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
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, 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.
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.
Sustainability is difficult to assess in the short term but QI champions from the nursing to administrative team will help ensure sustainability.
Marginal gains can add to significant improvements no one intervention led to a significant change.
Engaging the stakeholders is vital. Using a patient-centered approach to procedural preparation helped reduced squandered appointments. We also engaged with the admin and nursing team.
Figure 1: Driver Diagram
Figure 2: Process mapping of the patient journey on arrival to endoscopy
Figure 3: Time taken on activities prior to start of endoscopic procedure at baseline
Fig 4: Tools: [implementation methods; processes required; IT support etc.