Authors (including presenting author) :
SUEN D(1), LEUNG SS(1), CHUNG SC(1), WONG SP(1), LEUNG HY(1), LI KY(1), CHAN WMM(2)
Affiliation :
(1) Community Nursing Service, Princess Margaret Hospital (2) Community Health Care, Kowloon West Cluster
Keyword 1: :
Service Transformation
Keyword 2: :
Community Nursing Service
Introduction :
PMH Community Nursing Service (CNS) is experiencing escalating service demand driven by rapid ageing population. CNS referrals increased by 10% annually from 2020/21 to 2023/24. PMH CGAS expansion to 12 Residential Care Homes for the Elderly from 1 July 2024 generated a significant rise in service demand, further intensifying service pressure amid ongoing manpower shortage. Concurrently, multiple digital capabilities enabled in recent years, including the Electronic Referral System in Patient Clinical Handover System (PCHOS), Patient Wound Summary of KWC Wound App, Electronic Injection Record, and Wound and Packing Module in Clinical Management System, and Cross-Team and Hospital Access in the Community-based Nursing Service System, help reduce service delays and clinical risk. To sustain high-quality patient-centered community care, PMH CNS transforms the referral practices to a hybrid mode.
Objectives :
(1) To achieve higher process efficiency
(2) To reduce cost and resource
(3) To improve customer experience
Methodology :
PMH CNS centralizes and triages referrals via PCHOS. After screening, intake assessment would be conducted by phone for new or old case admitted for 7 days or above. For cross-hospital referrals and clinically complex cases, CNS liaison nurse would conduct onsite assessment. When a new case referral is accepted, instant communication is established by providing general CNS information to patient/carer via WhatsApp/ SMS. All clinical handover was documented in PCHOS for cross-team communication.
Result & Outcome :
From 1 July 2024 to 30 June 2025, PMH CNS managed 6,980 referrals, of which 73% (5,485) were completed via phone intake. By reducing intake time from 40 to 23 minutes, phone intakes saved 17 minutes of nursing time per case. This efficiency freed up 1,554 hours in total, representing the capacity of approximately one full-time nurse (0.94 FTE), thereby boosting productivity and reallocating nursing time for outreach care. In addition, our green office initiative was supported by saving 4,218 sheets of paper for 1,406 cases (3 sheets per case). Under the standardized workflow and 24/7 communication platform, there were no missing referrals. The constant availability of communication simultaneously enhanced patient experience and safety. This initiative of service transformation on CNS Referrals improved productivity and efficiency, reduced cost and resource use, and enhanced patient safety and experience.
