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Home > Reports & Publications > Performance audit reports |
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Access to specialist medical outpatient care 1. EXECUTIVE SUMMARY 1.1 Specialist medical outpatient services Hospitals provide outpatient services to non-admitted patients for services that include specialist medical assessment and treatment, consultations before and after admission to hospital, managing chronic conditions and diagnostic tests. Outpatient clinics provide important support and services to both hospital-based inpatients and to community-based, non-admitted patients. Outpatient clinics are an entry point to inpatient care and provide ongoing care to patients after discharge from inpatient care. Outpatient clinics also provide essential specialist diagnosis and treatment to support community-based care. Timely access to outpatient services is important for patient wellbeing and has the potential to affect patient outcomes and demand on other areas of the health system. Promptly diagnosing and treating medical conditions may prevent unnecessary inpatient admissions, reducing demand on health services and associated health care costs. There are both state and Commonwealth funding streams for specialist outpatient care. The Commonwealth funds Victoria, under the Australian Health Care Agreement (AHCA), to provide a range of specialist medical outpatient clinics free of charge to public patients. The Department of Human Services (DHS) distributes these funds to health services under the Victorian Ambulatory Classification System (VACS) or through a non-admitted grant. The Commonwealth also funds specialist medical care where specialists provide care in a private capacity through the Medicare Benefits Schedule (MBS) system. Generally, these private MBS-billed services are not within the scope of this audit. However, there are many MBS-billed clinics located within public hospital outpatient departments. Where health services provided resources to MBS-billed clinics located within hospital outpatient departments, we examined whether the management arrangements provided appropriate safeguards against financial and legal risks. 1.2 Is central planning and management of outpatient services effective? DHS determines funding and target activity levels for outpatient clinics each year as part of the process of setting system-wide health funding priorities. Over the period 2000-01 to 2005-06, outpatient funding for the major health services has increased by 42 per cent. Activity targets have also increased over this period, although not at the same rate (15 per cent). Generally, health services have delivered greater than target levels of activity. Between 2000-01 and 2004-05, VACS-funded health services reported 327 000 patient encounters in addition to their agreed targets. DHS only funds health services for the agreed level of activity, and health services must absorb the costs of any unfunded activity. While DHS has paid significant attention in recent years to developing a comprehensive health planning framework, current statewide planning for outpatient services is significantly weaker than other elements of the framework. The Metropolitan Health Strategy is one of the key strategic service planning documents for health services. While this strategy considers inpatient and emergency department services in detail (including access, usage and demand), it does not contain any analysis of demand, patient demographics or presentation patterns for outpatient services. In 2006, DHS released its Care in your community framework. As ambulatory services, outpatient services fall within this framework. The framework document considers outpatient services, although not in detail. DHS currently collects limited information to inform outpatient planning. It collects activity data (the number of people accessing these services) for VACS-funded patient encounters and non-admitted grant-funded occasions of service. It has also developed a Schedule of Clinics, which details the outpatient services Victoria’s health services provide. However, it contains only VACS-funded outpatient clinics. Outpatient clinics funded through the non-admitted grant and MBS-billed clinics located in health services are not included. This is the extent of data collection by DHS relating to outpatient services. DHS does not collect any performance data. The rudimentary nature of current data collection means that DHS is not able to adequately inform planning, know whether it is meeting its policy objectives or assess how well health services are performing. Considerable work needs to be done to obtain better information on service needs, demand and use for outpatient services. DHS has recently commenced work in a number of areas. The Care in your community framework identifies several key actions in relation to outpatient services, including the review and improvement of outpatient services. In addition, DHS has recently commenced several targeted initiatives to examine outpatient services and provide leadership for health service improvement in this area. These include a Patient Flow Collaborative and an Outpatient Improvement Program. It is too early to tell how effective these initiatives will be in improving statewide planning for outpatient services.
1. DHS should develop a targeted access plan for outpatient services. 2. DHS should collect better information, including: • service profiles, with information on the number and type of non-admitted grant and MBS clinics added to the Schedule of Clinics • outpatient activity, with information on non-admitted grant and MBS clinic activity, that is consistent with VACS reporting • the number of patients receiving inpatient care following assessment or treatment at an outpatient clinic, and the type of inpatient care received • demographic data on outpatient services users • outpatient demand forecasting. 3. DHS should develop a range of benchmarks to measure service delivery performance in outpatient services, including measures of access and timeliness. 4. DHS’ planned review of VACS should ensure that: • the funding model provides adequate incentive and flexibility for health services to consider emerging models of care • the activity target setting process takes into account the number of people waiting for outpatient care and the length of time they have waited. RESPONSE provided by Chief Executive Officer, Bendigo Health Care Group Recommendation 1 Agree. Recommendation 2 Agree. Recommendation 3 Agree. Recommendation 4 Agree. RESPONSE provided by Secretary, Department of Human Services In general, with some exceptions as provided below, the report presents a fair picture of the difficulties and complexities of operating outpatient services, involving more than 2 million medical, allied health and ancillary public occasions of service in Victorian hospitals annually, covering a range of acute and chronic conditions, that may or may not be associated with a hospital admission. The move to shorter lengths of stay in hospitals, more same-day surgery, the shortage of specialist services in some areas and the establishment of demand management programs, especially for elective surgery, has led to increased interest in new models of ambulatory care and better management of outpatient services. The performance audit is timely in that it coincides with several recent initiatives of DHS that focus on outpatient services, and these have been identified in the audit report. A key strength of the Victorian model of human services delivery is that the government sets the broad policy parameters and individual agencies are responsible for managing within the resources provided to deliver services that meet the needs of their local population. In health, this means an emphasis on local clinical and financial decision-making that promotes service planning and service delivery designed to meet the needs of particular groups. Accountability is provided through the Health Services Act 1988. The Act establishes the statutory framework for the governance of public hospitals (including public health services). Boards of health services are appointed by the Governor in Council and are charged with the responsibility for independently overseeing the performance of the hospital. In the case of public health services, the Act also sets out a comprehensive list of the functions of the board and CEO. The Act balances the need to allow boards sufficient discretion to perform their role, with the need to ensure adequate accountability to parliament and government, and contains a variety of tools to achieve this. While welcoming advice provided by the Auditor-General on fine-tuning policy settings, the department is of the view that some of the recommendations envisage prescriptive centralised management of health services that would be cumbersome, inflexible and would not allow the exercise of clinical judgement, innovation and localised expertise in the delivery of health services. Information on waiting times for outpatient appointments have been published in the report at Appendix C that could be misleading, due to the potential lack of data comparability. Recommendation 1 Agree. The development of a targeted access plan, along the lines of the Statewide Elective Surgery Program and the Statewide Emergency Access Program previously developed by DHS will be considered as part of the Outpatient Services Review. The current contacts in DHS for VACS development and service improvement (changes to clinics and funding arrangements etc.) are posted on the Department’s website www.health.vic.gov.au/vacs. This information will be reviewed to ensure comprehensive coverage and clarity. With regard to Figure 3C, the Statewide Planning Framework for ear, nose and throat services has now developed recommendations related to consistent guidelines and practices for accessing public ear, nose and throat outpatient services so that access is equitable, appropriate and based on clinical need. These can be viewed at www.health.vic.gov.au/ent/index.htm. Recommendation 2 Partially agree. DHS has been collecting information on attendances by detailed clinical category from a greater number of health services from July 2005, in compliance with National Minimum Data Set (NMDS) requirements for outpatients. This increased the number of hospitals reporting outpatient attendances consistent with VACS clinical categories from 19 to 29 health service campuses across Victoria. Also in cooperation with the Commonwealth Government, DHS is progressing towards unit-record level data collection of public outpatient services for 95 Victorian health services and public hospitals, for progressive implementation from July 2008. As the clinic schedules currently collected by DHS inform funding distribution for public clinics at VACS-funded health services, the services concerned have an incentive to ensure accuracy. DHS is not convinced of the cost-effectiveness of increasing the reporting burden on hospitals to collect information that will not be required for funding purposes. However, development of a targeted access plan could include the development of key performance measures for which there will be data requirements, and development of a strategic policy framework; both of which will involve obtaining an overview of privately-funded hospital outpatient services, most likely through surveys. The development of unit-record level data containing patient identifiers will enable overview of service provision between inpatient and outpatient care. This will also enable the collection of relevant demographic data on outpatient services users, facilitated by the progressive introduction of HealthSMART into both VACS and non-VACS-funded health services. DHS has undertaken limited outpatient demand forecasting utilising existing VACS data. The introduction of unit-record level data, and periodic surveys of both public and private (MBS-funded) outpatient services will enable more cohesive and comprehensive forecasting for planning purposes. The forecast of outpatient demand data also needs to take into account changing inpatient demand, as this is one key driver (but not the only driver) of outpatient demand. Recommendation 3 Partially agree. Consideration of benchmarks and performance indicators will be possible when unit-record level data are available and will be investigated as part of the Outpatient Services Review. However, DHS considers that a performance indicator targeting access based on need for care will not be introduced easily, given the difficulty of achieving standard definitions for urgency of care. Recommendation 4 Partially agree. Part one of recommendation 4 is a key action of “Care in your community: a planning framework for integrated ambulatory health care”, DHS’ overarching planning framework for ambulatory care, and will be taken up by DHS’ Outpatient Services Review to commence in 2006. The VACS target setting process currently includes review of hospital-provided information on demand for services. Implementation of unit record data collection will inform part of the target setting process by providing standardised data on the number of patients waiting for appointments and information on time waited. However, negotiation of targets involves coming to an understanding of what constitutes appropriate increased demand and what kind of demand needs to be managed by health services. There are many other factors involved in setting targets for individual health services, including community health availability, private specialists’ availability and whether the health service has undertaken any relevant service reviews. RESPONSE provided by Chief Executive Officer, Eastern Health Recommendation 1 Agree. Recommendation 2 Agree. Only non-admitted grant-funded clinics should be added to the Schedule of Clinics. Only outpatient activity for non-admitted grant clinics should be collected in addition to the VACS activity. Recommendation 3 Agree. Recommendation 4 Agree. RESPONSE provided by Chief Executive Officer, St Vincent’s Health We fully support the proposed review of outpatients’ services by DHS and look forward to participating in the patient flow collaborative and outpatient improvement program. St Vincent’s Health is committed to continuing the reforms it commenced in 2004 and 2005. 1.3 Is health service planning and management of outpatient services effective? Health services undertake a range of planning activities, although the extent of planning varied across those that we audited. All 4 health services performed strategic planning in line with the DHS guidance. However, only some health services formally planned for outpatient services operationally. Health services undertook basic forecasting, using their inpatient data to estimate growth in outpatient demand. Health services may decide to open new outpatient clinics to better meet demand for services or to complement inpatient services. Opening new clinics can create additional costs for the health service, through staff wages and also through downstream impacts on other hospital services. Health services varied in their approach to assessing the costs associated with new clinics. The dual funding streams for outpatient clinics (state-funded VACS or MBS-billed clinics by agreement with specialists) create both flexibility and complexity for health services in making decisions about service delivery. Arrangements with specialists to provide MBS-billed clinics can allow health services to facilitate specialist service provision even when VACS funds are not available. However, the decision to provide clinics under VACS or through arrangements for MBS-billed clinics can impact on health service financial performance. Most health services charged MBS-billed clinics fees, although for those that did, the revenue was not always sufficient to cover the cost of the resources (such as physical space, staff, administration costs and consumables). While we accept that at times a decision may be made to provide services at a deficit, this needs to be an informed business decision. Arrangements for MBS-billed clinics also bring legal complexities, which if not fully understood and managed appropriately can place the health service and the state at risk of non-compliance with the Australian Health Care Agreement or the Health Insurance Act 1973. If health services make arrangements to use MBS-billed clinics, they need to ensure that there is clear legal separation between state-funded health service operations and MBS-billed clinics, and that there are effective processes in place to ensure that patient election procedures are followed. In the 4 health services we audited, we found that arrangements for MBS-clinics were not comprehensively documented, and in some health services MBS-billed clinics were operating without agreements at all. Patient election procedures were also often weak. While DHS has previously issued advice to health services on this area, the development of revised guidance, including model agreements, should be a priority.
5. DHS should work closely with hospitals to ensure that: • hospitals are aware of, and comply with, the AHCA and Health Insurance Act requirements as they relate to outpatient services • hospitals have appropriate documentation of private practice and licence agreements for outpatient services • hospitals have appropriate documentation relating to outpatient election processes. 6. DHS should issue guidance to health services on fees for MBS-billed clinics, with consideration for appropriate costs. RESPONSE provided by Chief Executive Officer, Bendigo Health Care Group Recommendation 5 Agree. Recommendation 6 Agree. RESPONSE provided by Secretary, Department of Human Services Recommendation 5 Agree. DHS considers that the issue identified in this audit of inadequate documentation regarding private practice agreements and patient election processes in the health services that were audited is a matter of serious concern. DHS acknowledges that inadequate documentation gives rise to potential risks for health services and for the state, and will continue to work closely with health services to: • ensure that they are aware of the requirements of the Australian Health Care Agreement and the Health Insurance Act 1973 as they relate to outpatient services, noting that DHS has previously advised health services of their Australian Health Care Agreement obligations through hospital circulars 33/2003 of 11 December 2003 and 34/2004 of 24 November 2004 • ensure that all health services have appropriate documentation in place regarding private practice arrangements and, where appropriate, patient election processes relevant to outpatient services. Recommendation 6 Partially agree. Arrangements are between individual health services and private practitioners and these vary across health services, and it is not practicable to provide a template for fees and cost recovery. DHS will work closely with hospitals to ensure that they have written agreements in place with private practitioners relating to the use of hospital facilities and services. RESPONSE provided by Chief Executive Officer, St Vincent’s Health The lack of comprehensive documentation in regard to the “MBS clinics” does not necessarily imply that health services are not appropriately managing risks of potential non-compliance with the ACHA or the Health Insurance Act. St Vincent’s Health is committed to improving its documentation and is progressing the implementation of its comprehensive private practice agreements (as endorsed by DHS) and policy processes in keeping with its legal obligations. RESPONSE provided by Chief Executive Officer, Eastern Health At the outset, Eastern Health believes that the report is generally fair and balanced with respect to its discussion and recommendations regarding: • data collection • planning • funding mechanisms. Eastern Health agrees with all but 2 of the recommendations. However, Eastern Health does not agree that the report’s analysis and recommendations regarding the attendance of patients at private practitioners located on public hospital premises are fair, balanced or accurate. Moreover, the recommendations on this issue contain an inherent contradiction. On one hand, the report recommends more control and management of “MBS-billed clinics” and on the other, it recommends more separation of public hospitals and private clinics. The 2 recommendations are contradictory. This contradiction stems, in our view, from a presumption that there is a difference between the patients attending private practitioners located in rooms at public hospitals and the patients attending private practitioners located in premises outside public hospitals. This misunderstanding is best demonstrated in Figure 2C. This Figure suggests that there are 4 types of patients of which 3 receive “free” services. However, in fact, there are only 2 kinds of patients: public VACS/non-admitted grant patients who receive “free” services”; and patients attending a private practitioner whose treatment is paid for, or reimbursed to the patient, by Medicare. The latter is not “free” wherever it is located. The Australian Health Care Agreement itself states that a patient receiving services from a medical specialist exercising a right of private practice or having a contract with a public hospital is not a patient of a public hospital. A medical practitioner may bill a patient direct or “bulk bill” Medicare. This arrangement does not make the service “free” and neither does it make the attending patients “public”. A public hospital service, by comparison, is “free” because there is no specific charge for it and the patient is not required to pay either the public hospital or the medical practitioner. Second, the report argues that election processes which apply to admitted inpatients under the agreement also apply to private outpatients. However, the agreement itself does not refer to an election process for anyone other than admitted inpatients. As noted above, the agreement states that a patient receiving services from a private practitioner exercising a right of private practice or having a contract with a public hospital is not a patient of that public hospital. As a result, the report’s suggestion that there is a risk of a perception that public hospitals with private clinics without election processes or private practice agreements do not fully comply with the Australian Healthcare agreement or the Health Insurance Act 1973 is, in our view, unwarranted. Recommendation 5 Partially agree. Disagree that an election process is required. Recommendation 6 Disagree. There is no need for DHS to issue guidelines, as these arrangements do not relate to public patients. Further comment by the Auditor-General I disagree that there is an inherent contradiction in recommendations 4 and 5. The report does not recommend there be more “control and management”. It notes, based on legal advice from the Victorian Government Solicitor’s Office, what actions a health service should take to ensure there is adequate separation of private clinics that are commonly located in outpatient departments. What the report does recommend is that health services have the appropriate documentation to clearly demonstrate that these private clinics, because of their location in outpatient departments, are not services provided by, or on behalf of, the health service. Figure 2C reflects the observations and findings made by my staff. While some private practitioners lease “rooms” within the hospital and are therefore quite distinct from the services the hospital provides, in many instances private clinics were located within the outpatient department. To the patient attending at the outpatient clinic, there is no discernable difference between the public and private clinics. This is what Figure 2C demonstrates. The statement within the Australian Health Care Agreement, that a patient receiving services from a medical specialist , exercising a right of private practice or having a contract with a public hospital, is not a patient of a public hospital, is included as a note to the definition of “private patient”. We sought advice from the Victorian Government Solicitor’s Office on this definition note. The advice stated that for a patient not to be a patient of a public hospital in these circumstances, the patient must elect to be treated as a private patient. Clause 41(b) of the Australian Health Care Agreement is very similar to the private patient definition note. It states: “An eligible patient presenting at a public hospital outpatient department will be treated free of charge as a public patient unless: (b) the patient has been referred to a named medical specialist who is exercising a right of private practice and the patient chooses to be treated as a private patient”. Two elements must therefore be satisfied before the patient is not a patient of the hospital: • the named specialist must be exercising a right of private practice. In the majority of cases, private clinics were run by doctors contracted to the health service. This relationship was neither employment or governed by a visiting medical officer agreement. • The patient must choose to be treated as a private patient. This is what the advice from the Victorian Government Solicitor’s Office stated. To choose is undoubtedly the same as electing. While the Australian Health Care Agreement does not describe an election process (and neither do I recommend an election process), the agreement does state the need for election. 1.4 Are health services managing outpatient appointments effectively? There is currently little publicly available data that measures access to outpatient services, and no common methodology for measuring the time that patients wait for appointments. We surveyed major health services to establish how long patients wait for a first appointment for 6 high-volume outpatient specialties. Across all surveyed hospitals, the median time to first appointment for patients classified as “urgent” was between 5-9 days across the 6 specialties. Times ranged from zero to 41 days for urgent appointments. The median time to first appointment for patients classified as “semi-urgent” was between 14 and 34 days across the 6 specialties. Times ranged from zero to 182 days. The median time to first appointment for patients classified as “non-urgent” (or “routine”) was between 15 and 165 days across the 6 specialties. Times ranged from zero to 912 days. While health services advise that they can generally facilitate appointments for the most urgent patients reasonably quickly (usually by overbooking), patients classified as “non-urgent” may have significant waits for an appointment. The possible length of wait means that it is crucial that general practitioners and health service staff have a shared understanding of ratings of urgency. Effective prioritisation of patients needs to ensure that patients are seen according to their clinical urgency, and not simply in the order they were referred. While some health services had developed internal prioritisation guidelines to assist staff undertaking this process, each of the 4 health services prioritised patients differently. The inconsistent approach creates the potential for patients with the same condition to wait different times for their first appointment. The information technology systems in place to manage bookings of patients waiting for outpatient appointments limit the capacity of health services to track referrals, prepare reports or do any analysis of bookings. Some electronic booking systems do not have the capacity to manage long waits, and secondary waiting lists need to be created. DHS plans to address many of the IT issues with the implementation of HealthSMART. However effective the technology for managing outpatient waiting lists becomes, problems will remain in ensuring the accuracy of lists if current practices for managing outpatient waiting lists in health services do not improve. Outpatient waiting lists are currently not always accurate. Patients who have been on the lists for a long time may no longer need their appointment, either because their medical condition has changed or because they have been treated elsewhere. Auditing waiting lists can identify patients who no longer need their appointment, potentially reducing the number of patients who “fail-to-attend” and freeing-up appointments for other patients. Only limited (often targeted) auditing of outpatient waiting lists occurred at each of the 4 health services we visited, with many not regarding the benefits of freeing-up appointments and reducing “fail-to-attends” as a worthwhile investment. Auditing waiting lists can be an intensive exercise, and with limited resources, health services often have to give priority to other aspects of outpatient service delivery.
7. DHS should develop guidelines for referral policies and procedures. 8. To aid in clinical assessment, DHS should develop recommended clinical prioritisation protocols and clinical categories of urgency, with recommended performance standards for each category. 9. DHS should take action to develop and report measures of access (waiting times) for outpatient services. 10. All health services should progress to electronic booking systems. RESPONSE provided by Chief Executive Officer, Bendigo Health Care Group Recommendation 7 Agree . Recommendation 8 Agree. Recommendation 9 Agree. Recommendation 10 Agree. RESPONSE provided by Secretary, Department of Human Services Recommendation 7 Agree. DHS has developed a standard GP referral form that meets international standards and has been taken up by some GPs and health services. The methodology used in the Patient Flow Collaborative allows individual sites to identify the problems or blockages that are specific to their health service. The Patient Flow Collaborative - Outpatients will utilise this methodology so that health services can design solutions that fit with their circumstances. Further, data definitions developed in the outpatient NMDS process will provide national guidelines for processing referrals to assist with achieving national data consistency. Recommendation 8 Partially agree. Clinical prioritisation protocols will be considered as part of the Patient Flow Collaborative - Outpatients. Clinical categories of urgency are appropriate for managing emergency demand, where the majority of clinical categories of urgency are based on the length of time that can elapse without treatment before a patient’s condition becomes life threatening or deteriorates significantly, and for managing access to elective surgery once a patient has been assessed by a specialist. However, the development of clinical categories of urgency for outpatient appointments involves more subjective criteria, which are more difficult to codify and monitor. DHS is aware that categorisation of urgency guidelines have been developed in the United Kingdom and New Zealand as aids to assessment, rather than replacement for individual clinical judgement. These are not internationally recognised standards but may be useful tools for guiding individual clinical decisions. DHS will continue to monitor and evaluate these developments, but until international standards are available, it would be more appropriate to continue to enable individual clinicians to make clinical decisions at the local level about urgency and treatment time in the context of their assessment of the individual patient. Recommendation 9 Agree. DHS is examining the capability of current hospital systems to collect unit-record level data, including waiting times. Data definitions that have been agreed nationally are essential to the uniform treatment and classification of the waiting period. The current Australian Health Care Agreement between the Commonwealth and Victoria requires both parties to work together to develop performance indicators, including waiting times, for access to services for admitted and non-admitted patient services. Recommendation 10 Agree. DHS’ HealthSMART strategy is making a significant investment in upgrading hospital IT infrastructure and, progressively from 2008, will provide additional capacity for bookings to be performed electronically and for standardised referral forms to be lodged electronically. RESPONSE provided by Chief Executive Officer, Eastern Health Recommendation 7 Agree. Recommendation 8 Agree. Recommendation 9 Agree. Recommendation 10 Agree. RESPONSE provided by Chief Executive Officer, Northern Health Recommendation 10 Agree. RESPONSE provided by Chief Executive Officer, St Vincent’s Health It is our view that the data collection tool utilised by the Victorian Auditor-General’s Office does not adequately reflect the activities of outpatient services. The exclusion of over-bookings from the data misrepresents how “urgent” and “semi-urgent” patients are managed and does not reflect the length of time in which “urgent” and “semi-urgent” patients are seen (from the date of referral). While St Vincent’s has taken considerable steps to reduce over-bookings, due to 3 weeks of low activity during the Christmas period, demand was underestimated and over-bookings had to be made. 1.5 Are health services optimising the productive use of outpatient resources? If demand for outpatient services is greater than available capacity, then patients will have to wait to see a specialist. However, lack of capacity is not the only factor that can cause waiting times to grow. Even if average capacity matches average demand, a mismatch between daily demand and daily capacity can cause queues. Understanding variations in demand and capacity and better matching them can lead to shorter waiting times for patients and more efficient use of resources. All 4 health services we audited used clinic schedules to manage capacity. Clinic schedules were generally set by the specialist in charge of the clinic with limited input from health service management to monitor patient throughput, fairness in specialist workload or the match of capacity to demand. All health services used overbooking of "full" outpatient clinics to see patients at short notice. While this action provided increased flexibility, it can also lead to greater waiting times for those attending the clinic or a clinic running over time as the specialist has to see more patients. Some health services also reserved spaces for urgent patients, reducing the need to overbook clinics. This system was most effective, however, if the reserved spots were allocated to other patients if not filled before the clinic. At the 2 health services that reserved appointments, practices varied. Many booked patients at outpatient clinics “fail-to-attend” their appointments, with rates of non-attendance at some clinics ranging from 5 per cent to 30 per cent of booked patients. Patients waiting for a first appointment are more likely not to attend than review patients. Non-attendance can mean underutilised capacity and health services commonly compensated for anticipated non-attendance by over-booking clinics. However, the administrative costs (such as the cost of retrieving medical records) for each patient that “fails-to-attend” can be significant, and these costs are not recoverable. All health services had strategies to manage “fail-to-attend” patients, although the extent of these strategies varied. However, strategies were developed without formally investigating the reasons for non-attendance and none had formally assessed the effectiveness of the strategies they had put in place. Health service cancellation of outpatient clinics is a common occurrence and is most often caused by specialist unavailability. While unplanned absences are often unavoidable, planned absences at short notice are problematic. All health services had polices requiring specific periods of notice for planned leave. However, compliance with these policies by many specialists was poor, and not enforced by hospital management. At all the health services we audited, access to diagnostic services was timely. However, for most health services, strategies to ensure that patients had undergone their diagnostic tests before their appointment were limited and inconsistent. This can often mean that the patient needs to be re-appointed purely because full information was not available at the time of the appointment. Ensuring that the medical record is complete, contains the relevant test results and is available at the time of the appointment is also essential to preventing unnecessary re-appointment. Most health services reported that medical record transfer and preparation was not as good as it could be. Medical records were often transferred to the outpatient department on the day the clinic ran, providing inadequate time for clinical staff to review the files. With high demand for outpatient appointments and specialists’ time, it is essential that patients are only brought back for review of their medical condition if it is clinically necessary. In a number of specialties we examined, up to 80 per cent of patients seen in outpatient clinics were there for review visits. While the decision to discharge a patient at the end of their outpatient treatment is ultimately one for the specialist, little work had occurred at most of the health services in reviewing rates of discharge and re-appointment and developing guidance on discharge. The approach to discharge from outpatient clinics was generally less active than it typically is in inpatient wards. Most health services were conscious of the issues identified above, but reported that they were too busy to formally review or evaluate outpatient clinic practices. Practice change tended to be incremental and ad-hoc and depending upon the nature of the change, was reliant on specialist support. One health service we examined had received funding to systematically review and improve clinic practices. The health service reported that having the assistance and capacity to address outpatient clinic practices as a project had been a key success factor in implementing improvement.
11. Health services should review their clinic schedules to ensure they: • reflect specialist attendance time at clinics • address variation in new and review patient quotas for specialists working in the same specialty • factor in teaching time • optimise the sequence of new and review patients. 12. Health services and DHS should review “fail-to-attend” patients, including: • investigating the reasons why patients “fail-to-attend” • performing a cost analysis of “fail-to-attend” patients • developing strategies to reduce the rate of “fail-to-attend” patients • collecting and monitoring “fail-to-attend” data. 13. To improve the operations of outpatient clinics, health services should: • ensure effective discharge strategies are in place in outpatient clinics, and monitor discharge rates • implement strategies to ensure regular review of outpatient clinic practices • take steps to ensure that all necessary tests are completed before the patient attends for their appointment • put systems in place to ensure that medical records are available at the time of the clinic and that all relevant documentation is included • develop internal guidelines to better manage clinic overbookings. RESPONSE provided by Chief Executive Officer, Bendigo Health Care Group Recommendation 11 Agree. Recommendation 12 Agree. Recommendation 13 Agree. RESPONSE provided by Secretary, Department of Human Services Recommendation 12 Partially agree. Rather than manage the issue of ”fails-to-attend” centrally, DHS considers it more appropriate and cost-effective for individual hospitals to develop and monitor strategies to reduce “fails-to-attend”, tailored to their individual circumstances. DHS is prepared to consider providing guidance to health services on auditing waiting lists. RESPONSE provided by Chief Executive Officer, Eastern Health Recommendation 11 Agree. Recommendation 12 Agree. Investigating the reasons why patients “fail-to-attend” is very labour intensive and not covered in the VACS model. Specific enhancement funding is required to develop strategies to reduce the rate of patients “failing-to-attend”, given the legacy of IT systems in place. Recommendation 13 Agree . There is a need to bolster GP liaison to ensure that all necessary tests are completed before the patient attends for an appointment. RESPONSE provided by Chief Executive Officer, Northern Health Recommendation 11 Agree. Recommendation 12 Agree. Recommendation 13 Agree. RESPONSE provided by Chief Executive Officer, St Vincent’s Health Improving access for surgical outpatients cannot be achieved until the surgical waiting list key performance indicators are reviewed. Recommendation 11, referring to the optimisation of “new” and “review” patients, is unrealistic in relation to key performance indicators which require hospitals to meet total waiting list targets. An increase in new outpatients causes an increase in referrals to the elective surgery waiting list (due to the high proportion of new patients requiring surgical intervention), which reduces the ability to meet waiting list targets. St Vincent’s would welcome the opportunity to increase the number of new patients seen within our surgical clinics, however, this would require increased WIES to fund the resulting increase in surgical activity as well as revised key performance indicators which measure the flow of patients through the health service. |
Recommendations