Outpatient Fundamentals: Definitions, Wait Lists, Strategies & More - Academy
In this blog
- Outpatients Definitions
- What Happens When Patients Wait Too Long?
- Examples of Outpatient Long Wait Impacts
- Why a Waitlist is an Important Hospital Management Tool
- What Does a ‘Normal’ Outpatient Waitlist Look Like?
- Challenges with Managing Outpatient Waitlists
- Outpatient Waitlist Management Strategies
- Manage Outpatient Waitlists with Hospital Improvement Software
- Start Improving OPD Waitlists Today
- Learn More: Resources for Outpatient Fundamentals
- Share Your Knowledge
- How Do Manage Your Outpatient Waitlist?
Interested in learning more about how the outpatient department works? Want to know why waitlists are used so widely or how you can reduce patient wait times for your OPD?
Managing outpatient waitlists is a challenge for most hospitals — even more so during the COVID pandemic. Long waiting patients, or those that have waited longer than is clinically recommended for care, have an impact on patient experience and outcomes, as well as a broad range of hospital processes, roles, and departments. Getting OPD waitlists under control is both essential and critical to affordable and sustainable care, as well as hospital improvement.
|Long outpatient waitlists impact patient experience, clinical outcomes, and hospital processes.|
So, whether you’re a leader in your hospital and accountable for access to outpatient services, or you are responsible for providing care within an outpatient department itself, it’s worth taking time to better understand outpatients. This includes access pathways, waiting lists, clinically recommended waiting times, and the ‘rules’ in place to support patients to receive and hospitals to provide equitable and timely access to care. Plus, the role of OPD waitlists in regards to access, why they can be so hard to manage, and some strategies that might help reduce waiting times and the number of long waits.
Here, we’ll break down the various issues that may be causing you to exceed wait times — and some strategies that may help you understand outpatient waitlists better and start to improve the situation. Plus, we’ll list out some handy resources so you can explore this topic further.
|Note: We’re talking specifically about outpatient department waitlists and how long patients who have been referred by their GP or other care provider are waiting for their initial hospital appointment (which could be days, weeks, months, or years). We’re not referring to the time spent sitting in the clinic or in waiting rooms on the actual appointment day.|
From our experience, public hospitals use the same or very similar processes for handling referrals and booking patients into clinics, but different facilities or jurisdictions may use different language to describe these processes. So, let’s start by defining a few key terms.
Understanding the concept of ‘scheduled care’ is very helpful to understand how outpatients fits into the broader hospital system. Scheduled care refers to any care that is ‘planned’ and starts with a referral from one care provider to another. Another way of thinking about this is that the patient pathway does not start with a visit or ‘presentation’ to the emergency department.
A referral is simply a request for an appointment. Referrals are often written by one care provider for a patient to be seen by another care provider. Referrals usually contain patient demographics such as their name, age, and date of birth as well as information about why they need to be seen. Information on this referral is used to create a waitlist, such as who the patient needs to see, the severity of their symptoms, how long the patient has been unwell, and the date of the referral.
What is an outpatient? Here, when referring to an ‘outpatient’, we’re talking about a patient that hasn’t been admitted by a doctor as an inpatient (usually this means getting a bed and possibly staying for more than 8 hours or so in hospital). Outpatients can include people who are at home, but need to come to a clinic to see a doctor, nurse, or another clinician for a consultation, a small procedure, test, or treatment. It also includes those who were previously in a hospital bed but have now been discharged and need follow up with the person who provided care.
Outpatient Department (OPD)
The Outpatient Department (OPD) refers to the clinics, staff, and services for patients who aren't admitted to hospital. Outpatient services include specialist clinic consultations to diagnose patients and refer them for inpatient treatment, surgery, allied health support, or specialist nursing care. Some outpatients may also receive minor procedures, tests, treatments, and education during their appointment without needing to be admitted to hospital. Outpatient departments are often where patients will receive a review with a specialist, following surgery or an inpatient stay.
An outpatient waitlist refers to the list that patients go onto while waiting for their outpatient appointment. This includes patients waiting to be booked, and those waiting for their scheduled appointment.
Categorisation is the process of reviewing a referral and assigning an urgency rating to help care providers, particular;y those who are high in demand, organise who to see next. Almost all jurisdictions categorise urgent patients separately from those who are less urgent (also known as routine). Some jurisdictions will have more waiting list categories. For example, cancer pathways, urgent, semi-urgent, and non urgent. The process of categorising patients is fundamental to waitlist management as it is what enables a priority order or ‘list’ to be created. Without categorisation, it would not be a ‘waitlist’ — it would be a ‘waitpile’.
An addition to the waiting list is any new referral that has been added to the waiting list. For example, if six (6) referrals were received yesterday, there would be 6 additions.
A removal from the waiting list is any referral that was taken off the waiting list — regardless of why it was removed. This includes patients who were treated, as well as those who were removed because they cancelled and asked to be removed, failed to attend and couldn't be contacted, or those who were audited off the waiting list. For example, if four people were treated yesterday, one patient called and asked to be removed, and another was audited off, there were six removals.
The Outpatients Patient Journey Simplified
There are two ways that patients enter the hospital system.
- Through a planned care pathway (or as an outpatient referral)
- Through an unplanned care pathway (or the emergency department)
Here, we’ll be focusing on the planned care — even more specifically, the outpatients pathway. For more detail on elective surgery, see our guide on Surgery Fundamentals.
So, how does someone become an outpatient or get on the outpatient waitlist?
Usually, it starts with a visit to the GP. If a patient needs assessment or treatment with a specialist, their GP will send a referral to the local hospital, requesting an appointment at the outpatient clinic. After the hospital receives the referral, the most appropriate clinical staff categorise it based on urgency and add it to the right specialist waitlist. The clinician could be a Doctor, Nurse, or Allied Health Practitioner.
The patient receives an appointment based on their category and the order in which they joined the waitlist. Target times for the first appointment will vary based on the urgency and this will also vary between hospital jurisdictions and possibly even hospital facilities. For example:
- Urgent – see within 30 days
- Semi-urgent – see within 90 days
- Routine – see within 1 year
Although categories and target timeframes vary, the idea behind them is the same. Patients should gradually move up the queue and be seen by a specialist in the outpatient clinic in the order that they joined their waitlist category.
|Patients should gradually move up the queue and be seen by a specialist in the outpatient clinic in the order that they joined their waitlist category.|
After attending an initial outpatient appointment, the patient’s specialist will determine the next steps, which may include providing a diagnosis, requesting further tests, providing or referring for treatment, surgery, education, discharging back to GP care, or referral to other healthcare providers. If surgery is required, the specialist will assign a urgency category again and the patient will join another waitlist for elective surgery.
Following treatment or surgery when their care is complete, the patient will be discharged. This may include a plan for ongoing treatment and monitoring under another healthcare provider.
Why Public Health Services Use Outpatient Waitlists
We’ve identified three main reasons why outpatient waitlists are needed.
1. To Manage Finite Hospital Resources Responsibly
Nobody likes to wait. Even more so: nobody likes to wait when they are not feeling well, or when they are in pain, or are concerned about a symptom that is impacting on how they live their life.
But the reality is, there is finite funding available for public hospitals to spend, which means there is only so much care they can provide. It can be difficult for hospitals to determine where they should allocate resources. A waitlist is a great tool to understand demand, how urgently people need to be seen, and what resources are required to service the demand.
|In public health, the waitlist is a useful tool to help leaders and clinicians understand the demand for their care|
2. To Support Equitable Access to Care
Public healthcare is funded by the government using taxpayer funds. Public healthcare should, therefore, be accessible to all who require care. And the order that a patient receives care should be both equitable and needs-based, rather than driven by a patient’s demographics.
Good waitlist management processes ensure that people are seen in the order in which they join the waitlist, and take into account the urgency of their care needs.
|Because public healthcare is funded by the government through taxes raised, it should provide an equitable service.|
3. To Support Healthier Communities and Individuals
With a healthcare system that is ‘in control’, limited resources go to those most in need, which supports healthier communities and individuals.
Hospital beds are very expensive. And not all patients who need to see a specialist need to be in a hospital bed.
In addition, not all patients are sick enough to require specialist urgently, as they may have just started experiencing symptoms. What this means is that some patients have the time to wait. And when specialists do see these patients, they are content to see them in an outpatient clinic rather than seeing them in a hospital bed.
This frees up funding for patients who require emergency care and ensures more hospital beds available for those that need it.
But this only works well when outpatient waitlists are under control. This means that patients are seen, diagnosed, and receive the treatment they need within clinically recommended timeframes.
Sometimes the demand for outpatients increases and the hospital is unable to increase the number of clinics. At other times, the number of clinics available reduces but the number of referrals being received stays the same. When this happens, outpatient waiting times can increase — and often, this means fewer patients get treated within the clinically recommended timeframes.
Patients who are not seen within their clinically recommended timeframes are often referred to as ‘overdues’ or ‘long waits’.
Long waiting patients are a concern, as this can cause significant harm to individuals and communities, such as:
- A patient’s condition gets worse and can not be reversed, leaving them with long term disability
- A patient experiences additional health issues — for example, while waiting a long time for a cataract replacement, a patient may trip and fall on an object they don't see and break their hip
- Prolonged discomfort, pain, and reliance on pain medication
- Temporary disability, causing an inability to work (and resulting loss of income or reliance on social care)
- Impaired quality of life, as well as difficulty with social and family interactions
- Greater uncertainty about the future
- Poor emotional wellbeing
Plus, some of these patients will progress into urgent referrals over time, or even present at the emergency department.
To better understand the human impact of long outpatient waitlists, let’s look at some more specific examples…
Neurology is a great example for understanding why managing and improving outpatient waitlists matters. Every headache, faint, fit, fall, or pseudo seizure could have an underlying neurological cause, so the requests to see a neurologist are often high. However, not all patients need to be seen by a neurologist, and many can be treated by their GP.
Good referral criteria can help GPs understand who they should be referring, and who they should be treating locally. But those who meet the criteria will expect to be seen within the clinically recommended timeframe they are told.
Examples of patients who might be waiting to see a neurologist include:
- A person with epilepsy who is waiting for clearance to drive — if they wait too long for care, they’ll experience greater impacts on their ability to work, socialise, or be able to provide care for their family
- A person with recurring migraines who is waiting for specialist pharmaceutical options — if they wait too long for care, they’ll experience pain and rely on strong painkillers for longer, and have very poor quality of life
A hospital with their wait list in control will prevent these types of patients from waiting too long. This will prevent unnecessary loss of quality of life, as well as unneeded pain and discomfort, while enabling simpler surgeries, faster recoveries, and better outcomes.
There is no doubt that the waitlist is an important management tool for an outpatient department and the people who work in it. However, outside the outpatients department, it is often poorly understood. In fact, many services see the management of it as a burden and the conversations about it as tiresome and often unnecessary.
So, let's explore why it is necessary for every department to either understand it, or at least appreciate its role as a management tool within the hospital.
Poor Outpatient Processes Causes Poor Inpatient Flow
The outpatient department is a part of almost every patient journey. This is where many patients start their journey, and where almost all patients — even those that come in via the emergency department — end it.
If outpatient clinic schedules are not managed (especially if there are no appointments available in upcoming clinics), hospital inpatients can often stay in hospital longer than they need. Without proper waitlist management, hospitals end up with more bottlenecks.
Learn more about this in our article on How Outpatients Impacts on Patient Flow Throughout the Hospital.
Every good clinician has one main goal — to positively impact a patient’s life and ensure the best possible health outcome. A well managed waitlist helps clinicians, not only impact just one person, but many. This is only made possible through patient prioritisation and treating patients within the clinically recommended time.
|A well managed outpatient waitlist helps clinicians provide better care by treating more patients in time.|
Outpatient wait times are one of the key metrics that health department officials, politicians, and the general public look at to get a sense of how the Hospital is running, understand how a hospital is investing their resources, whether a hospital is improving, and also how it compares to other similar hospitals.
The OPD waitlist is particularly important for hospital administrators and senior members of the management team who are held accountable for hospital performance.
It’s hard to say what ‘normal’ looks like anymore, with hospitals facing significant disruption due to COVID-19 pandemic over the last few years. It is expected that ‘yet-to-be-determined’ effects will emerge and continue to impact health services for a number of years.
|It’s hard to say what ‘normal’ looks like anymore, with hospitals facing significant disruption due to COVID-19 pandemic over the last few years.|
It can also be difficult to compare hospital data for a number of reasons.
- Inconsistent waitlist practices – Some hospitals have limited outpatient clinics and patients are instead seen in specialist clinics in the community. In these instances, there are no waitlists, and it is impossible to know how many people are waiting for care.
- Limited data released – Some hospitals don’t release their OPD waitlist data, and in some jurisdictions, it is not a requirement to do so.
- Inconsistent measures – The hospitals that do release data may count their referrals slightly differently. For example, some jurisdictions just want to know how many people are unbooked on a waiting list, while others want to know the number of people who haven’t yet had their appointment. The circumstances impacting each hospital is also unique, from community dynamics to how and when they were impacted by COVID.
But there’s still value in looking at and comparing hospital outpatient waiting list data to see what’s happening around the world and the overall trends. By doing this, you can get a better idea of trends, the services the organisation can offer, and what some organisations might be doing well.
For example, a lot of the data shows that in most areas, the same specialties tend to have longer waits. Typically, access to Orthopaedic Surgery, Ophthalmology, Gastroenterology, ENT, and Urology tend to have long waits.
Some of this can be attributed to an ageing population — when people live longer, more people are likely to require a joint replacement or cataract surgery. And some of this is because research has shown the impact of poor hearing on child development, with many more children now being referred for grommets. On top of this, many jurisdictions have increased national screening tests to detect more conditions earlier — for example, bowel cancer screenings, which require a Colonoscopy.
This information gives policy makers, commissioners, and hospital executives information about the impact or effectiveness of these influences — and an indication of what resources are required to meet the needs of the population.
Take a closer look at the outpatient data we’ve found across a range of jurisdictions in our blog on comparing outpatient waitlists: what’s normal?
So, why are so many hospitals struggling with long wait times for outpatient appointments?
|Long waiting times for public hospitals is a multi-layered problem — and each hospital and jurisdiction has a unique set of processes and factors that influence the volume of long waits.|
Long waits for public hospitals are a multi-layered problem — and each hospital and jurisdiction has a unique set of processes and factors that influence wait times. To understand these layers, let's work through some of the most common challenges that lead to long waits.
Increasing Demand for Specialist Services
One major cause of long outpatient wait times is that demand for specialist appointments is on the rise. So, why is this happening?
In large part, it’s due to ageing populations. Records show that the average Australian aged 85+ had around three times more hospital admissions per year, compared to the average 30-34 year old.
People are living longer. The ‘funny’ thing about this is that people are living longer because of good, accessible healthcare. But at the same time, this trend is driving up demand for hospital services because:
- The older you are, the more likely you will need procedures such as joint replacements, cataracts, or a geriatrician assessment
- Age is often a factor in chronic or lifestyle diseases which often need ongoing management by a specialist
All of this means increasing demand for inpatient beds and outpatient appointments — including both new initial appointments and review visits.
Every hospital resource is limited, whether it’s clinicians, administration staff, facilities, or equipment. Access to these resources influences the number of potential outpatient appointments booked each day.
What is interesting (and sometimes challenging), is that adding new resources (while often necessary) isn’t going to resolve the capacity shortage on its own. Often re-allocating space to give more clinic rooms to outpatients when you have a finite budget means you are taking space away from other important services.
Similarly, providing more equipment doesn’t mean that it’ll be used effectively or efficiently enough to make a significant impact on wait times. That’s especially true when you consider that the biggest resource challenge is appropriately skilled clinicians.
And access to skilled clinicians is influenced by:
- The private healthcare market
- Having adequate university placements to train students
- Having adequate training positions in Medical Colleges train specialists
- Changing workplace expectations on the new generation of clinicians
All variables that the public healthcare service cannot directly or easily influence without the right support and leaders — and even then, any change tends to be slow-moving.
Demand and Costs Outpacing Investment, Innovation, and Change
Demand for and the cost of healthcare is increasing faster than the investment, innovation, and the workforce’s ability to process change.
|When you combine scarce resources with increasing demand, what do you get? Health systems that struggle to keep up.|
When you combine scarce resources with increasing demand, what do you get? Health systems that struggle to keep up. And one way this is reflected in the data is higher volumes of patients on the waitlist, and longer waiting patients.
Stakeholders & Change Culture
It can be tricky to drive change in any organisation — even when that change is necessary and good. Even when key and influential stakeholders are voicing concerns over inefficiencies and poor outcomes. In hospitals, it can be even harder, with clinicians who have different tolerance thresholds when it comes to patient safety or managing clinical risk.
|In hospitals, there are many stakeholders with different risk tolerances when it comes to patient safety, which can make it difficult to implement new practices.|
For example, reallocating or redistributing certain skills and procedures (normally done by a specialist clinician) to a different professional that is more readily available or cost-effective is a potential solution to a stubborn staff shortage. An example of this would be to hold nurse-led injection clinics in Ophthalmology to support patients diagnosed with Macular Degeneration and free up the Ophthalmologist (or trainee Doctor’s) time. We explore this waitlist management strategy in further detail below (along with many others), but it’s a good example of a really practical change that often comes up against roadblocks.
Implementing transformation like this requires each profession, as well as associated quality and safety experts, support teams, hospital executives, possibly legal teams, and (on occasion) even medical colleges and departments of health to support and embrace the change. There are many stakeholder groups — and especially in big hospitals, a large number of people first need to get onboard, and this can be a lengthy process.
Changing Patient Expectations
As other service industries evolve, offer more choice, increase personalisation, embrace technology, and modernise their environments, patients are expecting more from public health providers, too.
They have easier access to information about their condition, treatment options and expected care timeframes. They want to be more involved in decisions around their health, and expect better, if not the best, quality care.
They’re also more proactive about their wellness. This, of course, isn’t a bad thing in itself, but it does explain some of the increased demand for outpatient services, and the need for existing models of care to change.
Studies show that outpatient processes vary across jurisdictions, facilities and even within departments, which means that there is likely opportunities for outpatient departments to operate more efficiently and effectively
While some variability is necessary to accommodate individual patient needs, too much variation in how patient referrals are handled, waitlisted, booked and treated means that errors and inefficiencies are more likely to occur.
Impact of the COVID-19 Pandemic
Although managing outpatient demand and capacity has always had its challenges, COVID-19 has added a new dimension to treating patients as outpatients. While some changes have been positive (like tech innovation and new models of care), there’s been a largely negative impact on public waitlists in many hospitals around the world, with:
- Non-urgent appointments postponed
- Increases in cancelled, postponed, and rescheduled appointments
- A temporary drop in referrals
- Growing waitlists
- Reduced staff availability and changes to the workforce
We discuss the issues in more detail in our article on How Outpatient Waitlists Are Being Impacted by COVID-19.
What is clear is that healthcare organisations and clinical teams are now faced with a huge task. They need to make up for reduced ‘scheduled care’ capacity during the COVID-19 peaks in order to get outpatient wait times back on target. It’s also clear that in order to reduce the backlog, hospitals will need to look beyond their existing approaches to waitlist management.
|In order to reduce the backlog, hospitals will need to look beyond their routine approaches to waitlist management.|
Let’s go through some of the strategies being used in hospitals to improve outpatient waitlists, as well as some ways to manage demand and capacity that can help to reduce patient wait times.
Improve Access to Data
You can’t improve what you can’t measure! And again, for extra emphasis…
|You can’t improve what you can’t measure!|
The best place to start improving your outpatient waitlists and hospital performance is by making sure you have access to the right data… which in our experience means it has to be timely, accurate, and meaningful.
- Timely – You receive it with little lag and at the frequency you need it.
- Accurate – It has the right ‘logic’ or business rules applied so you can trust it, and/or it reflects the source system as it was entered.
- Meaningful – It helps us understand and monitor the situation. There is definitely such a thing as too much information (that’s why we have the phrase “paralysis by analysis”!).
Access to timely, accurate and meaningful data, enables you to draw clearer insights, identify trends, and then make data-backed decisions. This includes:
- Day-to-day decisions – Such as which patient should be booked next
- High level decisions – Like where to best allocate or invest in resources to make the biggest impact
While many hospitals have already invested in building big data warehouses and increasing their analytic capabilities, it is difficult for hospital analytic teams to keep up with the number of data requests. More can always be done to standardise and automate data to enable staff to access insights and leverage the benefits.
Looking for hospital improvement software? SystemView integrates data from all your hospital source systems into a single, beautiful platform that delivers meaningful insights on your outpatient waitlists (along with hundreds of other metrics across all your departments).
Learn more about what you can do inside SystemView >>
Increase Data Transparency
Outpatient wait times are impacted by a number of different roles, from referring GPs and booking/clinic clerks, to clinicians and executive administrators. In most hospitals, different roles have very different privileges or permissions to access data, which limits their understanding of what’s going on.
Improving staff access to the appropriate datasets that impact outpatient waitlists can lead to a better (and broader) understanding of the situation, greater accountability, and more individuals motivated to drive improvements in the areas they work in.
Improvement Roles Embedded Within Outpatient Teams
While improvement teams often exist in hospitals, having a ‘business process improvement officer’ within the outpatient department or working across outpatient strategy to routinely look at and analyse workflows can facilitate process change. Having process experts also supports:
- The creation of more standardised practices with less room for error
- Developing strong policy and procedure documentation
- The learning and development needs of staff who work within the department
Define Business Logic
The volume of people waiting to be seen and how long patients have been waiting are important performance metrics. It allows you to measure the performance of those who are accountable for access to these services. But what exactly are you measuring? And does it line up with your overall goals?
As we’ve already shared, there’s limited and inconsistent data between jurisdictions, hospitals, and how they define waitlists and when a patient’s wait time actually starts.
Unfortunately, this lack of standardised business rules can lead to a variety of approaches, which may even allow the system to be ‘gamed’ (for example, sharing what looks or sounds good to the public instead of reporting the true situation). This slows down progress towards genuine performance improvement.
|Standard definitions of ‘business rules’ for outpatients between hospital jurisdictions, would make it easier to measure performance, know who is doing well, identify opportunities to improve, and drive positive change.|
That’s why it’s important to think critically about what performance measures are meaningful to each of your stakeholders, as well as those that enable sustainable improvement so that you achieve better outcomes for patients.
Consider creating standard definitions of ‘business rules’ or logic that informs metrics for outpatients. This could create more consistency between hospital jurisdictions, making it easier to measure performance, know who is doing well, and identify opportunities for improvement.
Multi-Disciplinary Led, Data-Backed Decision Making
Increasing shared decision making — engaging both patients and a team of clinicians — has been shown to lead to more patient-focused care with more consistent outcomes. Not only that, but a team-based approach to care (for example, using allied health professionals) has been shown to improve performance, speed up access, reduce wait times, and provide better outcomes.
Of course, shared decision making is easier said than done. To make this approach more feasible, some health systems are already using tools and resources that support informed, data-backed decision making. These tools have information available at a team and clinician level demand, capacity, activity, and productivity as well as information to support different care options to help both patients and clinicians weigh up risks and benefits.
Better Teamwork and Continuum of Care
Improving continuation of care for patients has been shown to improve health outcomes, as well as improve health service efficiency. Working as a team can also take the pressure off outpatient departments.
By engaging and forming trusting relationships with external service providers for ongoing care, it frees up hospital resources for more initial appointments. Of course, shared and integrated care (like shared decision making) comes with its challenges and barriers. But as new communication and eHR tools are developed to improve collaboration between providers, this approach will get easier. Every safe opportunity to move people out of the hospital and into the care of a community care provider should be explored — it is better for the patient, and the population.
|Hospital care should be reserved for those who are the most unwell or are at risk of becoming the most unwell and need access to specialist care providers. If a patient has care needs that can be managed in the community, every effort should be made to provide this care closer to home.|
Understand Total Service Demand
Many hospitals track outpatient waitlist data, but they only look at patients that have not yet booked an appointment. The problem with this approach is that:
- You could be booking referrals a long way into the future
- Your future appointment capacity may not be clear
- This ‘out of sight, out of mind’ mentality could give you an unrealistic understanding of your actual ‘waiting to be seen’ demand
Understanding total service demand (booked and unbooked patients) requires you to look at the total services required against all of your true and known service capacity. Then you can begin to determine whether you have a demand and capacity imbalance in outpatients. Then if you do have an imbalance (and you don’t make any changes), this will lead to increasing numbers of long waits.
Having an understanding of total service demand will also help you plan your resources accordingly.
In SystemView, you can find out your Outpatients Demand and Activity — or the total number of appointments needed each week to keep up with your waitlist. You can also filter by specialty to see charts that display the average productive new appointments per week vs the appointments needed in the clinic to manage incoming demand.
To find this metric, go to Domains > Outpatients > Demand and Activity.
For big hospitals especially (with 30,000+ records), outpatient waitlists can get out of date quickly, making it hard for teams to understand their true demand. One of the most effective strategies to keep on top of waitlists is to embed auditing as a routine practice.
There are several types of audits you can use, but the most commonly used are:
- An administrative audit – Admin staff contact patients to confirm their info is correct and if they still are waiting for care at the hospital (for example, if they haven't received the care elsewhere). Plus, they can look for data input errors, like patients incorrectly booked into the future, appointments not linked to the waiting list (which means they have already been seen), and whether patients added to the waiting list are new patients only.
- A clinical audit – Clinical staff contact the patients to understand if their condition has progressed or resolved, and if they still require care.
|One of the best strategies to manage outpatient waitlists is embed auditing into routine practice.|
Clinical and administrative audits can be conducted by internal staff or by staff external to the organisation if they have clear rules and criteria to support auditing.
A thorough and routine auditing process contributes to making your waitlist more accurate and up-to-date.
Learn more about how to audit your outpatient waitlists.
Identify Greatest Risk Specialties
There is no single outpatient waitlist. Hospitals have waitlists for every specialty — and chances are, some of them are managing well with their current demand and capacity, while others could do with some extra strategies and support. It’s important to review the waitlist, filter by specialty, and understand the dynamics so you can identify:
- Where the majority of your long waits are
- Which specialties getting better or worse over time
- What specialties you need to work on first
For example, we have observed that in most SystemView hospitals, orthopaedics, ENT, urology, ophthalmology, and gastroenterology have the most patients waiting, as well as the most long waits.
Balance Clinical Risk Alongside Time-Based Risk When Booking
One of the most common booking practices we see is that urgent patients are identified and booked first. This ensures that the patient with the highest perceived risk is being cared for — but it often leads to only these patients being seen, and those less urgent waiting on the list indefinitely.
Each week, you will ideally book a mix of patients across all categories to get the most patients seen within target times so that you can either avoid long waits or (if you already have them) bring your long waits or overdues down.
We cover this strategy in more detail in our article on Why Consider Clinical Risk Alongside Time-Based Risk When Booking Patients.
We’ve already touched on the challenge of limited resources and how difficult this is for hospitals to resolve. But it’s true that increasing resources is a valid (and often unavoidable) strategy to tackle a demand and capacity imbalance in outpatients.
It’s important to be aware that short-term boosts in funding only tend to have a short-term impact on waitlists. The exception to this is if they are directed at specialties without a stubborn demand and capacity imbalance, and those that have good booking practices in place. Plus, they can help teams address their backlog while they redesign the model of care or reorganise their resources to be more sustainable.
|Short-term boosts to funding and resources only tend to have a short-term impact on waitlists.|
Longer term (or recurrent) funding needs to be considered where there is a significant demand and capacity imbalance that an improvement project can not address.
For example, let’s say the urology clinic has a requirement to see 50 people per week. This is their demand that is due to be treated — not what is being received. They are currently seeing 40 people per week, which means that they have an imbalance of ten appointments per week. In just 10 weeks, they will develop a long waitlist of 100 people if they don’t take action to address the imbalance.
There is no doubt that additional short-term funding will help the team treat the 100 patients who are now a long wait. But this number will continue to grow once the funding dries up unless something is done to address the ten person per week imbalance.
However, this doesn’t necessarily mean additional recurrent funding is needed.
It’s worth looking at the new appointments being held in existing clinics to identify:
- The balance of cases across clinicians – Are all doctors seeing the same number of new patients and is it reasonable to expect they should? A different casemix could mean a different appointment length is required.
- Time gaps – Are the clinics starting late or finishing early? Is it reasonable to see additional appointments added using the existing resources to close the gap?
- Underutilised resources – Are there existing resources available within the team to increase the number of patients seen? For example, does the team have a highly skilled nurse who is not working to their full scope of practice that could provide care to some patients (while handing over more routine or admin tasks)?
- Empty appointments – Is the did not attend or cancellation rate high? Could the specialty improve attendance rates and fill more cancelled appointments?
- Discharge rates – Are a large number of patients discharged from their first appointment? If so, review referral processing systems to ensure referred patients are appropriate for care in a hospital.
If the answer to the above questions are no (or even if just some of them are no), it’s likely that additional resources will be needed to close the gap.
Feeling overwhelmed about how much data you need to request to be able to answer these questions? SystemView provides you with your demand and activity imbalance, clinic activity, clinic cancellation and did not attend rates, clinic bookings for all specialities in one location - presented in beautiful, intuitive software.
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Improve Operational Efficiency
Time management strategies can help to reduce outpatient waitlists by maximising clinic capacity to fit more patients in each day.
Outpatient Clinic Managers and Booking Clerks can improve operational efficiency by ensuring clinics are booked, clinics and appointments start on time, follow up appointments are not overbooked, and by simplifying queues.
Improve Clinic Effectiveness
Clinic effectiveness refers to how well a service is managing their clinic resources. This may involve looking at:
- The percentage of patients attending appointments (compared to cancellations and do not attends)
- The distribution of appointments (new patients and patients who require follow up)
- How clinics are managing discharges
- Conversion rate to surgery (where appropriate)
|Effective outpatient clinics maximise resource use and minimise missed opportunity costs, ensuring that more patients get seen on time.|
To improve clinic effectiveness, consider what resources you need in place for a patient to see a clinician in outpatients. Consider the opportunity cost if a patient does not attend — and the opportunity cost if they do attend but don’t have the correct or up-to-date diagnostics and then need another appointment.
Effective outpatient clinics maximise resource use and minimise missed opportunity costs, ensuring that more patients get seen on time.
Book in the Order in Which They Need to Be Seen
Where possible, appointments should be given to patients in chronological order — in other words, the order in which they arrived on the waiting list.
This can be difficult, as different doctors have different skills and different availability. But if two people with the same presenting complaint are waiting for the same doctor, the person who was added to the waiting list first should be seen first.
Often when dealing with large volumes of patients, booking errors happen. In some cases, bookings may be assigned to those who have not waited long — ahead of those that have waited longer. The consequence of this when the demand and capacity is very ‘tight’ is that we unnecessarily create long waits (or we make people wait too long).
By using ‘wait groups’ to sort patients we can focus on who we should be booking next and also make it easy to identify those who we may have booked out of turn (and may need to reschedule to prevent long waits.
SystemView creates the following wait groups:
- Booked long waits
- Booked risk
- Booked beyond breach
- Booked in time
- Unbooked long waits
- Unbooked risk
|Using SystemView wait groups, outpatient teams can easily see who to book next and minimise treating out of turn.|
To learn more about how wait groups work (and why they’re so useful) check out our blog on Using Wait Groups to Manage Hospital Waitlists.
Use a Patient Target List (PTL)
A patient target list (PTL) is a version of the waiting list that helps you proactively manage the waiting list. It is sorted in a way that minimises booking errors and reduces long waits.
A PTL is a go-to tool for long wait reduction initiatives. In the context of reducing long waits, it contains a list of every single patient that needs to be treated on or before a certain date. Patients are then selected one at a time, an action plan for that patient is created, and then the patient is crossed off the list until every single patient has a plan.
Here’s an example scenario where a PTL would be helpful…
The Department of Health issues a new target to hospitals that states no patient will be waiting for their first outpatient beyond 12 months after December 31.
Here’s how the hospitals in this jurisdiction could respond:
Backlog reduction projects are another good way to use a PTL to manage the outpatient waitlist. In backlog reduction projects, a PTL is typically static. Patients can be removed because they have a plan, but no new patients are added onto the list once it is generated.
PTLs are also valuable for embedding into daily routines. For this to occur, the list needs to be dynamic, with patients coming onto and off the list. Embedding a dynamic PTL into daily practice goes hand in hand with measures like:
- Generating a list of people to be booked, sorted by time-based urgency
- Creating an action plan for each patient
- Monitoring patients who have been booked to prevent them becoming unbooked
- Escalating every patient who can not be seen in time for extraordinary support
If too many patients are being escalated in a specialty, it is an indication that the specialty needs additional support or funding in order to prevent a long wait problem from emerging.
Overbook – Only Sparingly and With Permission
Sometimes there are no vacancies to book a patient who will otherwise become a long wait — and no patients who have been booked too early to reschedule. In some cases, it may be necessary to overbook, but only with permission from the clinician. This strategy should only be used sparingly. If it is being used too often, it is an indicator that there is a bigger issue to be resolved — whether that is a capacity imbalance, incorrect clinic templates, or a breakdown in communication.
Account for Holidays
Holidays can impact both demand and capacity in outpatients, with a drop in referrals and an increase in staff leave. Following holidays, there may be an increase in referrals as GPs reopen and patients seek treatment for health conditions, and an increase in capacity as staff return to regular schedules.
It is a good idea to plan for holiday periods. Have open lines of communications between clinicians, booking staff, and clinic staff to ensure you account for reduced capacity and possible influxes when services resume.
Improve Patient Communication
One report looked at attendance patterns and found that 60% of uncontactable patients who did not confirm their appointment (but it was held for them anyway) failed to attend their appointment. Patients may not attend for a number of reasons. Perhaps they:
- No longer need care
- Have moved to another location
- Require a new appointment time but could not contact the service in time to reschedule
Audits can help to clean up waiting lists to reduce failure to attends. But patient communication can also play a significant role.
|Access to patient communication channels can play a significant role in reducing failed to attend rates|
Despite the many challenges healthcare systems face with accessing digital systems (due to patient privacy laws), many hospitals are progressing within online solutions. There are more and more digital platforms being developed to support communication.
But improving patient communication could be as simple as incorporating SMS. Hospitals can contact patients via SMS and phone to confirm an appointment (with a reasonable number of attempts). If unsuccessful in receiving a response, hospital admin can inform the treating clinician, remove the referral, and send follow up communication to the patient and GP advising of this action. This can serve to reduce the number of failure to attends — and ensures that the appointment spot can be utilised for another patient that is more likely to attend.
Patient Focused Bookings
Patients have growing expectations around how easy it should be to book, change, or cancel an appointment.
Patient focused bookings or “OPTing IN” is another strategy used to successfully reduce failed to attends. Instead of issuing them an appointment time, the patient is contacted to advise that they are at the top of the waiting list and should call to select an available appointment. The patient calls and is given a choice of three or four available upcoming appointments at a suitable clinic. On the call, they confirm they will be attending.
If the patient does not contact the hospital as requested, hospital admin will use their usual process to follow up with the patient before safely, reasonably, and appropriately removing them from the waitlist.
Fill Appointments at Short Notice
Some patients may be willing to declare they can be available at short notice and go on a flexible cancellation list. These are patients that may live nearby or have flexible working arrangements, allowing them to come to the hospital quickly, without needing a lot of preparation time. This list is then used when a patient is no longer able to attend an appointment so that the appointment slot can still be filled.
An efficient cancellation and booking system will enable outpatient departments to fill more appointments, even at short notice.
Improve Screening & Categorisation
Better screening of referred patients can help to remove unnecessary demand for outpatient appointments and improve booking efficiency. In some cases, it might be helpful be to develop resources or education programs for GPs to:
- Explain the the referral process and waiting list process
- Encourage better quality referrals with information that helps to more accurately assign and categorise patients
- Encourage referrals with specific criteria to go to alternative providers like allied health professionals
- Suggest potential alternatives to surgical interventions
Match Resources with Areas of Demand
Your resources should be aligned to support your areas of demand. Available appointments should be distributed across each specialty to match the case mix demand.
Areas of demand may change over time, so it’s important to look at where your increases in new case activity are and to bring on new resources (or redistribute existing resources) to match this activity as needed.
This will enable more specialties to see patients within the recommended time.
Implement Alternative Models of Care
Alternative models of care can involve integrating care providers with other skills into the clinical team or referring patients to another provider altogether.
Through a clinical referral audit, you can identify patients that may be able to receive the care they need elsewhere, whether it's another profession or facility.
For example, a patient who is referred with carpal tunnel syndrome symptoms may be seen by a plastic surgeon, a neurosurgeon, or an orthopaedic surgeon. A referral audit may assist with distributing this patient to the specialty with the shortest waiting time. Alternatively, they may be able to be seen by an occupational therapist to first try non-surgical interventions, like nerve gliding exercises or wearing a split overnight.
This can take a lot of pressure off outpatient clinics because some patients may not need to come into hospital at all. Others may be able to be discharged sooner or avoid an invasive procedure altogether. As a result, more patients who require hospital care can be seen sooner — and specialised clinicians can focus on more urgent cases or patients that require specific treatments.
Alternative models of care may include:
- GP shared care
- Allied health services
- Specialist clinics run by nurses or nurse practitioners
- Self management
Read more about how alternative models of care can take the pressure off outpatients.
Improved Information Management Systems
Better information management systems can enable a lot of the other strategies here, by:
- Streamlining referral processes
- Improving referral quality and consistency
- Better directing referrals
- Sharing more information between care providers and teams
- Improving system and care integration
- Improving patient journey and referral tracking
For example, QLD Health has been trialling GP smart referral software with some early success, with 9 Hospital and Health Services enabling smart referrals and 22% of GPs with compatible practice management software using smart referrals. This gives the GPs access to a directory of public hospital services and a platform to securely message these hospitals — in order to support and direct referrals.
In addition, over the last few years, GPs in Queensland have also been able to access parts of their patients’ public hospital records through an online Health Provider Portal, ‘The Viewer’. This helps to support the care provider who will continue to see the patient in the community after they have been discharged from hospital. It can give them a better understanding of the condition the patient was treated for, the care they received, and how to (hopefully) prevent readmission or other complications.
New information systems are useful tools that no doubt can improve workflows and reduce error — but it’s also important to note their limitations. Any system’s impact on processes will be limited unless adoption of the system is high and careful consideration is given to implementation.
Define or Refine Clinical Prioritisation Criteria
One of the challenges with current booking processes is the limited or inconsistent information used to accept referrals, clinically categorise patients, and prioritise bookings. Each GP may have a different approach, making it tricky for outpatient teams to compare referrals and decide who belongs on a waitlist and in what order they need to be seen. This variation in the referral process appears to contribute to outpatient waiting times.
|Variation in the referral process appears to contribute to outpatient waiting times.|
Some jurisdictions have created and introduced Clinical Prioritisation Criteria (CPC) or are in the process of designing criteria in order to address this issue.
This criteria defines what needs to go into a referral, including diagnostics and test results. The criteria also defines what constitutes an urgent or less urgent case (or category 1, 2, or 3) for specific specialties. This makes the referral process more transparent and more efficient for GPs, patients, clinicians, and booking administrators.
CPC can help to ensure that patients are ready for their outpatient appointment or treatment. It can redirect referrals to more suitable treatment options, freeing up an appointment spot for more urgent cases. It also eliminates guesswork by ensuring that clinicians have all the information and criteria they need to categorise referrals accurately and fairly.
CPC can also help to reassure GPs that a patient may be more suitable for care in the community, does not need to see a specialist, and that a referral isn’t required at all.
Reduce Triage Complexity
There’s been some evidence that simplifying triage can improve reliability and throughput. The suggestion is aligned to queue theory. This suggests that patients should be grouped into the most aggregated groups where they don't need special services, which makes managing the waiting list and scheduling appointments easier.
It makes sense when you think about it: with less rules to follow, it’s much easier for a human to understand and follow the rules.
For example, in Australia there are typically three urgency groups used for scheduled care:
Urgent (cat 1)
Semi-urgent (cat 2)
Routine (cat 3)
At present, it means that urgent people need to be booked and treated first. After that, we need to consider semi-urgent and routine patients next. It seems straightforward — simply book the semi urgent patient next.. Right?
But when there are long waiting patients it becomes more difficult.
Who is more urgent:
- A semi urgent patient waiting 85 days (out of 90 recommended days), or
- A patient who was routine when referred but has now waited 500 days (out of a recommended 365 days)?
- One way to simplify triage is to use just two categories for cases — urgent and non-urgent.
This is a popular way of thinking, and many operational leaders are supportive of the idea. But for clinicians who need to assign urgency and treat patients, there is a significant grey area between those patients that are urgent and need to be seen quickly, and those that can wait a while.
Specific and Timely Appointments for Triage
Another model that’s being trialled in some hospitals is Specific and Timely Appointments for Triage (STAT).
Here’s how the model works:
- Specific – Clinicians schedule a certain number of protected appointments each week for assessing new referrals
- Timely – New referrals are immediately booked into the next available assessment appointment (no waitlist or triage)
- Appointments – The first appointment should combine triage, initial assessment, early advice, and treatment initiation
- Triage – The clinician uses their own judgement at the point of care to decide the patient’s priority relative to their existing cases
STAT has been found to reduce waiting times in health services where supply and demand is relatively stable — and where most patients typically require multiple appointments. In one study it was found to reduce waiting time to first appointment by 33.8%, though it did not generally impact on secondary outcomes and was associated with a small increase in missed appointments.
|Earlier interventions can lead to better health outcomes and seeing patients sooner may eliminate the need for reassessments.|
Another potential benefit could be that some non-urgent patients start diagnosis and treatment within weeks, rather than waiting months or longer. Earlier interventions can lead to better health outcomes and if patients get seen sooner, it may eliminate the need for resource-intensive reassessments.
One clinical trial looking at waiting list referral criteria (unrelated to STAT) recruited 55 participants from a new patient waiting list who had been classified as having routine conditions (for example, bladder flow obstruction) based on their referral letter. In this trial, patients were seen at around 13 weeks, compared to an average wait of eight months for this particular outpatient clinic. When investigating these patients, seven of them were diagnosed with prostate cancer. If they'd remained on the usual waitlist, their diagnosis and treatment would have been delayed. With 84% of localised cancer of the prostate progressing if left untreated, it illustrates the importance of well documented referrals and the potential impact of waiting longer due to the wrong urgency assignment.
It may also indicate how effective STAT could be at managing the risk of long waiting lists.
Standardise Outpatient Care
Too much variation in care means that some patients are receiving better quality, more care or more efficient care than others. This will likely impact patient health outcomes, as well as wait times.
If you observe that there’s too much variation happening in some specialties (unrelated to patient needs and preferences), it may be worth introducing more standardised procedures for care. A few examples of this are:
- Criteria-led discharge policies – For example, a patient can be discharged from the service following an elective knee replacement when the wound is healed and they are able to achieve 90° knee joint range of motion.
- Standard care pathways – For example, a patient will receive one new and three postoperative review appointments as a standard. Patients should only have more appointments scheduled if they have extenuating circumstances that suggest they will breach this pathway.
These kinds of policies can be easily created and introduced for routine procedures — and many are already available online.
Review Funding Systems & Models
This strategy targets the health care system itself, and is best driven by hospital executives, health department officials, and people with political influence.
Because funding models (particularly the mix of private and public funding) can be a major contributor to outpatient wait times (and resulting inequity and health outcomes), it’s worth considering how to best fund the hospital system and incentivise the community providers who support (and enable) the broader health system.
|Because funding models can be a major contributor to outpatient wait times, we need to always be exploring ways to best fund the hospital system.|
Hospitals need funding in order to provide services and resources, as well as provide incentives for referring clinicians to provide quality care (not just process high volumes of billables). Some areas that are often under question include:
- The fee-for-service system that pays doctors — both those in the community as well as those within hospitals
- Whether healthcare budgets are enough (and the ROI of investing in community health)
- How private health can deliver value to patients beyond timely access to care (and how to incentivise more private health patients to use private facilities instead of public hospitals)
Implement COVID-19 Pandemic Recovery Measures
Finally, it’s important to consider COVID-19 when developing strategies to manage your outpatient waitlists.
It’s hard to know for sure what lasting impact the pandemic will have on waitlists. Health economists and expert clinicians are speculating that we may see increased health problems following COVID infections or delayed referrals due to people avoiding the hospital during peaks.
This may feed further increases in demand for outpatient appointments in the coming years, requiring additional resources. Or it may actually serve to reset how patients view hospitals and the care they provide.
|Even if your demand and capacity is currently in balance, you may have a backlog of patients that need to be seen.|
What we do know is that most outpatient departments have experienced capacity disruptions throughout the pandemic. Many have had to cancel/reschedule a number of appointments during peaks. This means that even if your demand and capacity is currently in balance, you may have a backlog of patients that need to be seen.
Some hospitals are implementing measures to bring their waitlists back within normal ranges, like:
- Getting in touch with cancelled/rescheduled patients and seeing if they still need care
- Reviewing and auditing all overdue patients
- Continuing to maintain (and even extending the scope of) virtual clinics where appropriate
- Running pop up clinics to temporarily boost capacity and get through backlogs
Plus, a number of other strategies that we’ve already covered here.
Managing outpatient waitlists and improving patient wait times is a huge task that requires appropriate tools and resources. SystemView can help support your department with the strategic insights and specific information you need to make decisions at every level, from booking the next patient, right up to implementing new resources and systems.
SystemView is hospital improvement software that combines data from source systems to deliver beautiful dashboards, tailored reports, trends, and predictive analysis — not just in outpatients, but across the entire hospital. It enables accurate performance monitoring, helping teams to understand and improve their processes to deliver better patient outcomes, staff productivity, and resource utilisation.
Originally designed to help with waitlist management, SystemView includes a number of useful components and features to support waitlist audits, demand/capacity monitoring, and patient bookings.
Take a closer look at SystemView’s features here.
Ready to get started? Roll up your sleeves — you have a big job ahead. But an important one that will have a huge impact on hospital processes, healthcare providers, patient outcomes, and the community.
|Dive deeper into your data so that you can discover where your biggest issues are and what’s causing them.|
Hopefully by now you’re a lot more familiar with the complex issues that may be at play — as well as some of the short and long-term strategies that may lead to change.
It’s overwhelming, but the best place to start is by understanding your situation. So, dive deeper into your data so that you can discover where your biggest issues are and what’s causing them. Then you can begin to explore the best strategies for those problems.
Hospitals all over the world are grappling with the same issues relating to outpatient waitlist management, and the never-ending balancing act between demand and capacity.
If you learn something interesting from your data analytics or outpatient strategies, then share it with others. And if you’re facing a specific issue, reach out for help from the community. Someone else may already have the answer you’re looking for.
Want to contribute to our community? Take a look at our Outpatient User Group here.
What have you found helpful in managing outpatient wait times? Or is there a topic related to outpatient service improvement that you’d like us to cover in future pieces? Leave a comment below.
We plan to share more insights like this in future blogs, so be sure to subscribe to get updates.
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