Patient Pathways In NHS: Redesigning Services For Increased Efficiency And Quality

About Patient care NHS management ?

National Health Service (NHS) Improvement (2017) service redesign is a process through which healthcare organisations can improve efficiency and quality in patient management by developing patient pathways.

Strengths, Weaknesses, Opportunities and Threats analysis (SWOT)?

Patient care and no extra flow of finance involved and NHS hospital may face budget Constraints?

Challenges Faced by NHS

To improve efficiency and quality of patient’s management in the healthcare organisation National Health Service Improvement has redesigned their process by developing patient pathways. Improved quality and service of patient care will help patients and staff members in meeting their needs (Teitelbaum and Wilensky, 2016). The quality and service patient’s care can be achieved through remodelling and evaluation of existing patient processes which will help health organisation in eliminating those steps which do not add value to the patients experience and by focusing on patient’s as a customer (Teitelbaum and Wilensky, 2016). Due to changing problem of disease and demographic changes the NHS has experienced an increase in demand for those services which increases the expenses (Maguire, Dunn, and McKenna, 2016).  Even though the NHS is experiencing increase in demand of service, the government of England has reduced NHS funding, although the focus of government remains headed for improved quality, better efficiency, improved capacity and abridged waiting times (Anandaciva, 2018).  Extended waiting lines are the main reason behind the patient dissatisfaction (Zhenzhan and Calvin, 2017). To measure performance and patient satisfaction it is important to identify waiting time (Anandaciva, 2017).

In Accordance of the National Framework for Radiology Service Improvement, this new process of service redesigning will emphasis on unnecessary waiting time experienced by outpatients of General Practitioner and Orthopaedic in the general department of X-Ray of a local hospital (NHS Modernisation Agency, 2003). The main aim of this service redesign is to decrease waiting time, minimise patient complaints, improves staff motivation (appendix 1) and to reduce disturbance to scheduled orthopaedic clinics (appendix 2) (RCR, 2014). The general X-Ray department works on FIFO system that is first in first out (The Health Foundation, 2013) from Monday to Friday between 9.00 am to 5.00 pm, for outpatients of both General Practitioner and Orthopaedic who are referred for X-rays. However, at the same time the appointment of Orthopaedic Clinic are scheduled. Previously the department of General Practitioner had a particular slot but due to lack of ability and patient grievances about extended waiting line department has adopted FIFO system. Sometimes it happen that many of Orthopaedic patients request management to consider them on priority over General Practitioner patients, which lead to increased waiting line and restricted access (appendix 3). A Team is trying to control the system but there are numerous complaints were receive form Orthopaedic consultants and patients which leads to a reduction in staff productivity and morale (appendix 3). In 2017, The Care Quality Commission (CQC) has inspected all hospital services and rates them and also mentions if they required improvement (appendix 4), (CQC, 2018), and this is an indication for specific department to evaluate and make the require changes to improve the quality of services delivered. There are two Digital Radiography X-ray rooms in the radiology department for emergency and for general X-ray department of General Practitioner and Orthopaedic there are one Digital Radiography room and they can also use Fluoroscopy room if it is free (appendix 3). In the general X-ray department on an average 4 staff members work all days (appendix 5), staff also needs to wait in a line for the room which decreases patients movement, waste time and reduces staff efficiency (Dixon, 2010). The Government has decided a target of four hours for the patients in care of accident and emergency but there is no specific waiting time target for general X-ray patients (NHS, 2017). However, the patients who are waiting for their chance have a valid anticipation that they will be seen in a sensible time period but their expectation shattered when they have to wait for more than 2 hours to be X-rayed (appendix 2) is intolerable (National Institute for Health and Care Excellence, 2018).

Tools Used to Assess Present Service

Strengths, Weaknesses, Opportunities and Threats analysis (SWOT),and Conventional Process mapping (figure 1) are those tools which are used to assess the present service (Gottwald and Lansdown, 2014). The Conventional Process Mapping tool is used in identifying journey of patients and the service provided by clinics to their patients (Phillips & Simmonds, 2013). This process will help in identifying the steps those are valuable and non-valuable for patient journey and also help in identifying the accessible resources to enhanced patient care system (Trebble, et al, 2010). The journey procedure mapped and observed X for Orthopaedic patients and Y for General Practitioner patients (Figure 1) to finally eliminate the unwanted steps, to identify the flow and quality of the service (appendix 7) and to reduce patients waiting time (NHS improvement, 2017). Radiology service SWOT analysis was shaped to understand the external and internal environment and to evaluate patients waiting time. The SWOT analysis will help in identifying barriers which delay the amenity and are going to affect the upcoming plans for improvement (Krushkal et al., 2011; Phadermrod, et al, 2016). SWOT analysis will help to implement changes to overcome barriers. The service will concentrate on strengths to reduce threats and on opportunities to reduce weaknesses.

The tool will help to eliminate unwanted steps from arrival of patients at reception and then changing for check-up to complete unproductive administration of patient flow (RCR, 2017). This got worse because of use of paper request cards, uncontrolled patient flow, insufficient X-Ray rooms and ineffective management of General Practitioner and Orthopaedic patient’s requests. Although there are sufficient skilled staff members and good leaders in the department, who all are very much committed to patient care, they are ready to accept changes to improve their service.  

Figure 1: Patient Journey

Options for improvement were appraised below:

 Figure 2: Option appraisal

From the above mention table, it is been drawn that the second option is the most preferred option as it got the best marks (figure 2), this option includes the process which is short and easy to improve patient care and no extra flow of finance involved. The second best option is third option, even though this option gets best marks in staff productivity and in access to service, but by exercising this option the NHS hospital may face budget Constraints (Anandaciva, 2018). However, the department needs to balance demand and capacity to enhance experience of patient’s and for long-term workflow. Third option could be a long-term investment plan. The first option involves very less cost but in performance indicator, this option gets worst marks as per performance indicator so it considers being the worst option for service development because this option will lead to the constant increase in waiting time of patients and will reduce the morale of staff and service efficiency.

The patient outcomes and service delivery will improve if general X-ray department reduced waiting time for patients (NICE, 2018). After implementation of changes the patient journey will exclude unwanted steps like, while x-ray goes to viewing room for verifying image the patient’s need to wait in the room for staff, Orthopaedic Doctors phone call in to speed up his patient’s process. From initial patient journey, seven steps were removed to bring out the optimistic outcome for staff and experience for patient (Ardagh, 2015; Worth et al., 2012). The whole amenity will be observed through audit.

The Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis (appendix 4) and Conventional process mapping (figure 1) are considerable tools to analysis the present service (Gottwald and Lansdown, 2014). The SWOT analysis (appendix 4) for radiology services was used to analyse both external and internal environments and also to evaluate reasons for patients waiting time. SWOT analysis helps to identify those areas which occur as barriers for forthcoming improvement plans (Krushkal et al., 2011; Phadermrod, et al, 2016), or any barriers come between applying changes to succeed. SWOT allows service to concentrate more on strengths so that will minimize threats and also on opportunities to bring down weaknesses. Conventional process mapping is a dynamic tool which helps in identifying the process of patient journey and delivery of clinical service as per patient’s perception (Phillips & Simmonds, 2013).  This help in identifying effective various ways to eliminate unnecessary steps from the working process, also help in identifying the non-valuable and valuable steps of patient’s journey and lead to the effective use of resources which are available to improve patient care (Trebble, et al, 2010). This process of patient journey include Orthopaedic patients and General Practitioner both are represent by X and Y, process is design to observe and mapped (Figure 1) the flow and quality of service, also to eliminate unwanted steps (appendix ) and to reduce waiting time of patients (NHS improvement, 2017).

These tools will identify the unwanted steps from the arrival of patient at reception to changing for check-up which lead to unproductive managing of patient flow. The reasons behind gaps are uncontrolled patent flow, lack of appropriate x-ray rooms, ineffective workload arrangement and use of paper request cards. But there are staff members who are self-sufficient to provide best care to patients.