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Listen
Learning
Evolvement: Regional and National Working
The programme commenced in June 2003 with 1 Programme Manager, 7 Regional Facilitators and 1 Information Manager.
Although working individually in each region with the respective cancer team, much emphasis was placed on feedback and sharing of information across the team (on a 2 weekly basis at Programme Team Meetings) and more importantly with corresponding specific tumour site colleagues in each of the regions. This was extended further on a number of occasions to bring the Clinical Leads for each region together with us as a group, offering the opportunity for each region to feedback progress on improvement ideas. These sessions worked well, providing peers with an opportunity to discuss implementation of ideas, difficulties faced and potential solutions, a good learning environment for all!
New Cancers
Time spent supporting each of the cancer teams varied. By the end of the first 12 months it was apparent that the original level of support provided by the Facilitators was not required as cancer teams took ownership of progress of their changes but more of a regular contact/update session or concentrated effort on a specific problem/difficulty. Discussion with each of the cancer networks to identify the subsequent tumour sites allowed Facilitators to start working with new teams whilst still supporting initial teams as needed.
New Staff
The end of the first 18 months of the Programme saw a change in team personnel as three members returned to their host organisations. Three new facilitators joined the team between September and November 2004.
Process Mapping Event
Impact
Teams were asked to use PDSA documentation to record progress of change ideas and updates were requested on a monthly basis. As there was no dedicated time/resource in each network to gather or record the information we were dependent on the identified lead for each change to provide this information. Lack of data and dedicated resource was a challenge both for the programme and the cancer teams in demonstrating the impact of their changes and subsequent sustainability.
Ensuring baseline data was available, prior to implementation of a change, was crucial to facilitating clear demonstration of impact of the change.
The most appropriate method found as a team to illustrate impact to others was through a 'Storyboard' publication. Examples of successful changes were captured by the Regional Facilitators as work progressed and documented in a storyboard format for publication and communication throughout the three cancer networks. Much of the programme's literature is based around these and they are a useful tool in providing working examples in Scotland of the Top 20 Actions for Change. Feedback has been positive on this methodology as the storyboard provides the necessary detail and impact of a change and in an easy to read format.
Only a few of the improvements have required additional funding. It has simply needed the willingness of staff to examine how they deliver services for patients and an enthusiasm to make improvements happen.
Examples of Impact
1. In Elgin the lung team are now receiving fax referrals directly from GP's to the central referral point in Aberdeen Royal Infirmary. This has reduced the potential time to making an appointment from 2 weeks to 2 days.
2. In Greater Glasgow, members of the urology, radiology and primary care teams have developed a fast track haematuria service for patients with suspected cancer, reducing waiting times from 90 days to 1 day.
Dedicated or Fast-track clinics with rapid reporting Top 20 CID 2
In Glasgow, within urology services, a multidisciplinary team are working together to reduce the time to diagnose patients with frank haematuria. This change resulted in several improvements for patients.
Making It Happen
At a Cancer Service Improvement Programme ( CSIP) mapping event it was highlighted that urology patients were required to visit their local hospital several times to see a doctor and have tests. Each visit was to a different department and patient information and support services were not coordinated.
Staff decided to develop a one stop fast track haematuria system where patients could be seen quickly and diagnosed in 1 day.
The urology, radiology and primary care teams were keen to develop a team diagnostics approach where patients would undergo all three diagnostic procedures in one day and information and communication would be coordinated.
- 1 clinic a week is run with 5 patients every day. The patients receive detailed information leaflets with their appointment card explaining the diagnostic tests and format for the clinic.
- Every patient sees a specialist nurse who performs a full assessment and gives the patient a support phone number.
- Patients have a consultation with results and next steps before leaving the urology department
Implementation Advice
A multidisciplinary steering group was formed. Precise preparation and collaboration is essential. The lead cancer GP was instrumental in gaining primary care support and formulating policies to inform and guide primary care staff.
Impact
The benefits from this change are:
- Reduction of on average 3 months to diagnosis for patients
- Elimination of delay between investigations
- Reduced number of visits to hospital departments
- Improved communication and support systems for patients
- Improved communication and coordination between departments
Next steps
Since this is a new service, reviews will be 3 monthly, assessing capacity and demand to ensure sustainability of service.
Contact
Mr Naeem Akhtar - Consultant Urologist
Naeem.akhtar@sgh.scot.nhs.uk tel 0141 201 1100
Dr Paul Duffy - Consultant Radiologis
t Paul.duffy@sgh.scot.nhs.uk tel: 0141 201 1558
Sister Una Daly - Nurse Specialist
Una.daly@sch.scot.nhs.uk tel : 0141 201 1559
Dr George Barlow - GP
George.barlow@gp52058.glasgow-hb.scot.nhs.uk tel: 0141 427 1581
Referral to a service, not a named consultant Top 20 Referral 3
In Tayside, doctors, nurses, managers and medical records staff, asked GPs to add "Colorectal" to the referral letter. A letter was written to all GP practices in Tayside. The number of patients waiting for a hospital appointment has now reduced.
Making It Happen
Prior to this change, referral letters sent into the hospital by GPs about patients with colorectal symptoms were all received within medical records, then sent through the hospital internal mail to one doctor to be vetted. They were batched together with all the other general surgical referrals.
After vetting and categorising into urgent, soon and routine, the letters were sent back to medical records and placed onto an appointment waiting system.
This process took a maximum of 8 weeks to complete.
After a team mapping event, a PDSA cycle was tested. A letter was sent to all GP practices in Tayside to request that the word "Colorectal" be added to the referral letters to distinguish them from the general surgical referrals when received in medical records.
The letters are still vetted, but the doctor responsible now hands the letters with "colorectal" highlighted to the Colorectal Clinical Nurse Specialist who now either allocates appropriate clinic appointments or organises investigations before returning the letters by hand to medical records.
Implementation Advice
Consultation and communication with Primary Care colleagues is essential.
Impact
The benefits from this change have been:
- Reduction in vetting referral letters from a maximum of 8 weeks to 2 weeks
- Referral letters are now being reviewed by the Colorectal Clinical Nurse Specialist and dealt with appropriately
- Approximately 2500 patients are referred each year to general surgery in Tayside and most of these referrals have colorectal symptoms, therefore this change will benefit these patients.
Next Steps
Reduce the time to vet referral letters further by allowing the Colorectal Clinical Nurse Specialist access to the electronic referral system to view all referral to the colorectal service, thus allowing "on line" review and decisions transferred back to medical records electronically by email.
Contact
Jackie Kerrigan, Macmillan Colorectal Nurse Specialist, Ninewells Hospital, Dundee
Jackie.kerrigan@tuht.scot.nhs.uk tel: 01382 425 563
Spread
In order to achieve greater impact and awareness, the programme used a variety of methods to engage and share positive improvements. Not only were NHS staff our target but also our health department colleagues and other stakeholders. Spread was not only making our improvements known but contributing to other publications, articles, reports, organisations, providing updates and examples to waiting times unit, delivery groups and the minister.
CSIP Examples of Spread
Oral Chemotherapy
This improvement began in Perth Royal Infirmary, where the chemotherapy regimes were changed to allow oral medication to be given to patients rather than having them stay over in hospital for treatment. The benefits for the patient are that no overnight stay is required to receive treatment and less travel is involved. This also means that patients who need to stay in Perth Royal Infirmary receive their treatment more quickly as beds are freed up by those who receive oral chemo medication. The improvement has now spread further to Ninewells Hospital.
Direct Referral from Diagnostics
In Tayside, within gynaecological services, if the radiologist picks up abnormal Ultrasound scan on a patient sent from GP with suspected ovarian cancer, the report is directed to the gynaecological clinic for prompt action and a letter sent to the GP informing them of the action taken. This has resulted in the patient being seen more quickly at the clinic, receiving speedier treatment. This improvement originated from the Ninewells lung cancer team, who implemented the change first and shared it with the gynaecological cancer team.
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