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Transforming Gynaecology Services

Applying process redesign methodology to improve the management of outpatient clinics
Why was the initiative launched?
What was done?
What benefits were achieved?
Tips for success
To find out more contact

Applying process redesign methodology to improve the management of outpatient clinics

Why was the initiative launched?

In 1995, staff in the Gynaecology Department in Leicester were concerned about the clinical management of outpatients. They feelt that the process could be handled better. These concerns were mirrored by the views of patients in a local research study. Several problems were identified, including delays in making initial appointments, the number of visits required before a diagnosis was made and the fragmented nature of the service. At about the same time, Leicester Royal Infirmary was setting up one of two nationally funded pilot projects to examine whether re-engineering methods could improve performance and transform the organisation's capacity for change.

Publication of an Effectiveness Bulletin in 1995 about the management of menorrhagia added scope for a redesign project. It eliminated debate about evidence and allowed the Trust to create a project which brought together the application of process redesign methodology and the implementation of evidence based practice.

What was done?

A group of senior clinicians from the Gynaecology Department and the Trust's re-engineering team, with support from the Directorate and the Trust's chief executive, undertook two preparatory tasks.

Firstly, they analysed current activity to pick out a group of patients whose management could be looked at in process terms. They chose women who had been referred with menstrual problems.

Secondly, they set about establishing a broad understanding, or a process map, of patients' experience in the system at that time.

The two tasks also helped to identify who should be involved in the redesign work. The aim was to ensure that all staff could contribute to the redesign. A meeting of a multi-discipline group was arranged to launch the redesign process. Each member of the group was individually briefed about the purpose of the meeting and asked to assemble background data to inform the debate. The initial group meeting lasted for about three hours and provided an opportunity to investigate the existing process and, for example, ask basic questions about the value added by each stage. A member of the hospital's redesign team facilitated the meeting. The multidisciplinary team continued to meet monthly to review progress for the initial six months.

There was broad agreement about the key features of the redesign. The aim was to create a single visit clinic where all aspects of routine cases could be handled.

A redesign team, nurse Jill Diaper and midwife Caroline Shaw, was appointed to undertake the detailed redesign work. This took about eight weeks and involved discussions with individual members of the group and two Group meetings. Two tasks were particularly important, the formulation of:

Selection and scheduling criteria which would enable a new role for the clinic coordinator to function. Tasks include allocating referrals within clinic schedules and providing information for patients to ensure they know what to expect: patients are encouraged to phone the clinic if they have any questions - not leave any doubts until the appointment.

A protocol for diagnostic tests, a key activity that would have to be handled promptly if the one visit service was to be practical.

Once the redesign was complete and agreed by the Group, plans were put in place to pilot the new approach. Because staff had been involved in the service redesign, special training was not necessary. Indeed a ‘Hawthorn effect' was evident as staff started to work in the spirit of the new service before the formal pilot stage was launched. The period of trial of the new service proved to be very helpful in spotting aspects of the redesign that needed additional work. For example, from the outset it became evident that it would not be possible to achieve the required turn-round for diagnostic tests if the regular hospital distribution system was used. Specimens are taken to the laboratory by staff from the clinic and results faxed through the same day.

What benefits were achieved?

All the projects in the Trust's re-engineering programme were subjected to careful evaluation. A framework to define success was developed to measure how organisational effectiveness was achieved. The framework covered measures related to service process and patient outcomes.

The introduction of the service redesign for the menstrual clinic has demonstrated dramatic benefits for staff and for patients. The Tables show what has been achieved for patients.

Table 1: Menstrual clinic impact on patients

  Before redesign After redesign
Number of visits to diagnosis 4 1
Time from consultation to diagnosis 16 weeks Same day
Women treated by evidence-based protocols 0% 100%

Table 2: Teamworking impact on patients

  Before redesign After redesign
Percent of patients seen within 30 minutes 63 99
Percent of patients not attending 9 1
Percent of letters sent to GP the same day 0 78
Percent of appointments within 24 hours of receiving referral 4 96
Percent of theatre sessions starting late 25 3


The way that the work was managed helped staff to take ownership of a problem and enabled them to create a solution. It enhanced multidisciplinary working and allowed new roles to be identified and implemented successfully. Clinical staff showed that they could implement evidence-based practice. While GPs were not actively involved in the development work they now enjoy a single point of access to the service. Communications between the Gynaecology Department and primary care have improved: consultants are in regular contact to guide GPs to ensure that the right patients are referred to the clinic. Overall, the project has helped to achieve a change in culture.

The work has also played an important part in the Trust's overall re-engineering programme: a wide range of successful projects has been completed in the last four years. The redesign team is now part of the Centre for Best Practice at the Trust and provides support and expertise to those in the NHS and abroad that are interested in adopting the re-engineering approach.

Tips for success

√ Clinical leadership is essential - but ensure also that senior managers are actively involved.
√ Promote a culture of openness where differences of opinion are valued and initiative welcomed.
√ Make sure that everyone who will be affected by the work is involved from the start - ownership is important and will ease the process of change.
√ Create opportunities for the problem to be looked at from different perspectives - hear all views.
√ Don't expect to get it right first time - plan a pilot implementation phase to allow for fine-tuning.
√ Change can be made quickly - if the solution is created by those involved, specific training may not be required.
√ Ensure that team meetings are learning opportunities - someone with facilitation skills can help that process.
√ Expertise in applying analytic skills and change management tools will speed the process.

To find out more contact

Ron Cullen
Centre for Best Practice
Leicester Royal Infirmary NHS Trust
Leicester LE1 5WW
Telephone 0116 254 1414
Fax 0116 258 5631

The following materials are available


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