Streamlining the patient journey in musculoskeletal medicine

Abstract

Introduction: Orthopaedic ICATS was established in the NHS in Northern Ireland in 2006. The founding principle of this service was to provide specialist musculoskeletal assessment and triage for patients whose musculoskeletal complaints had not resolved with GP, physiotherapy or podiatry care. The service forms part of the pathway for referral to Orthopaedic Surgery. An element of its remit involves appropriate investigation prior to surgical consultation and provision of treatment to ensure optimum conservative management has been achieved. When surgery is not advocated, Orthopaedic ICATS manages these patients by signposting them to the most appropriate service which can better address their condition. As a result direct referrals are made to pain clinics, neurology, neurosurgery, core physiotherapy and podiatry services. Problem statement, Targeted population/stakeholders: The musculoskeletal patient journey can be a complicated one. Patients may require input from a number of services in order to resolve their complaint. Previously Physiotherapists and Podiatrists, who recognised the need for further management in their patients, had to refer back to a GP in order to initiate a referral to Orthopaedic ICATS. This process significantly increased the patients waiting time for essential assessment and treatment. The backward step to GP did not easily facilitate good transmission of patient assessment and management data to the ICATS team, often useful clinical information may have been lost in the indirect handover. In addition it added to the burden for already stretched GP services. Aim and Theory of Change: The aim behind the changes in the Southern Trust was to clarify the roles and remits of all stakeholders and to streamline the patient journey by establishing a direct referral pathway thus removing the need for core Physiotherapists and Podiatrists to refer back to the GP in order to gain access to ICATS for their patients. The theory underpinning the concept was that the patient should get the right treatment from the right clinician at the right time. This small practice change had wider financial implications in terms of cost saving by reducing unnecessary appointments. Timeline: The ICATS team started working in conjunction with the team leads in Core Podiatry and Physiotherapy to establish a pathway for direct transfer of patients from their initial musculoskeletal management in physiotherapy and podiatry to Orthopaedic ICATS. The system was implemented initially with defining roles and responsibilities and then producing clear guidelines to aid staff in deciding appropriate patients to refer. Highlights innovation, impact and Outcomes: The system is simple but it opens a pathway which for many years was unnecessarily complicated. It improves dialogue between services and therefore enhances overall management. Closer collaboration between services, with the patient experience as its focus, will ensure innovative service improvement. With the negative publicity that waiting times attract, speeding up the patient journey is a welcomed improvement. Sustainability and Transferability: The system has been in operation in physiotherapy for a number of years, all referrals are triaged in the ICATS service and with the guidance in place referrals have been appropriate. The system has more recently opened up for the referral of musculoskeletal podiatry patients and has been welcomed trust wide as a means of optimising patient flow. The initiative has also been taken up and is gradually being implemented in other ICATS services throughout the region. Conclusion, Discussions, Lessons learned: Streamlining a referral pathway can be viewed as a small change, but this simple step has had a major impact on patient flow and reduced waiting times. It has wider reaching implications helping reduce burdens on GP time. Staff also reap benefits as the new referral pathway has improved dialogue and working relationships between services who are all striving to provide the best possible outcomes, in a timely fashion for the management of those in our care.