Fast Track Outpatients
The Fast Track Clinic is a "one stop shop" for women being referred by their GP with any breast related issues. At the Fast Track Clinic the patient will see a clinician and have any relevant imaging undertaken.
In January 2014, members from the Fast Track Outpatient Clinic decided to meet weekly to commence some improvement work with the help of a Microsystem Improvement Coach.
In order to better understand their system and ensure they were not making any assumptions about what they needed to improve they started by carrying out a 5P Assessment (Patient, Professional, Patterns, Process, Purpose). Their 5P poster can be seen in the picture below.
To define the direction of the improvement work the team came up with a common "Purpose". They defined their purpose as :-
To provide a high end quality and timely service with the patient at its core where physical and emotional needs are met and that others aspire to
Process Map – this confirmed the suspicion that waiting times (seen in red below) were potentially an issue for patients.
A number of themes came out of our initial 5P assessment of the system and where we believe there is room for improvement. They are:-
The team decided that the first theme we would work on should be Clinic Process & Flow. From this “Theme” we came up with the following global aim:-
We aim to improve the efficiency and quality of the service for patients and staff in the Fast Track Clinic. The process begins with arrival at reception and the process ends with leaving the department. By working on the process we expect to reduce patient waiting times, improve patient and staff satisfaction and increase staff capacity. It is important to work on this now because we care about improving the service for the patient and those who work in the service. In achieving the aforementioned we hope to be a service that others aspire to
We then came up with a Specific Aim so we could have a target to aim for by a specific period in time.
We aim to reduce total patient waiting time within the Fast Track Service by 20% from our baseline measure of 40 minutes by the end of September 2014
The team then decided to look for some of the root causes that were causing patients to be waiting in the the clinic. They came up with the below Fishbone Diagram:-
Once the team had defined what some of the reasons were for patient waiting they started to think about the changes they could make to impact on this. Their 'Change Ideas' were as follows:-
The team was all set to start testing some of these ideas but by the next meeting they had had some time to think about the issues they had considered and came to the conclusion that we needed more data on what the patient was actually doing in the system before they decided what changes they actually wanted to make next. The team then decided that they were going to collect some cycle time data to better understand the patient journey. The results painted quite a vivid picture:-
Orange = Check-in
Yellow = Waiting before appointment time
Red = Patient Waiting Time
Green = Time with Clinician
Blue = Time in Imaging
What did the cycle time data tell us?
Demand was not being matched by the resources
- Patients were being seen before their allocated appointment times
- Clinicians saw patients on an ad hoc basis
What was the consequence of this?
- There were bottlenecks and queues forming in every clinic, the by product of this being lots of patient waiting time in the clinic
- Staff felt that they were rushed off their feet and had no time to do anything else i.e. admin
By understanding optimal cycle times for each stage and the fact that the clinic had to process a minimum of 20 new Fast Track patients we designed a schedule where demand was matched by the resource available. We realised that 2 clinicians could only realistically see 17 patients without bottlenecks and queues forming in the system. The only way to see 20 new Fast Track patients in the allocated time and in a standardised fashion would be if a third clinician came to assist from 14:40.
The team tested the above schedule and we saw the following:-
PDSA 1 Follow-Up
After the first test the team highlighted a number of issues that arose. They were as follows:-
- A third clinician not realistic. Needs to be 2 when they move upstairs
- 10 less follow up patients than normal
- Too many points in the clinic when clinicians not doing anything
- Radiology did not get started until late and ended up finishing late
- Radiology found it frustrating that patients who did not need a mammogram
- still had to wait 10 minutes to keep the structure
The team revised the schedule (see below) taking into account the above and as you can see it is more front loaded.
The team tested the updated schedule and achieved the following:-
Reduction in Total Waiting Time
After PDSA 1 = 41.2% Reduction
After PDSA 2 = 35.2% Reduction
Reduction in total time in department
After PDSA 1 – 23.3% Reduction
After PDSA 2 – 22.4% Reduction