Urology Outpatients – Treatment Clinic
Microsystem Improvement Case Study
Summary
Nurses and admin staff in Urology Outpatients worked together to turn a ‘hectic clinic’ into one that is calmer, more organised, and more timely for patients. They re-organised the patient mix in each clinic and gave appropriate times for each appointment type.
The resulting benefits are:
•A 50% reduction in the number of nurses required to run the service. This nursing capacity is being used in other services within the department
•The last patient on every list during the trial was seen on time or early
Background
Treatment Clinic is a nurse led service in Urology Outpatients providing around 80 treatments per week and runs most days. Many of the patients are on long-term follow-up so are well known by the team.
There was dissatisfaction with the way the clinic ran, largely due to the way patients were scheduled. Some clinics would have few patients on and others would be overbooked. This made it hard to plan nursing requirements in advance and there would often be a surge of patients in the middle of a clinic.
Assessment
An improvement team formed, with representatives from the nursing team and reception. Previous activity data was reviewed to understand how many of which treatment type were required each week. A staff survey was completed to gather input from staff on their feelings about how the clinic ran and to gain ideas for improvement.
Diagnosis
Through regular meetings, each profession built their understanding of each other’s roles and explored alternative ways of delivering the service.
It became clear that the standard appointment length of 10 minutes created many of the problems as a third of all appointments take longer than this, some of which take around 30mins. A new schedule was developed based around the typical time required for each treatment type, including time for writing up patient notes. Typically because clinics ran late, writing up notes was left until all patients had been seen. It was agreed as preferable to write up each patient as the clinic progressed. Because the majority of the patients are well known and attend regularly, the team had a deep understanding of patient needs and could plan accordingly – a longer slot for a patient in a wheelchair, for example.
The new schedule grouped treatments together to decrease variation, allowing the nurses to plan their work better and get into a flow. In order to maintain patient choice, most treatment types are still available each day. With more accurate appointment lengths, appointments were spread more evenly through the session to stop a bottleneck of patients in the middle of clinic. The booking rules were also changed to not allow overbooking. An extra clinic on Friday morning was prepared that they could overflow and book into if required.
These findings and proposals were shared in a big meeting with the wider nursing and reception teams to bring them up to date with the work the improvement team had been doing and to seek feedback ahead of a trial of the new schedule.
Treatment
The new schedule was initially trialled on Wednesday afternoon clinic only. A small trial allowed the team to test the new booking processes and appointment lengths without having a significant impact if the changes weren’t an improvement. Different staff were deliberately rostered on to this clinic each week to capture the broadest experience of the new clinic and gain feedback. Feedback showed this clinic was now running much smoother, so the new schedule was implemented for the whole week and patients moved over to this new schedule.
One month after full implementation the feedback was: “The last patient on every list has been seen on time or early”.
The new schedule delivers the same number of treatments but now only requires seven nurses per week compared to 14 previously - halving the nursing cost per treatment and allowing this nurse capacity to be used in other parts of the service.