Cork University Hospital (the Hospital) is the referral centre for all Orthopaedic trauma for a population of c. 500,000 in the catchment area served by the hospital in the south of Ireland. Rehabilitation services for this cohort of patients are provided in the Hospital initially and subsequently in one of two other hospitals in Cork city. This dependence on other hospitals to accept referrals without having a “non-refusal” policy in place leads to delays in patients transferring from the Hospital for on-going rehabilitation services, thereby increasing inefficiencies in the patient pathway.
The Hospital is constantly challenged to improve flow for all emergency patients of which c. 20,000 require admission each year. Delays in flow result in patients on trolleys in the Emergency Department which is not an acceptable situation.
Earlier this year (2017) a Lean review was undertaken into the patient pathway for Orthopaedic trauma patients in the Hospital that identified inter alia opportunities for service efficiencies:
- Significant opportunities to improve scheduling of theatre cases for this cohort of patients;
- Processes that could substantially save bed days in the Hospital;
- Potential for reduction in cancellation of theatre cases that cause reputational damage to the Hospital;
- Capacity for reduction in the variation in lengths of stay between Orthopaedic surgeons;
- Potential for improvements in the streamlining of patients for rehabilitation services.
The outcome of the Lean review and recommendations for improvements were presented to the Orthopaedic Department in recent weeks and was not met with an acceptance that there are opportunities for improvement in process, rather the focus was on the accuracy of the data and the need for improved IT processes for theatre planning and the need for all Orthopaedic patients to be cohorted in a single area.
The challenge for hospital leadership in implementing these recommendations are significant because leadership of the Orthopaedic service does not accept that there is validity in the outcome of the Lean review or that there is a need for fundamental changes in the delivery of the service in the Hospital. It should be noted that in the Irish health system each individual consultant holds a personal contract with the employer which conveys on him / her clinical autonomy to practice autonomously. Notwithstanding this there is a substantial dividend to be obtained in reduced lengths of stay for Orthopaedic trauma patients in the Hospital and the issues raised must be addressed.
This experience (and others encountered in other services) highlights the challenge in translating recommendations from Lean reviews into changes in individual or team practice and suggests that representatives from the Department whose practices are being reviewed should be represented on the Lean review group.