SAS - Sustainable Access to Surgery at SWAHS

Sydney West Area Health Service

This project won the Baxter 2006 NSW Health Awards, Access to Services category.

 Presentation given at the 2006 NSW Health Expo.

Contact: Cathie Whitehurst

Abstract

The Sustainable Access to Surgery (SAS) program at SWAHS sought to create long term and sustainable improvement to the access of surgical services for the communities of SWAHS.

There are 9 hospitals in SWAHS that provide surgical services with 8 of those hospitals also providing emergency services.
In June 2005, there were 736 patients waiting greater than 12 months for booked surgery and 621 patients waiting greater than 30 days for urgent surgery across SWAHS.

Based on the analysis of waiting lists, infrastructure and capacity within each specialty and hospital, negotiations were undertaken with the consultants within each specialty to identify strategies to reduce long waits and address the waiting times for patients on a sustainable basis utilising all available capacity across the area
This resulted in the development of systems that supported a seamless patient flow of surgical patients, which reduced to zero the number of patients waiting greater than 12 months for booked surgery and urgent surgery patients waiting greater than 30 days.

Aim  

To reduce to zero the number of patients waiting greater than 12 months for booked surgery and urgent patients waiting greater than 30 days by June 2006.

Background

SWAHS had improved waiting times significantly since January 2005 for patients waiting greater than 12 months (1642 only waiting by Jan 2005) by implementing a series of strategies across the area health service. However, by June 2005 there were still 736 patients waiting greater than 12 months and 621 patients overdue for urgent surgery.

Analysis of information identified constraints relating directly to capacity within Nepean Hospital and available infrastructure at 2 of the metropolitan hospitals. Issues such as capacity with the large tertiary hospitals fulfilling roles as major trauma services as well as highly complex booked and urgent surgery, and the smaller facilities having well established booked and emergency surgical profiles with spare capacity added to the complexity and out ability to further reduce the waiting times.

Method

Significant consultation was necessary amongst all stakeholders including consumers, operating suite staff, bookings staff, wait list coordinators and clinicians to identify the underlying issues impacting on improvement.

In-depth analysis of the infrastructure of each hospital took place to identify possible reconfiguration of services that would allow us to incorporate additional surgical activity for appropriate specialties in facilities that had spare capacity. The following was identified:

• Mount Druitt Hospital's could gather safely for all elective joint replacement patients for the Area not just for patients from Auburn to Blacktown.
• Hawkesbury District Hospital can gather for all elective orthopaedics from Nepean to Lithgow.
• Nepean's bed capacity was impacting on surgical throughput.
• Auburn Hospital could extend its booked services in general surgery, ENT, gynaecology and plastics to include patients beyond Blacktown.
• Springwood Hospital can safely become an ophthalmology centre for patients.
• Westmead could reduce its waiting lists for cataracts if some enhancements were made.

Upon consultation with clinicians (nurses, surgeons) within each specialty to identify strategies to reduce long waiting and address the waiting times for patients, they identified the following issues:

• Lack of flexibility of patients in having a procedure in a different hospital with a different surgeon.
• Inability to use spare surgical capacity in other hospitals within the Area Health Service.
• Lack of information on performance.
• Poor coordination of surgical lists. No one to liaise directly with the surgeon regarding possible cancellations, conflicting operating schedules, etc.
• Inability to engage private health service providers to assist with demand.
• Unplanned patient cancellations.

Upon consultation with consumers, they identified that issues impacting on having their surgery at other facilities were:

• Transport costs for the patient.
• Transport arrangements for their relatives.

Planning and Implementation

The interventions put in place were based on the following:

Establishing the "best fit" for facilities and specialties dependent on infrastructure and capacity available:

• Mt Druitt Hospital services were extended to provide elective joint replacement to all patients within Sydney West.
• Auburn Hospital elective general surgery, ENT, gynaecology and plastics services were escalated to include patients from Nepean to Lithgow.
• Springwood Hospital services was extended to provide ophthalmology services to patients from Nepean to Lithgow.
• Enhancement of the ambulatory cataract service at Westmead with engagement of a NSW Private Provider for cataract surgery.
• Engaging Nepean Private Hospital to support bed demand from Nepean Public Hospital therefore enabling more surgical throughput.

Implementing creative solutions to ensure effective, safe and appropriate transfer of patients across the area:

• All consultants (surgeons) from Auburn to Lithgow were advised of additional operating capacity at specific facilities.
• A surgical forum inclusive of waiting list coordinators, nurse managers, operating suite staff and surgical coordinators was established and meet fortnightly to discuss weekly performance by facility against target, surgeons' leave, session allocation, session capacity and forecast performance by specialty.
• Audits of the waiting list were conducted on an ongoing basis to ensure absolute accuracy of the list and remove patients who did not longer require surgery.
• Surgical coordinators were chosen to liaise directly with patients and the clinical teams. They provided a clinical oversight of bookings and operating lists ensuring patients were scheduled as clinically appropriate in the appropriate facility and they didn't get cancelled.
• Implementation of the NSW Health Waiting Time and Elective Patient Management, including a standard telephone audit criteria and documentation.

Ongoing communication with patients:

• All patients waiting greater than 9 months were offered an opportunity to have their surgery earlier at an alternative facility often under an alternative surgeon.
• Facilitate transport services for patients and their families via the use of private transport providers, cab charge vouchers for relatives and patients and the use of a visitor transport service between the metropolitan hospitals.

Outcomes and Evaluation

Monitoring of waiting list data shows that by 30 June 2006, SWAHS has reduced to zero the number of patients waiting greater than 12 months for booked surgery and urgent patients waiting greater than 30 days. (Graph 1 & 2)

In June 2005, there were 296 patients waiting greater than 12 months for joint replacement surgery in SWAHS, the average wait for those patients was in fact  >18 months with some patients waiting up until 4 years. As a result of the program all of those patients have had their surgery performed and have now recovered, returning to their normal activities within their community.

In January 2005, there were 700 patients were waiting greater than 12 months for cataract surgery. Now there are zero patients waiting greater than 12 months for cataract surgery in SWAHS.

Springwood, Mt Druitt and Auburn hospitals are performing at full capacity and fulfilling a vital role in providing access to booked Day Only and 23 hour surgery for 80% of patients waiting for Orthopaedics, Plastics and ENT surgery across SWAHS.

The tertiary and major facilities within SWAHS are providing high-level surgical access to patients requiring complex or urgent surgery and ensuring capacity for trauma and emergency surgery is preserved.

A further positive outcome of the project was that it crossed hospital and disciplines boundaries in order to achieve what is best for the patient.

Future scope

The results of the SWAHS sustainable access for surgery (SAS) program are easily transferable across NSW. In fact, this project is a clear example of transferability as it is based on an earlier model, the Elective Surgical Program (ESP) a concept developed in 2001, which covered Auburn, Westmead, Blacktown and Mt Druitt Hospitals very successfully.

SAS linked the capacity and infrastructure of each facility with the waiting list for each specialty in consultation with clinicians and patients. This clearly demonstrates that agreement can be reached when there is involvement of stakeholders and a sense of shared purpose.