Achieving real choice for patients
- Developing the colposcopy service in South Tees
- Why was the initiative launched?
- What was done?
- What has changed?
- Tips for success
- To find out more contact
Developing the colposcopy service in South Tees
Why was the initiative launched?
In 1996 a number of incidents in UK hospitals put the spotlight on the quality of cervical screening. Their reliability was questioned. In South Tees the service had achieved some Patients Charter standards, but the colposcopy team felt that a better service was possible from the resources available. Some improvements had been achieved, but the service was a bit of a Cinderella: management was concerned with larger issues. The team was determined to make their colposcopy service better.
What was done?
The Trust was already adopting the EFQM Excellence Model®. Three pilot projects in 1996 had shown that significant innovative change could be achieved. The colposcopy team and lead consultants, Mr Stewart Hutchison and Mr Derek Cruickshank, decided that the way forward was to apply the EFQM Excellence Model to colposcopy.
The team, including a local GP and every member of staff who had a role in colposcopy care within the Trust, developed a project plan. This had nine steps, using the EFQM model as a framework for the work. The first step ( 1) was to identify the scope of the work. The next steps helped them understand the service then provided, by:
2 Establishing a full picture of the service using a benchmarking approach. Benchmarking showed a service in need of care and attention. Some of the main points were:
- 13.5 days to generate an appointment.
- Long waiting times for initial and treatment appointments: 13 - 18 weeks. High rates (20%) of did not attends.
- Poorly organised, overbooked clinics.
- Delays of six to eight weeks from smear being reported and the GP referring the patient.
- Poor quality, confusing patient information.
- 35% of nursing time finding results and preparing notes.
3 Describing local processes: mapping how the service operated. Mapping was challenging because it demonstrated how little some people knew about the overall process. It enabled the team to understand its problems. The whole team identified the main steps, and small project groups produced detailed maps for the individual process steps.
4 Identifying what patients wanted from the service and the issues of concern to them. Patient focus groups contributed to fact-finding, ensuring that professionals were fully aware of the issues of concern to patients.
5 Designing the new service involved the whole team identifying the ideal requirements for the new service such as:
- Minimal waiting times for patients.
- Greater choice for patients.
- Improving communications to patients and GPs.
- Appointments generated from abnormal smear results.
- Reducing inappropriate care.
- A service improving on national standards.
The guidelines in Standards and Quality in Colposcopy from the NHS Cervical Screening Programme provided a basis for developing local standards. Three groups looking at pre-attendance administration and care, attendance and post attendance administration, and follow-up care undertook the redesign. Coherence between the separate stages was important to ensure that each activity added value to the overall service. Key features of the new service would be:
- Direct referral from cytology.
- Introduction of see and treat, that is, offering patients with severe abnormal smears treatment at their first visit and therefore eliminating a further clinic visit.
- Longer consultations for patients, supported by high quality information.
- Introduction of a default management strategy to ensure consistent action when patients failed to attend.
- Elimination of inappropriate referrals to the clinic.
Effects of EFQM Excellence Model applied to colposcopy services in South Tees
| Outcome | Benchmark before review | Target | December
1997 6 months |
June 1998
I year |
June 1999
2 years |
| Time from smear result being available and receipt of referral letter | 6 weeks | To have direct referral from cytology within 24 hours of results being reported | 24 hours | 24 hours | 24 hours |
| Time to generate appointment letter | 13.5 days | 3 working days | 24 hours | 24 hours | 24 hours |
| Waiting time for new referrals | Maximum 18 weeks | Within 6 weeks with prioritisation system | 13 weeks | 7 weeks | 7 weeks |
| Clinic defaulter rate | 20% | 10% in year 1 5% in year 3 | 12.60% | 11.50% | 10.70% |
| Consultation time | Average 10 minutes | 30 minutes per patient | target achieved | target achieved | target achieved
|
6 Appraising the implications of the new service was important because some radical changes were required. A number of new roles had been defined to respond to frustration among team members, for example, providing an extended role for nurses to free doctors time.
One of the more radical proposals was to use abnormal smear results as a referral trigger and eliminate about eight weeks of delay out of the process. This challenged the traditional responsibilities of GPs so the team talked directly to all practices to convince them that this was the right way forward. GPs were content so long as monitoring systems were put in place.
7 Planning implementation focused on training to ensure that staff understood their roles in the new service. It was estimated that 40% less clinic time would be required, but at the same time providing twice as much time for each individual patient. The senior nurse, Sandra Knott, led the implementation stage of the project plan ( 8).
What has changed?
The redesigned service was implemented in June 1997 and the team put in place evaluation measures as the final part of their project plan ( 9). Any emerging problems can be identified and acted upon promptly . This involves regular team reviews and continuous audit, and discussion with primary care teams, the health authority and service users.
The evaluation has demonstrated dramatic improvement.
- Appointments generated in 24 hours not 13.5 days.
- Consultation time increased by 50%.
- Patient choice for see and treat service.
- After six months the rate of patient failing to attend appointments was reduced from 21% to 10%.
- Very high patient, GP and staff satisfaction.
Tips for success
√ Don't expect a ‘quick fix' - high quality services take time and energy to construct.
√ Find a good leader - someone who can handle service design, staff development and advocacy for patients.
√ Build on the creativity of professionals and patients: together they generate ideas and help, not hinder change.
√ Be prepared for uncomfortable discussions: questioning traditional boundaries is difficult. Get help from someone trained to deal with change.
√ Two (or more) heads are better than one: create teams which cross traditional boundaries.
√ Remember that working across organisational boundaries is different: leadership is important
To find out more contact
Karen Picking
Senior Organisation Development Adviser
South Tees Acute Hospitals NHS Trust
Education Centre, South Cleveland Hospital
Marton Road, Middlesbrough TS4 3BW
Telephone 01642 854199 Fax 01642 282429
The following materials are available:
♦ Project report
♦ Patient focus groups reports (2)
♦ Patient satisfaction reports (2)
♦ GP satisfaction report.
ImpAct Bottom Line
Don't rest on the status quo - encourage innovative ideas and the potential of new roles as ways to improve service quality.