Weston Park Hospital Outpatients
Towards the end of last year a microsystem coach was invited to work with the Weston Park Outpatient team to investigate new ways of working that might improve the experience of patients when they attend clinic.
Weston Park Hospital is one of only three dedicated cancer hospitals in the UK delivering around 35,000 Outpatient appointments each year alongside day-case Chemotherapy and inpatient care.
The microsystem improvement approach aims to engage all staff groups working in the department, from receptionist to consultant, along with other linked staff groups such as medical records, to work together to identify problems in existing pathways and seek changes to improve these. The aim is to identify a series of small changes which, when added together, make a significant difference to the overall pathway.
A multidisciplinary group have been meeting weekly to explore these opportunities. A large amount of baseline data was collected including:
- A staff survey.
- A patient survey.
- Timing of patients passing through the department in relation to appointment times.
- Mapping of current processes for clinic booking and looking after patients in clinic.
The key findings from this exercise were that huge numbers of patients pass through the department, and that many have very long waiting times. The team hope to demonstrate significant improvements in this area.
Although patient waiting in clinic was the most dominant theme, the team chose to start earlier in the process and focus on a theme of clinic preparation. By looking at the work done for the patient before they arrive they hoped to ‘set themselves up for success’ and hopefully improve the flow of the clinic by reducing delays due to key information (medical notes, scan results etc) being missing. This would also reduce the time nurses are spent away from clinical duties preparing notes.
The team created a Global Aim statement:
“We aim to improve clinic preparation in WPH Outpatients. The process starts when the doctor records what is needed at the end of a previous consultation. The process ends when notes are fully prepared before the patient arrives. By working on this we expect to reduce the number of nursing hours spent prepping and reworking ahead of clinic. We also expect to reduce the amount of missing information in clinic.”
The team process mapped the clinic preparation process and identified lots of small changes throughout the whole process which when added together would have a significant impact.
Changes that have been identified and instituted across all clinics include:
- Improving access to District General Hospital (DGH) IT systems so that clinical staff can access laboratory and radiology reports directly rather than spending long periods of time on the phone requesting results to be sent.
- Giving patients who will require an X-Ray at next visit the request card as they leave. Previously cards were being lost and required re-writing at the start of clinics, delaying the start of clinic.
- Standardising the process for locating missing notes to ensure time wasn’t wasted searching and re-searching for missing notes.
Other changes that have been piloted in a limited number of clinics include:
- Introducing a communication sheet filed in the front of the notes indicating exactly what information will be required at the next visit.
- Marking on clinic lists which patients have had a letter dictated so that the remaining notes can be returned directly to file.
The team implemented the above changes, and measured the impact in terms of time spent preparing clinics. The particular change that sparked a difference was the introduction of the communication sheet. The communication sheet was inserted into the notes when the patient visited and the doctor recorded what was required for their next visit. This impact of the change would only be noticed several weeks later when they attended their next appointment.
To aid the test of change, a consistent nurse was allocated to the consultant to prepare the clinic the day before and also be in the clinic. An unanticipated benefit of this consistent team approach was the familiarity with the patients and how the clinic worked, leading to the clinic running more smoothly.
The graph below shows the average time taken to prepare each set of notes reducing from 4 minutes per patient to 2 minutes. This equates to 40-60 minutes less preparing each clinic.
The spike on the red line was traced back to the consultant being on leave three weeks prior and the clinic being covered by a registrar who wasn’t aware of the trial and didn’t complete the forms. This highlighted the impact of completing the form.
The communication sheet is now being rolled out across all Outpatient clinics.
The team are now moving on to their second theme - ‘clinic on the day’. Clinics are being timed to ensure appointments are set to the right lengths and better spread through the day with clearer booking rules, such as no overbooking. New clinic timetables will be trialled from June onwards. They are also looking at increasing the use of technology and reviewing other process steps which cause delays for patients.