Did you know that for people over the age of 80, 10 days in bed ages muscles by 10 years?

MidCentral District Health Board Frailty Campaign 2017

This is one of the startling facts highlighted in campaigns across the world to get patients up, dressed and moving. With the #EndPJparalysis summit finished for another year, we’ve been reflecting on the number of campaigns we’ve supported across New Zealand to tackle the harm caused from deconditioning and to give back the most precious commodity in healthcare: Patients’ Time!  

One example was the #GetUP,GetDRESSED,GetMOVING campaign in MidCentral DHB. The month-long campaign targeted both consumers and staff and the team were keen to go BIG:

• ·Take5 presentations delivered by geriatricians across the inpatient wards to raise awareness about the f-word (hint: it’s 7 letters long, not 4).

• A hospital-wide frailty quiz and online Ko Awatea educational package to test out baseline and new-found knowledge and skills.

• Take-over of the hospital foyer with a booth full of information on preventing deconditioning and staffed by a multidisciplinary team of frailty experts.

• Posters up across the corridors, on people’s computers and one of the busiest places in all hospitals: the café!

• Advertising to encourage the Palmerston North community to #GetUP,GetDRESSED,GetMOVING across all the local papers.

• Stories shared on how MidCentral DHB was making differences to individual patients in helping them stay mobile and stay independent.  

• A pledge wall where doctors, nurses, patients, whānau, health care assistants, managers, administrators, even the CEO pledged to make a change that would support #EndPJparalysis.

Needless to say, the campaign was a great success with some wards doubling the percentage of patients up, dressed and moving each morning! With the #EndPJparalysis summit finished for another year, what’s your pledge to help end PJ paralysis once and for all?

Jacqui Summers
Senior Consultant

Changing thinking and behaviour in health systems

Much has been made of the need for change in health systems as each year demand growth and financial constraints continue to inexplicably worsen.  More services for less cost.  More integrated care: fewer cracks for patients to fall through, faster care decisions from shared information and planning and less duplication between providers.  The provision of ‘care closer to home’ implying greater convenience for patients and lower cost care settings.  More empowerment and choice for patients.

Health Board CEOs from 2020 are facing a mounting mix of new pressures many of which have never been previously imagined.  In New Zealand, ongoing pandemic readiness, contemplating the impact of the Simpson report – implications of a locality focus, PHO relationships, potential DHB merger/integration – a workforce heavily reliant on costly locums, regional interdependence, national collaboration and, last but by no means least, the clinical and financial sustainability of their own Health Board.

But, and it is a big but:  why is the system, and it’s constituent member organisations, struggling to deliver – at least in the eyes of system owners (notably the public at large and their politicians)?

1. Need for real relationships between individual clinicians across the care network.
   People work with others, but they don’t often relate to them.  How strong is genuine, shared buy in to mutually rewarding outcomes?  Will you go that extra mile because it helps a colleague in another organisation deliver better service for your patient?  Or is the primary focus one’s own priorities (and budgets)? 
   I recall a new executive director commissioner in New Zealand being mystified that it fell to him personally to introduce for the first time the clinical director of the district general hospital’s emergency department to a long standing local general practitioner who had for years held national roles in medical leadership in New Zealand.

2. Build enthusiasm rather than resignation where staff have been worn down by the system’s inability to change.

   We all know that no one wants to do a poor job, but somehow decades of organisational antibodies to change wear down even the most compassionate clinicians.  And when compassion goes, the smile goes, and ‘task completion’ rules supreme.
   In a look at the role of junior medical staff for a university hospital, there was a palpable sense of disillusionment from them as they see an increasing gap between what they have come into the profession for and the reality of their day to day job.

3. Ensure leaders are equipped with necessary foundation skills.

   Leaders require basic skills such as facilitation, change management, project management (practical project management I might add, not theoretical management of projects in a mythical “controlled environment”), stakeholder engagement, relationship management, problem analysis and the synthesis, distillation and crystallisation of issues, their impact and resolution.  Such skills, where they exist, are usually vested in ‘change agents’ who are tasked with swimming across the river, not in it or are lost by the noise and lack of direction.
   Running a training session for clinical leads on a theatre improvement programme, the consultant orthopaedic surgeon who was chair of the new theatre management committee commented that nowhere in his medical career had he been trained how to chair a meeting or facilitate group sessions let alone deal with change management issues or undertake process analysis and improvement.

4. Share awareness of how to lead in complex adaptive systems to ameliorate a thirst for immediacy. 

   We all know that annual budgets, cost saving expectations and elections act counter to efforts to implement longer-term, transformation and sustainable change.  Naivety as regards to managing change with people and an urgency for action over quality system design and interdependency management creates simplistic and unrealistic expectations.  Sustainable change comes from helping people to think and behave in new ways.
   The focus for operational teams seems to be on achieving the latest target imposed by managers who are accountable for the results. This is keeping the system in a reactionary state – and usually frustrates both operational teams and their managers.  One client who engaged us in a long term development programme for sustainable change nearly derailed the programme by unexpected and unrealistic expectations for immediate benefits just as implementation began (the programme went on to achieve the target long term sustainable savings).

5. Let the courageous, and responsible, step forward!

   Don’t be afraid to be brave!  Healthcare is inherently risky and as we have seen in recent years, risk needs to be effectively managed and connected from the frontline, through leadership to the board room.  Waving the risk flag to delay or abdicate decision making is the cloak of the weak.  Flag waving risk in meetings to avoid decisions that are required to change the way we do things for the better is neither professional nor useful.  How often are people discouraged to act because ‘they’ won’t approve anyway or because there is some unspecific ‘patient risk’? 
   I recall a client saying that the revision of rosters to patient demand was the most thorough she’d seen in her 20 years in her department.  Yet despite senior managers wanting significant cost reductions she and her seniors struggled to find the courage to reduce staffing or to fully implement the new rosters that had been designed with their own frontline managers.  

6. Value adding, capability building, improvement interventions. 

   The best quality and most sustainable learning is a product of cognitive, emotional and behavioural learning.  We see this learning best in clinical simulation rooms, where time pressure and noise adds stress to staff learning how to respond to specific clinical situations.  The expenditure however on health systems improvement skills is still predominantly focused on old fashioned pedagogy.  Courses, conferences, web seminars, lectures, short courses and unstructured learning sets are the antithesis of the combination of cognitive, emotional and behavioural learning that we see in best practice clinical education. 
   As performance improvement and organisational development consultants, our experience is that it is not by writing reports that you achieve meaningful change in an individual’s daily work.  Business driven action learning, with coaching, support and mentoring from performance improvement and organisational development experts, is the way to sustainable change in the way people think and behave.   A central element of our Change Collaborative’s pedagogy is through the use of the participant’s own case studies, where in teams they problem solve, role play and present their findings and recommendations creating immediate behavioural integration of learning.

There may also something about power here.  As Jim Green (former chief executive of The Royal Society of Medicine) once said, ‘there is no kingdom too small for a doctor to be king of’.  Most health systems have a handful of powerful senior clinicians that have built their kingdoms exactly how they suit them.  They are not only clinically untouchable but they are also astute political poker players and the reality is that most senior managers, while not necessarily scared of them, simply don’t have the knowledge or wherewithal to challenge or manage them.  Clearly the renaissance for putting clinicians into real (not figurehead) leadership roles will help to tackle this.  But are we doing enough to support these senior clinicians in the meantime? 
Many clinicians would consider themselves professional ‘change survivors’ and see waiting the latest manager who inevitably moves on to another role within a year or two as part and parcel of the job. One consultant physician once explained to me that he’d been occupying his office (with its lovely sea view) for more than 22 years, and over that period had seen more than that number of hospital managers cycle through their office (windowless, on the ground floor!)

The next step, as stewards of health systems for our generation and the next, is to learn how to bridge the gap between ideas and implementation.  As well as thinking through new ways to deal with the issues I have described above, we also need to:

1. Create awareness of the need to change.  

   This is achieved by contrasting the current, with a desired, state and is important for anything from even minor process changes to large system-wide transformation projects. People need to know why the change is necessary before they will engage in it.  
   Patient-centred care is about timely, safe and quality care where decisions are made in a timely manner, teamwork efficiently delivers care and waste of all forms is minimised.  Focus on doing the right thing for patients – good flow, less congestion – means fewer financial resources get expended as a consequence of implementation (rather than financials being the focus of implementation).

2. Confront custom and practice. 

   Systems and behaviours that are meant to protect, often do more harm when we are trying to make improvements, for instance, financial controls and human resource policies. 
   In one of my clients, an explicit email calling for a specific action from a trust chief executive was rebutted with forms, middle management approvals and more delay from those under his leadership.  Truly a case of the tail wagging the dog.

3. Action planning and meeting management. 

   We have all experienced healthcare ‘management meetings’ that have too much talk, too little time, focus overly on sweating the least important issues, decisions are re-litigated and left unmade and actions logged that are process measures not outcome focused.  Of course, clinicians have better things to do with their time than waste it in another meeting.
   With a client in Australia, we created an architecture to make sure teams that are meeting have the necessary information and the authority and delegation to make improvement decisions.  They also had a clear and transparent escalation process for decisions outside their span of authority.  Many organisations have delegations for spending money and managing staff, but not for making improvement related change.

4. Resources to support action. 

   We all know that it is hard to change the wings on the plane while it keeps flying.  Implementing change needs time limited support and this needs to be focused on supporting action.  The most successful change is when internal staff lead action, are coached/supported on the job to be change champions through business driven action learning, and importantly, senior managers are physically involved and present.  Delegating improvements down the chain and crossing one’s fingers doesn’t work.
   It is commonplace in our support programmes to transition over leadership team support to internal improvement teams who often lack the change management and leadership development skills necessary to develop sufficient initial momentum for cultural and process change. 

5. Winning hearts and minds. 

   Hospitals are good for ‘having tried that’, usually anything from 3 months to 15 years ago.  Communication needs to be carefully crafted and executed, and need not necessarily be resource intensive.  It does need to communicate both sides of the coin – funnily enough most everyone knows the elephant in the room, and you will be judged by what you don’t say as much as what you do.  Stakeholder engagement needs to be meaningful, conducted with respect and integrity and not for ‘ticking the box’.  Working constructively with stakeholders to improve their ability to contribute, also builds more sustainable solutions.
   We use a stakeholder maturity model when examining communication and stakeholder engagement needs for programmes.  More than a decade ago, when assisting the development of the New Zealand health information strategy, we recognised that there were parts of the health sector that had no or a limited voice when it came to contributing to the debate on enhancing health information nationally.  With some stakeholder groups we facilitated the establishment of special interest committees within the groups, with whom we could engage, and who could more effectively advise the groups on health information issues.

6. Tools and techniques to support continuous improvement.

   Thinking and behaving in new ways needs new or redesigned systems.  These span everything from meeting management techniques, to improvement methods, scheduling and rostering processes, utilisation and performance monitoring tools, planning and communications processes, and engagement and relationship management processes.  Insight alone does not produce change.  Stopping doing things one way and starting to do them another is the only way forward.
   Our Change Collaborative has developed more than 50 topics that we’ve incorporated in programmes delivered in the United Kingdom, Thailand, Australia and New Zealand. Participants have included clinical directors, executive team members, operational managers and front-line clinicians.  Aside from learning to lead, leader’s need knowledge of improvement science, personal skills to engage and collaborate productively and how to manage through change.

7. Remove systems or processes of the old way of doing things.

   Physically removing or shutting down processes or systems that enable people to go back to the way they used to gives new work practices time to become embedded.  Making the new ways ‘Business As Usual’ stops ‘change drift’ where things diverge and potentially revert to previous ways of working.  Make sure your management processes support the new ways of working.  Are standard operating procedures (SOPs) simple, easy to follow and aligned with new processes? Are peoples role descriptions aligned with new responsibilities? Are resources in the right time and place?
   Behavioural integration – the learning of how to think and behave in new ways – takes practice; developing muscle memory. Rapid cycle tests of change are an ideal way to learn, to engage staff, and to ultimately influence change in the complex adaptive system that healthcare delivery is.

Changing thinking and behaviour within our health system is without doubt hard work.  But it should also be rewarding and we need to celebrate success.  Highlighting and rewarding any instances or improvements that are a result of the new way of working needs to go hand in hand with having the courage to follow through on espoused consequences for those who block change.  Meeting the expectations of patients, the public and, yes, the politicians, needs us to make decisions that are for the greater good – quality care with a smile brings with it, compassion.  That’s why we work in health.

Stuart Francis

Stuart is a Fellow of the Australasian College of Health Service Management, a Chartered Member of the Institute of Directors and is the founder and Executive Chairman of Francis Health, a specialist health sector organisational development consultancy.

Do we want to return to 'business as usual' in healthcare?

In response to Covid-19, many ‘business as usual’ activities were put on hold so that healthcare employees had time to focus their attention on rapid preparation. For many, pushing pause on routine meetings, reports and even some projects has been a welcome reprieve. Most of us are familiar with the feeling of completing reports of questionable value or taking part in meetings that were far from the best use of our time. For many, this is the daily experience of working in healthcare.

We are now entering a new phase of response to Covid-19, where healthcare organisations are both reflecting on the rapid and impressive changes that have been made, while also looking at how to recover from a backlog of deferred care and delayed projects. A lot of attention is already being given to how to sustain the positive changes that have been implemented over the last few months, but less is being said about whether there are also things that have been stopped that should never be started again. 

Now is the time to question the value of ‘business as usual’ activity. This isn’t just the responsibility of senior leaders but for anyone who draws on the time of others.

Before hitting the restart button, take some time to ask yourself and your team:

• How does this activity align with achieving our overall mission?

• Is the purpose clear?

• Is it delivering value? (over and above the opportunity cost of what we are not doing instead)

• Is there another way to achieve this purpose that makes better use of our time?

• Can this [task, report, meeting] be shortened, improved, or eliminated

• Could this output be created or delivered in a different way?

• Is there someone else who could complete this task?

The way we work is heavily influenced by our previous experiences, structures, processes and cultural norms so changing this is harder than it first appears. For example, when someone says the word ‘meeting’ we quickly form a visual image of what this means – so resisting the natural pull back to what is familiar requires intentionality…. and maybe even changing some of our language.

Now is the time to unleash the creativity of teams – to break apart the old, and design ways of working that value the precious time and skills of healthcare staff. If we don’t, we may look back a year from now and regret the missed opportunity to radically reinvent ‘business as usual’.

Stephanie Easthope
Manager

Caught yourself wondering about the maelstrom of emotions you’ve experienced during lockdown?

There’s a school of thought that suggests that we have been living through a version of the emotional cycle of grief, with a sense that some good has to come out of the last few unprecedented weeks of our lives. If there is, it is going to have to be intentionally sought out and locked in!

Here is what I mean about the emotional cycle of grief and our COVID experiences:

David Kessler, foremost expert on grief who co-wrote Grief and Grieving with Kubler-Ross, observed that we may be feeling a number of griefs and understanding them is a first step. It feels like the world has changed and it has; things will never be the same again and this is the point at which they will have changed. We’re also not used to this level of collective grief in the air. It doesn’t take much to recall images of nurses crying with exhaustion or mass burial scenes to bring back those visceral feelings of grief – even if they weren’t on our door step.

“We are all dealing with the collective loss of the world we knew”  David Kessler

Think back a few weeks to the feeling of disbelief and denial caused by the sudden loss of structure and social connection. This is when we thought ‘that’s looks shocking’ (images of the initial assault in China) and ‘I’m so glad that’s not going to happen to us…’

Then slowly it becomes real and we felt bloody angry as our inner voices complained that through no fault of our own we were going to lose our freedom and be forced to stay at home. The thing with anger is that it is strangely empowering. It gives us a sense of control.

However being angry for any length of time can be quite draining and as we acknowledged reality we started bargaining that if we followed the rules, practiced social distancing and washed our hands this too would pass and we could have our lives back.

Time passed and we experienced a sadness in the pit of our stomachs. We didn’t know when this would end, we were getting tired of putting on a brave face (after all we should be grateful, there are so many worse off than us). A leader of a large health centre commented in conversation ‘I don’t how to be me anymore. . . I always made a point of being visible, there when anyone needed me, supporting my team, welcoming new recruits and having those meaningful corridor conversations’. This role loss hit many of us at our core. Our identity. Coupled with loss of traditions, routine and normalcy. It’s been quite a load to bear.

With little gains, virtual connection and settling into our temporary norm we regained some power. Through acceptance we reflected that our lives hadn’t indeed stopped. We were going to be ok, or simply that we were at least having more good days than bad days.

In Kessler’s own personal dealings with grief, he felt once he had reached a stage of acceptance, what he really longed for was meaning. Kessler describes, it is often in our darkest moments we look for and can experience real meaning. For us, this lockdown provides numerous opportunities to find meaning. Parents are spending more time with their children, we are learning to connect with people via technology, we are appreciating the freedom of getting outside for exercise. We are learning new skills and new ways of being.

One unfortunate by product of the self-help movement is we’re the first generation to have feelings about our feelings.

Some tips for moving towards meaning from researcher Emily Acraman.

Acknowledge your feelings

Name your emotions and allow yourself to feel them… and don’t compare your feelings with those of others.

Find balance in your thoughts

When we talk about anticipatory grief, often this involves our minds imagining worst case scenarios. The key here is not to ignore these feelings, but rather to balance them out with positive thoughts.

Live in the present

If you feel yourself starting to get carried away worrying about the future, to calm yourself you need to come back to the present moment. Realise that in the present moment, nothing you’ve anticipated has happened. In this moment, you’re okay.

Let go of what you can’t control

Try not to focus your energy on the things outside of your locus of control. For example, you cannot control what the economic impact of COVID-19 will be, but you may be able to make some decisions about how you can minimise the personal impact on you and loved ones.

Finally, it’s a good time to stock up on compassion. Everyone will have different levels of fear and grief and it manifests in different ways. So be patient. Think about who someone usually is and not who they seem to be in this moment.

And finally… give yourself permission to feel your feelings!

“It’s important we acknowledge what we go through. One unfortunate by product of the self-help movement is we’re the first generation to have feelings about our feelings. We tell ourselves things like, I feel sad, but I shouldn’t feel that; other people have it worse. We can — we should — stop at the first feeling. I feel sad. Let me go for five minutes to feel sad. Your work is to feel your sadness and fear and anger whether or not someone else is feeling something.” Kessler

Naila Naseem
Lead Partner - Change Collaborative

Unravelling the change. How patient and whānau experience can reveal new opportunities

Preface: Sophie is a registered pharmacist who draws on her experiences working clinically to describe some of the barriers patients can face in New Zealand’s health system.

Think about the last time you were sick. It is miserable and stressful and makes everything difficult. It can totally disrupt your intentions for the day, week, even month. You’re feeling so terrible you want to be seen by a doctor, so you pick up the phone and call your local practice, crossing your fingers that your usual doctor will be in and can actually see you that day. You manage to get an appointment and you drive to the doctor’s office and then the waiting starts. You turn up on time but are expecting to wait because your doctor seems to always be running late. Your GP provides excellent care but it can feel like it’s only a few minutes long before you are given a prescription of some sort and politely ushered out the door so the next unwell patient you sat next to in the waiting room can have their turn. Great staff and great medical advice wrapped in a poor user experience in a health system that relies heavily on you, the unwell patient, investing your own time.

Feeling sick and miserable, you might go to the pharmacy where you wait some more – luckily, they have a range of retail products you don’t need to kill the time. You’ll notice other sick people too, stressed parents with sick children, elderly getting their repeat medications, people dashing in and out asking “how long is it going to be?” or “the other two pharmacies don’t stock this, do you?” “I can only afford one this month, what medicine is most important?”. We’ve come to accept this is just how it has to be. It’s enough to avoid going in, delaying treatments, the onus of refilling prescriptions and navigating the health system relying on you – the sick patient managing this administrative and financial burden. In extreme cases, this whole process could take three hours of your day. For some this is just an inconvenience while for others it can cause significant social and financial hardship as a result of juggling family commitments, time off work and the cost of engaging with the sector. At its simplest level, our public healthcare system exists to look after people so why do we accept this sort of experience when we wouldn’t from other customer-focused industries?

This “chronic waiting” is exacerbated if you have a chronic health condition that requires ongoing follow-up, or need specialist advice from a hospital. That clinical consultation can be a valuable 10 minute appointment. So valuable that you take time off work, arrange childcare or recruit whanāu to drive you. For many, this trip from home to outpatient clinic could be well over an hour. You might arrange your day so you can catch a health shuttle, wait to be seen and then turn around to reverse the journey home again. Just in time for tea.

Valuing patients’ time

Fast-forward to present day adjusting to post-COVID-19 and think about if you were to get that sick now. You have far greater choice and preference in how you access healthcare. The technology that has been developed and adopted at snail’s pace over the last decade has finally been embraced by providers and patients’ alike. You might ring the practice and talk directly with the GP so that you are provided with a decision about your health needs as soon as possible. You might be given the option to have a virtual consult with your usual GP – who then asks you what pharmacy you would like to pick up your medication from – directly sending on the prescription. In this situation, you’d only have to leave the house to pick up your medication (or a family member might do that on your behalf). The rest of the day for you to recover without contacting others. 

You might now see your specialists for the same amount of time, but given the option to zoom in, only come for an in-person appointment when necessary. You could have joint consultations with your specialists and your GP. Either way, you still have access to care. Only now, you have saved on time, parking, transport costs and time away from work. Your time as a patient, who the health system is designed to serve, has been valued.

We have proven that we can move away from one-size-fits-most service provision.

As we design or improve services, the value of patient journeys and experiences through our complex processes and systems can be an incredibly insightful way of understanding that what might work for the system, is not working equitably for our populations. Now that we have had a taste of a flexible, adaptable and digital health system, we can see that blending both in-person and virtual options to empower patient’s with choice and determine how they would like to access care. We have proven that we can move away from one-size-fits-most service provision.

Healthcare globally is an astonishingly fragmented industry; with many stakeholders (with differing priorities), third party funding and an extensive network of regulations. The soil we have laid in healthcare often barricades our best attempts for transformational change and innovation. But what we do have is passionate health providers that can be empowered to disrupt how we work to better deliver to our patients. With the richness of patient experiences and journeys to help unravel the changes that have occurred during the pandemic, we can begin to understand what should be invested in, be sustained and what has not worked well for different populations and patients.

COVID-19 has tested the health system and those that work in it at all levels to really ask ourselves– why didn’t we give each other the permission to test new ways of working sooner?

Sophie Oliff
Senior Consultant

A simple tool for prioritising delivery of the backlog of planned care

An estimated 30, 000 New Zealanders missed out on their elective surgery over the Covid-19 lockdown period and many more had their first specialist appointment or diagnostics delayed.

Now, with case numbers declining, hospitals have been able to shift their attention to how they can increase delivery of planned care. Herein lie some big challenges. How do we ensure, that as elective surgeries and outpatient clinics resume, patients are seen according to their clinical priority? Not just within specialties but across specialties. How do we fairly allocate theatre time or clinic space? And how do we ensure that our response does not increase the health inequities that already exist?

On every list of patients waiting for an appointment, a diagnostic or treatment there are multiple levels of unknown increasing clinical risk. The longer a patient waits, beyond their maximum clinically acceptable wait time, the greater the level of unknown risk. We can ask clinicians to review their lists and re-prioritise patients, but we balance that with time not spent in clinic or in theatre seeing patients. What’s more, this approach leaves clinicians to ‘go into battle’ for their patients risking increased mistrust between clinicians and managers and the potential for unconscious biases to influence decision making.

The answer lies in a simple ratio.

The ratio between the time the patient has waited and the length of the clinically accepted wait. Known as the acuity index, the ratio was first mooted circa 2013 by the Ministry of Health. It enables patient priority to be objectively compared across lists, specialties and ethnic groups based on the clinical priority assigned on referral to the waiting list. A ratio less than 1 indicates the patient has waited less than the maximum acceptable time, a ratio of greater than 1 indicates they have exceeded the maximum acceptable time, a score of 2 indicates they have waited double the maximum acceptable time and so on. The ratio is grounded in clinical decision making – the clinician determines the clinical priority and therefore the maximum acceptable wait – yet provides a simple, common language for administrators, managers and executives working to coordinate delivery of the backlog of planned care. The acuity index for a patient with a shorter acceptable wait time will grow more quickly than the acuity index of a patient with a longer acceptable wait time but at some point the risk for the patient that’s been waiting two years for their next annual review overtakes that of the patient that’s been classified as urgent (unless the follow up wasn’t actually necessary but that’s a whole other topic). The acuity index enables us to objectively compare those patients and determine who should be booked next on the list or where we should target our interventions to mitigate the risk of delayed treatment.

Figure 1. The acuity index enables us to objectively compare patients with different clinical priorities

It doesn’t stop there though. The acuity index enables us to view and compare waitlists visually and to understand whether we are making gains towards addressing the backlog or not. For example, in figure 2 there is a large group of patients that have waited more than twice their clinically accepted wait. This information could be used to target interventions to mitigate the risk for these patients. The two charts in figure 3 illustrate how we can track how different specialties are performing. Here, we have a problem in general surgery where on average patients are waiting 2.5 times their clinically accepted wait, but the situation is improving. Whereas orthopaedics was tracking quite well but something has changed, and the acuity index is now increasing. This information might prompt conversations about whether theatre or clinic resource is allocated where it is needed most throughout the Covid-19 recovery. Again, the acuity index provides a common language for communication between clinicians and managers and helps to build trust and foster collaboration between specialty groups. 

Figure 2. The acuity index can be used to understand the backlog of patients waiting.

Figure 3. The acuity index can be used to understand whether we’re improving or getting worse.

Once we have a common language, to understand the multiple levels of unknown clinical risk posed by patients waiting, then we can target our interventions to manage the risk of deterioration or harm. We can use the data to inform decision making around using our allied health and nursing workforces to provide alternate methods of advice and treatment, we can appropriately communicate with referrers and patients and we can make the best use of our theatre and clinic resources, both public and private.

Bridget Thompson
Senior Consultant