Core Service Review Gastroenterology and Endoscopy May 2013
Contents Page Section 1 Introduction 2 Section 2 Headline Themes 5 Section 2 Length of Stay 7 Section 3 Outpatients 12 Section 4 Endoscopy Utilisation 22 Section 5 Consultant Time 33 Section 6 Appendix 37 1
Section 1 Introduction
Overview of Deep Dive Approach Functional Productivity Medical Productivity Beds ALOS Operating Theatres + Financial Impact Out patients Diagnostics Market Testing/Outsourcing Capacity & Demand Modelling Waiting List Management - Overheads + - Strategic Services Assessment Core Core Service delivering positive contribution Non-Core Non-core service delivering positive contribution Negative Negative contribution contribution but core & non-core? Delivery of improvements in underlying financial position Disinvestment Commissioning Intent Investment Clarity of services gained through Functional Productivity Medical Staffing Service Prioritisation matrix Contribution to underlying financial position Rational decisions taken to optimise position Formal links into Business Planning Structures Working systematically through the approach opposite to: Understand current performance Identify opportunities to improve Plan and deliver schemes to make significant difference to financial position 3
Data quality Data limitations The data/information available from the Cardiff & Vale UHB does have limitations, and is not always accurate We have used the information and data available to us, applying sensible assumptions where necessary We have made every effort to check the accuracy of the information in this document, however it is only as good as the source data, which comes from the Information Services Department, TheatreMan, Finance and other UHB systems. As such it is important that: Data is not used in a pejorative way You agree to work with the data available and are committed to helping the UHB to improve data quality We keep an open mind and accept that it isn t always necessary to have 100% accuracy before action can be taken. Successful organisations in the public and private sectors work on the basis of it s good enough We engage in robust debate and welcome challenge as an essential part of the process We commit to working together 4
Section 2 Headline Themes
Headline Themes Context Gastroenterology and endoscopy services at C&V UHB currently have long waiting lists in both outpatient clinics and for endoscopy services which has resulted in breach of RTT targets The service review A clinical service review was conducted for Gastroenterology and Endoscopy in May 2013 to assess the current state of the service The review has found some significant issues with the Gastroenterology and Endoscopy services which need urgent attention Main headlines of the review The key headlines that have surfaced from the review are as follows: There is an indication of high LOS compared to peers although a part of this can be attributed to the case mix (there is also an issue of data quality and coding which might be skewing the outputs) High New to Follow-up ratio of 1:3.6 which means more follow-up patients seen when compared to new patients; it is acknowledged that in some cases a high New to Follow-up ratio is expected given the case mix There was a significant gap between the capacity and demand (for 13/14 and 14/15) for both new and follow-up clinics; while a part of the demand can be eradicated by reducing the New to Follow-up ratio and employing other measures, the capacity still lags demand Overall clinic utilisation is 91% which is good, but due to the high New:Follow-up ratio, the follow-up slots are well utilised (92% utilisation) while the new slots are slightly underutilised (85%) contributing to the significant waiting list The overall DNA rate is 17.5% which is high and can be improved; Please note that DNA rates are generally higher in Wales and Hepatology could be contributing to the high DNA rate Overall Endoscopy utilisation is 88% and both sites are utilised equally well although the DNA rate at UHW is higher than at UHL Main issues are that Endoscopy lists are not standardised across AM and PM sessions (e.g., 12 slots in AM and 10 in PM); Endoscopy unit is unutilised for 1 hr everyday; Points per list performed by consultants and Nurse Endoscopists can be increased; Nurse Endoscopists are underutilised can be used to do more non-complex procedures 6
Section 3 Length of stay
Average length of stay 12/13: Non-Elective Inpatients The following table and graph show the average length of stay by consultant and HRG group. The HRGs have been clubbed into their specific groups to provide a similar case mix for comparison and also to provide a large enough sample size. Please note that this data is for 10 months only. Site Consultant HRG Group D HRG Group F HRG Group G HRG Group L HRG Group S FCE ALOS FCE ALOS FCE ALOS FCE ALOS FCE ALOS Dr A Godkin 0 0.0 0 0.0 2 1.5 0 0.0 0 0.0 Dr A Hawthorne 1 1.0 37 7.7 8 5.1 0 0.0 1 6.0 UHW Dr D Durai 1 6.0 19 10.7 13 18.2 1 27.0 0 0.0 Dr G Thomas 2 3.5 9 20.2 3 12.3 2 4.5 0 0.0 Dr L Sunderraj 2 29.5 18 7.6 9 9.6 4 9.5 0 0.0 UHW Total 6 10.0 83 11.5 35 9.3 7 13.7 1 6.0 UHL Dr J Green 0 0.0 0 0.0 0 0.0 1 2.0 1 1.0 Dr J Turner 54 7.4 184 8.4 53 16.4 56 12.1 23 4.6 Dr K Keshk 10 6.0 25 4.5 8 13.5 7 5.4 6 0.7 Dr S Dolwani 0 0.0 0 0.0 0 0.0 1 2.0 0 0.0 UHL Total 64 6.7 209 6.4 61 14.9 65 5.4 30 2.1 UHW + UHL Total 70 7.6 294 8.4 96 14.4 72 11 31 6.7 The above data is for the top five HRG groups with the highest number of FCEs for UHW and UHL respectively As can be inferred from the above data, there is significant variation in the ALOS across the consultants Group F has the highest number of FCEs and the ALOS varies between 20.2 and 4.5 According to this data, 16 beds were needed to accommodate patients under the care of a Gastroenterologist with a Gastroenterology HRG. This figure does not include patients not under the care of a Gastroenterologist. A list of HRGs for each group can be found at the end of the presentation Source: Information Services Department 'Specialist Division Average Length of Stay information Apr 12 to Jan 13 8
Length of stay Non-Elective Inpatients The tables below shows the top 5 HRGs with the highest number of FCEs by bed days based on benchmarking analysis completed by C&V UHB on 11-12 activity data Comparison to peer group HRG FCEs Average LOS Bed days HRG HRG Code FCEs Average LOS Bed days Non-Malignant Liver Disorders with Major CCs GC15C 36 14 504 1.38 Non-Malignant Liver Disorders without Major CCs GC15D 36 10 344 0.94 Cardiff & Vale Peer Group LQ Peer Number of beds Total Cost Mean LOS Bed days Number of beds Total Cost Number of beds Inflammatory Bowel Disease, with length of stay 2 days or more, without Interventions, without Major CC FZ37J 32 7 212 0.58 Gastrointestinal Bleed with length of stay 1 day or more without Major CC FZ38E 23 6 128 0.35 Inflammatory Bowel Disease, with length of stay 2 days or more, without Interventions, with Major CC FZ37H 22 12 260 0.71 Total 149 10 1,448 3.97 The tables below shows that there is an opportunity to save upto 1 bed by reducing the length of stay to that of the peer for the top 5 HRGs discussed above Total Cost GC15C 36 14 504 1.38 128,761 10 353 0.97 85,739 55,475 GC15D 36 10 344 0.94 105,529 6 230 0.63 67,564 38,103 FZ37J 32 7 212 0.58 63,122 5 163 0.45 56,929 45,951 FZ38E 23 6 128 0.35 40,231 5 111 0.30 35,044 30,819 FZ37H 22 12 260 0.71 66,614 7 159 0.44 54,630 47,369 Total 149 10 1,448 3.97 404,257 7 1,017 2.78 299,906 217,716 Opportunity to save beds through reduced length of stay 1.18 104,351 186,540 Source: 20130225_Bed opportunities National HES benchmark.xlsx No. Of Bed days = Length of stay/ 365 LQ = Lower Quartile 9
Peer group used The benchmarking work carried out by C&V UHB used the following peer group of English Trusts Trust Royal Liverpool & Broad Green University Hospitals NHS Trust Sheffield Teaching Hospitals NHS Trust Southampton University Hospital NHS Trust Organisation Code RQ6 RHQ RHM Source: 20130225_Bed opportunities National HES benchmark.xlsx 10
Points to consider Comparing the ALOS by a similar case mix shows that the there is an opportunity to reduce the length of stay to free up bed capacity Peer analysis suggests that these can be reduced significantly to release more capacity and reduce costs Questions What is driving the longer length of stays? Are longer lengths of stay and waiting lists times affecting the non-elective activity? What are the discharge procedures? Is there a standard set of measures that need to be followed? How are the beds managed in the general medicine ward? Do general medicine patients often occupy gastro beds? 11
Section 4 Outpatients
Outpatient Clinic Booking Rules The table below shows the current outpatient clinic booking rules across UHW and UHL. The number of clinics per week and the number of new and follow-up slots have been calculated from the provided clinic templates Clinic Booked Under Clinic Lead Type Clinic code Frequency New Slots F/U Slots Total Dolwani, Dr S Con and SpR GAST3 Weekly 6 13 19 Dolwani, Dr S Sister H Ludlow CNS GAST14 Weekly 0 6 6 Sister Kay Charles CNS GAST5 Weekly 2 4 6 General gastro GAST13 3/month 3 8 11 Durai, Dr D Durai, Dr D HPN GAST16 1/month 0 10 10 IBD Con and SpR W85/W86 Weekly 2 15 17 Gastro, Mr UHW -GT GAST11* 1/month 7 0 7 Pool Consultant UHL -JS,JT,Locum GAST9** Weekly 16 0 16 Godkin, Dr A Godkin, Dr A Liver Con and SpR GMED19 Weekly 9 9 18 Nurse led Liver GMED19N Weekly 0 8 8 SpR SpR GMED16 Weekly 3 4 7 Green, Dr J Consultant GMED15 Weekly 3 9 12 Green, Dr J Sister Kay Charles GMED53 Weekly 2 4 6 CNS Sister H Ludlow GMED39 Weekly 0 6 6 IBS GAST12 Weekly 2 4 6 Nurse led IBD GAST15&GMED34 3/month 0 6 6 Virtual Clinic anti-tnf VCIBD1 1/month/adhoc 2 10 12 Hawthorne, Dr A SpR General gastro P89/P90 3/month 2 7 9 IBD R44/R45 Weekly 1 8 9 General gastro N82/N83 3/month 2 9 11 Hawthorne, Dr A IBD N80/N81 Weekly 1 8 9 HPN GMED22 1/month 0 13 13 General gastro GMED18 Weekly 3 8 11 Sunderraj, Dr L Sunderraj, Dr L Joint Transplant LT1 1/3months 0 11 11 Liver W87/W88 Weekly 3 8 11 Nurse led Liver W87/W88N Weekly 1 6 7 Nurse led CNS GAST4 Weekly 0 6 6 Swift, Dr G Sister A Green CNS GAST1 Weekly 2 4 6 VCGAST1 Weekly 0 6 6 Swift, Dr G Con and SpR GAST2 Weekly 6 13 19 Thomas, Dr G Thomas, Dr G Gen gastro and SpR W83/W84 Weekly 6 20 26 Turner, Dr Jeffrey SpR SpR E02/D28 Weekly 3 4 7 Turner, Dr Jeffrey Consultant 233/234 Weekly 3 9 12 Source: Clinic Templates *In 12/13 GAST11 ran weekly for 18 weeks with 4 consultants and there after once per month with one consultant (Dr. Thomas) ** in 12/13 GAST9 ran once per week with 2 full time consultants and 1 locum The clinics are equally divided so that 2 out of 3 consultants are always present. 13
Outpatient Utilisation Available Appointment Slots 1 Booked Appointments 2 Utilisation Consultant News Follow Ups Total News Follow Ups Total News Follow Ups Overall Durai, Dr D 160 869 1029 141 1173 1314 88% 135% 128% Turner, Dr J 202 479 681 205 561 766 101% 117% 112% Thomas, Dr G 195 650 845 217 646 863 111% 99% 102% Swift, Dr G 315 931 1246 241 1002 1243 77% 108% 100% Gastro, Mr Consultant 756 0 756 739 2 741 98% NA 98% Dolwani, Dr S 315 931 1246 277 908 1185 88% 98% 95% Sunderraj, Dr L 252 968 1220 218 808 1026 87% 83% 84% Hawthorne, Dr A 298 1692 1990 211 1373 1584 71% 81% 80% Green, Dr J 290 919 1209 215 646 861 74% 70% 71% Godkin, Dr A 264 714 978 136 418 554 52% 59% 57% Total 3047 8153 11200 2600 7537 10137 85% 92% 91% The graph above shows the total number of appointments booked as a percentage of the total number of appointments available based on the OP clinic templates for 2012/13 Telephone and virtual clinics have been excluded The available appointment slots are a sum of all slots booked under the consultant s name which include nurse led clinics, DNAs and Cancellations It is assumed that registrars are available for 60% of the year only for the reminder 40% of the year when registrars are not available templated slots are reduced by 25% for SpR clinics only Dr G Thomas at UHW and Dr G Swift, Dr J Turner and locum at UHL do the Mr Gastro pool clinic and their contribution is recoded separately in this clinic i.e. this is additional activity than that recorded next to the names of these consultants. 1 Based on clinic templates from Clinical Boards 2 Source: Information Services Department, Apr 12 Mar 13 3 The booked appointments data for this clinic seems to be incorrect and this issue has been recognised 14
Outpatient Utilisation Excluding nurse led clinics Available Appointment Slots 1 Booked Appointments 2 Utilisation Consultant News Follow Ups Total News Follow Ups Total News Follow Ups Overall Gastro, Mr Consultant - UHW 84 0 84 212 0 212 252% 0% 252% Durai, Dr D 160 869 1029 141 1173 1314 88% 135% 128% Dolwani, Dr S 227 491 718 213 600 813 94% 122% 113% Turner, Dr J 202 479 681 205 561 766 101% 117% 112% Swift, Dr G 227 491 718 171 583 754 75% 119% 105% Thomas, Dr G 195 650 845 217 646 863 111% 99% 102% Green, Dr J 202 479 681 155 537 692 77% 112% 102% Hawthorne, Dr A 214 1215 1429 146 1155 1301 68% 95% 91% Sunderraj, Dr L 252 968 1220 218 808 1026 87% 83% 84% Gastro, Mr Consultant - UHL 672 0 672 527 2 529 78% 0% 79% Godkin, Dr A 264 714 978 136 418 554 52% 59% 57% Nurse Led Clinics - UHW 84 477 561 65 218 283 77% 46% 50% Nurse Led Clinics - UHL 264 1320 1584 194 836 1030 73% 63% 65% Total 3047 8153 11200 2600 7537 10137 85% 92% 91% Following on from the previous slide, the above table shows the number of available outpatient slots and booked appointments by consultant after removing the specialist nurse led clinics. The specialist nurse led clinics have been recorded separately for UHW and UHL The data includes DNAs and cancellations Removing the nurse led clinics shows some significant variation in the consultant clinic utilisation when compared to the previous slide which shows follow-up clinics in most cases are well utilised, where as for the new patient clinics there is an opportunity for better utilisation Overall, the nurse led clinics are underutilised and can be used to increase the throughput of follow-up patients Please note that with the given data, it is difficult to extract the exact number of nurse led clinics from consultant clinics due to coding issues The utilisation of Mr. Consultant Gastro clinic at UHW might be slightly misleading as for a part of the previous year the clinic had higher capacity and hence had more patient bookings 1 Based on clinic templates from divisions 2 Source: Information Services Department, Apr 12 Mar 13 3 The booked appointments data for this clinic seems to be incorrect and this issue has been recognised 15
Outpatients Utilisation contd. Outpatient utilisation varies between Gastroenterologists but on average they see 3.5 new outpatients per clinic based on clinic templates If utilisation levels for new booked appointments were at the level of the best performer (in this case, Dr S Dolwani at 94%) there is additional outpatient capacity of 271 new outpatients Based on an average clinic template with 3.5 new outpatients to be seen each week, the number of clinics could be reduced by up to 77. This purely focuses on the additional new outpatients that could be booked into an appointment slot Consultant Additional new patient capacity if 94% utilised Equivalent OP clinics Additional new patient capacity if 100% utilised Equivalent OP clinics Godkin, Dr A 112 32 128 37 Hawthorne, Dr A 55 16 68 19 Swift, Dr G 42 12 56 16 Green, Dr J 35 10 47 13 Sunderraj, Dr L 18 5 34 10 Durai, Dr D 9 3 19 5 Dolwani, Dr S 0 0 14 4 Turner, Dr J 0 0 0 0 Thomas, Dr G 0 0 0 0 Total 271 77 366 105 16
Outpatients Metrics Consultant New Follow Ups DNA Rate Total N:F/U Ratio Attended DNA Attended DNA New Follow Ups Dr D Durai 171 36 994 243 1444 5.98 2.49% 16.83% Dr G Swift 197 32 987 225 1441 5.29 2.22% 15.61% Dr A Hawthorne 237 23 1164 212 1636 5.29 1.41% 12.96% Dr A Godkin 117 25 494 58 694 3.89 3.60% 8.36% Dr L Sunderraj 172 45 585 203 1005 3.63 4.48% 20.20% Dr S Dolwani 237 32 757 160 1186 3.41 2.70% 13.49% Dr J Green 190 22 536 124 872 3.11 2.52% 14.22% Dr J Turner 167 31 448 120 766 2.87 4.05% 15.67% Dr G Thomas 517 32 583 139 1271 1.32 2.52% 10.94% Mr Consultant Gastro 567 126 3 0 696 0.00 18.10% 0.00% Total 2576 404 6562 1487 11029 3.6 3.66% 13.48% National Benchmark National Benchmark 1.89 11.56% There may be slight discrepancies between the figures on this slide and those in the previous slide for available and booked slots The appointments under each consultant include nurse led clinics As the Mr Consultant Gastro clinic sees routine, long waiting patients, it has an extremely low follow up rate. This means that Dr Turners & Dr Swifts overall new to follow up rate will be much lower than figures quoted above which relate just to their named clinics. Source: Information Services Department, Apr 12 Mar 13 National Benchmark source: NHS Institute for Innovation and Improvement The overall N:FU ratio of 1:3.6 is an average of the N:FU ratios of all consultants excluding any outliers and zeros 17
Outpatient Capacity & Demand Current Capacity Demand in 12/13 Activity in 12/13 Demand for 13/14 Variance in capacity and demand Increase by 5% Increase by 10% 12/13 13/14 inc. by 5% 13/14 inc. by 10% New 3,047 5,343 2,980 5,610 5,877 (2,296) (2,563) (2,830) Follow-Up 8,153 17,632 8,049 18,513 19,395 (9,479) (10,360) (11,242) Total 11,200 22,975 11,029 24,124 25,272 (11,775) (12,924) (14,072) Capacity Shortfalls Assumptions: The current capacity is based on clinic templates Outpatient demand for 12/13 is derived from the number of new OP appointments added in 12/13 and Follow-ups have been calculated based on a new to follow-up ratio of 1:3.6 Outpatient demand for 13/14 is based on the assumption that the number of new referrals will increase by 5% - 10% The analysis assumes that the waiting lists remain at current levels Source: Information Services, OP added tab 18
Outpatient Capacity & Demand contd.. With all other factors remaining constant, significant capacity can be gained by reducing the N:F/U ratio and DNA rates Excluding DNAs, by reducing the new to follow-up ratio to 1:1.89 (national average) overall about 3153 appointments can be saved which equates to 287 clinic sessions given an average of 11 appointments (new and follow-up) per clinic Further, reduction in the DNA rates to that of the national average of 11.56% can result in a saving of 570 appointments which equates to 52 clinic sessions given an average of 11 appointments (new and follow-up) per clinic The table and graph below show the change in capacity and demand just by reducing the new to follow-up ratio Current Capacity Demand in 12/13 Activity in 12/13 Demand for 13/14 Variance in capacity and demand Increase by 5% Increase by 10% 12/13 13/14 inc. by 5% 13/14 inc. by 10% New 3,047 5,343 2,980 5,610 5,877 (2,296) (2,563) (2,830) Follow-Up 8,153 10,098 8,049 10,603 11,108 (1,945) (2,450) (2,955) Total 11,200 15,441 11,029 16,213 16,985 (4,241) (5,013) (5,785) Capacity Shortfalls Reduced Source: Information Services, OP added tab 19
Waiting lists breaches The table below shows the number of patients on the Gastroenterology elective waiting list by pathway. At the end of March 2013 there were a total of 4,985 patients on the waiting list. Pathway Type No of Patients Endoscopy Waiting List 2021 Outpatient Waiting List 1505 Inpatient/Daycase Waiting List 676 In Follow-Up Cycle 741 On Multiple Components 40 Total 4985 The graph below shows the number of patients on the waiting for Outpatient and Inpatient list for 14 weeks or higher Patients waiting for 14 weeks or higher Source: Information Services Gastroenterology Waiting Lists 11-04-13 20
Points to consider There are capacity gains that can result from increasing the efficiency of clinic utilisation Significant capacity can also be gained by increasing the SpR time in clinics If utilisation levels for new booked appointments was at the level of the best performer (in this case, Dr S Dolwani at 94%) there is additional outpatient capacity of 271 new outpatients which is equivalent to 77 extra outpatient clinics There is also an opportunity to free-up capacity by reducing the first to follow-up ratio from 3.3 (current average) to 1.89 (National average for Gastro) and overall DNA rate from 17.5% (current average) to 11.5% (National average for Gastro) Questions What is the conversion rate from outpatient appointment to endoscopy? What are the booking processes for clinics? Can clinic templates be increased to meet current and future demand? Should all consultant clinic templates be the same? Can the frequency of clinics be increased? Can the number of nurse and registrar led clinics be increased to accommodate for more appointments? Has any benchmarking been done with similar trusts around clinic templates? Next steps: Align outpatient clinic capacity and demand Review the need for varying consultant clinic templates Identify ways to reduce first to follow-up ratio and DNA rates 21
Section 5 Endoscopy Utilisation Analysis
Data analysis methodology Data tools The Endoscopy activity data for UHL was extracted from the Theatreman system The Endoscopy activity data for UHW was extracted from the ADAM system while the number of slots/points equating to the number of procedures performed (Actual Activity) where provided by the service manager for Surgery Support Services Data analysis The data reporting period for UHL was for one year between April 12 to March 13 and where possible, the number of slots/points for procedures were extracted from the Theatreman data. The data also provided procedure cancellations. For procedures where number of slots/points were unavailable Gastroscopy has been scored at 1.1, Colonoscopy at 2.4 and Flexible Sigmoidoscopy at 1.1 For UHW, the data received was only nine months between April 12 and Dec 13. This is because the number of slots/points equating to the number of procedures performed (Actual Activity) are recorded manually and since Dec 13 have not been update. Please note that this data has been extrapolated to get a years worth of data to maintain uniformity in analysis. Procedure cancellations have been recorded from PMS Endoscopy utilisation Endoscopy utilisation and capacity is based on points assigned to procedures. One point equates to 20 minutes scheduled, therefore more complex procedures provide more points. Four hours per list and 12 points is the recommended medical benchmark by JAG (Joint Advisory Group for Gastroenterology). In addition, it is standard practice for Nurse Endoscopists to deliver 10 points per four hour list. At C&V UHB, 12 points and 10 points have been allocated for an AM and a PM list respectively for a consultant while 10 points and 8 points have been allocated for an AM and a PM list respectively for a Nurse Endoscopist. Points allocated to training lists vary between 8 and 10. 23
Definition of key matrices used Endoscopy utilisation metrics The following metrics have been used in this report to highlight endoscopy utilisation opportunities: Number Metric Calculation 1. Potential capacity Lists that ran in reporting period X UHB templated point allocation (12 points AM and 10 points PM for a consultant and 10 points AM and 8 points PM Nurse Endoscopist) 2. Booked capacity Points that were scheduled onto the lists during the reporting periods 3. Actual activity Points that attended (procedure undertaken) during the reporting period 4. Booked versus potential utilisation Metric 2 / Metric 1 (%) 5. Actual versus booked utilisation Metric 3 / Metric 2 (%) 6. Actual versus potential utilisation Metric 3 / Metric 1 (%) 7. Mean points per list Metric 2 / Number lists that ran in the reporting period & Metric 3 / Number lists that ran in the reporting period 8. Patient Did Not attend (DNA) rate 100% - Metric 5 24
Assumptions 25
Endoscopy Booking Rules The table below shows the current Endoscopy booking rules across UHW and UHL. Lists per consultant have been divided up into AM and PM lists so that appropriate points can be allocated. These include training lists. It is assumed that registrars are available for only 60% of the year to scope Consultant Designation No. Of Weeks Site As per Procedure room templates No. of AM lists No. of PM lists Total Karen Wright CNS 44 UHW 1.5 2.5 4 Guy Blackshaw Consultant 38 UHW 0 1 1 Damesh Durai Consultant 42 UHW 1.5 0.5 2 Gareth Thomas Consultant 42 UHW 1.5 0 1.5 Jane Turner CNS 44 UHW 1.5 0 1.5 Barney Hawthorne Consultant 42 UHW 1 1 2 Geoff Clark Consultant 38 UHW 0 1 1 Andy Godkin Consultant 42 UHW 0 0.5 0.5 L Sunder Raj Consultant 42 UHW 0 1.5 1.5 Sue Cunningham GP 44 UHW 0 1 1 John Green Consultant 42 UHL 1 1 2 Mike Davies Consultant 38 UHL 1 0 1 Jill Swift Consultant 42 UHL 1 2 3 Jeff Turner Consultant 42 UHL 0 2 2 Sunil Dolwani Consultant 42 UHL 1 1 2 Simon Phillips Consultant 38 UHL 1 0 1 Kay Charles CNS 44 UHL 1 2 3 Locum Consultant 44 UHL 3 1 4 Chris Morris Consultant 38 UHL 1 0 1 Leigh Davies Consultant 39 UHL 0 1 1 Jane Turner CNS 44 UHL 1 1.5 2.5 Source: Procedure room templates 26
Clinical Productivity Site JAG recommended Capacity* UHB template Capacity Booked Capacity Actual Activity Booked versus potential utilisation Actual versus booked utilisation Actual versus potential utilisation DNA rate UHL 10,176 9,251 8,911 8,140 96.32% 91.35% 87.99% 3.66% UHW 7,642 6,198 6,104 5,526 98.48% 90.53% 89.16% 6.63% Total 17,818 15,449 15,015 13,666 97.19% 91.02% 88.46% 5.04% The table above demonstrates the key findings for the reporting period The analysis highlights that UHL is the larger of the two sites and performs more endoscopy procedures; UHL has 3 rooms and a theatre in Day Surgery ( Grey theatre ) that has been used for up to 2 days a week in recently while UHW has two Endoscopy rooms The overall Endoscopy utilisation rate is 88.46% UHB patient attendance rate is 91.02% Overall, both sites are well utilised although there is an opportunity to improve the utilisation further, especially the actual v potential utilisation Operational Efficiency The chart alongside shows the current DNA rate by site in comparison with JAG suggested target of 5%. The analysis shows that the overall DNA rate is 4.91% and the DNA rate at UHW is significantly higher than UHL Although both sites have low DNA rates, there is an opportunity at UHW to reduce DNAs further to the JAG suggested targets * Calculated based on 12 points for consultants and 10 points for nurses 27
Endoscopy Utilisation UHW Consultant Designation As per clinic templates Template Actual Actual No. Of Total Points Total Points Template Actual Actual No. of AM No. of PM Lists/ Lists/ Points/ Weeks in AM list in PM list Capacity Activity Utilisation lists lists Year Year list Sunder Raj Dr. L Consultant 42 0 1.5 12 10 430 564 131.1% 63 52 10.84 Thomas, Dr G Consultant 42 1.5 0 12 10 556 706 127.0% 63 76 9.29 Blackshaw, Mr. G Consultant 38 0 1 12 10 380 455 119.6% 38 39 11.66 Cunningham Dr, S GP 44 0 1 10 8 352 374 106.2% 44 43 8.70 Hawthorne Dr. B Consultant 42 1 1 12 10 724 760 105.0% 84 88 8.64 Godkin Dr. A Consultant 42 0 0.5 12 10 210 196 93.3% 21 16 12.24 Durai, Dr D Consultant 42 1.5 0.5 12 10 966 743 76.9% 84 85 8.74 Clark Dr G Consultant 38 0 1 12 10 380 279 73.3% 38 29 9.61 Sister J Turner CNS 44 1.5 0 10 8 660 470 71.3% 66 49 9.60 Sister K Wright CNS 44 1.5 2.5 10 8 1540 980 63.6% 176 124 7.90 Total 7 9 6198 5526 89.2% 677 601 9.20 The table and graph above show the list utilisation rates and average points per list at UHW The analysis factors in the impact of training lists on capacity; At UHW there are 4 training lists and run for an average of 60% of the year at 8 points per list SpRs train under consultants, but when a trained SpR is available and is able to perform a list independently, the total capacity will increase There are variations in the number of points per list and overall, the consultants perform 10 points per list against an average of 11 points while Nurse Endoscopist perform only 8.75 points against and average of 9 which indicates that the list are slightly underutilised although a part of this could be attributed to the DNA rate List utilisation at UHW varies between 131.1% and 63.6% with the overall utilisation being 89.2% which indicates that there is potential to increase throughput by better utilising the lists 0.5 inpatient emergency lists run on Mon (Durai), Tues (Sunderraj), Thurs (Hawthorne) and Fri (Thomas) and only one of these 0.5 lists are included in agreed job plans is Dr Durai. The others are additional, non-agreed activity Dr Dolwani also does regular endoscopy lists in main theatres which include joint procedures with upper/colorectal surgeons. Many are scheduled as prolonged cases with multiple slots. It is uncertain if this activity is included in this data 28
Endoscopy Utilisation UHL Consultant Designation As per clinic templates Template Actual Actual No. Of Total Points Total Points Actual Actual No. of AM No. of PM Capacity Lists/ Lists/ Points/ Weeks in AM list in PM list Activity Utilisation lists lists Year Year list Turner Dr. J Consultant 42 0 2 12 10 671 745 111.0% 84 79 9.43 Swift Dr. G Consultant 42 1 2 12 10 1175 1191 101.3% 126 135 8.82 Green Dr. J Consultant 42 1 1 12 10 755 740 98.0% 84 82 9.02 Locum Consultant 44 3 1 12 10 2024 1892 93.5% 176 219 8.64 Sister K Charles CNS 44 1 2 10 8 1144 985 86.1% 132 133 7.41 Sister J Turner CNS 44 1 1.5 10 8 968 833 86.1% 110 112 7.44 Morris Mr. C Consultant 38 1 0 12 10 456 385 84.4% 38 36 10.69 Phillips Mr. S Consultant 38 1 0 12 10 456 321 70.4% 38 31 10.35 Dolwani Dr. S Consultant 42 1 1 12 10 755 526 69.6% 84 57 9.23 Davies Dr. L Consultant 39 0 1 12 10 390 241 61.8% 39 28 8.61 Davies Mr. M Consultant 38 1 0 12 10 456 281 61.6% 38 28 10.04 Total 11 12.5 9251 8140 88.0% 949 940 8.66 The table and graph above show the list utilisation rates and average points per list at UHL The analysis factors in the impact of training lists on capacity. At UHL are 3 training lists and run for an average of 60% of the year with 10 points for an AM list and 8 points for a PM list SpRs train under consultants, but when a trained SpR is available and is able to perform a list independently, the total capacity will increase There are variations in the number of points per list and overall, the consultants perform 9 points per list against an average of 11 points while Nurse Endoscopist perform 8 points against and average of 9 which indicates that the list are underutilised although a part of this could be attributed to the DNA rate List utilisation at UHL varies between 111% and 61.6% with the overall utilisation being 86.8% which indicates that there is potential to increase throughput by better utilising the lists 29
Endoscopy Capacity & Demand Capacity 12/13 Demand in 12/13 Activity in 12/13 Capacity 13/14 Demand for 13/14 Demand for 14/15 C&V UHB 15,449 16,254 13,666 16,564 16,364 16,889 Assumptions: The current capacity is based on procedure room templates Endoscopy demand for 12/13 is derived from the number of Gastroscopy, Colonoscopy and Flexible Sigmoidoscopy patients added to the waiting list in 12/13 which is then multiplied by the respective weights of 1.1,2.4 and 1.1 The capacity and demand for 13/14 have been extracted from the capacity demand review conducted by the UHB Endoscopy demand for 14/15 is based on the assumption that the number of new referrals will increase 15% and assumes that the waiting lists from 13/14 were fully cleared Source: Information Services, OP added tab 30
Endoscopy productivity and Skill mix Consultant Number of Cancelled Number of procedures procedures sessions # late starts % late # early % early Average Total late Total early starts finishes finishes turnaround start time finish time Dead time Davies Dr. L 118 13 28 8 29% 13 46% 00:20:17 03:57:00 02:44:00 07:01:17 Davies Mr. M 155 7 28 7 25% 17 61% 00:13:52 01:47:00 00:26:00 02:26:52 Dolwani Dr. S 194 6 57 48 84% 36 63% 00:14:42 04:38:00 08:55:00 13:47:42 Locum 557 43 106 54 51% 45 42% 00:15:49 04:23:00 04:59:00 09:37:49 Green Dr. J 394 34 82 43 52% 54 66% 00:17:34 16:06:00 04:44:00 21:07:34 Keshk Dr. K 505 50 113 60 53% 52 46% 00:18:18 21:43:00 08:11:00 06:12:18 Morris Mr. C 190 14 36 21 58% 10 28% 00:15:00 08:43:00 00:10:00 09:08:00 Nurse Endoscopist 1627 156 245 70 29% 103 42% 00:18:15 16:39:00 05:29:00 22:26:15 Phillips Mr. S 164 11 31 9 29% 11 35% 00:17:11 04:28:00 01:21:00 06:06:11 Swift Dr. G 679 58 135 55 41% 32 24% 00:14:52 17:05:00 06:03:00 23:22:52 Turner Dr. J 376 22 79 25 32% 54 68% 00:17:08 10:38:00 08:17:00 19:12:08 Total 4959 414 940 400 43% 427 45% 00:16:38 158:07:00 51:19:00 212:28:57 The table above shows the endoscopy procedure room productivity at UHL The analysis shows that 43% of the procedures started late while 45% of the procedures finished early and the average turnaround time was 16 mins Assuming 3.75 hrs per session, upto the equivalent of 55 sessions could be added per year just by reducing the late starts and early finishes Dead time is the total time the procedure room is idle and is the sum of turnaround time and late start and early finish time Skill Mix Review The chart alongside demonstrates the proportion of activity delivered by Nurse Endoscopists compared with Consultant /Medical Endoscopists across C&V UHB The Royal College of Nursing suggests that Nurse Endoscopists should be able to perform up to 20% of non complex endoscopy procedures Overall, the number of Endoscopic procedures being performed by Nurse Endoscopists is at par with the guidelines although there are some discrepancies in the data that need to be investigated further 31
Points to consider This analysis suggest that currently, the endoscopy utilisation is good but there are opportunities to improve it further by increasing bookings and reducing DNAs and cancellations Capacity can also be increased by increasing the number of procedures performed by nurse endoscopists Questions How is procedure room availability managed? How long does it take to prep a room before a procedure takes place? What is the current turnaround time? What is the Endoscopy waiting list looking like at the moment? Are there stringent vetting procedures in place to identify the right patients? Can the number of junior staff be increased to provide more capacity? How many list do nurse endoscopists manage? Can the number of lists be increased? Are nurse endoscopists being trained to perform Colonoscopies? Can the number of training lists be decreased? How many lists do registrars manage? Are registrars allowed to manage lists autonomously? Can the number of sessions performed by surgeons be increase from 38 to 42 per year? Can variation between consultant with regards to number of list be reduced? Are extended days, three session days and weekend working an option to increase capacity? How many sessions are consultants allocated for endoscopy lists in their jobplans? Has overbooking been considered as an option to reduce DNA? Next steps: Align endoscopy capacity and demand Consider standardising consultant lists and increasing nurse led lists 32
Section 6 Consultant time
Consultant time breakdown in Gastroenterology The pie chart below displays the split of programmed activities across Direct Clinical Care and Supporting Professional Activities according to informal job plans* Breakdown of PA s Number of PA s % of total Direct Clinical Care 70 68% Supporting Professional Activities 25 24% Other externally funded activities 8 8% Total 103 100% * Job plans as at 12 th May 13 sent by Richard Evans. Please note that the job plans are under consideration and still being updated. Numbers on this slide are for conversation purposes only as there is a likelihood that they might change 34
Consultant time breakdown The graph below displays the split of programmed activities by Consultant across Direct Clinical Care and Supporting Professional Activities according to informal job plans* Of a total of 103 PA s across the consultants, 24% are allocated to Supporting Professional Activities The graph on the right displays the time allocated to Supporting Professional Activities as a percentage of Direct Clinical Care by consultant *Job plans as at 12 th May 13 sent by Richard Evans. Please note that the job plans are under consideration and still being updated. Numbers on this slide are for conversation purposes only as there is a likelihood that they might change 35
Detail of Direct Clinical Care The graph below displays the split of direct clinical care according to informal job plans*. The graph below displays the split of DCC Category Number of PA's Endoscopy 20.40 Outpatients 13.84 Ward Rounds 11.32 PR Admin 9.40 Emergency (on call) 5.33 MDT Meeting 4.54 Emergency (endoscopy) 0.90 Other 4.8 Total 70.53 The other DCCs include 2 sessions of ERCP + 0.5 sessions of Manometry for Dr Thomas and 2.5 for Bowel cancer screening sessions - 1 each for Dr Dolwani and Dr Green and 0.5 for Dr. Hawthorne *Job plans as at 12 th May 13 sent by Richard Evans. Please note that the job plans are under consideration and still being updated. Numbers on this slide are for conversation purposes only as there is a likelihood that they might change 36
Section 7 Appendix
HRG description HRG Group D Bronchiectasis Bronchopneumonia w cc Bronchopneumonia w/o cc Chronic Obstructive Pulmonary Disease or Bronchitis w cc Chronic Obstructive Pulmonary Disease or Bronchitis w/o cc Pulmonary Embolis w/o cc Pulmonary Oedema Respiratory Failure w cc Respiratory Neoplasms Sleep Disordered Breathing Unspecified Acute Lower Respiratory Infection HRG Group G Acute Liver Disorders Biliary Tract Disorders <70 w/o cc Biliary Tract Disorders >69 or w cc Chronic Liver Disorders <70 w/o cc Chronic Liver Disorders >69 or w cc Chronic Pancreatic Disease <70 Chronic Pancreatic Disease >69 Complex Elderly with a Hepato-Biliary or Pancreatic System Primary Diagnosis Liver - Major Procedures <70 w/o cc Liver - Major Procedures >69 or w cc Liver - Very Major Procedures Therapeutic Pancreatic or Biliary Procedures Therapeutic Pancreatic or Billary Procedures with Neoplasms HRG Group F Anal Disorders Diagnostic Procedures, Oesophagus and Stomach Disorders of the Oesophagus <70 w/o cc Disorders of the Oesophagus >69 or w cc Gastrointestinal Bleed - Diagnostic Endoscopic or Intermediate Procedures Gastrointestinal Bleed - Major or Therapeutic Endoscopic Procedures Gastrointestinal Bleed - Very Major Procedures Gastrointestinal Bleed <70 w/o cc Gastrointestinal Bleed >69 or w cc General Abdominal - Diagnostic Procedures General Abdominal - Endoscopic or Intermediate Procedures >69 or w cc General Abdominal - Very Major or Major Procedures <70 w/o cc General Abdominal Disorders <70 w/o cc General Abdominal Disorders >69 or w cc Inflammatory Bowel Disease - Endoscopic or Intermediate Procedures <70 w/o cc Inflammatory Bowel Disease - Endoscopic or Intermediate Procedures >69 or w cc Inflammatory Bowel Disease <70 w/o cc Inflammatory Bowel Disease >69 or w cc Intestinal Infectious Disorders <70 w/o cc Intestinal Infectious Disorders >69 or w cc Large Intestinal Disorders <70 w/o cc Large Intestinal Disorders >69 or w cc Large Intestine - Very Major Procedures Oesophagus - Major Procedures or Prostheses Oesophagus - Very Major Procedures Stomach or Duodenum - Major Procedures >69 or w cc Stomach or Duodenum - Therapeutic Endoscopic or Intermediate Procedures Stomach or Duodenum Disorders <70 w/o cc Stomach or Duodenum Disorders >69 or w cc Stomach or Duodenum Disorders >69 or w cc HRG Group L Acute Renal Failure >69 or w cc Complex Elderly with a Urinary Tract or Male Reproductive System Primary Diagnosis Kidney or Urinary Tract Infections <70 w/o cc Kidney or Urinary Tract Infections >69 or w cc Non OR Admission for Kidney or Urinary Tract Neoplasms >69 or w cc Renal General Disorders <70 w/o cc Renal General Disorders >69 or w cc Renal Replacement Therapy w/o cc Ureter Major Endoscopic Procedure Urinary Tract Findings <70 w/o cc Urinary Tract Findings >69 or w cc HRG Group S Complex Elderly with a Haematology, Infectious Disease, Poisoning, or Non-specific Primary Diagnosis Malignant Disorder of the Lymphatic/ Haematological Systems with los <2 days Malignant Disorder of the Lymphatic/ Haematological Systems with los >1 day Poisoning, Toxic, Environmental and Unspecified Effects 38
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