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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
3 08.30 09:20 09:20 11:45
PM 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 pre-assessment, 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
• 2nd class post – significant delays
• Telephones often unmanned
• Huge amount of rework (25%)
• Patients query – often anti-coagulation or co-morbidities (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
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
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
Week 2
Week 1
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)
8
4 4hrs 12(am) 10(pm)
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
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
Actual Points
(11 point list)
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
-
Measures
-
- design
-
Productive Endoscopy
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
• 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
Why cancer?
