Transforming Outpatient Services: Patient Reminder Services Change Package

Aim, vision and making it happen

Transforming Outpatient Services is aimed at supporting NHS Boards and local partnerships to move care closer to home and enable more people to receive the right care, from the right person, at the right time, in the right place.

It supports teams working together with patients and the public to understand and diagnose system issues, design and innovate and use continuous improvement to deliver high quality person centred care and best value for money.

Healthcare teams, working with patients and public representatives, have developed Towards Our 2020 Vision a picture of how the services that we currently call outpatient services will need to change for patients and staff as we move towards 2020. (Towards Our 2020 Vision is available in poster format from QuEST.)

Now all NHS Boards working with partners are beginning to take the strategic actions necessary to create the contextual, cultural and leadership conditions to enable staff, practitioners and patients to achieve their 2020 vision. Some Boards have already formalised outpatient transformation as a strategic priority. In other Boards specialties, or teams are undertaking improvement led by enthusiastic service managers, or clinicians who may or may not have been given support and resource.

Four NHS Boards have been commissioned (2012-2014) to use three different improvement methodologies: invention and innovation through technology, benchmarking to improve utilisation of appointment resources and clinic space, and rapidly testing changes and contributing to change packages that help spread reliable improvements.

During year 2013/14 Chief Executives of all NHS Boards agreed to support rapid adoption and spread of five evidence based, high impact change concepts. Adopting and spreading systematic use of reliable patient reminder services is one of these. (See the Transforming Outpatient Services Driver Diagram.)

Are we making the right changes?

The rationale for providing reminder services is that more people will arrive for their planned appointment and where appointments need to be cancelled the appointments are made available for other people to use. There are many reasons that contribute to people not attending outpatient appointments. Deprivation, age and clinical specialty are factors. People may feel that their condition has improved, or do not receive the right information. More efficient use can be made of available resources. The average cost of a traditional outpatient appointment in 2013/14 is £115.

What's the purpose of the change package?

The change package describes in detail the steps needed and how to plan for, how to adopt, how to implement and how to monitor effectiveness of patient reminder services. It includes evidence base, resources, information and contacts for teams to use.

The package is the result of webex and face to face learning sessions and workshops (from April to September 2013) involving people who have day to day responsibility for managing and providing safe, effective and person centred appointment booking processes and colleagues in NHS Special Boards.

How do we use the change package?

1. Familiarise yourself with change package, sustainability guidance, resources & experiential learning from other Boards

2. Form a multidisciplinary project team with enough autonomy to implement change: ensure public and senior management buy-in

3. Assess readiness & understand current state: apply the principles of improvement methodologies (e.g. DCAQ, process map)

4. Identify changes you will make: consider the factors that first need to be addressed to help build sustainable change

5. Implement your changes: apply the principles of improvement methodologies (e.g. PDSA cycles)

6. Maintain your improvement: evaluate, sustain, modify (as required) and spread

Spread and sustainability

The concept of providing patient reminder services incorporating telephony and digital systems has moved beyond the innovation phase. Prototype services and systems have been tested in a range of Boards, sites and specialties and some spread has taken place. This has enabled us to amass evidence and information about creating the right conditions including leadership for change, intended and unintended consequences, costs and benefits and factors affecting reliability. This change package will guide teams through the decision to adopt and implementation phases. Sustainability although depicted as the final stage of the framework below should be planned for from the very early stages.

(Health Improvement Scotland Spread and Sustainability Framework)

The usefulness of this change package has been tested. However, we aim for it to be a live document that incorporates new findings and examples from research and experience as knowledge develops.
Any feedback is very welcome. Please contact gillian.borthwick@scotland.gsi.gov.uk

Change Concept	Change Package	Essential Resources
Reduced DNAs by utilising reminder systems (PRS) Outcome: 2016: Reduction in DNAs to 7% (Represents achievement of 2013 upper quartile). 2016: Review and reset See the Transforming Outpatient Services Measurement Plan for definitions and more detail. Rationale: Provide safe, effective and person centred appointment booking Improve patient flow and capacity management Optimise utilisation of clinic resources and maximise opportunity of filling cancelled slots Evidence: There are many reasons that contribute to people not attending outpatient appointments. Deprivation, age and clinical specialty are factors. People may feel that their condition has improved, or do not receive the right information. Non-attendance at clinics can cause system inefficiencies, as teams tend to respond by overbooking. This can lead to bottle necks in the system. Several methods aimed at increasing the number of people who attend a planned appointment have been researched. These include text, telephone, email and letter reminders. Research demonstrates that these approaches decrease the number of 'failed to attends'. For example, reductions of 29-39% from the baseline DNA rate. NHS 24 provides evidence of reduction in DNA rates associated with use of their propensity model and focussed reminder services for those most likely to fail to attend. Success of the reminder service has been shown to be linked with the appointment booking and confirmation processes being used. PRS Evidence Healthcare Improvement Scotland literature reviews: HIS Improving Outpatient Services Literature Review HIS Outpatient Bibliography HIS Outpatient Services UK Literature Review HIS Outpatient Services Literature Review Summary	Communication and engagement Form multidisciplinary PRS project team Engage specialty teams Engage senior management colleagues Engage public and local communities Engage primary care colleagues Develop communication plan Identify and agree key benefits and messages (patient experience, quality, clinic utilisation, waiting times, financial etc.) Implement publicity campaign (pre and post-implementation of service) Review / assess patient and service user views on PRS Develop spread strategy and plan	Local media (press & radio) Signs /posters/leaflets/ stickers for: NHS Board Outpatient Departments GP surgeries Patient letters NHS Borders PRS Borders Press Release IHI spread and sustainability web page IHI Spread and Sustainability How To Guide HIS spread and sustainability web page HIS Spread and Sustainability Guide NHS Institute Sustainability Guide QuEST Spread of Innovations QuEST Spread Action Plan Template QuEST Innovation Reflection Checklist QuEST Developing a Communication Plan QuEST Reflection on Innovation Rights & responsibilities legislation National Access Policy NHSScotland "your health your rights"
	Capture and communicate current demographics, additional needs and preferred mode of communication Verify and update patient demographics, contact details and additional needs at every consultation (GP and Clinic). Ascertain and record patients' preferred mode of communication (letter/email/ landline/mobile phone/SMS). Provide patient information in primary, community and acute settings about the local referral process, what to expect and use of reminder services Include a conversation with the patient about his/her rights and responsibilities as part of every referral Create operational linkages between GP Practice Systems and Patient Administration Systems to support regular updating of demographics, additional needs and communication preferences Put in place a reliable mechanism for patients to update contact information
	Design Patient Reminder Service and select system provider(s) Use propensity software (or other similar tool) to identify groups least likely to attend / identify most effective mode of communication and focus efforts where results are most achievable Consider additional software packages, e.g. queue management systems Select provider(s) to meet the needs of identified groups; review patient groups/ DNA risk factors and consider blend of methods to maximise impact (method, sequence, frequency of contacts) Undertake equalities impact assessment Risk assess data sharing, governance arrangements and patient consent to ensure the provision of a person centred service Agree provider Service Level Agreements (SLAs) including agreed key performance indicators (KPIs) Script calls to ensure quality assurance and confidentiality are maintained. Consider requirement to record calls in order to ensure appropriate governance and support staff training Implement reliable mechanism to ensure that patients are directed smoothly to the correct pathway, e.g. feedback loop to bookings office Identify and implement reliable mechanism to enable patients to cancel/rebook Undertake best value assessment of services provided. Review performance and improvement and select to maximise return on investment. Enlist procurement and health economist support. * Ref: NHS 24	Factors to Consider when choosing provider(s) (Chronos 360, Netcall and NHS 24) Data Utilising propensity software (NHS 24) Ability to data cleanse / amend contact details Capable of integrating with local PAS system Reliable mechanism to extract PAS appointment/ patient contact data Reliable mechanism to enter PRS completed data to PAS system, including updated phone numbers Reliable mechanism to identify patients requiring to rebook Method of contact (Methods (channels) can be stand alone or blended) Automated Voice messages Email SMS Agent calls Blend agent calls and SMS Fully automated or blended service of automation. SMS agent calls. This could be a blend of providers Best value assessment Economic evaluation of propensity model. (to follow) Contact logistics Timescale of contact prior to appointment to maximise opportunity of cancelled slots and to ensure provision of reasonable offers Escalation process (sequence of contact methods) Use of landline and mobile numbers Optimise call times/frequency and time lapse between of contact attempts to maximise contact rates Local caller display number visible to patients Loopback via 1471 dials to NHS booking office for confirmation/reschedule/cancellation of appointment (liaise with telecoms provider and PRS provider) Cancellation / rebooking Mechanism to transfer call to board/rebook if unable to attend Mechanism to alert Board of cancelled slots Consider how do you want patients to communicate with you Interactive - as part of the call Text/email you back Provision of an appointment number If reminders outside normal working hours ensure mechanism for patient to rebook Management reports Content, quality and frequency of reports Overall summary data Invalid entries on import Call Statistics, e.g. length of call and number of attempts Time of day when calls are made What happened during the call, i.e. call outcome Results of campaigns Impact of PRS on clinic utilisation Useful contacts / resources: Health Scotland Caldicott Guardian Scottish Guidance NHS Inform HRIS NHS Inform QuEST NHS 24 NHS NSS - national procurement Board Status and Contacts Local EQIA assessor
	Implement Patient Reminder Service Undertake baseline measurement Consider phased implementation, by specialty/ sub-specialty, clinical condition or location Identify high volume DNA services / specialties for initial roll-out Ensure appropriate clinic templates are scheduled and available to book Identify services / specialties for exclusion (e.g. Sexual Health, patients due to attend for termination of pregnancy) Design robust evaluation framework for proposed method(s) PDSA and measurement for improvement to test changes	PRS project team (Including project manager, systems manager, clinical team, medical records / booking, eHealth, Information Services, public representative) Business process to support data transfer, and appointment booking flow Collect baseline data and work with Information Services support to agree measurement for improvement and evaluation methodology QuEST PDSA Template
	Review demand and capacity management at the start and on an on-going basis Plan for additional attendance through reduced cancellation / DNAs On-going use of local data Review available capacity on day-to-day basis to account for additional attendance and reduced cancellation of appointments
	On-going communication and review Implement post-implementation publicity campaign Review / assess patient and service user views on PRS Share learning with other teams and Boards	Post-implementation publicity suggestions: Number of appointment opportunities that have been created for patients and the equivalent cost, or cost of missed appointments Examples of health benefits for patients of being treated on time The responsibilities of the patient in achieving all of the above