Interactive Urological Outpatient Workshop One Stop Urology Clinic design Norfolk and Norwich University Hospitals 25 th September 2014
Is this your service? Multiple entry points into the service new patients seen in over 12 different clinics (Cons, Haem, PSA, PAC, N&N, Cromer) Care being delivered by junior, less trained staff Long waits for clinic visit - subsequent investigations - delay in diagnosis and impair outcome Poor satisfaction with traditional system for staff & patients Increasing demands on service Age of population, targets, competition
Is this your service? Audit of the old clinics ( 2 studies each with >100 consecutive pts): - referral to appointment: >7 weeks - time to further investigations: 12 to 80 days - referral to diagnosis: 3.7 months - discharge after 1 st visit: 5.4%
Design of Diagnostic clinics Liverpool Guys/Norwich
Why have a one-stop clinic? Rapid access - ideally all seen within 14-28d of referral Single entry point for all new patients Consultant delivered clinic Investigations available within the clinic Minimise hospital visits for investigations Reduce number of outpatient visits Diagnosis and management plan at end of first visit Letter for GP and patient at end of visit Create separate specialist follow up clinics
Norwich Urology stats Population of >750,000 (aging) Outpatient referrals 2006/2007-5140 2011/2012-7022 2013/2014-7780 New patient referrals per week approx 140 7 full time and 2 ( now 3) part time Consultants 3 Registrars 4 Clinical fellows
The one stop clinic How it works the Guys/ Norwich model Ideally single entry for all new patients Actually still run separate PSA clinic ( biopsies) And one stop Haematuria clinic once a week
Components of the One-stop Clinic Clinic Suite Clinic staff Medical staff Investigations Admin Communication with patients Communication with GPs
Components of the One-stop Clinic Medical Staff Medical staff All clinics staffed by Consultants and middle grade Drs. 36 new patients per clinic ( based upon calculations for number of referrals per week) 3 clinics per week 6 doctors allocated to a clinic Each consultant paired with middle grade allowing consultant input for all Drs share computer and room to facilitate interaction
Components of the One-stop Clinic Investigations Urine dipstick Flow rate Plain abdominal film Bloods Ultrasound renal/ scrotal Flexible cystoscopy Trusp and biopsy
Components of the One-stop Clinic Investigations Ultrasound room radiologist radiology helper booking system machine and probes integration with PACs reporting system
Components of the One-stop Clinic - Investigations Flexible cystoscopy requirements cystoscope room sterilisation system bottles/toilet consumables referring doctor does scope 2 staff: 1 to run scope, 1 to assist Vision Sciences Cystoscope utilises the Slide-On EndoSheath system
Components of the One-stop Clinic - Investigations Flexible cystoscopy room
Components of the One-stop Clinic Clinic Staff 5-6 nursing staff in each clinic 1 in ultrasound, 2 in cystoscopy, 1 testing urine, collecting notes and 2-3 with doctors and running flow tests Staff trained to manage cystoscopy, help as radiology assistants Additional nurse practitioners to help with TRUS and counselling
Components of the One-stop Clinic Admin. Communication with patients new clinic letters, patient information leaflets etc Communication with GPs letters dictated during clinic and typed during clinic by secretaries. Letters to be signed on same day and sent. General Admin - note preparation with specially designed front cover to direct flow through clinic, additional information leaflet packs in clinic. - clinic template to allow good mix of patients ( 2ww)
Components of the One-stop Clinic - Clinic suite General surgical outpatient clinic Space for 6 doctors plus investigations Redesign of rooms Retraining of doctors! Flexible cystoscopy TRUS Clinic rooms Admin Waiting area Urine dip Clinic rooms Reception Ultrasound Flow Clinic rooms Waiting area
How the Clinic Works Patient Flow Flexible cystoscopy TRUS Clinic rooms Admin Waiting area Urine dip Clinic rooms Reception Ultrasound Flow Clinic rooms Waiting area
Impact of One Stop clinic Sarah Wood Barnaby Barrass
Have we improved our service? One stop running for 36 months Continue to monitor and audit the process Monthly service evaluation of the clinics 100 consecutive patients before and after one stop Patient satisfaction questionnaires Transferred service to additional site (Cromer) Transferred experience to improve haematuria clinic
Have we improved our service? Time from GP referral to clinic appointment Reduced. No more PTL clinics to see extra 2ww patients Choose and book at best 2 weeks Gradually creeping to 4-6 weeks DNA rate 3.5% vs 8% in old clinics
Have we improved our service? Monthly service evaluation Ave Number 2012 1 st 6mth 2013 Jan 2014 Seen per month 339 393 418 Discharged 31.1% 32.4% 32.0% Put on daycase w/l 15.0% 14.3% 15.9% Put on in-pt w/l 4.2% 3.7% 6.2% Ave clinic time 1hr 21min 1hr 19min 1hr 40min Flexis 125 127 157 Uss 119 138 n/a DNA 2.2%
Have we improved our service? Audit of 100 patients before and after one-stop (B Barras) Clinician seeing patients Clinician performing cystoscopy % total 90 80 70 60 50 40 30 20 10 0 consultant specialty registrar associate specialist clinical fellow old style one stop nurse % total 100 90 80 70 60 50 40 30 20 10 0 Clinical fellow Associate specialist old style one stop Specialty registrar Consultant urologist GP assistant Referring clinician
Have we improved our service? Audit of 100 patients before and after one-stop (B Barras) Investigation ordered old one stop Ultrasound 34.8 36.7 Flexible cystoscopy 30.4 25.5 Flow rate 16 11 Blood test 12 14 CT scan 9 10 TRUS biopsy 7 5 Frequency voiding chart 5 5
Have we improved our service? Audit of 100 patients before and after one-stop (B Barras) Wait times for Investigation Waiting time (days) Old style one stop p value Ultrasound 34.3 0 <0.0001 Flexible cystoscopy 31.4 1.6 <0.0001 Flow rate 79.9 16.4 0.0003 KUB 27.0 0.0 0.3 FVC 15.7 21.3 0.7 CT 35.2 24.4 0.5
Are patients happy with the service? Patient satisfaction questionnaires (199 replies from 432 patients) Were you pleased to have your tests on the same day? % total 90 80 70 60 50 40 30 20 10 0 yes no blank n/a
Are patients happy with the service? Patient satisfaction questionnaire How satisfied were you with your clinic visit overall? 45 % total 40 35 30 25 20 15 10 5 0 score < 5 score 5/10 score 6/10 score 7/10 score 8/10 score 9/10 score 10/10 n/a
Are patients happy with the service? Very helpful and friendly staff and also very re-assuring. The relief of having all test and results in one visit, to me is invaluable. I had a consultant who took time and patience to listen, explain the treatment. First time I have really experienced a urology consultant who has done so. This is a great clinic, very quick and easy. A lovely team. Efficient prompt and polite staff who explained everything clearly to me. Thank You. Great idea stops people worrying. BUT Better Magazines in waiting room. Only 2 WC's in a Urology clinic seems inadequate. Waiting time could have been better.
Happy staff? Clinic staff Radiology Doctors
Sustainability Issues Increasing referrals ( + blood in pee campaign) Numbers possible to see in clinic depends upon who is in clinic, mix of patients seen Staff changes registrars, clinical fellows, ultrasonographer Hospital pressures theatres, assistants 2WW referrals
Impact on other services Other clinics - in urology One stop haem clinics More specialist follow up clinics Generic follow up clinics Radiology Standard flexi lists check cystoscopies on time.
Lessons learnt Numbers of doctors in clinic Minimum four must watch mix of doctors Number of patients seen ( and mix) - not too many not too few - Not all 2ww or no 2ww Constantly monitor Team work
Designing the one stop service Developed working group of key staff and set up regular meetings from all departments involved Outpatient sister Clinic coordinator Radiologist Radiology service improvement manager Senior surgical sister Urology divisional ops manager Clinical director
Designing the service - When, where, who, what, how & cost How Designed service, addressing all components Where, when, who, what, cost Ran pilot clinics and identified any issues then re-trialled clinic Re-negotiated all job-plans to staff clinic Appointed motivated staff who share vision for success Regular audit of process and outcome
Designing the service - When, where, who, what, how & cost Cost Clinic space Staff Equipment Training already available re distribution Scopes - USS probes in house Of clinic billing to gps/ coding
Components of the One-stop Clinic Clinic suite Flexible cystoscopy TRUS Clinic rooms Admin Waiting area Urine dip Clinic rooms Reception Ultrasound Flow Clinic rooms Waiting area
How the Clinic Works Flexible cystoscopy TRUS Clinic rooms Admin Waiting area Urine dip Clinic rooms Reception Ultrasound Flow Clinic rooms Waiting area