Improving an Outpatients' Appointments System
Setting the Scene for Change. In the late 1990s, the Hospital Executive Committee (HEC) of an NHS Trust agreed to take action to reduce the number of alterations to outpatient appointments generated by the hospital, in an attempt to improve the reliability of the service to patients. Of the 300,000 advance outpatient appointments made each year, about 10% were altered because clinicians had cancelled clinics, and a further 10% by patients. Consultants were altering some patients' appointments up to 4 times in succession, causing extensive delays for some people in particular. These altered appointments created reduced quality of service to patients, wasted appointment time, and further costs in administration, postage, telephone calls of some £15,000 per year.
The Outpatients' Manager presented an initial analysis of the problem together with recommendations for improving the situation. Whilst accepting these in principle, the HEC asked the Outpatients Manager to gather additional information for 3 months on patterns of alterations among the various clinicians and the reasons for the altered appointments, before they would agree to implement the recommendations in her report. A new data collection system was temporarily set up and run by the Outpatients clerical staff to generate the information required. It was agreed that during the 3 months, individual Divisional Managers would receive the information about clinicians in their division, for them to disseminate to, and analyse with their clinicians. At the end of the 3 months, the HEC agreed to implement a plan of action to reduce the number of altered appointments.
The Outcome. There were some initial problems with the information gathering and dissemination, which led some managers and clinicians to doubt the accuracy and validity of the information. For instance, some medical secretaries recorded the date of the cancellation, but did not record the reason for the cancellation, nor the name of the doctor making the cancellation. Information was recorded manually and passed from secretaries to the audit department, where it had to be transcribed manually. As it was too expensive and time-consuming to double check all entries, some people worried that information had been entered incorrectly and information created to fill any gaps. The processing of the information took some two months, and some Divisional Managers argued that it was difficult to investigate with clinicians the reasons for cancellation of clinics after this time lapse. Some Divisional Managers claimed there were other priorities, which had taken precedence over the Outpatients' project.
In spite of these difficulties, useful information was produced which confirmed the rate of altered appointments and avoidable circumstances leading to the cancellation of clinics. The HEC gave the go-ahead for the Outpatients Manager's plan to be implemented. The temporary information system became a permanent feature used to report back to managers, the compliance of individual consultants in altering their working practices in line with the HEC's plan of action to reduce the numbers of altered appointments.
However, the trust were disappointed to realise that even after four years, there had still been no significant reduction in the numbers of altered appointments in all but a couple of the clinicians. There was resistance from clinicians, who doubted the validity of the information upon which the original diagnosis had been formed. Eventually, in 2002, Outpatients' staff started to notice changes in the way senior clinicians handled outpatients' appointments, and the numbers of altered appointments started to fall. At that time, new patient-choice orientated booking systems were being promoted nationally and within the region, by the Modernisation Agency, created in 2001.
Analysing the Change. The impetus to reduce the number of altered appointments in the Outpatients Department came from the Outpatients clerical staff, keen to change what they saw as poor service to patients and the impression of incompetence it gave to users. They also recognised that if improvements could be made, it would reduce one aspect of their workload, and enable them to work more efficiently to increase the number of patients able to get a successful appointment first time around. The Outpatients Administrative team was enthusiastic, therefore, and convinced of the need for a change to persuade clinicians to reduce the number of clinics they cancelled.
But improvements were reliant on other people altering long-established working practices. Although it was recognised that clinicians in the trust had limited enthusiasm for such changes, it was thought that a more detailed analysis carried out over the 3 months, would provide a more powerful argument for change. The Consultants, in particular were "unfrozen" - either unconvinced of a need to change, or unwilling to change at that time for other reasons. The HEC's initial reluctance to sanction a plan of action based on initial findings without evidence from a further 3-month study could be seen as a clear signal they thought it would be difficult to convince Consultants of a significant problem, and of a need to alter working practices.
The Outpatients Administrative team, the Outpatients Manager and the HEC put a lot of store by the power of the evidence, alone, in persuading clinicians and managers of the need to change. The facts do not always speak for themselves. The rational ear might hear, but are hearts and minds won over ? And are there sufficient drivers to persuade people of the need to change. Alternatively, if change is to be driven through an organisation, do the people in the driving seat in a position to do so ?
Perceptions of a problem and its significance vary among people and constituencies. The Consultant Clinicians, already voicing concerns about managers encroaching on their clinical autonomy, perceived this move as another step to undermine clinical freedoms further. Even when they could see a logical case for change argued in the investigative reports, their hearts and minds were not ready to commit to a change.
It would have been useful to secure the more active help of some of the Consultants using Outpatients to put the case to their colleagues.
The Divisional Managers were in a position to help lead and implement changes in the Consultants' working practices. The HEC had agreed with Divisional Managers that they would be responsible for disseminating the information to clinicians in their patch, not all the Divisional Managers carried this out, and information was ignored. The argument that information was received too late to investigate with clinicians was rather spurious, and more indicative of an unwillingness on the managers' part to work to reduce the Consultants' resistance on this issue, at a time when they were trying to achieve other changes.
The scheme promoted by the Modernisation Agency was not dissimilar to the recommendations made accepted by the trust's own HEC a few years before. Yet its existence created a new and significant external strategic 'driver' for change that helped tipped the balance in favour of creating a need for change, to help counter the resistors.
The overall conclusion drawn by the Outpatients team in the trust was that the factual evidence-base, may not be sufficient alone as a change agent. It is a vital part of the change tool-kit. Important also are other ways of winning the commitment and support of those involved in the change, such as ensuring sufficient positive drivers and incentives for change.
