This paper presents a case study on the use of mathematical-computer models in developing operating policies for a university-health-service outpatient clinic. Based on results predicted by the models, actual policy changes were made in the system; the paper compares the subsequent real-world results with those predicted by the models. The comparison demonstrated the validity of the models, and significant improvements were realized in the changed system. An analysis of daily arrival patterns was used to schedule more appointment patients during periods of low walk-in demand in order to smooth the overall daily arrivals. A Monte Carlo simulation model showed the effects of alternative decision rules for scheduling appointment periods during the day to increase patient throughput and physician utilization.

BackgroundWestern Australia (WA) passed legislation supporting formal advance care planning (ACP) in 2010, allowing Advance Health Directive (AHD) and Enduring Power of Guardianship (EPG) forms. It is timely to audit the quality of end-of-life care provided in a rural area.AimReport ACP uptake and impact on end-of-life care in a rural hospital setting.MethodsThis retrospective case notes-based audit of 90 admissions resulting in death was conducted in five rural hospitals in the Great Southern region of WA in 2012: the 100-bed regional centre (N=50) and four more remote ∼10-bed facilities (N=10). A palliative care nurse used an in-house designed audit tool to collect data on demographics, process and outcomes measures. A palliative physician double coded five randomly selected sets of notes.ResultsMost patients elderly (M=79.6 years), admitted via ED (58%), on average 13 days before death. Malignancy accounted for 40% of deaths. Some form of ACP was documented in 34%, with 9% having an AHD and 1% having an EPG. 50% died on the Liverpool end-of-life care pathway, those on the pathway scored higher on a composite measure of care quality (χ2(2,90)=31.6, p<0.001). ACP documentation did not predict likelihood of being commenced on the pathway (p>0.05) or scores on the composite measure (p>0.05).DiscussionAs ACP is promoted in our community, our rural hospital network must develop system-wide responses to guarantee ACP influences care.ConclusionThis audit reports baseline data, which can be repeated following ACP-based interventions.

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