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Evaluating the impact of integrated change initiatives on wait time for outpatient primary care physiotherapy service

Authors:John Nwobo

Abstract Introduction: Widespread public demand for improved access, political pressure for shorter wait times, a stretched workforce challenge healthcare leaders to adopt new management approaches1. The healthcare service used to implement this initiative is a community-based primary care physiotherapy service providing care to a population of 118,542 (2011 census). In 2015, the physiotherapy service had a 29.3% increase in demand over 2013 level leading to 990 patients on the waiting list and the number of patients waiting longer than 12 weeks for the first appointment increasing to 45%, and the average wait time at 53 weeks and longest wait time at 78 weeks. There was no addition to the staffing resources to cope with this increased demand.A. Cause & Effect Analysis of the problem highlighted the constraints to patient flow identified the key stakeholders whose actions or inactions contributed to the problem.a. Management/LeadershipNeed to:i. Clarify vision for the serviceii. Link service delivery to organisational goalsiii. Develop mechanism to evaluate performanceiv. Acknowledge high performanceb. Organisational Structuresi. Structural Issues- Infrastructural deficiencies (clinic space, IT, equipment etc)- Staffing deficit- Inadequate service delivery modelii. Process Issues- Poorly optimised work systems- Poorly established links with community groups / local authoritiesc. Staffi. Cultural Issues- ‘Cherry-picking’ of patients on the waiting list- Traditional 1-to-1 service delivery model- Underbooking of appointmentsd. Referrersi. Appropriateness of referrals & data qualityii. Poor communication linkse. Patienti. Non-attendance at appointmentsii. Changing patient profileiii. Changing patient expectations of the servicef. Unique Demographic Factorsi. Extensive geographical areaii. No acute hospital outpatient supportiii. High comparative deprivation indexiv. Increased service demand Short description of practice change implemented:The initiatives implemented include:i. Negotiated and increased staff performance targets for new patient appointments from 1.2 per staff day present in 2013 to 1.7 in 2016ii. Developed and implemented Group Physiotherapy Service targeted at patient groups with similar diagnosis or referral reasoniii. Streamlined and optimised clerical support role to physiotherapy serviceiv. Optimised time spent by physiotherapists on patient contacts and documentationv. Introduced text message reminder for follow-up patient appointmentsvi. Engaged with referrers on appropriateness of referralsHSE Change Model and IHI Model for Improvement (PDSA Cycle) were used to implement the initiativesAim & Theory of Change: The objectives of the initiatives implemented are by the end of December 2016:(1) Reduce the percentage of patient waiting over 12 weeks to 35% and the longest wait time for physiotherapy appointment to 39 weeks(2) Evaluate staff effectiveness and efficiency(3) Evaluate patient satisfaction with the service(4) Evaluate impact on organisational goalsThe Psychology Theory of Behavioural Change and the Organisational Development Theory of Constraints underpinned the implementation of the change initiatives. Targeted Population & Stakeholders: The targeted population is as described in the Introduction above:Stakeholders include:a. Management/Leadershipb. Staff (Physiotherapy, Clerical, MDT)c. Referral Sources (GPs, Consultants, PHNs, HSCPs etc)d. Patiente. Local AuthoritiesTimeline: The implementation of the change initiatives first began in July 2014 and have continued into 2016 with more initiatives introduced as the PDSA cycle was used to test and re-test the changes. Data monitoring and analysis started in Jan 2015Highlights (innovation, impact & outcome): The data for quantitative and qualitative outcomes were obtained from: (a) Staff Monthly Metrics Return; (b) Review of staff attendance and WTE and time allocation for patient contact and (c) Evaluation of feedback questionnaires.As a result of the above change actions and initiatives:By the end of 2016:1. We had optimized the clinic hours’ utilization rate for patient contact by 17.6% since 2013 (from 64.2% to 81.8%)2. New patient appointments had increased by 53.1% above 2013 level (2804 appts in 2013 and 4293 appts in 2016), and 7.6% more than expected target for 20163. Patients waiting over 12 weeks for appointment had reduced marginally from a peak of 45% to 42%4. The longest waiting time had reduced significantly to 38 weeks from 78 weeks.5. 2016 Patient Experience Survey of 105 patients who responded showed that:a. 90.5% of the patients reported that the service met their need and expectationb. 96% of the patients were satisfied with the service. Even though 42% of them remained dis-satisfied with wait time, it still represented a 20% improvement over 2015 evaluation.Comments on Sustainability: The initiatives have been integrated into our work processes and staff performance reviewComments on Transferability: The learning and outcomes from the initiatives have been shared with other physiotherapy managers in the area who have adopted them in their locationsConclusions, Discussions & Lessons Learned: The outcome of these initiatives indicate that extended wait times are not always due to demand, but may be attributable to capacity under-utilization. The implementation of the initiatives, particularly the Group Physiotherapy Service has the potential to develop into a service delivery model with the capacity to facilitate the delivery and attainment of key organisational service goals in the areas of integrated care. The outcomes indicate that the change initiatives require sustained action and continued monitoring.Reference:1. Patrick, J., & Puterman, M. L. Reducing Wait Times through Operations Research: Optimizing the Use of Surge Capacity. Healthcare Policy, 2008;3(3):75–88.


physiotherapy, primary care, wait times, management theories, change initiatives

How to Cite:

Nwobo J. Evaluating the impact of integrated change initiatives on wait time for outpatient primary care physiotherapy service. International Journal of Integrated Care. 2017;17(5):A111.

DOI: on 17th October 2017