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A pathway to better breast care

Creating a care pathway to improve the quality of breast cancer services at Salisbury Hospital

Why the work was started
Undertaking development work
Doing the detailed work
Facing difficulties as they arose
Impact on services to patients
Elements of the new service
Patient perspectives
Recognition of success
Tips for success
For more information contact

Why the work was started


In the mid-1990s Salisbury Hospital had introduced an informal breast care pathway and more formal care pathways, particularly in urology. Salisbury was experienced also in developing and using occupational standards. It was in a good position when the NHSE South West sought proposals in 1996 to develop a care pathway in breast cancer. Their bid was successful.

Undertaking development work


A pathway embracing the full episode of care was intended: starting with the GP, going through hospital treatment and back to discharge to primary care. A Steering Group led by Nick Carty brought together staff from the breast cancer service and those looking at the development of pathways in the Trust. External facilitators supported the work.

The care pathway was divided into five manageable pieces that could be addressed by individual teams:


Doing the detailed work


Multidisciplinary teams designed each piece of the pathway. They identified key tasks, competencies and occupational standards required to deliver an optimum service. The Steering Group decided to arrange separate discussions to talk through ideas and seek views of women rather than involve them in the teams.

Work started in 1997, with 18 months development work envisaged. Each team developed its own timetable. Project-wide sessions were arranged every three months to ensure that the five pieces would fit. External facilitators managed these sessions. Progress was summarised and fed back to the Group. Facilitators made sure that everyone said what they thought . The sessions helped those involved get a good grasp of the contribution of others. Importantly it ensured consistent information: different staff don't give different messages to women.

Facing difficulties as they arose


It was not all plain sailing. It took time to engage some staff who saw themselves at the periphery of the service. Careful effort was needed: for example radiographers who only saw women at the initial stages needed to understand what happened later in the process so that they did not raise false expectations. The definition of occupational standards proved to be tedious and detailed. Nevertheless, it highlighted areas where additional staffing would be required, like clerical support and more medical and nursing staff.

The timetable was frustrating. Many sensed that the work could have been completed quicker. Indeed some changes (mammogram appointments before clinic as an example) were introduced after they had been agreed, rather than delayed until general implementation. Despite the difficulties the task was completed on time and the care pathway ready for implementation in October 1998. Key supporting documents are a referral fax for use by GPs, pre-operative anaesthetic questionnaire, patient diary and discharge fax.

Impact on services to patients


Seminars were arranged to describe the new process to GPs and explain how it would affect them. About 75% of the GPs who routinely refer women to Salisbury Hospital attended. IT support was offered. The sessions went well and GPs welcomed the new approach. Indeed the first referral fax was received in the Hospital on the day after the seminar! Since launch the Department has arranged visits to practices not involved in the seminar to explain the pathway and the use of the fax referral form.

The pathway is working well and providing a valid framework within which staff can work (Table 1). Before the introduction of the pathway, waiting times to be seen in clinic and for operation were well within guidelines. Since the introduction of the pathway these intervals have been reduced despite a big increase in the number of women seen. Intervals are more standard: for example, it is almost always nine days between the patient being diagnosed in an outpatient clinic and being admitted for operation. Better care is being provided. Whether the process has improved health as well as reducing anxiety remains unclear.


Table 1: Salisbury Breast Care Pathway: Key measures of success

  Before pathway introduced After pathway introduced
Numbers of patients seen each week 12-15 35
Days between referral and outpatient visit (urgent pathway) 7 4
Days between referral from GP to operation 10-40 21
Proportion of patients admitted for operation within 10 days of initial clinic appointment 40% 80%
Length of stay (days, mean) 8 3

Elements of the new service


The referral fax offers a template on which GPs can suggest urgent or soon appointment. The information allows the breast clinic coordinator to prioritise and make appointments without reference to consultants. Almost all (95%) of referrals are made using the referral fax. Most (87%) women have an appointment within 6 days.

The one-stop clinic allows an increasing number of immediate diagnoses. Previously about 60% of women could be diagnosed and counselled at their first clinic: now 95% have a one-stop investigation.

The pre-admission clinic is nurse-led. Nursing and anaesthetic assessments are completed before admission, which then occurs on the day of operation. Average length of stay has been reduced from eight to three days. Pre-admission clinics are run by a breast care and/or a ward nurse to ensure continuity when women are admitted to the ward: most women now see a familiar face . Women are told that discharge is likely to be on the second or third day after the operation. They are taught how to care for their surgical drain. This caused some problems at first because nurses were not used to women leaving hospital with drains still operational. Drains are now removed in primary care.

Information for patients : each woman receives a leaflet about their initial out patient appointment. At the clinic women receive a personal plan covering diagnosis, investigations and follow up. A resource room staffed by a counsellor is available where women can get other information. A personal diary is prepared for women with breast cancer to describe proposed treatment, important dates and plans for discharge.

Patient perspectives


A survey by the CHC concluded that the experience of the one stop clinic reported has been a generally positive one . Women were positive about the care and treatment received. Detailed points picked up in the survey have been acted on. These included visits to practices unaware of the new process, changes to the referral form and better liaison between the Department and practices to report results. The special needs of women living alone has also been addressed.

Recognition of success

Staff are rewarded for their efforts: administrative staff (critical for the smooth running of the system) and nurses have been upgraded. The Department was awarded Beacon status in 1999. They have tackled dissemination themselves rather than rely on the national programme. They have had a good deal of success with presentations at conferences and visitors to the Department. More recently they have become involved with the National Cancer Collaborative.

Plans are already in hand to build on the progress so far. Training is being developed for practice nurses to provide care after discharge, and an induction programme for new staff. Work with GPs is exploring how they can develop their skills in assessing women and to share post-surgical management. Use of e-mail for transmitting information about referrals and discharge is also being explored.

There are some downsides. Innovation leaders find it hard to return to normal routine, as coping with stability is not exciting! There is also a danger of de-skilling for surgeons if they do not maintain their general surgical experiences.

Tips for success


√ External facilitators can smooth the development process: they can ask the difficult questions.
√ Find practical ways to talk through proposals with patients: separate meetings may be more suitable than involving them in team meetings.
√ Be flexible over time-tabling: don't defer change for a big bang. Introduce small changes as work is completed.
√ Make the process easy for GPs: provide suitable forms and/or software to speed up the referral process.
√ Get systems ready to meet needs for additional resources, such as increased use of X-ray and drugs.
√ Make sure that local staff induction training gets over "how we do it here".

For more information contact


Nick Carty, Consultant Surgeon
Debbie Postlethwaite, Breast Care Co-ordinator
Department of General Surgery
Salisbury Health Care NHS Trust
Salisbury District Hospital, Salisbury SP2 8BJ

Tel: 01722 336262 ext 4778 Fax: 01722 524294
Email: Debbie.Postlethwaite@shc-tr.swest.nhs.uk

ImpAct bottom line

Allow time for staff involved to understand the role of others: better understanding is a key element of good team working.

 


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