Case Study: Developing a protocol based single pathway for patients with skin cancer or lesions suspicious of cancer.
What was the problem?
Before our event collaborative working had been ongoing between Plastic Surgery and Dermatology but always seemed to get to a point, then halted. Something always prevented progress and months would go by with no solutions. This was causing delays for patients and frustration for staff as there was inequitable use of available resources across both specialties, and Oral Maxillo-Facial.
Other issues identified by the team were:-
Ø A lack of support for the patient throughout the journey
Ø Paper based processes incurring delays, duplication and waste
Ø Inequity of access across Tayside
Ø Difference in waiting times in specialties for similar patient groups
What improvement tools used?
A Rapid Improvement Event (RIE) using Lean methodology was held from 25th-29th June 2007. A multi-disciplinary team of 14 staff, including 3 Consultants from Plastic Surgery, Dermatology and Oral Maxillo-Facial, and NHS Tayside Modernisation and Development Team, were freed from their work commitments and were facilitated through the week by 2 members of the Improvement and Support Team. Following the introduction to the principles of Lean Methodology the team split into groups and visited sites across Tayside which receive referrals for patients with skin lesions. Every step of the patient journey was examined from receipt of referral to discharge to Primary Care. The teams noted any problems experienced at each stage. This was also an opportunity to speak to staff and patients about their experiences. Giving them the opportunity to say what frustrated them about the current process and what, from their point of view, would improve things.
A set of team goals was developed and the team set to work designing solutions which were discussed with staff at the sites in order to obtain their views and acceptance to the suggested changes.
A 90 day action plan was developed to improve the journey for patients with skin cancer or lesions suspicious of cancer. Each member of the team had responsibility for specific action points.
What is the planned future situation?
A streamlined service that is equitable across Tayside / Improved support and information for patients along the whole pathwayImproved joint working between Plastic Surgery, Dermatology and Oral Maxillo-Facial / New improved signage at Ninewells and PRI
A single electronic protocol based referral pathway for skin cancer is in the interests of patients and clinicians, both in Primary and Secondary Care / Joint working to optimise the use of available resources
Support and encouragement for Primary Care in the use of digital imaging for referrals / Maximised use of skin tumour team
Regular audit of all steps in the pathway including digital imaging / Aiming for 100% e-referrals
Reduction of paper based processes / Electronic screening within 1 working day of referral by a cross-specialty team
Having a single point of referral will remove uncertainty for GPs and provide a streamlined pathway for patients. Each patient will be directed to the most appropriate part of the pathway, many will proceed directly to surgery. Running joint clinical sessions will improve patient journey time, utilisation of resources across the specialties and collaborative working
Measurable Outcomes
Process Measures
1) Increase in the total number of patients being referred electronically.
2) All referrals into pathway will be screened within 2 working days of receipt.
3) Increase in percentage of referrals incorporating a digital image.
Outcome Measures
1) An increase in the number of patients meeting the 62 day cancer target- both urgent and non-urgent referrals.
2) Improvement in patient journey times from receipt of referral to first appointment
3) Improvement in utilisation of resources and multi-disciplinary working across the 3 specialties
Balancing Measure
1) Improvement in patients achieving 62 day cancer target will not have a negative impact on the 18 week target.
What are the benefits to patients?Access to the right person at the right time
Equity of access to service across Tayside / NE Fife
Facilitated support along the whole patient journey / What are the benefits to staff?
Agreed protocols will give clear direction and expectations – reduce duplication of work
Appointments can be made to any specialty clinic and / or surgical lists from screening
Identified cancer slots will make tracking and appointment allocation much easier
WHAT ARE THE BENEFITS TO THE ORGANISATION?
Reduction in duplication and waste
Clear patient pathway
Anticipated improvement in patients achieving 62 day cancer target.
KEY SUCCESS FACTORS
Willingness for collaborative working across the three specialties to ensure an improved patient experience
The patient was the central focus of the week
Team members open and receptive to change
WHAT WOULD WE DO DIFFERENTLY NEXT TIME?
Ensure role of project lead is fully supported for duration of action plan
Clarify expectations of team member roles in the lead up to the event.
Further Information available from the Lead Clinicians for the event:Dr Colin Fleming
Consultant Dermatologist
Mr Howard Stevenson
Consultant Plastic Surgeon
February 2008