Urology Outpatients – Flexible Cystoscopy Service
Microsystem Improvement Case Study
Summary
Doctors, nurses, managers and administrators worked together to standardise and simplify the scheduling of flexible cystoscopy appointments.
The resulting benefits are:
• Three hours less admin time required per week
• Reduction in variation for appointment lengths
• Decrease in typical patient visit time (80% of patients are now seen in 75 mins or less, down from 93 mins)
• Increased staff satisfaction of how clinic lists run
• Improved clinical information on clinic lists
Background
The Flexible Cystoscopy service, based in Urology Outpatients sees around 120 patients per week for a day-case procedure. A typical patient has been referred in by their GP with haematuria, which could be a symptom of bladder cancer. Other patients attend for bladder tumour surveillance, botox injections in their bladder or for stent removal.
This service is a significant proportion of the activity in Urology Outpatients and the team were keen to explore ways to improve the quality of service for patients and staff.
Assessment
This process started with a thorough assessment of how the current service was working, with the team collecting information around how long each part of the service took to deliver, mapping the whole process, defined typical patients, looked at activity data and did a staff and patient survey to build a shared understanding of the whole service and identify where to start focussing for improvement. Patients were pleased with the service, but were frustrated by delays in their appointment.
Diagnosis
It became clear the lack of detailed information showing the casemix was creating challenges for booking patients into clinic slots and planning capacity. This was shown both in a lack of information on the clinic lists and also when trying to plan the number of clinics required per week.
The team agreed the main measure of success would be to reduce waiting time for patients. There were multiple opportunities for waits and delays along the process, so the simplest measure was the duration of the patient’s visit, from check-in to check-out. The newly installed electronic check-in system was invaluable in capturing this information with no extra work for the team.
Annual capacity and demand was also a key issue to be addressed as there was a back-log of overdue follow-up appointments. Understanding the number of patients that could be seen on a list would inform how many lists were required each week to meet the demand for appointments.
Treatment
Whilst the team knew the big win would be to standardise and improve the timings on the clinic schedule, that process would take time while detailed timings were completed, reviewed and a new draft schedule could be developed.
In order to start making an impact they focussed on a small number of patients who also have an imaging appointment immediately prior to their clinic appointment. Delays in imaging would create disruption to the clinic schedule so the team looked to minimise these delays. The process was simplified so patients didn’t check-in at Urology Outpatient reception first, and went direct to imaging. The principle of the change was to minimise the number of patients arriving late for their imaging appointment through getting lost or stood in queues unnecessarily. The trial involved 124 patients, across 31 lists, with only a couple of small issues which were addressed. Patients generally arrive in good time for their appointment so there was no significant shift in the number of patients arriving late, although those that were late were now less late than before. As the process was better for the patient the decision was made to standardise this process going forward.
In order to develop a new standardised clinic schedule, a large meeting represented by all professions was held to review the timing data, collectively agree some design principles and rules for a clinic schedule and to design some trial schedules which could be tested. The meeting was well attended and the different professions had some really engaging discussion about what made a good ‘flexi list’.
A new schedule was trialled for one month with more information around appointment type on the clinic list and more detailed timings for their appointment – patient arrival time, patient in theatre time and imaging appointment time (if appropriate).
All staff involved completed a feedback form at the end of each clinic reviewing how the list ran and what could be improved. This feedback, along with activity data and electronic check-in timings was used to review the trial, again in a large open invite meeting. Despite some improvements, patient visit time increased slightly and staff satisfaction decreased. Clinic timings were tweaked and the case mix and positioning of cases on lists adjusted.
The revised schedule was trialled with improved staff feedback and a reduction in patient visit times. 80% of patients are now seen in 75mins or less (compared to 93mins baseline).