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Improving the Efficiency of your Endoscopy Service

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Dr Kathleen Bryce & Dr Cheh Kuan Tai on behalf of Homerton Hospital Endoscopy Unit

 

Authors and Institution

Dr Kathleen Bryce, Gastroenterology SpR

Dr Cheh Kuan Tai, Endoscopy QI Fellow

Lauren Lee-Wilkins, Divisional Operations Manager

Jason Harvey, Endoscopy Unit Manager

Briony Crush, Endoscopy Administrative Manager

Dr Rob Fearn, Consultant Gastroenterologist

Dr Sam Murray, Consultant Gastroenterologist

Dr Laura Marelli, Consultant Gastroenterologist

 

Challenges

Demand for endoscopy in the UK has doubled in the last 5 years. In 2017, 64% of units failed to meet suspected cancer targets despite 66% of units having weekend lists and 27% outsourcing to external providers1. At our endoscopy unit, we have been running extra lists for the last 3 years on Tuesday evenings and Saturdays. While this strategy has allowed us to meet waiting times and targets, it has made an impact on staff morale as the additional lists are currently not part of the job plan and are covered out of goodwill.

UCL Cancer Collaborative (UCLCC) data has shown that demand can be met without the need for extra lists by improving efficiency. Therefore, our Quality Improvement Project (QIP) aimed to improve the efficiency of our endoscopy service. At baseline, our unit performed an average of 7.9 points per list, out of a planned 10. On average, 28.5 patients per month had procedures cancelled on the day due to poor bowel prep or inadequate fasting and the average DNA rate was 9%.

 

How we managed the challenges

From September 2017, the department has funded a QI fellowship. This QI fellow has led the work in this service improvement project. However, the fellow also backfills endoscopy lists ensuring that all lists are running at full capacity.

Through process mapping, we identified and targeted areas for improvement throughout the patient journey. We found that inefficiency in endoscopy is multifactorial.

To reduce DNAs, our administrative team sent text reminders before the appointments. Whenever possible, the clinician will book the endoscopy slots and give the patients the date and time and bowel prep in clinic.

On-the-day cancellations were predominantly due to poor bowel prep in surveillance colonoscopies or in direct access colonoscopies. We implemented telephone pre-assessment specifically for these patients.

At baseline, the turnaround time between procedures was 20.3 minutes. Consent, cannulation and room preparation were contributing factors towards lengthy turnaround time (Figure 2, 3, 4). We trained HCAs and nurses in cannulation. We also implemented a turnaround nurse whose role is to consent and help with room preparation between cases.

 

Evaluation and Outcomes

The DNA rate has improved to 7%.

Following pre-assessment, the average monthly on-the-day cancellations improved to 23.5. This saves the department 5 cases which would have needed to be rearranged. The average points per list performed improved to 8.3.

Following the implementation of the turnaround nurse, the turnaround time has improved to 9 minutes (Figure 5).

Despite these improvements, only 41.6% of lists are booked for 10-12 points. We are currently booking on average 9.3 points per list. Inadequate staffing numbers to sustain a regular turnaround nurse role and late starts are factors. We have found that only 5 out of 27 lists in a week started within 10 minutes of start times. This is currently the target in our QIP and we are working with the NHS England’s Transforming Cancer Services Team.

 

Learning Points

  1. Staff morale is important for engagement and heavily influenced by staff numbers and workload. We are working on a business case for more endoscopy nurses to sustain the additional lists running and the turnaround nurse role.
  2. Sustainability is difficult to assess in the short term but QI champions from the nursing to the administrative team will help ensure sustainability.
  3. Marginal gains can add to significant improvements no one intervention led to a significant change.
  4. Engaging stakeholders is vital. Using a patient-centred approach to procedural preparation helped reduced squandered appointments. We also engaged with the admin and nursing team.

 

Supporting information

Figure 1 (above): Driver Diagram

 

 

 

Figure 2 (above): Process mapping of the patient journey on arrival to endoscopy

 

 

Figure 3 (above): Time taken on activities prior to start of endoscopic procedure at baseline
Figure 4 (above): Mean time taken on activities per list and turnaround

 

Figure 5 (above): Run chart of turnaround times

 

Figure 6 (above): Table of turnaround time, DNA, cancellations on day and points performed before and after intervention

 

References

Shenbagaraj, L., Thomas-Gibson, S., Stebbing, J., Broughton, R., Dron, M., Johnston, D. et al. (2018) Endoscopy in 2017: A national survey of practice in the UK, Frontline Gastroenterology, pp. 100970. DOI: 10.1136/flgastro-2018-100970.

 

Contact details for members interested in getting more information

Homerton University Hospital, Homerton Row, E96SR London.

[email protected]