Deborah Debono1, Janet Long1, Melvin Chin2, Rachel Williams2, Elizabeth Salisbury3, Tracey Dunlop4, Kim-Chi Phan-Thien4, Elizabeth Eykman4, Sharron O’Neill5, Jeffrey Braithwaite1,

Natalie Taylor1

1Centre for Healthcare Resilience and Implementation Science (CHRIS), Australian Institute of Health Innovation (AIHI), Macquarie University; 2Prince of Wales Hospital; 3SEALS, Prince of Wales Hospital;

4St George Hospital; 5Lynch Syndrome Australia

Referral as imagined versus referral as done: mapping the referral process for genetic counselling for Lynch Syndrome patients

Introduction: What is Lynch Syndrome?

• Lynch syndrome (LS) is a genetic mutation that increases the risk of aggressive cancers, particularly colorectal cancer (CRC), at a young age

• Cancer patients with a high risk of LS can take a genetic test

• Carriers can undertake effective surveillance, detect and treat cancer early and educate relatives

• Early diagnosis of LS can save lives

However …

The problem: referral to genetic counselling for CRC patients with high risk of LS

• Less than half of NSW CRC patients with high risk of LS are referred for genetic counselling and testing

‘Seeing’ the problem: mapping the referral process

“If people do not see the process, they cannot improve it.”

(Deming (1900-93))

• To improve the referral process for genetic testing for LS, we first need to identify and visualise the process

• Process mapping creates a visual representation of the actors, steps, and decisions involved in a process

• Cross referencing the described process with audit data collected at various steps of the process can highlight the process as it exists (work-as-done (WAD)) rather than as it is imagined to occur (work-as-imagined (WAI))

The project aim

To co-develop at two hospitals a map of the current referral process for genetic counselling of colorectal cancer patients with a high likelihood of LS

Methods

• May – September 2015• Two hospitals in Sydney• Face-to-face process mapping sessions (n=6) with key

healthcare professionals involved in the referral process for genetic counselling for testing for LS

• Implementation team meetings (n=2) with multidisciplinary health care professionals (Medical Oncologists, Pathology Registrars, Genetics Counsellors, Colorectal Surgeons, Radiation Oncologists)

• Audit data collection points identified• Electronic feedback on process map iterations

Method: co-creating the referral process map

Process begins

Process ends

Yes

Yes

No

No

A

A

A

A

Results

• Nine iterations of the referral process map have been developed

Results: Referral Process Map - Iteration 1

Results: Referral Process Map – Iteration 9

Results

Co-mapping the referral process has: • Highlighted steps of the process at which data can be

collected to validate the process map and to measure the effect of improvement strategies

• Exposed work-as-imagined (WAI) versus work-as-done (WAD)

• Helped to create a shared understanding of the current process

• Illuminated potential barriers for further exploration

Implications

Co-developing a process map with multidisciplinary stakeholders provides a powerful tool to:• Garner their unique knowledge of different aspects of the process to

produce a detailed representation • Facilitate communication between team members• Generate a shared understanding of the current referral process (work-

as-done)• Make ‘visible’ specific challenges to appropriate referral to genetic

counselling • Highlight potential targets for intervention to improve accuracy and

timeliness of referral

Thank you and acknowledgements

This project is a Translational Cancer Research Network’s Cancer Challenge of the Year initiative, supported by Cancer Institute NSW’s translational cancer research centre program grant