Pre Admissions Clinic

Develop generic SMS Reminders 3 days prior to surgery, to confirm

surgery

Implement a telephone queueing system, which places patients in a

queue, informs them of the importance of their call & the number of callers

before them

Develop a electronic “Patient Check-in” for patients to confirm their

attendance for the Pre Admissions Clinic

Utilise SurgiNet to develop surgical lists based on the average historical

time taken by the individual surgeon to complete each procedure

Final operating run lists to be published four hours earlier

Collaborate with the Inner West Medicare Local to facilitating patient

document preparation & provide screening preparatory to attending the

Pre Admissions Clinic

The most common reason for cancellations on day of surgery is due to

the patient being unfit, due to an acute medical condition.

Permission has been granted by NBG to utilise the PACMAN

image in our marketing campaign. Our Marketing Department

is currently in the process of developing material.

52 stakeholders were involved in the creation and development of

solutions, of these 31 attended a multidisciplinary solution design

brainstorming workshop. 99% of respondents

rated the overall care as

either excellent or good.

98% of respondents rated the

information provided for surgery

as either very satisfied or

satisfied.

99% of respondents rated the

information provided for admission

as either very satisfied or satisfied.

The majority (47%) of respondents

experienced a waiting time of

approximately 2 hours.

12% of respondents indicated

that they were never or seldom

informed of delays.

The below data was collected utilising Patient Experience Trackers (PETs), with a total of 213

respondents participating in the survey