Optimising Orthopaedic Trauma Patient Flow in Cork University Hospital, Ireland

A Lean review of the pathway for Orthopaedic trauma patients identified many opportunities for improvement but changing practice and process is exceedingly challenging.

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.


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Participant comments on Optimising Orthopaedic Trauma Patient Flow in Cork University Hospital, Ireland

  1. I don’t know how the lean review group is organized, but while reading your assignment I reached the same conclusion as you did in your final paragraph. It seems that there is no commitment to the outcome of the review because the ‘subject’ the Orthopedic Department does’t feel they were involved. If you only confront departments with the outcome of this process without involving them they will feel judged. If you try to impose the outcome on this or any other department you will create your own resistance. I would not go that way if I were in your shoes. You need to take them serious from the beginning. There is not only one truth. The situation you are working in is far too complex for that. Change will only come with acceptance. I think you really need to think hard about how to select people being part of this review group. Even the name doesn’t really sound inviting. Involve various members of this department. Don’t make it all about efficiency, but make it about the patient. I would most certainly include patients (who had undergone the procedure) in the process. Or those that are on a waiting list. Get this group trained in some lean principles, so they are empowered to look at their own work processes. Even the biggest criticasters of change or management principles (I am thinking about the doctors now) might surprise you if you give them responsibility in improving service.

    Two examples from my own practice: we confront healthcare providers with our data to benchmark them and there is always a discussion about validity etc. They feel judged and not helped. If we give our data to GP’s to discuss it amongst themselves in their own effort to learn and get better it does work. Something I tried recently and didn’t work out: I had a group working on how to improve their work. But the group only consisted of employees actually doing this job. So the reverse situation from what you described. They didn’t come up with any new ideas. The conclusion was more or less that what they were doing was perfect. I think this result was all about not putting togheter a more diverse team.

    It is a good thing you write blogs about it on your website. If you do the same thing within your organization it might be a great platform to share your dilemmas and get people involved.

    Good Luck, Erik

  2. To a certain extent the consultant would have to point out to you how the data was flawed and present their own data as rebuttal. I think it is fine to question data that was not compiled by the orthopaedic service, but then one of the surgeons really has to sit down with the folks collecting the data and determine where the inaccuracies lie. Doesn’t have to be the chairman, but maybe a registrar or someone they trust.

    Very difficult in a trauma center (at least one that handles major multisystem blunt trauma) to put all the orthopaedic patients in one area, has that been done in other centers in Ireland?

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