Betsi Cadwaladr University Health Board Committee Paper 13.6.13 Item QS13/112.1 Name of Committee: Subject: Summary or Issues of Significance Quality and Safety Committee Endoscopy action plan Situation:.This paper aims to identify the corrective action proposed to improve access to endoscopy Background: The waiting times for access to endoscopy pose a clinical risk to patient care and require urgent correct action to improve. Previous proposals were not adequate to meet with a reasonable time the access requirements for patients and therefore the Q&S committee tasked the CPG with providing a deliverable plan which addressed the issue in a shorter timeframe Assessment: This paper proposes actions for delivery of improved access and also updates the Committee on progress against previous DSU recommendations. Strategic Theme / Priority / Values addressed by this paper Making it safe / better / sound / work / happen Making it Safe Healthcare Standard addressed Equality Impact Assessment (EqIA) Has EqIA screening been undertaken? Improvement is equally applicable to all patients based on their clinical need Recommendations: The Committee are asked to approve the actions proposed. Author(s) Presented by Jill Newman and Olwen Williams Date of report 5.6.13. Date of meeting 13.6.13. BCUHB Committee Coversheet v5.02 Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board
Primary Care, Community and Specialist Medicine Clinical Programme Group Endoscopy Improvement Plan Objectives : This action plan is designed to improve all endoscopy services across BCULHB so as to deliver safe, effective, timely and efficiency care in line with the national standards as laid out in the GRS and JAG accreditation and meeting national targets for patient access in relation to elective urgent and routine cases, suspected cancers and bowel screening patients. Endoscopy Improvement Plan Actions 2013-2014 Recommendation Action to be taken Process Measure for progress and time Establish dedicated Endoscopy Clinical lead Establish network Endoscopy Unit structure o Complete JD June 13 o Interviews July 13 o Complete ToR for CPG Endoscopy User Group (EUG) Clinical lead with protected DCC in post July 13 First meeting of the CPG EUG to be held in July 13 Responsibility for achievement (clinical and managerial identified) / Olwen Williams Endoscopy Clinical lead / Update Gastroenterology Evening held in January 2013 Project manager support for 6 months to deliver Endoscopy Improvement Plan (EIP) o Appoint internal EIP project manager Project Manager to be appointed by CPG by August 13 Gareth Evans / Chris Lynes Glan Clwyd Hospital: Reduce endoscopy waiting times to meet 2 week and 8 week standards central o Consultant changes to increase backfill: YGC only o Offer patients appointments at other Endoscopy sites with Review patients waiting by 7 th June on east and west central area boarders, offer earlier appointments in July for patients at YGC and Area Central achieving the standard, additional capacity to be offered to west patients mainly for lower and upper GI endoscopy 1
shorter waiting times Two endoscopists at YGC have agreed to come out of on call for 6 months, provides 2 sessions pw from June to support additional activity for east and west long waits Ysbyty Gwynedd: Reduce endoscopy waiting times to meet 2 week and 8 week standards - west o Agreed WLI s May: YG and WMH only o Offer patients appointments at other Endoscopy sites with shorter waiting times As at end of may 200+ patients over 8 weeks for colonoscopy and 170 patients over 8 weeks for gastroscopy. Patients from west will be offered the additional capacity at YGC. and Area and Area April and may WLIs completed as requested at YG and WMH 4 th Consultant Gastroenterologist job plan review to provide 2 endoscopy sessions pw from September 2013. Salah Elghenzai Endoscopy recovery plan to deliver by end of Oct 13. and Area 2
Wrexham Maelor Hospital: Reduce endoscopy waiting times to meet 2 week and 8 week standards - east o Agreed WLI s May: YG and WMH only o Consider options with existing Consultant on annualised contract to bring forward Q3/4 activity into Q2 o Offer patients appointments at other Endoscopy sites with shorter waiting times Internal training Nurse Endoscopist to be appointed immediately. The difference in monthly salary will allow 4-6 backfill consultant sessions to be delivered as WLI s, this will bring east then within 8 week profile by end of October 13. and Area April and May WLIs completed as requested at YG and WMH Appointment of the 4 th Gastroenterologist post o Advert for YGC based 4 th Consultant gastroenterologist Advertise in June 13 Interviews in July 13 Start date November 13 and Ian Finnie Appointment of Endoscopy Nurses o Training posts to be established in YG and WMH due to failure to recruit nationally Immediate and Area Ensure delivery of the 2-week standard for urgent suspected cancer patients: currently only YGC outside of standard o Ensure all flexi sigmoidoscopy capacity is used (centre only); un-backfilled sessions due to surgical nurse endoscopist sessions. Surgical staff grade x 3 flexible sessions per week agreed for YGC endoscopy / Jan Ellis / Caroline Williams Mr Hadi sessions agreed as at 3 rd June Create additional endoscopic capacity o Consider use of Llandudno Hospital Endoscopy Unit No longer an option and Area west only The clinical space used to provide ToP repatriation space. 3
JAG Productivity Tool to be run at YG o Improvement in turnaround times July 13 Endoscopy Clinical lead / / Clare Lloyd Consider outsourcing of backlog endoscopic procedures; non-nhs o MediNet to be contacted MediNet can provide weekend sessions at approx cost of 350 per procedure (colonoscopy at 2 points) Consider outsourcing of backlog endoscopic procedures; NHS in Wales o Contact other Welsh Health Boards TBC Consider outsourcing of backlog endoscopic procedures; NHS in North West o Contact other COCH TBC Purchase Unisoft Scheduling System for all three Endoscopy Units o Demo to be arranged for all three sites o Secure funding and inyear installation Demo for all three sites in June Agree formal scheduling system Unisoft endoscopy reporting tool already in use at all three sites. The addition of the Unisoft scheduling system will allow centralised information reporting Complete Infrastructure works o Neurophysiology Completed in May 13 and Area Nest AER meeting in 4
the following areas to increase sessional flexibility: YGC 3 rd room YG 3 rd room / decon Secure lost endoscopy capacity at YG Endoscopy Unit relocation to LLGH o Complete AER purchases o Complete infra structure works o Agree solution to relocate paediatric dental from Friday pm in YG endoscopy Unit Order to be placed by June 13 Provide two additional sessions per week at YG from 1 st September 13 / Barry Williams June Secure solution to OOH cover o Option appraisal under consideration Await outcome of SIR Olwen Williams/Gareth Evans Further consideration of the impact of the acute services strategy required DSU Recommendations DSU Recommendation 1: Clinical consensus as to the appropriate indications for new and surveillance endoscopy procedures and the appropriate criteria for direct access. o Clinical Workshop to produce agreed pathways for referral o Clinical validation of surveillance and new waiting lists to manage future compliance against agreed criteria Date of workshop Audit programme on a rolling cycle commencing immediately post implementation and Ian Finnie and Ian Finnie January 2013 5
DSU Recommendation 2: Differences RoTT should be better understood and processes reviewed to minimise the frequency with which this occurs. o Discussion on reasons for variation with clinical teams with a view to reducing variation End of July 2013 Endoscopy Clinical lead / DSU Recommendation 3: Standardisation of the scheduled start and finish times of the Endoscopy sessions in order to achieve maximum use of the available facilities. o Standardisation of session start times with agreement on all start times aligned to job plans with a view to maximising use of endoscopy time End of January 2013 Endoscopy Clinical lead to identify any job planning conflicts and review start times supported by Mark Andrews Morning start time 9 am to 12.30 and afternoon start time 13.30 to 17.00 agreed at Gastroenterology Evening in Jan 13 DSU Recommendation 4: The Health Board should review the booking templates with each of the endoscopists to understand the reasons for variation from the 12-point standard. o 12 point standard should be adopted to include elective and emergency activity. o Exceptions to the 12 point standard to be agreed with Endoscopy Clinical lead End of February 13 Endoscopy Clinical lead / DSU Recommendation 5: Session utilisation (% of available sessions used) and booking rates should be routinely monitored against locally agreed targets. o Monthly performance data reported to CPG Endoscopy Users Group January 2013 Area Operational Managers / Area Clinical Leads 6
DSU Recommendation 6: The extent to which patients are treated in turn should be reviewed, and the obstacles to achieving this identified and addressed o Clinical Review of prioritisation criteria for USC and Urgent to be undertaken January 2013 Ian Finnie supported by DSU Recommendation 7: Reduce total Endoscopy waiting list as part of its delivery plan for achieving 8- week waits. o Optimise use of existing lists o Move patients to equalise waiting times across North Wales July 2013 and Area DSU Recommendation 8: The impact of ceasing nonrecurrent capacity, e.g. waiting list initiatives o Gastroenterology SBAR agreed which includes; 4 th Consultant Gastroenterologist and Nurse endoscopists x 3 Appointment of Consultant by Oct 13 Appointment of Nurse endoscopists by September 13 and Area o Increase productivity as proposed through template and booking change Achieve 8-week standard from Oct 13 and sustain Clinical Lead and Mark Andrews o Dyspepsia pathway to be implemented across North Wales Implement across all locality areas, Lisa Mitchell and Ian Finnie Pilot undertaken in Anglesey o Colorectal pathway development Implement across all locality areas Pathway development day 12 th June 13 Draft completed by Dr Finnie 7
DSU Recommendation 9: Reduce the variation in monthly demand and activity. o Vetting process for all referrals o Review job plans of current nurse endoscopists January 2013 July 2012 Area Operational Managers / Area Clinical Leads and Acute Matrons DSU Recommendation 10: Plan for average activity to exceed average demand. DSU Recommendation 11: Regular validation of the surveillance waiting list as recommended in the pre-jag visit reports o Re-work of Capacity analysis o Validate surveillance waiting list Completed May 2011 and outcome confirmed Reviewed again in 2012-13 and confirmed capacity exists providing productivity delivered. Report issued to CPG. Completed Central East West Jill Newman/Maureen Bold Area Operational Managers / Clinical Endoscopy Leads DSU Recommendation 12: Inpatient waits should be monitored at each of the Endoscopy units and action taken to address delays. o Monitor utilisation of the 10+2 point system o Establish process for identifying in-patient wait time from referral Monthly Endoscopy Clinical lead / September 2013 Endoscopy Clinical lead / 8
to procedure o Establish process for fast track appointment as an OP September 2013 Endoscopy Clinical lead / DSU Recommendation 13: Efficiency measures to be actively monitor, at both an operational and managerial level, time lost due to late starts, early finishes, and turnarounds and act on patterns of under-utilisation (linked to recommendations 3 & 5). o See 3and 5 above See 3and 5 above Endoscopy Clinical lead / through the CPG Endoscopy User Group DSU Recommendation 14: DNAs and last-minute cancellations should be routinely monitored (weekly) at all sites and audits undertaken to understand the reasons. Recommendation 15: Standardise pre-operative assessment processes based on an evaluation of the existing models o Weekly DNA figures to be sent to Clinical Leads for discussion at endoscopy user groups and actions agreed to reduce o BCU wide review of POAC process for endoscopy July 2013 Endoscopy Clinical lead / through the CPG Endoscopy User Group August 2013 Endoscopy Clinical lead / through the CPG Endoscopy User Group 9
Recommendation 16: The DSU will support the organisation to develop a demand and capacity tool to assist with the planning and monitoring of Endoscopy services. DSU Recommendation 17: Agree the appropriate number of endoscopists carrying out each procedure and adopt a culture of quality improvement through regular and robust audit. o CPT solutions agreed for 13-14 o Endoscopists falling below this standard to be offered further training May 13 May 2011 agreed additional training sourced at Llandough Area Operational Managers / Clinical Endoscopy Leads Clinical leads with NLIAH o Where insufficient volume undertaken endoscopist to discontinue activity By September 13 BCU clinical lead with COS / ACOS Ops o Review of location of service based on critical mass, clinical skills and facilities to be undertaken for ERCPs End July 2013 Ian Finnie and Mark Andrews o Audit outcomes to be reviewed by BCU Quarterly BCU clinical lead 10
clinical lead o Review of overall number of units undertaking endoscopy across BCU By September 2011: completed LLGH decommissioned COS and Reduced to 3 main GEUs: LLGH GEU decommissioned Prepared by Area Operational Manager June 2013 11