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Illustrating “how to” implement the
Top 20 Actions for Change
Storyboard Examples of Improvement Work
Cancer Service Improvement Programme
Illustrating “how to” implement the
Top 20 Actions for Change
Storyboard Examples of Improvement Work
Cancer Service Improvement Programme
© Crown copyright 2005
ISBN: 0-7559-4758-4
Scottish Executive
St Andrew’s House
Edinburgh
EH1 3DG
Produced for the Scottish Executive by Astron B42431 11/05
Published by the Scottish Executive, November, 2005
100% of this documment is printed on recycled paper and is 100% recyclable.
List of Contents
Introduction
1
Referral
5
Consultation/Investigation/Diagnosis (CID)
15
Multi Disciplinary Team (MDT)
35
Treatment
43
Contacts
59
Top 20 Actions for Change
Storyboard Examples of Improvement Work:
Introduction
The Cancer Service Improvement Programme (CSIP) is working in support of
improvement. The focus of the work is to enable clinical teams and their support staff
to make changes happen and to encourage the implementation of successful
changes.
Hundreds of staff at grass roots level along with patients and their families have
worked together to highlight where further improvements to cancer services can be
made.
The team uses a tried and tested model for improvement, which has been used
worldwide to make change happen in health care. The PDSA cycle, plan, do, study,
act – gives teams the discipline to plan a change, implement it, measure its effect and
act on the results.
We have gathered real examples from across Scotland of improvement work. The
examples offer a practical guide of “how to” implement the Top 20 Actions for
Change.
The examples in this booklet are only a snapshot of the improvements (over 500)
achieved throughout Scotland. They illustrate changes at key stages of the care
pathway.
This work is fully supported by the Cancer Service Improvement Programme’s
Regional Facilitators who are ready to help you implement the changes appropriate
to your local area.
The Top 20 Actions for Change are widely available to the Scottish NHS to support a
faster pace of change across Scotland.
Pauline Ferguson
National Programme Manager
Cancer Service Improvement Programme
Centre for Change and Innovation
October 2005
1
Top 20 Actions for Change
Maximum 62 days from urgent Primary
PATIENT
EXPERIENCE
AIMS
HOW
Information on
where these
improvements
have taken place
is on the reverse
of this leaflet.
Thinking something was wrong
Early Detection
Rapid Diagnosis
CONSULTATION/INVESTIGATION/
DIAGNOSIS (CID)
GP REFERRAL
“Eliminate delay and enable
appropriate processing of
referrals.”
1. Clear GP symptom-related
referral guidelines.
“Timely management of
investigations and results to
provide early communication
of diagnosis.”
2. Electronic/faxed referral to a
central point.
1. Pre-booking/scheduling of
investigations and
appointments.
3. Referral to a service, not a
consultant.
2. Dedicated or fast-track clinics
with rapid reporting.
4. Direct referral to specialist
service from diagnostics.
3. Reduce consultant vetting of
investigation requests.
5. No vetting or, as a minimum,
daily team vetting of all
referrals.
4. Telephone consultation/
communication of results.
6. Single route of referral and
access for endoscopy services.
6. Reduce follow-up appointments
at out-patient clinics.
GOOD COMMUNICATION IS THE KEY
2
5. Specialist nurse-led clinics.
Care referral to 1st definitive treatment
Seeing someone in the NHS, having tests
and being told what was wrong
Receiving treatment
Improve treatment and care
62 DAYS
MULTIDISCIPLINARY TEAM MEETING (MDT)
TREATMENT
“Ensures that a fully informed
discussion of all patients diagnosed
with cancer takes place and
appropriately formulated treatment
plan is documented.”
“No needless delays.”
1. Co-ordination of treatment processes
across network to ensure optimum
use of capacity, e.g. theatre time.
2. Planned management of annual leave and
public holidays.
1. Clear responsibility for co-ordination of
MDT to ensure all necessary information
is available at MDT for treatment
decision-making.
3. Streamlining of booking processes for
chemotherapy and radiotherapy.
4. Efficient system for appropriate referral to
palliative care.
2. MDT used to refer on for treatment,
i.e. investigations, surgery, oncology.
3. Timely communication with GP of MDT
decision.
4. Video conferencing/Telemedicine links to
be used where attendance is limited.
3
4
Referral
GP Referral
“Eliminate delay and enable appropriate
processing of referrals.”
1. Clear GP symptom-related referral guidelines.
2. Electronic/faxed referral to a central point.
3. Referral to a service, not a consultant.
4. Direct referral to specialist service from
diagnostics.
5. No vetting or, as a minimum, daily team
vetting of all referrals.
6. Single route of referral and access for
endoscopy services.
5
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Routine information regarding PSA blood testing
Top 20 Referral
In Oban and outlying rural areas, all patients are sent out routine information explaining implications
of PSA blood testing before first consultation.
Making It Happen
Following discussion with the Urology Nurse Practitioner and Local General Practitioner it became
evident that patient undergoing PSA blood testing in primary care or in hospital outpatient
department were not informed in a uniform fashion.
Both parties were keen for uniform verbal and written information for all patients. Appropriate
patient information leaflets were chosen and agreed on.
PSA information leaflets are sent out to all patients in local and outlying areas with the appointment
card for first consultation.
Implementation Advice
Implementation was quick and easy with cooperation of outpatient department staff and Primary
health care teams.
Impact
All patients receive uniform information about PSA blood testing.
Contact
Rosemary Noon
Urology Nurse Practitioner
Vale of Leven Hospital
[email protected]
01631 789 059
6
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Clear GP symptom–related referral guidelines.
Top 20
Referral 1
In Borders General Hospital, the medical director discussed with general practitioners (GP’s) the
need to provide accurate and full history details of patients with suspected lung cancer. This has
resulted in referral letters being processed without the need of secretarial staff to retrieve the
necessary information from the GP practices.
Making it Happen
The lung cancer team highlighted that some of the GP referral letters did not have enough
information in them regarding the patients condition. This information is essential to make the first
consultation at the hospital efficient and aid to a prompt diagnosis.
The medical director wrote a letter to all GP’s requesting that they provide appropriate information
to allow swift progression from receipt of referral letter to the patient receiving an out patient
appointment.
Impact
The benefit of this change has been:
• Increase in the quality of the information within the referral letters
• Hospital secretaries have not had to phone the GP practices requesting additional information
• A reduction of 1 to 2 days processing time between receiving the referral letter and making an
out patient appointment
Contact
Dr John Gaddie, Consultant Respiratory Physician
Borders General Hospital
[email protected]
01896 754 333
7
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Electronic/faxed referral to a central point
Top 20 Referral 2
In Argyll and Clyde, Oban Hospital services a rural area with 4 outlying outpatient clinics. Staff have
developed electronic/faxed referral to a central point in Oban for all urgent suspected cancer
referrals. This now means all urgent referrals are seen quickly at a central point for first
consultation/assessment.
Making It Happen
Waiting time for 1st consultation time
reduced by 1 week if from outlying area
•
y
Au
gu
st
Ju
l
e
ay
M
Ju
n
M
ar
ch
Following discussion it was decided to appoint
all urgent patients to 1 central point where
they could be seen quickly.
5
4
3
2
1
0
Ap
ril
No. of Weeks
Before the change, it was discovered that
there was a variable referral system, with
referrals coming into outlying rural clinics and
the main district general hospital urology
service by several methods, casing delays in
appointing some patients.
Month (2005)
Staff from Outpatients department
contacted and visited all GP practices
with SCI Gateway team and assessed
their requirements to allow GPs to refer
electronically to a central point in
Oban.
Impact
The benefits from this change are:
•
•
An IT system was developed to allow
practices with incompatible software
packages to refer electronically.
•
•
IT education and support was offered
to all appropriate practice.
•
Practices
that
couldn’t
refer
electronically were encouraged to fax
referrals to the central point.
•
A urology proforma was developed by
the urology nurse practitioner and a
local GP which stated that all urgent
suspected cancer referrals should come
directly to a central point.
•
1 central referral point allowing
referrals to be vetted and appointed on
a daily basis.
All urgent patients seen in an equitable
time and at a central point.
Waiting time for first consultation
reduced by 1 week if from outlying
area.
Next Steps
ƒ
Review of guideline and monitoring of
service to ensure that single point of
referral is being maintained.
Implementation Advice
Contact
The General Practitioner was very keen on a
structured framework for referral to support
and guide primary care staff. Examples of
referral proformas were sourced from other
areas by Cancer Service Improvement
Programme Facilitator and utilised to reduce
workload.
Rosemary Noon
Urology Nurse Practitioner, Vale of Leven Hospital
[email protected]
Tel: 01631 789059
8
CANCER SERVICE IMPROVEMENT PROGRAMME EXAMPLES OF CHANGE
Electronic /faxed referral to a central point
Top 20 Referral 2
In Elgin, referrals to the lung team are being faxed directly to the central point in Aberdeen
Royal to be vetted on a daily basis.
Making It Happen
Impact
Prior to the change, referrals to the lung
team by GP’s in Elgin were received at
Elgin hospital and were only vetted on a
2 weekly basis when a respiratory
consultant from Aberdeen Royal was
undertaking an outreach clinic.
The benefit from this change has been:
This method built in delay
appointment for the patient.
to
first
This was highlighted at a mapping event
with the lung team and following this
staff in Elgin are now faxing these
referrals directly to the central referral
point in Aberdeen Royal.
This has
reduced the potential time to
making an appointment from 2
weeks to 2 days.
ƒ
One central focus for referrals allows
these to be triaged on a daily basis
and appointed as early as possible
ƒ
Potential time to appointment for
Elgin patients has been reduced
Next Steps
Ensure
sustainability
of
service.
Continued review of guideline and
monitoring of process to ensure that the
single point of referral is maintained.
Review the use and implementation of a
similar system for inter-hospital referrals
to streamline all referrals to the Lung
team.
Implementation Advice
Appropriate protocol in place within
outlying hospitals to ensure referrals do
not wait for triaging.
Contact
Dr Joe Legge, Respiratory Physician
Aberdeen Royal Infirmary, Aberdeen
[email protected]
01224 681 818
9
CANCER SERVICE IMPROVEMENT PROGRAMME EXAMPLES OF CHANGE
Electronic /faxed referral to a central point
Top 20 Referral 2
In Grampian, doctors, radiographers and admin staff, have reduced the delay for receiving a
chest x-ray from a maximum of 2 weeks to 2 days. GP’s can now fax a chest x-ray request to
Woodend Hospital and Aberdeen Royal Infirmary X-ray departments with the patient’s contact
details. The x-ray staff will then contact the patient and ask them to attend for their x-ray the
same day or the next day.
Making It Happen
weeks to 2 days contributing to a
reduction in time to diagnosis for all GP
referrals to the Lung Service.
Prior to the change, referral letters from
GP’s to the hospital requesting a chest
x-ray were dictated, typed and signed in
the GP practice then sent by mail to the
hospital. Once received by the x-ray
departments,
appointments
were
allocated and the patient sent an
appointment.
Implementation Advice
Consultation and communication with
Primary Care colleagues is essential.
This process took a maximum of 2
weeks to complete.
Impact
Once the x-ray was reported this was
sent back to the GP for them to review
and refer onto a specialist if appropriate.
The benefits from this change have
been:
ƒ Reduction in time to x-ray
appointment from a maximum of 3 days
to 2 days
After a team mapping event, a PDSA
cycle was tested. Chest x-ray requests
were faxed to the department from the
GP practices with the patient’s contact
details. These requests are dealt with
on a daily basis and the patient
contacted directly by the x-ray staff to
arrange an appointment on either the
same day or the next day. The intranet
guideline for referral of suspicious lung
cancer was reviewed and updated
following the mapping event and a
reminder letter sent to all GP practices in
Grampian advising of the updated
guideline.
ƒ
Direct communication with the
patient to ensure they can attend for
x-ray minimising cancellations and
re-appointments.
Next Steps
Ensure sustainability of service and
continued communication with Primary
Care.
Contact
In this way the time to receiving a chest
x-ray has reduced from a maximum of 2
Dr Joe Legge, Respiratory Physician
Aberdeen Royal Infirmary, Aberdeen
[email protected]
01224 681 818
10
CANCER SERVICE IMPROVEMENT PROGRAMME EXAMPLES OF CHANGE
Referral to a service, not a named consultant
Top 20 Referral 3
In Tayside, doctors, nurses, managers and medical records staff, asked GP’s to add “Colorectal”
to the referral letter. A letter was written to all GP practices in Tayside. The number of patients
waiting for a hospital appointment has now reduced.
Making It Happen
Reduction in time taken to vet GP referral letters from a maximum of 8 weeks to 3 days
9
8
7
6
Weeks
Prior to this change, referral letters
sent into the hospital by GP’s about
patients with colorectal symptoms were
all received within medical records,
then sent through the hospital internal
mail to one doctor to be vetted. They
were batched together with all the
other general surgical referrals.
5
4
3
2
After vetting and categorising into
urgent, soon and routine, the letters
were sent back to medical records and
placed onto an appointment waiting
system.
1
0
Jan-2004
Feb-2004
Apr-2004
Jun-2004
Months
This process took a maximum of 8
weeks to complete.
ƒ
After a team mapping event, a PDSA
cycle was tested. A letter was sent to
all GP practices in Tayside to request
that the word “Colorectal” be added to
the referral letters to distinguish them
from the general surgical referrals
when received in medical records.
ƒ
ƒ
The letters are still vetted, but the
doctor responsible now hands the
letters with “colorectal” highlighted to
the Colorectal Clinical Nurse Specialist
who now either allocates appropriate
clinic
appointments
or
organises
investigations before returning the
letters by hand to medical records.
Jan-2005
Aug-2005
Ninewells Hospital and Medical School, Dundee, Scotland
Reduction in vetting referral letters
from a maximum of 8 weeks to 2
weeks
Referral letters are now being
reviewed by the Colorectal Clinical
Nurse Specialist and dealt with
appropriately
Approximately 2500 patients are
referred each year to general
surgery in Tayside and most of
these referrals have colorectal
symptoms, therefore this change
will benefit these patients.
Next Steps
Reduce the time to vet referral letters
further by allowing the Colorectal
Clinical Nurse Specialist access to the
electronic referral system to view all
referral to the colorectal service, thus
allowing “on line” review and decisions
transferred back to medical records
electronically by email.
Implementation Advice
Consultation and communication with
Primary Care colleagues is essential.
Contact
Impact
Jackie Kerrigan, Macmillan Colorectal Nurse
Specialist, Ninewells Hospital, Dundee
[email protected]
01382 425 563
The benefits from this change have
been:
11
CANCER SERVICE IMPROVEMENT PROGRAMME EXAMPLES OF CHANGE
Direct referral to a specialist service from diagnostics
Top 20 Referral 4
In Dundee, doctors, radiologists and clerical staff have made a number of simple changes to their
working practices which has reduced the time that patients wait to be seen by a respiratory
physician. Previously patients could wait on average 23 days to be seen. This has now been
reduced to an average of 10.5 days. Radiology staff are now making a direct referral to the
Respiratory clinic after reporting a highly suspicious chest x-ray. Details of the results and the
patient appointment are sent to the GP.
Time from GP referral to 1st specialist hospital appointment
Making It Happen
25
23
20
15
15
14
Days
Prior to the change, patients would be asked
to attend the open access radiology service for
a chest x-ray. The results were reported &
would be dictated and sent back directly to the
patient’s GP. The GP would then review the
result, see the patient and recommend a
referral to the hospital specialist.
12
10.5
10
8
This method built in a considerable delay for
the patient and the time to diagnosis and
subsequent treatment could be significant.
5
This was highlighted at a lung team mapping
event and after discussion it was agreed to
test direct referral from Radiology to the
Hospital Specialist.
0
Apr - Jul 03
Nov-03
Feb-04
Jun-04
Months
After the x-ray was taken, if felt suspicious of
cancer the Radiographer would highlight this
as urgent. It would be reported and typed
within 48 hours. The secretary would then
contact the Hospital Chest Clinic and arrange
an appointment for the patient at the hospital.
The Chest Clinic sends or telephones the
appointment to the patient. The x-ray report
is returned to the GP with result and the date
of the patient’s hospital clinic appointment.
Oct-04
Feb-05
Ninewells Hospital and Medical School, Dundee,
Scotland
ƒ
Time from GP referral to seeing a
Specialist has reduced from an average
of 23 days to 10.5 days.
ƒ
Patients are being diagnosed and therefore
starting treatment, as appropriate, more
quickly.
ƒ
Alleviating patient’s anxiety by seeing and
diagnosing more quickly.
Next Steps
Implementation Advice
Ensure sustainability of service. Continued
review of process to maintain shortest waiting
times for patients, aim is to maintain time at
an average of 10 days.
Consultation and communication with Primary
Care colleagues is essential. Patients being
referred for a chest x-ray need to be made
aware that they may receive a further
appointment from the Hospital Chest Clinic.
Contact
Impact
Dr Peter Brown, Respiratory Physician
Ninewells Hospital, Dundee
[email protected]
01382 660 111
The benefit from this change has been:
12
CANCER SERVICE IMPROVEMENT PROGRAMME EXAMPLES OF CHANGE
No vetting or, as a minimum, daily team vettng of all referrals
Top 20 Referral 5
In Lothian, consultant gynaecologists and nursing staff have developed a system for daily vetting of
referral letters to ensure that there is no delay for patients to be seen by a consultant.
Making It Happen
Impact
Prior to the change, all consultants had
different vetting patterns and in some
cases were vetting referral letters only
once a week. In addition, if a consultant
were absent, the letters waited for
vetting until they returned, leading to a
potential delay of up to 39 days just
for a consultant to see a letter.
Impact of the change over time
70
65
62
60
Number of days
55
50
45
39
40
35
30
At a process mapping event, the team
identified that a daily vetting rota would
eradicate this delay in the patient’s
journey. This idea was tested using
PDSA (plan, do, study, act) cycles.
Through discussion and team working, a
rota was established and a consultant
and senior OPD nurses now vet letters
every day. Letters are categorised into
urgent,,
soon
or
routine
and
appointments are made accordingly.
25
20
Treatment Target
15
Days
10
5
1
0
Nov-04
Dec-04
Jan-05
Feb-05
Mar-05
Apr-05
Time to vet letters
The benefits of this change are:
ƒ
Now all referral letters are seen and the
patient’s appointment is made the day
the referral letter arrives at the hospital.
ƒ
ƒ
Patients who require to be seen urgently
are now given an appointment within 7
days of the letter arriving at the hospital
which means that patients are seen by a
consultant and can begin the process of
diagnosis and commence treatment up
to 39 days sooner than before.
Urgent referrals are identified within
1 day instead of up to 39 days
Patients are seen by a consultant
within 8 days of urgent GP referral
instead of a potential of 46 days
Diagnostic processes & treatment can
begin 46 days sooner than before
Next Steps
The team are continually auditing
sustainability of the change to ensure
that all patients who are referred
urgently for gynaecological cancer are
not delayed by the vetting process.
Implementation Advice
Contact
If it is difficult to get the whole team on
board, use the PDSA (plan, do, study,
act) model of improvement to test the
change – this is a good way to persuade
‘reluctant’ team members of the benefits
to patients and the service.
Dr David Farquharson, Clinical Director
Centre for Reproductive Health, Edinburgh
Royal Infirmary.
[email protected]
0131 536 1000
13
14
Consultation/Investigation/
Diagnosis (CID)
Consultation/Investigation/Diagnosis (CID)
“Timely management of investigtions and
results to provide early communication
of diagnosis.”
1. Pre-booking/scheduling of investigations and
appointments.
2. Dedicated or fast-track clinics with rapid
reporting.
3. Reduce consultant vetting of investigation
requests.
4. Telephone consultation/communication of
results.
5. Specialist nurse-led clinics.
6. Reduce follow-up appointments at out-patient
clinics.
15
CANCER SERVICE IMPROVEMENT PROGRAMME EXAMPLES OF CHANGE
Pre-booking/scheduling of investigations and appointments
Top 20 CID 1
Coagulation as a routine investigation: In the Edinburgh Royal Infirmary, all new patients
referred to the respiratory clinic with a suspected lung cancer have a routine blood test to
establish their clotting factor.
Making It Happen
The clinical nurse specialist discussed with the clinical team, the need to ensure that coagulation screening is included in the blood investigation request whilst the patient is in
the outpatient department.
This is essential for the patient to progress to the
bronchoscopy unit for further investigations.
Prior to the change, when the patient arrived for a bronchoscopy without a recent coagulation screen, bloods were taken and the patient had to wait until the report was
available. This process could result in a possible wait of several hours, for the patient.
Implementation Advice
Appropriate protocol in place within outlying hospitals to ensure referrals do not wait for
triaging.
Impact
Having the results readily available means that the patient can have the bronchoscopy
done without delay.
Contact
Gillian Whitson
Oncology Specialist Nurse
New Royal Infirmary
Edinburgh
[email protected]
0131 536 1000
16
CANCER SERVICE IMPROVEMENT PROGRAMME EXAMPLES OF CHANGE
Pre-booking/scheduling of investigations and appointments
Top 20 CID 1
In Dundee, closer working by doctors and clerical staff has helped reduce the delay for patients
receiving tests that will assist with providing a diagnosis. Patients now leave the chest clinic after
their first appointment with the respiratory physician with dates for their bronchoscopy, CT scan and
return outpatient appointment. The clinic receptionist now co-ordinates all tests for patients before
they leave. This not only means that the patient leaves knowing exactly what is happening next but
also in recent months the time to diagnosis has shortened.
Making It Happen
the smooth
patients.
Prior to the change, patients would see the
Physician and then leave the hospital being
advised that an appointment for a CT scan and
bronchoscopy would be sent to them. The
physician would then send a request for a CT
scan and bronchoscopy to the appropriate
departments. The requests would be mailed
and once received appointments made and
sent to the patient. After receiving the tests
the patient was required to contact the Chest
Clinic to say they had now had their tests and
a return outpatient appointment to see the
Physician would be made.
running
of
appointments
for
Impact
The benefits from this change are:
This method built in a considerable delay for
the patient and the time to diagnosis and
subsequent treatment could be significant.
This was highlighted at a mapping event with
the lung team and after discussion it was
agreed that the patient should be able to leave
their first appointment with dates for their
investigations and return appointment for the
results.
ƒ
Time to investigations has been reduced.
ƒ
Patients know exactly the next steps in
their journey on leaving their first
appointment. Potential anxiety is lessened
as they know exactly when and where the
next investigations are going to be and are
not
sitting
at
home
waiting
for
appointments.
ƒ
Time to diagnosis is reduced.
Next Steps
Ensure sustainability of service. Continued
review of process to ensure minimum waiting
times for investigations are achieved. Ensure
patient information and support available
following appointment.
The Receptionist at the Chest Clinic now
maintains an updated list of next available CT
scan slots and bronchoscopy slots. Once the
patient leaves their outpatient appointment
they agree their scan and bronchoscopy date
and receive the appropriate information
leaflets regarding these with their date to
return to see the Physician. The MDT Coordinator and Specialist Nurse are on hand
should the patient wish more information.
Contact
Dr Peter Brown, Respiratory Physician
Ninewells Hospital, Dundee
[email protected]
01382 660 111
Implementation Advice
Communication
between
Radiology,
Bronchoscopy and the Chest Clinic is vital for
17
CANCER SERVICE IMPROVEMENT PROGRAMME EXAMPLES OF CHANGE
Pre-booking/scheduling of investigations and appointments
Top 20 CID 1
In Victoria Hospital, South Glasgow, radiologists and secretarial staff are now using an electronic
system to alert secretarial staff to prioritise typing of abnormal chest x-ray reports. This now means
that the GP’s are alerted to suspicious chest x-ray results allowing them to refer the patient to the
respiratory unit quicker and reducing a previous delay.
Making It Happen
Prior to the change, all abnormal chest x-ray reports were sent back to the referring GP by post.
The GP’s then had to then re refer patients to the hospital to see a respiratory specialist. This meant
it took approximately 10 days for the report to get back to the GP.
After a process mapping event staff agreed to try out a PDSA (Plan, do, study, act) change cycle to
reduce the time taken to get the report back to the GP.
Implementation
An electronic prioritising system was put in place for reporting and reports are typed within 24
hours. The GP now gets a telephone call with the abnormal results and the written report is then
authorised and sent to GP by fax within 7 days.
Impact
ƒ
ƒ
ƒ
This has reduced the time taken for abnormal reports to be sent to the GP by 4 days
All abnormal chest x-ray reports are dealt with promptly
The GP is alerted to abnormal results allowing a speedier referral to a respiratory specialist
Contact
Dr Joe Sarvesvaran, Consultant Respiratory Physician
Victoria Hospital, South Glasgow
[email protected]
0141 201 6000
18
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Pre-booking/scheduling of all investigations and appointments
Top 20
CID 1
In the Victoria Infirmary, South Glasgow, doctors, nurses and clerical staff have made changes to
the timing of new patient appointments. All new patients being seen at the respiratory clinic are
now guaranteed to have all their lung function test carried out in a timely and appropriate manner.
Patients now have all relevant tests on the same day, instead of making two visits to the hospital.
Making it Happen
Patients who had been referred by their GP to be seen by a respiratory physician for suspected lung
cancer, were waiting a long times at the out patient clinic for a lung function test. Some patients had
to return on a different day as it was too late for this test to be completed if their appointment was
later in the afternoon.
After reviewing this, it was agreed to make appointments for these new patients at the start of the
clinic. This would allow plenty of time to complete all appropriate tests in the one day.
Impact
The benefits of this change are:
•
•
All patients have their lung function tests done on the 1 day saving them a hospital journey for a
return appointment.
Patients are waiting less for their lung function test and all patients are leaving the clinic by 5
pm.
Contact
Dr Joe Sarvesvaran, Consultant Respiratory Physician
Victoria Hospital, South Glasgow
[email protected]
0141 201 6000
19
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Pre-booking/scheduling of all investigations and appointments
Top 20
CID 1
In Glasgow, a surgeon, clinic and radiology staff have reduced the waiting time for a patient to have
a barium enema. They did this by simply improving the communication between the clinics and the
radiology department.
Making it Happen
Impact
Prior to the change, 20% of patients
were not attending for their pre
arranged barium enema investigation,
meaning approximately 1 in 5 of these
investigation slots were being lost or
wasted. This was highlighted by staff at
a colorectal process mapping event.
The benefits from this change have
been:
ƒ All patients now wait a maximum of
2 weeks for their barium enema, a
reduction of up to 6 weeks
ƒ The patients now know the date and
time of their barium enema before
they leave the out patients clinic
ƒ The DNA rate as been reduced from
and average of 20.5% before the
change to and average of 11.9%
after the change
After the patients had been seen by a
doctor in the out patients clinic and the
doctor had referred them for a barium
enema, they went home and waited for
an appointment to be sent to them by
post along with a bowel preparation kit.
The waiting time for this investigation
was 2 – 3 weeks for urgent referral and
over 8 weeks for routine referrals
Next Steps
ƒ To further reduce the DNA rates
ƒ Full explanation of the barium enema
and bowel preparation to be given at
the out patient clinic
ƒ The patients telephone number to be
written on the barium enema request
card so that cancelled appointments
can be re allocated quicker.
A PDSA cycle was tested to reduce the
“did not attend rate” (DNA) and to
increase the efficiency of the barium
enema appointments.
This involved sending a list of available
barium enema appointment slots to the
out patient clinic every Monday morning.
If required the patients were then given
an available appointment before they
left the clinic along with the bowel
preparation.
Contact
Dr Fatui Poon, Consultant Radiologist
Glasgow Royal Infirmary, Glasgow
0141 201 4000
Reduction in Did Not Attend (DNA) rate for Barium Enema Investigation
0.35
0.3
Percentage
0.25
0.2
0.15
0.1
0.05
0
Apr-2003
May2003
Jun2003
Jul-2003
Aug2003
Sep2003
Oct-2003
Nov2003
Month
20
Dec2003
Jan2004
Feb2004
Mar2004
Apr-2004
May2004
Dec2004
Greater Glasgow Health Board,
Glasgow, Scotland
CANCER SERVICE IMPROVEMENT PROGRAMME EXAMPLES OF CHANGE
Dedicated or fast track clinics with rapid reporting
Top 20 CID 2
The radiology department at Borders General Hospital identified a need to act more quickly when
abnormalities show up on chest x-rays. Radiographers can identify abnormal chest x-rays and
have reduced delays by up to 1 week.
Making It Happen
Prior to the change, chest x-ray films were sent for reporting as part of the routine list. This meant
a potential delay of 2 – 4 days for the potentially urgent abnormal chest x-ray to be reported.
The consultant radiologist trained ALL radiographers to recognise chest abnormalities, which
require rapid reporting.
This was achieved by providing in house training sessions for radiographers.
Implementation
When an x-ray highlights a chest abnormality, the radiographer seeks specialist advice to allow
same day reporting.
Impact
Film/Images are being promptly reported. The report is being sent back to the GP with
advice to refer urgently to the lung physician. This has reduced the delay by up to 1 week.
Contact
Dr John Reid, Consultant Radiologist
Borders General Hospital
[email protected]
01896 826 421
21
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Dedicated or fast track clinics with rapid reporting
Top 20 CID 2
Dedicated Lung Cancer Clinic: Patients attending their GP with highly suspicious symptoms
suggestive of lung cancer are now directly referred to the dedicated Lung Cancer Clinic at the
Western General Hospital, Edinburgh.
Making It Happen
At a process mapping event for lung cancer service in the Western General Hospital Edinburgh, it
was recognised that several delays occurred for patients suspected of lung cancer receiving their
first appointment with the respiratory physician.
A dedicated lung cancer clinic for patients referred with suspicious symptoms was implemented.
Previously, the chest clinic was held on a Monday morning when the radiology department was
working to maximum capacity, catching up with weekend work and added pressure/demand
from patients being sent from the clinic. This meant that sometimes arrangements had to be
made for patients to return on a different day for their CT Scan.
Holding the clinic on a Wednesday has ensured that patients have a CT scan on the same day as
attending the clinic. The radiologist discusses scan results with the physician and patients are
given results at their clinic appointment, ensuring a rapid diagnosis. Clinical nurse specialist
clinic attendance means prompt advice and support can be implemented when the patient is
given the diagnosis.
Implementation
Referrals to the dedicated lung clinic are made by fax/phone to the lung physician secretary who
provides an appointment for the next lung clinic, in some cases the next day. Information is also
provided for the patient at this stage. Having this speedy referral process to the specialist clinic
means that referral to the Multi-Disciplinary Team meeting (where each case is discussed and
treatment plans are decided) is quicker and patients receives their treatment options promptly.
Prior to implementation of the clinic, the % of patients referred to treatment within 62 days is
shown in the table below. The clinic was fully implemented in August 2004 (3rd quarter). The 4th
quarter demonstrates a significant increase in this percentage.
DEDICATED LUNG CANCER CLINIC – WESTERN GENERAL HOSPITAL EDINBURGH
Quarter in 2004
% of patients from referral to 1st treatment
1ST
48.5%
2ND
58.5%
RD
3
4TH
64.7%
92.3%
The change was
implemented in
August 04 and 4th
quarter
measurement
above is for
period 1/10/04 –
31/12/04.
Impact
ƒ
ƒ
ƒ
ƒ
Patients now have a CT Scan while attending the dedicated clinic.
Clinical nurse specialist support is available for the duration of the clinic.
Patients with suspicious symptoms are seen much quicker.
Change impacts and benefits approximately 372 patients a year referred to the service.
Contact
Dr Ron Fergusson, Consultant Respiratory Physician
Western General Hospital, Edinburgh
[email protected]
0131 537 1779
22
CANCER SERVICE IMPROVEMENT PROGRAMME EXAMPLES OF CHANGE
Dedicated or fast track clinics with rapid reporting
Top 20 CID 2
In Highland, the Nurse Endoscopist has changed the way she works to enable her to work in
endoscopy every day undertaking investigations for patients referred with colorectal symptoms.
This allows her to attend and contribute to the weekly meeting where staff discuss all patients
diagnosed with colorectal cancer and decide upon a treatment plan for each patient.
Making It Happen
The nurse endoscopist can:
Prior to the change the Nurse Endoscopist
undertook colonoscopy investigations working
alongside a consultant, on a part time basis,
at a rectal bleeding clinic. This working
arrangement did not allow her to attend the
weekly multidisciplinary meeting where the
colorectal team discuss all patients diagnosed
with colorectal cancer and decide upon a
treatment plan for each patient.
ƒ
now attend the weekly multidisciplinary
meeting and contribute to the patients
treatment plan
ƒ
now undertake an extra 12 colonoscopy
investigations a week. This has happened
as a result of a consultant freeing up
sessions to undertake different work
This meant the nurse endoscopist could not
input to the discussion to decide the best
treatment plan, despite being the person
undertaking the investigation that diagnosed
the cancer.
ƒ
able to undertake additional colonoscopies
when other sessions in endoscopy are
cancelled as a result of consultants annual
leave or their emergency on-call
commitments
This was highlighted at a mapping event with
the colorectal team and after discussion with
the manager, funding was made available to
let the endoscopy nurse work full time.
ƒ
implement a Nurse led colonoscopy service
and communicate results of investigation
to patients on the same day
Contact
Impact
Isla MacDonald, Nurse Endoscopist
Raigmore Hospital, Inverness
[email protected]
01463 704 000
The benefits from this change have been:
23
CANCER SERVICE IMPROVEMENT PROGRAMME EXAMPLES OF CHANGE
Dedicated or fast track clinics with rapid reporting
Top 20 CID 2
In Dundee, doctors, nurses, radiologists and admin staff are working together to reduce the time to
diagnosis for patients with frank haematuria. Patients are receiving all of their investigations at one
visit instead of three or more.
Making It Happen
Prior to the change, patients were required to
visit the hospital on several occasions to see
the Hospital Specialist and receive 3 separate
investigations in order to receive their
diagnosis.
ƒ
Time to diagnosis for patients has been
reduced
ƒ
Reduced number of visits to hospital for
patients
ƒ
Co-ordinated approach to care, ensuring
patients know exactly what is happening
next and when
ƒ
Elimination of delays between
investigations and diagnosis
This method built in a considerable delay for
the patient and the time to diagnosis and
subsequent treatment could be significant.
The urology team were keen to improve the
time to diagnosis for patients and reduce the
number of visits to hospital. The fast track
system for patients with frank haematuria has
been tested and implemented in Dundee. 3
clinics per week are now run seeing 3 patients
each day. The patients receive information
leaflets and an appointment card with times to
arrive at ultrasound and then endoscopy for
their tests. At the end of their tests the nurse
specialist and consultant will discuss with the
patient their next steps.
Next Steps
Ensure sustainability of service. Continued
review of process to ensure minimum waiting
times for investigations are achieved. Spread
of service to Perth and Angus. Potential for
Nurse Specialist to contact patients with
negative results by telephone to minimise outpatients appointments and delay to receiving
results for patients.
Implementation Advice
Communication
between
Radiology,
Endoscopy and the Urology Team is vital for
the smooth running of the clinic for patients.
Contact
Impact
Mr Chris Goodman, Consultant Urologist
Ninewells Hospital, Dundee
[email protected]
01382 660 111
The benefits from this change have been:
Reduction in time to diagnosis for patients with frank haematuria
from an average of 90 - 30 days
100
90
80
70
Delay - Diagnosis to informing patient
Delay Ultrasound to Intravenous Ultrasound
Delay flexible cystoscopy to ultrasound scan
Delay received to flexible cystoscopy
Delay referral to received
Days
60
50
40
30
Ninewells Hospital and Medical School, Dundee, Scotland
20
10
0
Before
After
24
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Dedicated or fast track clinics with rapid reporting
Top 20 CID 2
Rapid PSA Reporting – Prostate Specific Antigen: In Oban, all patients being referred to the nurse
led prostatic assessment clinic have a routine PSA blood test. This now means that patients are
seen 1 week sooner.
Making It Happen
Reduction of 8 days reporting PSA
blood samples
Blood testing for PSA levels could be carried
out by the GP prior to a clinic appointment or
at the first consultation at the prostatic
assessment clinic.
No. of Weeks
5
Before, all primary care blood samples came
into laboratories at Oban hospital before being
transferred to a Paisley hospital for testing.
This procedure took on average 10 days and
was reported by mail.
4
3
2
1
Laboratory staff investigated other more
efficient ways of testing and reporting PSA
blood samples.
Impact
The benefits from this change are:
ƒ
ƒ
A reduction of 8 days in reporting PSA
blood samples
Next day electronic reporting for blood
tests
A reduction of 2 weeks delay towards
diagnosis for patients
Contact
Rosemary Noon
Urology Nurse Practitioner, Vale of Leven Hospital
[email protected]
Tel: 01631 789059
25
ug
us
t
A
Ju
ly
ay
M
Month (2005)
Implementation Advice
ƒ
Ju
ne
M
Following consultation with other hospitals,
the procedure to test and report PSA was
changed and the samples were sent to
another Argyll and Clyde laboratory where the
results could be reported electronically.
A
pr
il
ar
c
h
0
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Dedicated or Fast-track clinics with rapid reporting
Top 20
CID 2
In Glasgow, within urology services, a multidisciplinary team are working together to reduce the
time to diagnose patients with frank haematuria. This change resulted in several improvements for
patients.
Making It Happen
•
At a Cancer Service Improvement Programme
(CSIP) mapping event it was highlighted that
urology patients were required to visit their
local hospital several times to see a doctor
and have tests. Each visit was to a different
department and patient information and
support services were not coordinated.
Elimination of delay between
investigations
Reduced number of visits to
hospital departments
Improved communication and
support systems for patients
Improved communication and
coordination between departments
•
•
•
Staff decided to develop a one stop fast track
haematuria system where patients could be
seen quickly and diagnosed in 1 day.
Reduction of 3 months to diagnosis
100
90
80
70
60
50
40
30
20
10
0
1 day
Se
pt
us
t
ug
ly
A
Ju
ne
Ju
A
pr
il
1 clinic a week is run with 5 patients
every day. The patients receive
detailed information leaflets with their
appointment card explaining the
diagnostic tests and format for the
clinic.
• Every patient sees a specialist nurse
who performs a full assessment and
gives the patient a support phone
number.
• Patients have a consultation with
results and next steps before leaving
the urology department
=
1
ay
•
90 days
M
No. of Days
The urology, radiology and primary care teams
were keen to develop a team diagnostics
approach where patients would undergo all
three diagnostic procedures in one day and
information and communication would be
coordinated.
Month (2005)
Next steps
Since this is a new service, reviews will be 3
monthly, assessing capacity and demand to
ensure sustainability of service.
Contact
Mr Naeem Akhtar – Consultant Urologist
[email protected] tel 0141 201 1100
Dr Paul Duffy – Consultant Radiologist
[email protected] tel: 0141 201 1558
Sister Una Daly
[email protected] tel : 0141 201 1559
Dr George Barlow – GP
[email protected]
0141 427 1581
Implementation Advice
A multidisciplinary steering group was formed.
Precise preparation and collaboration is
essential.
The
lead
cancer
Gp
was
instrumental in gaining primary care support
and formulating policies to inform and guide
primary care staff.
Impact
The benefits from this change are:
• Reduction of on average 3 months
to diagnosis for patients
26
CANCER SERVICE IMPROVEMENT PROGRAMME EXAMPLES OF CHANGE
Reduce consultant vetting of investigation requests
Top 20 CID 3
Daily vetting of radiology requests: In Dumfries and Galloway, radiology requests are vetted by a
radiologist on arrival in the department, reducing delay to investigation and diagnosis.
Making It Happen
Impact
At the process mapping event the team
identified that radiology request could sit in
the radiology department for 2 – 3 days
before being seen by a radiologist for
prioritisation. This was adding a delay of 2 – 3
days for patients to have their investigations
carried out and to start their treatment.
Now when radiology requests arrive in the
department, clerical staff ensures that they
are seen by a consultant radiologist the same
day. An appointment is made, patients have
their investigation carried out, diagnosis is
made and treatment can begin 2 - 3 days
sooner than before.
Radiology
Request
Radiology
Wait
for vetting
Appointed
Request
Investigation
Vetted same
day
Appointed
Investigation
2- 3 days
This change has benefited ALL patients
requiring urgent radiological investigation.
The consultant radiologist discussed this
problem with the team & it was agreed that
the clerical staff would show referrals to a
consultant radiologist when they arrive in the
department so that appointments can be
made 2 – 3 days sooner.
In tandem with many other improvement
ideas implemented in Dumfries & Galloway’s
for patients with suspected gynaecological
cancer, this system has helped to achieve
92.9% of patients with ovarian cancer
being treated within 62 days of GP
referral. Prior to working with CSIP to
redesign the service only 72.7% of patients
met the target – an increase of 20.2% since
2002.
Implementation Advice
This was very easy to implement by
consultation & communication to ensure that
the whole team were aware of the new
process.
Contact
Sustainability should be monitored by audit so
that any slippage can be immediately rectified
Dr David Hill, Consultant Radiologist
Radiology Department, Dumfries and Galloway
Royal Infirmary
[email protected]
01387 246 246
27
CANCER SERVICE IMPROVEMENT PROGRAMME EXAMPLES OF CHANGE
Telephone consultation/communication of results
Top 20 CID 4
In Dumfries and Galloway, the radiologist has developed a system to ensure that the GP is
informed of a negative report following radiological investigations, requested by a hospital
consultant.
Making It Happen
The radiologist developed a process within the department at Dumfries and Galloway
Royal Infirmary to ensure that the negative report is sent to the GP at the same time
that it is given to the referring consultant.
Prior to this change, the information was communicated by letter from the consultant,
after receiving the report from the radiologist.
Impact
ƒ
ƒ
This reduces the delay for patients being given results.
GPs now receive notification of results 7-10 days sooner, than prior to the change.
Contact
Dr David Hill, Consultant Radiologist
Radiology Department, Dumfries and Galloway Royal Infirmary
[email protected]
01387 246 246
28
CANCER SERVICE IMPROVEMENT PROGRAMME EXAMPLES OF CHANGE
Telephone consultation/communication of results
Top 20 CID 4
In Paisley, nurses and doctors can now obtain urgent test results within 48 hours. This happens by
phoning the laboratories in Glasgow rather than waiting for up to 7 days to receive written reports.
Making It Happen
Prior to the change, it was identified at a process mapping event that there was a delay in receiving
blood results form the laboratory in Glasgow. This was caused by the time taken to post them form
Glasgow to Paisley. The doctors required to have these results available before patients with
gynaecological cancer could start their treatment. It took up to 7 days for these results to be posted.
Implementation
The doctor in Paisley wrote to all other doctors to ensure they mark the blood tests ‘urgent’, and to
inform them of a telephone number to call for results within 48 hours, instead of waiting for the
written results in the post.
This information is also displayed on a sheet within easy access in the Gynaecology wards.
Impact
ƒ
ƒ
ƒ
All consultants now know to telephone the Glasgow laboratory for urgent results within 48 hours,
and patients do not have to wait so long for their results.
Patients can be presented earlier at the Multidisciplinary Team Meeting (MDT) and therefore have
their treatment started earlier.
Reduction in delay of up to 5 days.
Contact
Dr Laura Cassidy, Consultant Gynaecologist
Royal Alexandra Hospital, Paisley
[email protected]
Tel : 01475 504 839
29
CANCER SERVICE IMPROVEMENT PROGRAMME EXAMPLES OF CHANGE
Telephone consultation/communication of results
Top 20 CID 4
In Tayside, the colorectal clinical nurse specialist telephoned and sent letters to patients at home
who had waited the longest for an out patient appointment after being referred by a GP with
colorectal symptoms. This reduced the time patients had to wait to be seen at hospital.
Making It Happen
The benefits from this change have been:
At a CSIP colorectal service mapping event it
was discovered that there were 460 patients
listed on an out patient electronic system,
waiting to be allocated an appointment, with
the longest waiting 15 months.
Combined with colorectal patient and carer
interviews:
ƒ
ƒ
ƒ
“Unhappy at the time I
had to wait to be seen at
The number of patients waiting was
reduced from 463 to 5
The maximum wait was reduced from 15
to 1 month
The percentage of patients achieving the
62 day target from GP referral to first
treatment has increased from 60% to 80
%
hospital after referred by
GP” (6 months)
Increase from 60 - 80% of patients treated within 62 days from urgent GP referral to 1st treatment
1.2
Implementation Advice
1
0.8
Percentage
The Colorectal Clinical Nurse Specialist (CNS)
telephoned the first 25 patients who had
waited the longest, then a letter was sent to
the next 200 patients. The patients were all
asked if they would like a telephone
consultation by the CNS and then they were
either given an appropriate out patient
appointment or sent for an investigation, all
this was coordinated by the CNS.
0.6
0.4
0.2
The CNS found this to be time consuming at
first but felt it was a worth while exercise as
she is now fully aware, and has become much
more involved in the referral process and
complete patient journey.
0
Jul - Sept 04
Mar-05
Months
May-05
ƒ
Reduction in waiting time from 15 months to 1 month for first out patient appointment
500
Implementation of new, nurse led, out
patient clinics in Dundee and Angus.
463
Contact
400
Number of patients
350
300
Jackie Kerrigan, Macmillan Colorectal Nurse
Specialist
Ninewells Hospital, Dundee
[email protected]
01382 425 563
290
250
220
200
190
Page
150
100
70
50
40
25
5
0
Jan-2004
Feb-2004
Mar-2004
Apr-2004
May-2004
Month
Jun-2004
Jul-2004
Jul-05
Ninewells Hospital and Medical School, Dundee,
Scotland
Next Steps
Impact
450
Dec-04
Mar-2005
Ninewells Hospital and Medical School, Dundee,
Scotland
30
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Telephone consultation/communication of results
Top 20
CID 4
Telephoning patients to tell them their appointment details for the multidisciplinary clinic has
eliminated a potential delay of 7 days for patients starting their cancer treatment.
Making It Happen
In Fife, a Clinical Nurse Specialist noticed that several patients were not attending the
multidisciplinary clinic & discovered this was because the appointments were being posted to
patients too late for them to be able to attend. This caused a delay of 7 days in patients starting
their treatment for cancer.
This problem has been easily resolved, the Clinical Nurse Specialist now gets a copy o the list of
patients due to attend the clinic, she then telephones the patients at home to inform them of the
date and time of their appointment. She also makes sure they have transport organised to attend
the out patient clinic.
Impact
The benefits of this change are:
•
•
•
No patients have missed their out patient clinic appointment
All patients are now starting their treatment up to 7 days earlier
This change, along with several other improvements, has contributed to 100% of patients with
ovarian cancer meeting the 62 day target
Contact
Jane McCafferty, Gynaecology Clinical Nurse Specialist
Forth Park Hospital, Kirkcaldy
[email protected]
Tel : 01592 643355
31
CANCER SERVICE IMPROVEMENT PROGRAMME EXAMPLES OF CHANGE
Specialist nurse-led clinics
Top 20 CID 5
In Inverclyde, the colorectal nurse specialist has increased the capacity of the out patient clinic by
establishing her own out patient service for patients with low risk colorectal symptoms.
Making It Happen
Prior to the change, all patients referred to the hospital with colorectal symptoms were seen by a
doctor. After a process mapping event, it was highlighted that the current wait to be seen by a
doctor was 11 weeks.
A nurse led clinic was established for patients referred by their GP with low risk colorectal
symptoms. All referrals are still vetted by a doctor and then suitable patients are allocated a time
see the specialist nurse. This new nurse led clinic runs fortnightly alongside the doctor’s clinic.
Impact
A patient survey was carried out and patients said:
“we are very
pleased with the
service they
received from the
nurse”
ƒ
ƒ
ƒ
The specialist nurse can see an additional 4 patients every 2 weeks
The waiting time for this new nurse led clinic is approximately 1 month less than the wait to see
a doctor.
Patients are satisfied with nurse led service.
Contact
Iain Watt, Consultant Surgeon
Inverclyde Royal Hospital, Greenock
[email protected]
01475 633777
32
CANCER SERVICE IMPROVEMENT PROGRAMME EXAMPLES OF CHANGE
Specialist nurse led clinics
Top 20 CID 5
In Highland, doctors and nurses worked together to develop a new specialist nurse clinic. Patients
who previously had colorectal surgery now have a check up by the consultant and then are seen at
agreed regular intervals by the colorectal specialist nurse for continued routine checks. The
colorectal specialist nurse has also improved the way she communicates with the GP after the
patient has had surgery for colorectal cancer.
Making It Happen
Prior to the change, all patients who had colorectal surgery were seen by the consultant for their
routine post surgery check and at each follow up appointment.
The colorectal clinical nurse specialists (CNS) have undergone extra training and follow new
procedures and protocols written in conjunction with the colorectal consultant. This has enabled
them to now review patients at agreed intervals following colorectal surgery.
This change has freed up clinic spaces in the outpatients clinic, enabling the consultant to see
additional new patients.
Impact
The colorectal patients continue to benefit from a multidisciplinary team approach after their surgery
and are aware that they will have regular follow up appointments with support and guidance from
the clinical nurse specialist.
Specialist nurse led clinics
Top 20 CID 5
The colorectal specialist nurse has also improved the way she communicates with the GP after the
patient has had surgery for colorectal cancer.
Making It Happen
Before the change the nurses and the doctors each sent a separate letter to let the GP know that
their patients had been in hospital and were now discharged following their operation in Raigmore
Hospital.
This was a result of the nurses not having access to the electronic system the doctors
record the information after surgery that the GP required.
used to
After a process mapping event the nurses gained access to this electronic system and add
information to the same letter the doctor uses.
Impact
This had resulted in less administration time for the nurse and will allow GP’s to get information they
need to care of the patients at home more quickly.
Contact
Mr James Docherty, Colorectal Surgeon
Raigmore Hospital, Inverness
[email protected]
01463 704 000
33
CANCER SERVICE IMPROVEMENT PROGRAMME EXAMPLES OF CHANGE
Reduce follow-up appointments at outpatient clinics
Top 20 CID 6
In Highland, the nurse endoscopist now telephones patients at home after an endoscope
investigation to ask how they are feeling. This now means that patients do not have to come
back to the out patient department in the hospital for a check up.
ƒ 1 to 1 consultation with no interruptions or
observers i.e. medical students
Making It Happen
Prior to the change, all patients who had
undergone an endoscope investigation was
given an out patients appointment to return to
the hospital for a routine check up.
ƒ
It was discovered that when the patients
attended for this check up, they were asked
how they were feeling and if fine were
discharged from the hospital back to the care
of their GP.
ƒ
No further examination and no time limits
on consultation
Impact on service
Increased capacity in the out patient clinic
by 3 to 4 appointment slots per week,
allowing the doctors to see additional new
patients
The nurse endoscopist commented:
The nurse endoscopist now asks the patients
after their investigation and before they leave
the hospital whether they would agree to her
phoning them at home to ask how they are
feeling instead of an additional out patients’
appointment.
“Can give more
advice and
reassurance”
The nurse has a record of what type of
investigation the patients had and uses
structured questions when telephoning the
patients at home, three months after their
investigation.
“Patient
always
thanks me
for phoning
them”
Comments from patients include:
Next Steps
“Good, does that
mean I don’t have
to come back?”
A new information leaflet has been developed
and will be given to patients before they leave
the hospital. This will explain the new
telephone consultation and will include the
contact details of the nurse endoscopist.
Impact for patients
ƒ
Patient now aware what the next step is
ƒ
Patients don’t have to travel back to the
hospital for their check up
“Patients are
much more
relaxed and
cooperative
when at home
Contact
ƒ
Isla MacDonald, Nurse Endoscopist
Raigmore Hospital, Inverness
[email protected]
01463 704 000
No extra time off work or child care to
organise
34
Multi Disciplinary Team (MDT)
Multi Disciplinary Team (MDT)
“Ensures that a fully informed discussion of
all patients diagnosed with cancer takes
place and appropriately formulated
treatment plan is documented.”
1. Clear responsibility for co-ordination of MDT to
ensure all necessary information is available at
MDT for treatment decision-making.
2. MDT used to refer on for treatment, i.e.
investigations, surgery, oncology.
3. Timely communication with GP of MDT decision.
4. Video conferencing/Telemedicine links to be
used where attendance is limited.
35
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Clear responsibility for co-ordination of MDT to ensure all necessary information
is available at MDT for treatment decision making.
Top 20
MDT 1
In Victoria Hospital, Glasgow, changes have been made to the format for discussing patients and
agreeing appropriate treatment plans at the multidisciplinary team meeting (MDT). This has been
achieved by doctors, nurses and secretarial staff introducing a proforma to be used when discussing
each patient at the weekly meeting.
Making it Happen
At the weekly multidisciplinary team meeting (MDT) patients who had been recently diagnosed with
lung cancer are discussed and an appropriate treatment plan is formulated. Prior to the change, the
way in which patients were discussed was not coordinated and each week the meeting ran overtime,
not leaving enough time to discuss every patient. This discussion for some patients meant a delay of
up to 1 week.
Implementation Advice
The team developed a proforma sheet that is completed prior to the meeting with all the relevant
information needed to make a decision on the next stage of treatment.
The form is then updated at the MDT meeting, documenting the agreed treatment plan.
This change was reviewed after a few weeks and it was decided to transfer the information collected
on the form to an electronic system. This data is now used to review the clinical decision making and
outcomes of care.
Impact
The benefit of this change has been:
•
All newly diagnosed lung cancer patients are discussed each week without delay
Contact
Dr Joe Sarvesvaran, Respiratory Physician
Victoria Hospital, Glasgow
[email protected]
0141 201 6000
36
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Clear responsibility for co-ordination of MDT to ensure all necessary information
is available at MDT for treatment decision making.
Top 20
MDT 1
Timely communication with GP of MDT decision
Top 20 MDT 3
In Grampian, doctors and nurses now meet weekly to discuss all patients who have been diagnosed
with upper GI cancer to discuss an individual treatment plan for each patient. They have also
developed a new form that is used at this multidisciplinary team meeting to record the decisions
made about each patient. This is then faxed to the patient’s GP the next day. This means GP’s now
have timely information about their patients which may contribute to improved care for patients at
home once they have been discharged from hospital.
Making It Happen
Prior to this change, there was no formal multi-disciplinary team (MDT) meeting to discuss all
patients diagnosed with upper GI cancer and decide on an individual treatment plan for each
patient.
After a process mapping event, it was suggested that a formal weekly MDT meeting should be
established on a Monday.
A list of all patients to be discussed is typed and sent the Thursday before the meeting, to all the
doctors and nurses who attend. This allows time to prepare the correct documentation required to
make the best treatment decision for each patient.
A form is used to record decisions and the resulting treatment plan. This is faxed to the patients GP
the following day.
Impact
ƒ
ƒ
All patients diagnosed with upper GI cancer are discussed by a multi –disciplinary team and a
treatment plan formulated
GP’s now have timely information about their patients
Next Steps
The doctors and nurses from the palliative care team are also to be included in the weekly
multidisciplinary team meeting. The weekly list of patients who are to be discussed is to be sent to
them also so they can also attend the meeting and input to the patients treatment plan, when
required.
Contact
Mr Ken Park, Consultant Surgeon
Aberdeen Royal Infirmary, Aberdeen
[email protected]
01224 554 534
37
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Clear responsibility for co-ordination of MDT to ensure all necessary information
is available at MDT for treatment decision making.
Top 20
MDT 1
Top 20
MDT 3
Timely communication with GP of MDT decision
In Tayside, a multi-disciplinary team (MDT) Meeting Co-ordinator has been appointed within each
site specific cancer team. The co-ordinator organises the weekly MDT meeting and communicates
quickly with the GP about the patient’s treatment options.
Making It Happen
Previously, the clinical nurse specialist
organised the weekly MDT meetings involving
multiple administrative tasks and was time
consuming. This was identified as an issue at
a Cancer Service Improvement Programme
cancer team mapping event.
patients treatment was agreed, this was a
maximum of 40 days.
The current cancer audit co-ordinator’s role
was expanded to include the organisation and
administration of the weekly MDT meeting.
The GP now has information to support the
care of the patient in the community.
The co-ordinator now makes sure that all the
patient case notes and relevant investigation
results are available for the meeting.
Next Steps
Now, the GP receives a faxed copy of the
form detailing the result of a discussion held
at the MDT within 24 to 48 hours.
GP’s will be contacted and asked for feedback
on the usefulness, content and timeliness of
the new faxed forms and comments will be
used to further develop and improve the
communication with GP’s after the MDT
meeting.
Once the treatment plan is documented the
co-ordinator faxes the plan to the GP as soon
as possible after the MDT meeting either on
the same day or next morning.
This now happens after the breast, lung,
upper GI, colorectal and urology cancer MDT
meetings.
Contact
Jillian Galloway, Clinical Team Manager
Ward 32, Ninewells Hospital, Dundee
[email protected]
01382 660 111
Impact
Prior to the change, a small audit was
undertaken in one GP practice, looking at the
time in days, a letter took to be typed, posted
and received within the practice after the
38
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
MDT used to refer on for treatment, i.e. investigations, surgery, oncology
Top 20 MDT 2
Introduction of the MDT electronic proforma on the Clinical Oncology System (COS)/LINX System
has improved the management of the lung cancer patients meeting, held in the Western General
Hospital, Edinburgh.
Making It Happen
Prior to the change, it was difficult for those attending the MDT meeting to follow instructions and
decisions.
Collaboration between IT personnel and the clinical team enabled the development of an electronic
MDT form.
Impact
The COS system is displayed on the wall for all participants to see during the MDT meeting. This
allows the decisions and treatment options for the patient to be recorded during the meeting.
This provides a much more cohesive approach to decision making at the meeting.
Contact
Richard Renton, Clinical Systems Analyst
The Royal Hospital for Sick Children/Lothian University Hospitals Division
[email protected]
0131 536 0060
39
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Timely communication with GP of MDT decision
Top 20 MDT 3
In Fife, all patients with gynaecological cancer are discussed at the weekly multi-disciplinary team
(MDT) meeting in the Edinburgh Cancer Centre. The clinical nurse specialist (CNS) now faxes a copy
of the MDT decision to the patients’ GP to ensure seamless & timely communication.
Impact
Making It Happen
Prior to the change, the team identified that
GPs were not being informed of the decision
made at the gynaecology MDT until several
weeks later. This lead to a lack of continuity &
support for patients at a crucial stage in their
pathway. Patients often contact their GP to
ask for news from the hospital about their
results & what treatment they need.
ƒ
Better
informed
GPs,
improved
knowledge of treatment plans and the
stage of patients’ pathway
ƒ
Better informed
reducing anxiety.
patients
&
Contact
This problem was discussed by the team but
without an MDT co-ordinator it was difficult to
decide who should be responsible for
undertaking the task of faxing the MDT
proforma to the patient’s GP. The CNS for Fife
was keen to improve communication for her
patients so a PDSA (plan, do, study, act) cycle
was developed to test the change.
Jane McCafferty, Clinical Nurse Specialist
Forth Park Hospital, Kirkcaldy
[email protected]
01592 643 355
Now the Fife CNS, who attends the meeting
every week, sends a copy of the MDT
proforma by fax to her patients’ GP and the
referring gynaecology oncologist in Fife.
Implementation Advice
Although this is essentially an administrative
task, it does have significant clinical
implications for patients and helps to improve
communication between the hospital and the
GP. Ideally this task should be done by an
MDT co-ordinator but if none is available, it is
important to gain commitment from another
team member to ensure that GPs are informed
quickly what the next steps are for their
patients.
40
carers,
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Video conferencing/telemedicine links to be used where attendance of at MDT’s
is limited
Top 20 MDT 4
In Tayside, the day, time and venue for the uro-oncology weekly multidisciplinary team (MDT)
meeting has been changed to facilitate weekly participation of consultant staff in Perth and
Stracathro via teleconferencing.
Making It Happen
Previously, the consultant urologists in Perth and Stracathro could only attend the MDT meeting held
in Dundee on a 4 weekly basis due to other clinical commitments. This meant that their patients
case notes and information had to be sent to Dundee for discussion at the MDT by their consultant
colleagues. This was unsatisfactory from a full discussion of patient diagnosis and treatment by the
referring consultant and from a teaching perspective. In addition, delays/issues with a transfer of
case notes between sites caused subsequent delays for patients at clinics.
Following a process mapping event, where these issues were again highlighted as problems for the
service, the team agreed to review the MDT arrangements. The day and timing of the weekly
meeting has now been changed to allow consultants from all 3 sites to participate via
teleconferencing. The venue of the meeting has also been changed to facilitate this with the
potential to move to video conferencing in the near future.
Impact
All urology consultants can attend the weekly MDT meeting facilitating full and early discussion of all
patients with urological cancer and their future treatment plans. Patient case notes are no longer
transferring between sites thus minimising potential delays for future clinic appointments.
Next Steps
Continue to monitor the attendance at the MDT meeting to ensure the change is an improvement.
Move to video conferencing to further facilitate discussion and contact between sites.
Contact
Mr Chris Goodman, Consultant Urologist
Ninewells Hospital, Dundee
[email protected]
01382 660 111
41
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Video conferencing/telemedicine links to be used where attendance at MDT’s is
limited
Top 20 MDT 4
Electronic transfer of radiological images: Radiological images are electronically transferred to the
Western General Hospital from St John’s Hospital to ensure the appropriate images are available for
use at the weekly lung multi-disciplinary team (MDT) meeting.
Making It Happen
Prior to the change, the radiological team at St Johns Hospital in Livingston saved duplicated images
to CD-ROM for the consultant to take to the MDT meeting at the Western General Hospital in
Edinburgh.
Before this change, the consultant was required to carry all images to Edinburgh for the meeting. If
all images were not available, discussion might be delayed until the following MDT meeting.
This process always had the potential to miss the crucial image if a complete compliment of images
were not available and included.
Discussion with the Information Technology Department was undertaken to establish if radiological
images could be transferred to the Western General Hospital from St John’s Hospital in Livingston.
Implementation Advice
This was not an easy change to achieve. Full discussion with the IT department was necessary to
take it forward.
Impact
The change now ensures that all images are available for the weekly MDT meeting and allows full
discussion of the patient removing any potential delay in the journey.
Contact
Diana Borthwick, Clinical Nurse Specialist
Lung Cancer Support
Wetern General Hospital, Edinburgh
0131 537 1767
42
Treatment
Treatment
“No needless delays.”
1. Co-ordination of treatment processes across
network to ensure optimum use of capacity,
e.g. theatre time.
2. Planned management of annual leave and
public holidays.
3. Streamlining of booking processes for
chemotherapy and radiotherapy.
4. Efficient system for appropriate referral to
palliative care.
43
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Improved communication
Top 20
Treatment
In Dumfries and Galloway Royal Infirmary the clinical nurse specialist, for colorectal cancer has
developed a process for alerting the team if a patient is admitted with medical problems during their
chemotherapy treatment plan.
Making It Happen
Prior to the change if patients undergoing chemotherapy were admitted to the hospital with
medical problems this could result in potential difficulties if the information was not
communicated to the chemotherapy team.
The clinical nurse specialist developed a system to ensure that patients undergoing
chemotherapy who were admitted to the hospital with medical difficulties were brought to the
attention of the chemotherapy team. This is done by placing a sticker on the front of the case
note, at the beginning of chemotherapy treatment, indicating where staff can obtain advice
regarding the patient’s chemotherapy status.
This system has been disseminated to a wide range of staff over 2 hospital sites to ensure
compliance when patients are admitted.
Impact
This ensures that patients receive prompt care when abnormalities occur. Prior to this change
it was difficult to track patients if they were having problems. Now problems can be resolved
much more quickly if they are communicated to the team. Staff anxiety has been reduced, as
they can contact another member of staff for advice and support when the patient is admitted
between their chemotherapy sessions.
Contact
Isabel Williams, Colorectal Nurse Specialist
Dumfries and Galloway Royal Infirmary
[email protected]
01387 244 288
44
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Co-ordination of treatment processes across network to ensure optimum use of
capacity.
Top 20 Treatment 1
In Aberdeen, doctors and managers have reduced the time it takes to have an operation after being
diagnosed with colorectal cancer. This was achieved by coordinating the time available for doctors
and arranging a suitable day and time for patients to have their surgery.
Making It Happen
Prior to the change, the maximum time patients had to wait for their surgery after being diagnosed
with colorectal cancer was 3 months.
Following a colorectal team process mapping event, a PDSA (plan, do, study, act) improvement was
tested whereby a manager agreed to be the central point of contact and co-ordinate the date and
time of surgery, when patients were referred to a doctor for colorectal surgery.
Previously, two doctors were undertaking the majority of the surgery and after discussion, it was
agreed that an additional doctor would also be responsible for this work.
The manager now receives the details of all patients referred to the colorectal service for surgery
and co-ordinates which doctor the patient will see at the outpatient clinic and which doctor will carry
out the resulting surgery.
Impact
This managed co-ordination has now reduced the wait for patients receiving surgery from 3 months
to 2 weeks.
Contact
Mr Terry O’Kelly, Consultant Surgeon
Aberdeen Royal Infirmary, Aberdeen
[email protected]
01224 554 534
45
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Co-ordination of treatment processes across the network to ensure optimum
use of capacity, e.g. theatre time
Top 20 Treatment 1
In Ninewells Hospital, Dundee and Borders General Hospital, improved communication between
the specialist nursing staff and the surgical team in Edinburgh is ensuring that patients referred
for surgery, but who are not suitable, are urgently referred back to their local team for
discussion and commencement of alternative treatment. This ensures that patients are not left
waiting for a number of weeks before knowing what treatment they can pursue and also
ensures patients receive appropriate support and information during this time from the
Macmillan lung cancer nurses.
Making It Happen
Impact
Prior to the change, patients who were
referred to Edinburgh as potential surgical
candidates but who were subsequently found
to be inappropriate, had to wait several
weeks for a follow up appointment locally
and the time to commencing alternative
treatment could be significant
Time to treatment following positive mediastinoscopy
40
35
30
25
Days
20
15
10
Following the identification of this issue at
the lung team mapping event, the lung
specialist nursing staff agreed with the
thoracic surgical team, that a telephone call
would be made on the day of the test result
which ruled out surgery to advise of this.
The lung specialist nurse then ensures that
the patient receives the next available
appointment with the local clinician and is
further discussed at the multi disciplinary
team (MDT) meeting to decide on an
alternative method of treatment. The lung
nurse specialist then contacts the patient
directly
and
informs
of
their
next
appointment and the next steps in the
process for them.
5
0
Nov-03
Dec-03
Jan-04
Feb-04
Mar-04
Months
The benefit from this change has been
ƒ
ƒ
ƒ
Patients who are not suitable for
surgery are getting back into the
local system more quickly and
minimising time to treatment
Patients are informed as early as
possible of the results and the
next steps for them
Local support, information/advice
is in place for patients from the
lung nurse specialist
Implementation Advice
Next Steps
Good communication between the two
teams to minimise time to treatment.
Ensure
maintenance
of
this
communication system between the two
teams.
Contact
Lynn McAllister, Lung Cancer Specialist Nurse
Ninewells Hospital, Dundee
[email protected]
01382 660 111
46
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Co-ordination of treatment processes across network to ensure optimum use of
capacity
Top 20
Treatment 1
Top 20
Treatment 2
Planned management of annual leave and public holidays
The South East of Scotland Cancer Network’s (SCAN) gynaecology cancer team ensure that expert
gynaecology oncology treatment is co-ordinated across the network.
Making It Happen
Process mapping of the pathway of patients
with gynaecological cancer took place in all
SCAN regions during 2003 – 2004. At each
mapping event the teams identified that if the
local gynaecologist was absent, patients had
to wait until they returned for their surgery to
take place, this could be up to 21 days. In
addition, if a consultant was absent, his or her
theatre list was often not used.
Implementation Advice
This
change
requires
consultation,
commitment
&
co-operation
between
managers, doctors & nurses across the
network.
Impact
ƒ
The SCAN gynaecology lead estimated that
this reduction in capacity could be met by
consultants within the network working as a
‘team’ Through consultation & agreement
within the network, delays to surgical
treatment have now been reduced by
consultants working across the network.
Formal arrangements are in place for
consultants from Lothian to operate on
patients in their local hospital or for patients
to have their surgery in Edinburgh.
ƒ
ƒ
ƒ
ƒ
Reduction of up to 21 days in wait for
surgery
Patients being operated on locally
whenever possible – less travelling for
patients & carers
True spirit of network working
Less waste of theatre capacity
Better communication
Contact
The
waste
of
theatre
capacity
when
consultants are absent has also been
addressed. Consultants now advise one
another when they will not be using their list
so that the theatre time can be used by their
colleagues.
Dr David Farquharson, Clinical Director
Centre for Reproductive Health, Edinburgh Royal
Infirmary, Edinburgh
[email protected]
0131 536 1000
47
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Streamlining of booking processes for chemotherapy
Top 20 Treatment 3
In Dundee, nursing and administration staff now have a weekly discussion about the numbers of
patients who currently receive, and those who are waiting to start their chemotherapy. This meeting
is arranged to maximise the current slots used for chemotherapy within two areas of the hospital,
and to reduce the time patients have to wait to receive their chemotherapy treatment.
Making It Happen
Percentage of lung cancer patients receiving chemotherapy treatment within local guidelines
(increased from 33% to 89%)
1
Within the hospital there are two areas where
patients can receive their chemotherapy
treatment - a day unit that is open Monday to
Friday 9 am to 5 pm and a separate unit open
five days a week, day and night. Patients were
booked into these two units independently
depending on which type of treatment they
were to receive. If there was no space in the
day unit, the patients had their first treatment
in the five day unit, then transferred to the
day unit to complete their treatment.
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Nov-2004
ƒ
Before the change there was no discussion
between the two areas on how many patients
were currently receiving treatment and how
many where still on a waiting list in each area.
Dec-2004
Jan-2005
Feb-2005
Mar-2005
Apr-2005
Ninewells Hospital and Medical School, Dundee,
Scotland
The time for lung cancer patients waiting
to start chemotherapy treatment has been
reduced from 21 days to 14 days in
four months
Waiting time to start chemotherapy for lung cancer patients, 21 days reduced to 14 days
Now the nurses in charge of both units meet
weekly to plan the number of patients
attending for their treatment in each area and
try to utilise both areas to their maximum
capacity.
25
20
Days
15
Impact
10
ƒ
ƒ
ƒ
In the first 4 months 24 patients have
improved
benefited
from
the
communication between both areas by
completing their treatment in five day
area. This has meant the patients see the
same members of staff each time and it
has increased the capacity in the day area.
The percentage of lung cancer patients
that now received their chemotherapy
treatment within local guidelines has
increased from 33% before the change
to 89% after
the change has been sustained for
three months.
5
0
Nov-2004
Mar-2005
Months
Apr-2005
Ninewells Hospital and Medical School, Dundee,
Scotland
Next Steps
The existing electronic system used to record
completed treatment is being reviewed for use
as a booking system to aid the utilisation of
both chemotherapy areas.
Contact
Jackie Davie, Senior Charge Nurse
Ward 32, Ninewells Hospital, Dundee
[email protected]
01382 660 111
48
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Streamlining of booking processes for chemotherapy and radiotherapy
Top 20
Treatment 3
Radiotherapy Planning
At the Edinburgh Cancer Centre, in order to optimise patient flow through the system, the ‘plan
check’ step has been removed. Patients benefit from one less hospital visit AND can begin their
treatment up to 10 days sooner.
Making It Happen
Before
Historically, standard practice when planning
radical radiotherapy has been for all patients
to have two appointments; one for a planning
CT scan and a second for the conventional
simulator where the treatment plan is checked
and verified (‘plan check’).
(isocentre) according to a protocol. This is
then marked on the patient with tattoos. Using
special planning techniques the treatment is
planned around this isocentre. As no ‘isocentre
shifts’ occur, (these can be a potential source
of errors) once the treatment is planned the
patient can commence their radiotherapy. The
position of the treatment is verified against
reconstructed images from their CT scan
(DRRs).
Issue(s)
As no immediate decisions are necessary, the
CT SIM sessions do not require an Oncologist
to be present, which increases the flexibility of
appointments. Whereas, the conventional
simulator sessions require immediate clinical
decisions to be made so an Oncologist has to
be present. Therefore patients requiring a
conventional SIM session to verify their
treatment set-up, are given the next available
appointment coinciding with the appropriate
consultant/team sessions so there maybe be
up to 10 days between the two appointments
causing a potential delay in the start of
treatment.
Impact
The change has now been implemented for all
patients receiving CT planned radiotherapy
treatment for tumours in the pelvis. This has
This means that patients can begin treatment
up to 10 days sooner. From the patient
perspective, the change means 1 less
appointment for the patient to attend. Further
work is on going to assess the feasibility of
removing the ‘plan-check’ from other tumour
sites such as lung.
ƒ
For example, a patient undergoing radical
treatment of prostate cancer may be CT
simulated on a Monday and not attend the
conventional simulator until the Thursday of
the following week during a planned urology
session and would start their radiotherapy on
the next Monday.
ƒ
Reduction of up to 10 days in wait for
radiotherapy
Patients also benefit from 1 less visit
to hospital
Contact
Sara Erridge, Consultant Oncologist
Edinburgh Cancer Centre
Western General Hospital, Edinburgh
[email protected]
Implementation Advice
When introducing any change to the process,
it is imperative that no new errors occur.
Therefore, a robust process was designed and
audited prior to routine introduction. When the
patients attend for their planning CT scan,
specially trained radiographers establish the
likely centre of the treatment volume
49
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Streamlining of booking processes for chemotherapy and radiotherapy
Top 20
Treatment 3
At Hairmyres Hospital, the doctor has improved the process for referring patients to the oncology
unit. He has done this by ensuring the nursing staff get a copy of all referral letters to enable them
to book patients for their treatment immediately reducing the previous delay.
Making It Happen
Prior to the change, all referral letters were sent to doctors, who were not responsible for
undertaking the process of booking patients for their treatment. It was highlighted at a process
mapping event that this could cause a delay of up to 24 hours, before doctors passed on the letter
to nurses to process.
The copy of the referral letter now goes directly to the nurses, as well as the doctors and is now
processed immediately. The secretaries now also send a letter back to the referring doctor to advise
when the patient will commence their treatment.
Impact
ƒ
Patients are now being booked for their treatment to commence 3 days sooner than before.
Contact
Dr Gary Osborne, Consultant Gynaecologist
Hairmyres Hospital, Lanarkshire
01355 585 000
50
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Streamlining of booking processes for chemotherapy and radiotherapy
Top 20
Treatment 3
Pre-registration of patients referred to the Beatson Oncology Clinic
Timely communication between Lorn and Islands Hospital and the Beatson Oncology Clinic
ensures that patients are pre-registered at the Beatson Oncology Clinic, allowing case notes to
be available on 1st clinic visit and treatment to be booked up to 1 week earlier.
Making It Happen
Prior to the change, new patients
referred from Lorne and Islands Hospital
to the lung team at the Beatson
Oncology Centre, were being appointed
to the Oncology Clinic without notifying
the Beatson Oncology Centre.
This
resulted in patients attending the clinic
prior to being registered with the
Beatson Oncology Centre.
Since this change has been implemented
improved communication takes place
between the Beatson Oncology Centre
lung secretary and Lorn and Islands
hospital staff, prior to each clinic. This
means that clinic lists are up to date,
each patient is registered and that case
notes are available for all patients.
Impact
Beatson Oncology Centre case notes
cannot be compiled until the patient has
been registered with the Beatson
Oncology Centre.
Patients cannot be
booked for treatment until they have
been registered as a Beatson Oncology
Centre patient.
The benefits of this change are:
•
•
If the Beatson Oncology Centre lung
team were not notified of new patients
prior to the clinic, the patient would not
be registered; a case note would not be
available and the patient could not be
booked
for
chemotherapy
or
radiotherapy treatment. As such, the
patient’s treatment could be delayed by
up to 1 week.
•
Improved communication
between Beatson Oncology
Centre Lung Team and Lorn and
Islands Hospital
Patient registered with Beatson
Oncology Centre prior to clinic
visit allows patient to be booked
for treatment up to 1 week
sooner
Presence of case notes at 1st
clinic visit
Contact
Implementation Advice
Christine Douglas, Team Leader, Lung Team
Medical Secretaries
Beatson Oncology Centre, Glasgow
[email protected]
0141 211 2000
To ensure that patients were processed
through the system, as timeously as
possible, staff at Lorn and Islands
Hospital were asked to update the lung
secretarial team if they were appointing
lung patients to the Oncology Clinic.
This enables the lung team to register
the patient and ensure that Beatson
Oncology
Centre
case
notes
are
available at the patient’s 1st clinic
appointment ensuring the patient can be
referred and booked without further
delays.
51
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Streamlining of booking processes for chemotherapy and radiotherapy
Top 20
Treatment 3
Electronic Access to Pathology Reports: The Lung Secretarial Team at the Beatson Oncology Clinic
can now electronically access pathology results for newly referred patients. Electronic access to
other hospital pathology results has enabled patients to be appointed to Lung Oncology Clinics up to
a 1 week sooner.
Making It Happen
Prior to the change, on referral to the Beatson
Oncology Centre, the lung team secretarial
staff were required to phone the referring
hospital and request pathology results for the
patient.
Until these results had been
obtained, patients could not be appointed to
lung oncology clinics. The secretaries would
often spend up to an hour on the phone
tracing pathology results. Once the secretary
had tracked down the pathology results they
would request that these results were faxed to
the lung team, to enable the patient to be
appointed to the next clinic.
Since this change has been implemented, the
lung team secretarial staff are able to
electronically access pathology results for
patients referred to lung oncology. Secretaries
are no longer spending time phoning other
hospital sites to access these results. The
lung team no longer has to wait 2-3 days for
pathology results and patients can now be
appointed to the next Oncology clinic, as
pathology results are instantly accessible.
If the results were unable to be faxed they
would be sent to the lung team by post.
Results that are sent by post can take 2-3
days to reach staff at the Beatson Oncology
Centre. Appointments would be made, on the
receipt
of
the
pathology
results.
Consequently, if the results were sent by post,
this would often mean that the patient’s
appointment at the clinic would be delayed by
1 week as the results had not been received in
time to appoint to the next clinic.
The benefits from this change are:
Impact
•
•
•
Instant access to electronic pathology
results
Secretaries no longer have to phone
around hospitals, for results, saving
up to 1 hour per patient.
Patients can be appointed to next
oncology clinic, saving a delay of up
to 1 week.
Implementation Advice
Contact
To enable the lung team secretarial staff to
overcome the delays in accessing pathology
results, it was agreed that electronic access to
pathology reports should be provided to the
lung secretarial team. This allows secretaries
to access and print patient pathology reports
from other hospital sites.
Tanya McDonald, Acting Deputy Medical Records
Manager
Beatson Oncology Centre, Glasgow
[email protected]
0141 211 2858
52
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Streamlining of booking processes for chemotherapy and radiotherapy
Top 20 Treatment 3
Timely delivery of tapes & use of new/review dictation tapes
A change of working practice by consultants and secretaries within the Lung Team at the Beatson
Oncology Centre, has helped reduce the typing backlog from the 4 weeks to 2 weeks. This is due to
the introduction of separate new and review dictation tapes and the timely delivery of tapes after
each clinic.
Making It Happen
This has boosted morale within secretarial
teams and consultants are happier with the
secretarial service provided.
Prior to the change, lung team consultants
used the same tapes to dictate new and
review patient letters at clinics. This meant
that lung team secretaries were not easily able
to prioritise their workload.
Reduction in typing backlog of tapes
reduced from 4 to 2 weeks
Furthermore, if secretaries wished to access
new patient information they had to play
through each tape to source this. In addition,
secretaries were often not receiving clinic
tapes until a number of days after the clinic
had been held. These work practices meant
that before the change, a 4 week typing
backlog existed. Because of this, case notes
were often not up to date at the patient’s next
clinic appointment and consultants would be
required to phone secretaries and ask them
access the information required.
Weeks
5
4
3
2
1
0
April
May
June
July
Month (2005)
Implementation Advice
Impact
To help eliminate the 4 week typing backlog a
number of changes were agreed. The lung
team consultants agreed that they would
dictate new and review patient letters on
separate tapes. The consultants also agreed
to deliver these tapes, to the secretaries as
timeously as possible after each clinic.
The benefits of this change include:
•
•
•
•
Since these changes have been adopted,
secretaries receive tapes after each clinic.
Now the lung team secretaries can prioritise
new patient dictation which is typed
immediately. This means that when patients
arrive for their next clinic appointment all
relevant and up to date information is filed in
the case note.
Reduction of existing typing backlog of
tapes from 4 weeks to 2 weeks
Remove delays in dictation of new
patient histories.
Ability to prioritise workload
Up to date patient case notes
Contact
Christine Douglas, Team Leader, Lung Team
Medical Secretaries
Beatson Oncology Centre, Glasgow
[email protected]
0141 211 2000
53
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Streamlining of booking processes for chemotherapy and radiotherapy
Top 20 Treatment 3
Provision of clear information relating to Outpatient clinics: Patients referred to the Beatson
Oncology Clinic now receive clear information relating to their outpatient appointment and to the
hospital where the clinic is being held. This has resulted in fewer patient queries to the lung
secretarial team and less need for taxis to transfer patients between hospital sites.
Making It Happen
they have received fewer queries relating to
location of clinics. Now staff have reported
that they are no longer requiring to order taxis
to transfer patients to other hospital clinics.
Prior to the change, patients referred to the
Beatson Oncology Centre were sent their clinic
appointment on Beatson Oncology Centre
headed appointment cards. For many patients
this was confusing as the clinic they were to
attend was being held in their referring
hospital.
The lung team secretarial staff
reported that they were receiving a significant
number of telephone queries from patients,
asking which hospital the clinic was being held
in. Staff also reported that patients often
failed to attend their appointment as they
were turning up at the Beatson Oncology
Centre and not at the hospital where the clinic
was being held. This resulted in a taxi being
ordered to transfer the patient, or the
patient’s appointment being cancelled and
rearranged for the following week.
Impact
The benefits from this change are:
•
•
•
Improved
communication
between
Beatson Oncology Centre and patients
about follow up appointments
Fewer enquiries being made regarding
where clinic is to be held.
Reduction in the number of taxis used
to transfer patient to correct clinic, due
to patients now attending the correct
hospital site.
Contact
Implementation Advice
To overcome this confusion it was decided to
send patient appointments using the hospital
headed appointment cards for the hospital
where the clinic was being held.
Tanya McDonald, Acting Deputy Medical Records
Manager
Beatson Oncology Centre, Glasgow
[email protected]
0141 211 2858
Since this change has been implemented, the
lung team secretarial staff have reported
54
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Streamlining of booking processes for chemotherapy and radiotherapy
Top 20 Treatment 3
Increase the capacity within chemotherapy unit for patients receiving their treatment as in patients:
In Tayside, doctors, nurses and managers have increased the number of patients that can receive
chemotherapy treatment while staying overnight in the five day chemotherapy unit within Ninewells
hospital. They have done this by introducing an additional chemotherapy out patient service using
oral chemotherapy treatment in Perth Royal Infirmary, for patients being treated for colorectal
cancer.
Making It Happen
Prior to the change, all patients who were
having chemotherapy treatment for colorectal
cancer came to the chemotherapy 5-day unit
in Ninewells Hospital, regardless of where they
lived, and stayed one or two nights. The
chemotherapy was administered to these
patients by the use of an intravenous infusion
(drip).
Percentage of lung cancer patients receiving chemotherapy treatment within local guidelines
(increased from 33% to 89%)
1
0.9
0.8
0.7
0.6
0.5
0.4
A new outpatient chemotherapy clinic
commenced in Perth Royal Infirmary, January
2005.
0.3
0.2
0.1
0
Nov-2004
This now means that patients who live in Perth
or close vicinity can have their chemotherapy
treatment for colorectal cancer by taking oral
therapy (tablet format) given to them within
an out patient clinic setting, instead of the
previous intravenous infusion given on an
inpatient basis.
ƒ
ƒ
ƒ
Jan-2005
Feb-2005
Mar-2005
Apr-2005
Ninewells Hospital and Medical School, Dundee,
Scotland
Next Steps
It is hoped to adopt and spread this change to
Ninewells Hospital, Dundee and offer this
method of treatment to patients with
colorectal cancer who live in Dundee. This will
further increase the capacity within the 5-day
inpatient chemotherapy unit.
Impact
ƒ
Dec-2004
Patients now don’t have to stay
overnight in hospital and can have their
treatment closer to home in Perth and
don’t have to travel to Dundee.
Since commencement of clinic in
January 2005, 23 patients have had
their chemotherapy treatment this
way, increasing capacity at Ninewells
by the same number.
All colorectal patients are now receiving
their chemotherapy treatment within
local guidelines.
This change means the waiting time for
chemotherapy for all cancer patients is
reduced. Before, only 33% of lung
cancer
patients
received
their
treatment within local guidelines,
compared with 89% after the change
was implemented and sustained for
three months.
Contact
Jackie Davie, Senior Charge Nurse
Ward 32, Ninewells Hospital, Dundee
[email protected]
01382 660 111
55
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Efficient system for appropriate referral to palliative care
Top 20 Treatment 4
In Victoria Hospital, Fife, referral to palliative care from the ward or multidisciplinary team (MDT)
meeting now takes place on the same day. This removes potential referral delays to palliative care.
Making It Happen
Prior to this change, patients were referred to
palliative care informally. No record of referral
to palliative care was kept and no one
member of staff was responsible for ensuring
that the referral to palliative care was
seamless and timely.
This meant that
problems with referral were often only
highlighted once a delay had occurred.
Referral to palliative care can be made by
ward staff or directly from MDT. The nursing
staff or junior doctor is responsible for
telephoning the palliative care team with
patient details. The referral form acts as a
record of this referral and is placed in the
patient case record.
Implementation Advice
It was important to make the ward staff and
junior doctors aware of the correct procedures
for
referral
to
palliative
care.
These
procedures will be communicated at regular
and appropriate intervals to ensure that
awareness does not drop due to staff turnover
and junior doctor rotation.
Impact
ƒ
Staff are now aware of the service
provided by the palliative care team.
ƒ
A reduction in patient and staff anxiety.
Murdina MacDonald, Lead Cancer Nurse
Victoria Hospital, Fife
[email protected]
01592 643355
The palliative care team developed a referral
form to allow prompt referral to their service.
Patients are now being promptly seen by
the palliative care team to ensure
appropriate care.
The potential for blocking beds whilst
awaiting palliative care consultation is
reduced.
Contact
This system could allow a potential of 3-4
days delay to occur.
ƒ
ƒ
ƒ
56
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Efficient system for appropriate referral to palliative care
Top 20 Treatment 4
In Victoria Hospital, South Glasgow, doctors and nurses have improved access to the specialist
palliative care team for patients with lung cancer. The palliative care specialist nurse now attends
the weekly oncology ward round where she sees patients who need extra support in dealing with
their diagnosis and treatment. This has increased the numbers of referrals to palliative care and the
patients are benefiting as a result.
Making It Happen
It was highlighted at a Cancer Service Improvement Programme process mapping event that cancer
patients were not being referred in a timely fashion to the palliative care service for extra support
when dealing with their diagnosis or treatment.
The oncologist invited the palliative care clinical specialist nurse to join the weekly oncology ward
round. The specialist nurse now sees patients while they are in the oncology ward.
Impact
ƒ
ƒ
ƒ
Staff involved feel there is an improvement in communication and information sharing and as a
result referrals to the palliative care service are more appropriate
Patients were asked for feedback about benefits of service and two patients recently referred to
the service said they felt a benefit and symptom improvement
Referral to palliative care have increased by 20%
Contact
Dr Joe Sarvesvaran, Consultant Respiratory Physician
Victoria Hospital, South Glasgow
[email protected]
0141 201 6000
57
CANCER SERVICE IMPROVEMENT PROGRAMME - EXAMPLES OF CHANGE
Efficient system for appropriate referral into palliative care
Top 20
Treatment 4
Nurse referral to palliative care has reduced a delay of 3 days for patients to receive treatment.
Making It Happen
In Fife there was a delay of 3 days for patients to be referred to the palliative care team from the
gynaecology ward. This was because referral to this service could only be made by doctors.
Doctors & nurses got together to agree on a system to eliminate this delay. The solution was simply
to allow the clinical nurse specialist and the charge nurse to make the referral to the Specialist
Palliative Care Team immediately after the ward round. The team have also developed a responsive
patient pathway to ensure that the multidisciplinary team refer appropriately to either the
gynaecological oncology nurse or the palliative care service. An education programme is also
planned for all staff and will include these referral protocols.
Impact
The benefit of this change has been:
• Patients are now seen by the palliative care team 3 days sooner
• This change, along with several other improvements, has contributed to 100% of patients with
ovarian cancer meeting the 62 day target
Contact
Jane McCafferty, Gynaecology Clinical Nurse Specialist
Forth Park Hospital, Kirkcaldy
[email protected]
Tel: 01592 643355
58
Cancer Service Improvement
Programme – Contacts
Further information about the work of our programme is available on our website
www.cci.scot.nhs.uk (click on National Programmes). Information you will find includes,
conference write ups, presentations, publications, access to a wide variety of
information and useful links to other work.
Any member of the team would be happy to answer queries and provide further
contract details and advice.
Contact details for the Cancer Service Improvement Programme Team are below:
Contact Details
Programme Manager: Pauline Ferguson
t. 07786 661937 e. [email protected]
Information Manager: Marese O’Reilly
t. 0141 249 6562 e. marese.o’[email protected]
Regional Facilitators
Dawn Sturrock t. 07717 422367 e. [email protected]
Lynn Smith t. 07717 422362 e. [email protected]
Louise Hamill t. 07717 422366 e. [email protected]
Margaret Kelly t. 07717 422368 e. [email protected]
Gordon McLean t. 07717 422363 e. [email protected]
Information about CSIP and other CCI National Programmes is available at
www.cci.scot.nhs.uk
59
ISBN 0-7559-4758-4
© Crown copyright 2005
Please visit our website www.cci.scot.nhs.uk click on national
programmes then cancer service improvement programme
Astron B42431 11/05
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9 780755 947584
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