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

Productive Endoscopy

Email: england.si-enquiries@nhs.net

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?