Diabetic Foot Service

 

Background

The Diabetic Foot Service forms part of the Diabetes & Endocrinology Directorate and operates three clinics per week, two at NGH and one at RHH. Patients attending this service have advanced disease, often with multiple co-morbidities and require specialist input requiring frequent attendances at clinic. One of the major aims of this service is to reduce the risk to patients of amputation.

The clinic has a highly multidisciplinary focus to providing care.

Diabetes is a life-long condition and as such demand is increasing. Locally this has placed increasing pressure on the clinic to look at how best to meet this demand and provide the best quality service possible.


Assessment:

Assessing the system using the 5Ps. The Lead Improvement Group undertook the 5P assessment through multidisciplinary discussion using existing hospital data, staff and patient surveying and measurement / observation in clinic.

Purpose:

‘Our Purpose is to place the patient first, improve the chance & speed of healing existing ulcers & to prevent future ulceration and amputation’.

Patients:

What Our Patients Said:

  • Satisfaction- Overwhelmingly patients reported high satisfaction with the vast majority of clinical and A&C staff. Patients also had high satisfaction with the volume, level and detail of clinical advice and treatment received. Flexibility of service provided e.g. open access and the organisation of this was highly valued.
  • Continuity / Consistency- Patients value seeing the same people on repeat visits.
  • ‘I have to attend the clinic regularly, sometimes every 2 weeks, and I really value it when the staff know me so I don’t have to explain about my condition to lots of different people.’
  • Waiting- Overwhelmingly the main patient theme for improvement was waiting.
  • Transport- this was very much connected to waiting. Patients reported that the later they arrived the longer they waited to be seen.

Professionals:

What the staff said would improve services for patients and for the people who work in the clinic:

  • Patients should see the appropriate member of staff in the right order at the right time.
  • Shorter waiting times.
  • Better clinic preparation and set up.
  • More effective clinic scheduling to decrease chaos and increase control.
  • Improved management of transport patients to help plan clinics.
  • Work to improve patient information, education and communication as well as professional communication across the multidisciplinary team.

The team measured how long things took in clinic, professional cycle times, waiting and total time in clinic. They also made an assessment of their referral rates, DNA rates, the number of patients they planned to see over time, the amount of cancellations and subsequent re-work.


Diagnosis

The team identified multiple themes deciding that they should initially focus their improvement efforts on reducing the time patients waited in clinic. They developed aim statements and decided specifically to:

‘Decrease patient waiting by 50% by December 2012’
 

To do this they identified that the current way patients were scheduled in the clinic was inconsistent with the process map, the cycle times and that they did not currently plan in a consistent way. Initially a member of the clerical staff worked with a consultant to devise a new clinic schedule to test.

Data Collection:

Measurement was taken before the change so that the effects of a change could be measured.The team reviewed their findings and observations at their weekly improvement meeting. Initially patient waiting was captured by measuring consecutive patients in clinic by the time they waited before being seen and the time waiting in between steps in clinic. However this method was extremely time-consuming for the team so they re-evaluated their data. By capturing arrival time, time in clinic, time out of clinic and time booked for consecutive patients they were able to collect a range of measures.

• Time to book in.
• Time waiting before the consultation.
• Time in the consultation (patient care).
• Time to book out.

Treatment

To do this they identified that the current way patients were scheduled in the clinic was inconsistent with the process map, the cycle times and that they did not currently plan in a consistent way. Initially a member of the clerical staff worked with a consultant to devise a new clinic schedule to test.

Initially a member of the admin team worked with a consultant to design a new schedule. Through the development of the process map it was obvious that there were multiple potential pathways patients could travel down whilst in clinic and for many patients it was not immediately obvious which pathway they would be on until they had been assessed in clinic. To try to accommodate each possibility seemed an impossibility so it was decided at a regular meeting to start small test cycle to see what the effect was and reevaluate pending further changes.

The initial step was to create some order in terms of the rate patients arrived in clinic. The existing schedule was based on historical information and when the team studied it they quickly realised they were immediately incurring delays and waiting as more patients than could be seen were arriving at the same time. On further analysis it was noticed that the time intervals were also inconsistent across the schedule. The team knew the first step in the process for every patient was a dressing removal that consistently took 5 minutes or less. By planning patients arrival at regularly spaced intervals they deduced that they would more than likely have a nurse available to start the initial step for every patient.

In addition to the above steps the team considered the number of rooms available in clinic and the time patients were in the department. However given the multiple pathways, the team concluded that the initial steps they had taken should be tested first to see if this relieved pressure on the demand for rooms and consequently contribute to their goal of reducing patient waiting.

Results: Measurement was also taken during and after the change to ensure that any changes were improvements that could be proven with data.

 Continuous Improvement

The team continues to meet and discuss changes and how they can improve the service they offer to patients. A clinic specific patient information leaflet has been developed and the team are currently working a number of small scale changes including 5S and lean initiatives to standardise how the clinic is set up and ‘playbooks’ to describe how work should be prepared and conducted so all existing staff and new and transient staff understand how clinic runs. Additionally the service is embarking on a more ambitious programme to explore how simulation modelling can potentially help with ‘virtual PDSA cycles’ that can then be tested in real time.
 

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