Endoscopy Capacity & Productivity Service Improvement Review Fiona Thow Scientific Advisor to the CSO
Review approach site selection Identified 12 sites from reviewing DM01 returns & profiling the waiting lists over the last year some with rising waits / some not Cross referenced to GRS returns (via JAG) Used local & national intelligence e.g. cancer networks, IST, screening leads Not an exact science, but confident we had a range of sites 12 visits in 3 weeks one day on site
Review approach - method Service improvement opportunities Short-term & longer term capacity Process issues (admin, clinical, decontamination) Leadership assessment ( nurse leadership, ops management, clinical engagement & leadership) Trust infrastructure level of priority, escalation & integration into service delivery Service improvement understanding & capability (including information & data)
High level findings Clinical process Delays to start times of lists Delays in the middle of lists, but in addition waiting for scopes, interpreters, bleeps & interruptions High DNA rates due to complex admin processes +/- no pre-assessment (then not utilised due to inflexibility of working between rooms) Cancellations on the day anti-coagulation issues, co-morbidity drug issues Lack of monitoring or feed back mechanism of the above / shared ownership of issues/ action plan to address (or publishing as KPI s)
Delayed start times List nibbles Examples of data Good examples of recording sheets, with codes that are fed into management meetings pro-actively used Endoscopists didn t like it and nothing really happened with the information, no information to support need for more scopes
Day Date Room No List start time Doctor arrival time List Start time List finish time Monday 3-Oct-11 AM 1 08.30 09:05 09:35 12:10 2 08.30 08:55 09:10 13:00 3 08.30 09:05 09:18 11:35 PM 1 13.30 13:35 14:05 16:10 2 13.30 14:00 14:00 15:30 3 NO LIST Tuesday 4-Oct-11 AM 1 08.30 09:10 09:10 12:00 2 08.30 09:15 09:30 10:45 3 08.30 09:05 09:30 13:20 PM 1 13.30 14:10 14:20 18:05 2 13.30 NO LIST 3 13.30 14:15 14:20 16:25 Wednesday 5-Oct-11 AM 1 08.30 08:55 09:00 13:20 2 08.30 09:20 09:30 13:30 3 08.30 09:05 09:20 13:05 PM 1 13.30 14:00 14:14 17:40 2 13.30 14:05 14:30 18:15 3 13.30 13:40 14:30 17:30
Thursday 6-Oct-11 AM 1 08.30 08:50 08:53 12:10 2 08.30 09:00 09:15 12:25 PM 3 08.30 09:20 09:20 11:45 1 13.30 14:15 14:20 18:00 2 13.30 15:00 15:05 15:55 3 NO LIST Friday 7-Oct-11 AM 1 NO LIST 2 08.30 09:00 09:15 12:45 3 08.30 09:10 09:20 11:45 PM 1 NO LIST 2 13.30 14:10 14:20 17:00 3 13.30 14:00 14:05 17:35 14Hrs 35mins 6 Hrs 45mins Total in 1 week = 21hrs 20 mins
DNA s & cancellations High DNA rates reported at 10%, or 1-2 per day (one site 16%) High numbers of cancellations on the day particularly OGD Sites who pre-assess colons have fewer cancellations as have sorted anti-coagulation issues or co-morbidities & appropriate prep OGD health questionnaire & telephone preassessment, plus reminder service One site rings all patients who DNA to find out why?
DNA s & cancellations
Admin reasons for DNA & Cancellations Under pressure no choice given next available slot sent out 2 nd class post significant delays Telephones often unmanned Huge amount of rework (25%) Patients query often anti-coagulation or comorbidities (clinical queries) See direct booking as too difficult!(often last minute list cover problems or no clear or adhered to leave policies)
Insert Admin map - current
Insert Future state direct booking map
Uncovered / dropped sessions Annual leave policies not adhered to (could be a Trust wide problem) No agreement to cover leave routinely Some gained extra sessional payments Sometimes nursing cover but no endoscopist.whole team WLI on a Saturday! Poor communication resulted in lost opportunities to flex job plans & training lists Sites with experienced nurse endoscopists could manage list cover effectively Some nurse endoscopists under utilised due to job plans
Week 1 Monday 05/12/2011 Tuesday 06/12/2011 Wednesday 07/12/2011 Thursday 08/12/2011 Friday 09/12/2011 AM PM AM PM AM PM AM PM AM PM Room 1 Dr. H Dr. J Dr. B Dr. E Dr. E Dr. B Room 2 Dr. J Dr. G Dr. G Dr. D Dr. A Dr. D Dr. H Dr. I Week 2 Monday 12/12/2011 Tuesday13/12/ 2011 Wednesday 14/12/2011 Thursday 15/12/2011 Friday 16/12/2011 AM PM AM PM AM PM AM PM AM PM Room 1 Dr. H Dr. B Dr. F Dr. E Dr. B Dr. F Room 2 Dr. J Dr. D Dr. A Dr. H Dr. B Dr. I Session Used Session Lost Unbooked
Variability of points system Points system used as a guide (but also a barrier) long history Roughly reflects process time Doesn t account for turnaround time Do NOT want to squeeze procedure time (risk of compromising on quality gains) There are opportunities for productivity gains in turnaround times ( Pull system ) Saw a pod system on one site
Points System Site Session length No. of points Training No.of points 1 4 Hrs 10 (11) 8 2 4 Hrs 10 8 3 4hrs 12 (am) 10 ( pm) (some do 15 some do 8) 4 4hrs 12(am) 10(pm) 8 5 3.5 hrs 12(am) 10(pm) ( some 15) 6 4hrs 10 7 4 Hrs / 3.5Hrs 10 7 8 3.5 Hrs 10 8 (A) 4 Hrs 11 Competency (B) 4 hrs Uses own points system (C) 4 Hrs 13 Competency (D) 4 hrs 12
No of Points Date 12 3-Oct-11 9 3-Oct-11 7 3-Oct-11 6 3-Oct-11 4 3-Oct-11 8 3-Oct-11 12 4-Oct-11 2 4-Oct-11 4-Oct-11 9 4-Oct-11 4-Oct-11 7 4-Oct-11 9 5-Oct-11 10 5-Oct-11 8 5-Oct-11 10 5-Oct-11 7 5-Oct-11 9 5-Oct-11 Actual Points (11 point list) 11.5 6-Oct-11 8 6-Oct-11 5 6-Oct-11 11.5 6-Oct-11 6 6-Oct-11 6-Oct-11 7-Oct-11 6 7-Oct-11 5 7-Oct-11 7-Oct-11 6 7-Oct-11 10 7-Oct-11 6 10-Oct-11 7 10-Oct-11 7 10-Oct-11 10-Oct-11 7 10-Oct-11 7 10-Oct-11
Things that help Sequencing of lists to be site appropriate dedicated in patient lists, 8.30am bleeder (for scopes) Demand management self vetting referral forms (BSG guidance & one type) Same day pre-assessment Direct booking Clear list start & stop times Leave & list cover agreed (job plans) Data to support service delivery (Demand, capacity, not just activity)
Things that help A pull system that works to increase productivity Understanding new service demands & building effective business cases for expansion (EUS, Halo ablation, EMR) Visual display of KPI s Collaborative working across clusters An escalation policy to maintain capacity & stop rising waits Planning for the expected pressures with commissioner support
Endoscopy: Summary There is potential capacity & productivity gains that could be achieved through process redesign (6 areas of focus) Effective operational management Data collection & planning Understanding & appropriate demand management Ensuring capacity is optimised Review of variation to highlight potential Positive patient experience
These modules create the Productive Endoscopy Unit
- design - -
- design - - Measures
Productive Endoscopy
Productive Endoscopy Email: england.si-enquiries@nhs.net
100,000 Genomes Programme 13 Genomic Medicine Centres (GMCs) 3 London North Thames (GOSH) West London (Imperial) South London(Guy s & St.Thomas s) Collect samples of blood & tumours to undergo Whole Genome Sequencing To gather information about tumours to better target treatments https://www.genomicsengland.co.uk
Why cancer? To allow for molecular pathology in future cancer pathways (infrastructure for genomic testing) WGS or panel testing (improved panels with fresh frozen samples) Opens up more treatment options for patients understanding more specifics on how tumours behave Identifies cancer predisposition genes Identifies familial links e.g. Lynch Syndrome Opens up pharmaco genetics targeted drugs, chemo Future proofs the system to put in the infrastructure to build the evidence as new techniques and knowledge develops