MODERNISING ENDOSCOPY SERVICES A PRACTICAL GUIDE TO … the endoscopy... · 2011-11-11 · Modernising Endoscopy Services (MES) is a toolkit, which aims to provide a basis for multidisciplinary

1Modernisation Agency

A PRACTICAL GUIDE TO REDESIGNMODERNISING ENDOSCOPY SERVICES

1st Edition

2

Aims 3

Introduction 3

Background to National Endoscopy Programme 3

Key contacts 4

Summary action plan 5

Section A – The challengesChallenge One: Identifying strategic and clinical leadership 7

Challenge Two: Understanding the current service 9

Challenge Three: Seeing the service through patients’ eyes 13

Challenges 4 – 7 Introduction 14

Challenge Four: Being clear about actual demand 15

Challenge Five: Understanding existing backlog 20

Challenge Six: Being clear about actual capacity 22

Challenge Seven: Using activity records to identify trends 24

Challenge Eight: Promoting new ways of working 25

Section B – Step by step guide to the spreadsheet toolIntroducing the Endoscopy Spreadsheet Tool 27

The main worksheets and their constituent parts 28

Using the Overview Sheet 30

Using the macro 31

Using the monthly sheets 31

Recording Demand data 31

Recording Capacity and Activity data 34

Recording Waiting List data 37

Cancelled Sessions 38

Failed Procedures 38

Turn around time 39

Tables and graphs 40

Cutting and pasting tables and graphs 41

Other useful resources and documents 43

Acknowledgements 44

Appendices1. Definitions 45

2. Room utilisation 46

Section C – CD CD containing spreadsheet tool

Modernising Endoscopy Services

Contents Page

Modernising Endoscopy Services (MES) is atoolkit, which aims to provide a basis formultidisciplinary redesign of endoscopyservices. It consists of three interlinked parts:

� Challenges based on redesign principles

� Step by step guide to using thespreadsheet tool

� Spreadsheet tool, a computer basedmanagement tool in the form of a CD

Each issue is presented as a key challenge.For each challenge, a number of actionsare identified that will help teams identifyboth good practice and areas forimprovement for their service.

INTRODUCTION

Endoscopy teams across England havedeveloped this tool, in conjunction withthe National Endoscopy Programme. Theaims were to provide a resource for projectleads, clinicians and managers who areseeking ways of improving access to theirEndoscopy service. Timely patient access toendoscopy services is key to delivery ofseveral major target areas in the NHS Planand NHS Cancer Plan, including:

� Maximum 13 week outpatient wait forendoscopy (where they are classified1 asoutpatients)

� Sustainability of two week urgentreferral2 targets for patients withsuspected cancer, in those cases wherediagnosis by endoscopy is key e.g.upper and lower gastrointestinalcancers and lung cancer

� Maximum 31 days from urgent referralto first treatment for cancer patients, inthose cancers where endoscopy plays akey diagnostic step

� Implementation of booking systems(100 per cent booked appointments by2005)

This toolkit should be used for endoscopyservice redesign with the following at itscore:-

� The patient’s needs and views

� The whole service in mind (withoutdisadvantage to any groups of patients)

� Incorporation into health communityprogrammes of work where endoscopyhas been identified as a ‘hot spot’

� Have clear lines of communicationwhich are established from the outset

� To be an integral part of the CancerServices Collaborative, National BookingProgramme and local Trust/PCTModernisation Programmes

BACKGROUND TO THENATIONAL ENDOSCOPYPROGRAMME

In November 2000, the NHSModernisation Agency (then the NationalPatients Access Team) set up a nationalproject to take forward recommendationsregarding the need to:

� Redesign endoscopy services.

� Increase the numbers of endoscopists.

� Tackle variation in existing approachesto training of endoscopists.

� Address inconsistencies in theclassification of endoscopy.

A practical guide to redesign 3

AIMS

1 Guidance on how to classify endoscopic procedures is expected in 2002/3

2 Sustainable in the sense that other patients referred to endoscopy are not disadvantaged by carving out capacity for the cancer 2week wait referrals. Audit data exists to demonstrate that not all cancer patients are diagnosed through the cancer 2 week waitreferral routes.

The first stage of this project identified anumber of key issues common to manyendoscopy services which were found toinclude:

� Lack of strategic direction and variedclinical leadership

� Increasing activity both diagnostic andtherapeutic

� Poor demand information

� Complex, multiple referral routes

� Wide variation in access times forpatients

� Concerns about capacity, includingstaff, facilities and equipment

� Concerns about adequacy of training

An awareness of these issues from theoutset of any endoscopy serviceimprovement programme is important inensuring that options for change arebased on a thorough understanding ofthe issues facing the department and,importantly, that the improvementprogramme has the support of SeniorClinicians and Managers.

These key issues identified during theinitial stage of the national endoscopyproject form the framework for the toolkit and each is presented as a keychallenge. For each challenge, a numberof actions are identified that will helpteams identify both good practice andareas for improvement for their service. Instage two of this project 12 (phase one)pilot sites were established. They collectedcapacity and demand data for threemonths linked to preparation for serviceredesign. At the end of this period, eightsites then proceeded to undertake oneyear’s redesign linked to continued datacollection. These pilot sites used,evaluated and refined the toolkit and theapproach taken in this document. Theyreported that the framework provided bythe toolkit was very helpful in targeting

redesign efforts to maximise improvementin access times for patients.

In 2002, stage three of the nationalprogramme commenced with spread ofthe toolkit to 29 further endoscopy unitswho will be using it to aid serviceredesign. Each of these sites will beinvolved in partnership working to ensureseamless integration into establishedstreams of work. In addition to these 29sites the national endoscopy team havebeen training other independentendoscopy units who wish to use thetoolkit and have project support locallyfrom either a Regional Cancer ServicesFacilitator or Service ImprovementManager.

The key links originally established withCancer Services Collaborative, CancerAction Team and the National Redesignteam are still closely maintained. TheNational Endoscopy Programme ismanaged within the National BookingProgramme.

CONTACT INFORMATION

Contact information is available on thewebsite - www.modern.nhs.uk/booking

Modernising Endoscopy Services4

The table below provides a summary planof actions that the guide has beendesigned to support. Each summary actionpoint is presented in more detail with key

tools and techniques that have beensuccessfully used by NHS teams in manyother service improvement programmes.


SUMMARY ACTION PLAN

Summary Action Plan:

1. Identify strategic support and clinical leadership for redesign inendoscopy

• Agree links to other improvement projects and any joint working

• Agree the scope of the project, objectives, time scales and reportingmechanisms

• Establish a project team that includes a board ‘sponsor’

• Identify a clinical lead to support the project

2. Map the process for all points of access (from GP referral and internalreferral) to discharge of patient after result

• Run a process mapping workshop

• Shadow a sample group of patients

• Start timing each step of the process at the constraint

3. Set up a system to capture daily demand, capacity (including roomutilisation and staff/equipment availability) and activity

• Produce a demand process template for frequently performed procedures

• Produce a capacity template – identifying current scheduling, room availability,equipment availability and equipment turnaround times

4. Determine whether the waiting list is constant or changing over time

5. Run a workshop to analyse the findings from diagnostic phase (aminimum of 3 months complete data) and agree an action plan toimprove patient access

6. Agree how progress with the action plan will be monitored



Learning from the national project andthe NHS Modernisation Agency’s Researchinto Practice Programme identifies theimportance of strong clinical, executiveand senior managerial leadership indetermining the success of any redesignproject.

This was reinforced in the pilot sites.Ensuring the local project reported into aforum with authority for influencingService and Financial Framework (SaFF)negotiations was a key challenge for eachpilot site. Active support from the ChiefExecutive and/or Director ofOperations/Modernisation was a criticalsuccess factor.

It is important to establish who is"sponsoring" the project, what level ofauthority in influencing organisationalpriority setting that person has, and theirability to co-opt others to the project asnecessary. It is also important to agreewith that person clear objectives for theproject and time-scales involved. Thefollowing questions may be helpful indetermining actions necessary to securethe necessary leadership commitment:

What priority is given to endoscopyservices within the local healthcarecommunity?

� Is it a Trust, PCT or Strategic HealthAuthority priority?

� Are there any plans for capitalinvestment?

� How is the Trust Board made aware ofissues in endoscopy?

� Has a business case previously been tothe Trust Board for endoscopy?

� Is there an expectation that the projectwill result in a business case beingsubmitted to the Trust Board?

Who is identified as the clinical andmanagerial lead for endoscopy?

� What level of authority do they have formaking change across the various usersof the endoscopy service?

� Is that lead able to access centralsupport to aid in service improvement –for example, Local ModernisationReview Lead, Clinical Audit Support, ITsupport, Booking Programme support,Cancer Services Collaborative support,and so on?

� If not, who can?

� Is it possible to get an executive or non-executive director to act as "sponsor"for Endoscopy Service Improvement?

Is there an endoscopy user group inplace?

� Are there clear terms of reference forthat group?

� Does the membership reflect the keystakeholders – including seniormanagement, medical and surgicalclinicians, radiography, and primarycare?

� Is there an "impartial" and senior chair?

� How are decisions/recommendationsfrom the group communicated?

� What appears on the agenda?

CHALLENGE ONE: IDENTIFY STRATEGIC SUPPORT AND CLINICALLEADERSHIP FOR THE PROJECT

In one pilot site, the local project manager could not find an evidence of centralco-ordination of modernisation work across the health community. The resultinglack of accountability structures operating within the host organisation resulted inpoor integration of the pilot project into the overall strategic direction of the Trust.


� How does action planning and progresswith service redesign get on to theagenda?

� How does the group influence Trustplanning priorities?

Key to successful service improvementis:

• Ensuring the work is "sponsored" by senior management in the organisation.

• That the improvement objectives are signed off by the "sponsor".

• That progress monitoring is agreed with a clear timetable for reporting.

• Ensuring that redesign becomes part of the daily work of the organisation.


Agreeing the referral map

In endoscopy departments, patients accessthe service from many referral points. Inunderstanding current demand, it isimportant to ensure a comprehensivereferral map is identified that reflectsaccurately all points of referral intoendoscopy, including endoscopic workdone outside the main unit: e.g. theatres,community hospitals and so on. Thebooking clerks and medical secretaries arekey stakeholders in this work and need tobe included from the outset.

Method

The first step in detailing a comprehensivereferral map is to:

� Clarify all types of endoscopy beingundertaken in the existing services.

� Identify if endoscopy is performed inareas other than the main endoscopysuite.

� Capture all referrals in order tounderstand the demands on the serviceand to give meaningful information forcurrent and future service planning.

Have ALL entry points for endoscopyreferrals been clearly identified? Considerfor example:

� What type of GP referrals exist (Openaccess, two week cancer, others?)

� What types of outpatient referrals aremade (Consultant, Nurse specialist,others?)

� What types of in-patient referrals aremade (emergency, out of hours,others?)

� Do the referrals come into a singlecentral point or into multiple locations?

� Is all endoscopy done in one place – orare there referrals to main theatres,OPD, radiology?

� How are follow-up/surveillance patients"referred"?

� Is any endoscopy carried out in primarycare? Agree how this will be included inyour project

Mapping the existing patient pathway

Process mapping, although a simpleexercise, is one of the most powerful waysfor a multi-disciplinary group to identifyand understand the real problems in aservice from the patient’s perspective.

Analysis by the NHS ModernisationAgency has shown that:

� Typically, 30 to 70 per cent of the workin a patient process doesn’t add anyvalue for patients

� Around 90 per cent of the errors,duplication and delay in patientprocesses are at the point of "hand-off"– where responsibility for the patient ishanded from one professional ordepartment or agency to another. Upto 50 per cent of the steps in a typicalNHS patient process involves a "hand-off"

� Usually, no-one is responsible for thepatient’s journey through the careprocess and patients often receive carewhich is fragmented and subject todelays

CHALLENGE TWO: UNDERSTANDING THE CURRENT SERVICE MAPPING AND ANALYSING PATIENT PROCESSES


How to run a process mapping sessionfor your project

The objectives of this type of event are to:

� Help everyone to understand what thepatient is currently experiencing.

� Identify the stages in the processcausing the problems in relation toachieving NHS cancer plan targets andthe NHS Plan.

� Identify causes of waits and delays.

Preparation

� Define and agree which group ofpatients are being mapped.

� Define and agree what the first and laststep of the process is e.g.Start - the process starts when thereferral is made.End - the clinical decision as a result ofthe endoscopy findings is made e.g.discharge back to GP, onward referral toanother speciality, OPD follow-up,referral for surgery, etc.

� Be careful not to limit the scopeunnecessarily.

� Identify all staff groups within the scopeof the process being considered,including support staff, administrativestaff, porters and clinical staff.

� Invite the 10-15 representatives of thosestaff groups who are part of the patientprocess to map the process.

� Involve representatives of patients andcarers who use the service.

� You can get support locally from yourRegional CSC Facilitator, ServiceImprovement lead, National BookingProgramme Manager or ServiceImprovement Manager.

Resources

� Time allowed: this depends on the scope of the process to be mapped;Either one or two half days, no more than two weeks apart with same participants

� Two facilitators: One to map process and one to note comments, issues, etc

� Post-it notes

� Flip chart

� Flip chart pens

Method

Mapping the patient process – high levelmap

� Record on post-it notes who doeswhat to the patient

Example

GP

examines

patient

GP refers

patient to

hospital

Patient

waits at

home

Patient

receives

appointment

Patient

attends

OP clinic

Clerkchecks

patient’sdetails

Etc,

etc

Doctor

examines

patient

Nursechecks

patient’sdetails


� There are bound to be variations sorecord what happens 80 per cent of thetime

� Concentrate on what happens to thepatient. Don’t get side tracked by whathappens to a referral form or requestcard – these are other processes whichneed to be mapped, just don’t getbogged down in detail at this point.

Analysing the patient process:

Having mapped the patient process,analyse by considering the following:

� How many steps in the process?

� How many times is the patient passedfrom one person to another (handoff)?

� What is the approximate time of eachstep?

� What is the approximate time betweeneach step?

� What is the approximate time betweenfirst and last step?

� Where does the patient have a wait orhave to queue?

� Where are there waiting lists in thesystem?

� How many steps add no value to thepatient? (Ask the patients)

� Where are there problems for patients –what do patients complain about?

� Where are there problems for staff?

At the stages when there are thelongest delays:

� Ask ‘why?’ five times to get to the realreason for the delay

� Map that part of the process in muchmore detail

� Watch and shadow patients in this partof the process

� Map the relevant parallel process, whichmay have caused the delay. Parallelprocesses include:

� The referral letter - how long does it take from when the patient is told to when the patient receives the appointment in the post?

� The pathology specimen - how long does it take from when the specimenis taken to when the requesting clinician has the report back for use?

� The imaging reporting system - how long does it take from when the image is taken to when the image and report is back with the referring clinician?

At the end of the process mappingevent:

� Agree next steps

� Identify specific areas for further study

� Collect data where necessary

� Allocate specific actions

� Organise sessions where ideas forimprovement can be generated andtests of those ideas planned

� There may be some obvious actions thateveryone agrees with and whereimprovements could be made straightaway. Just do it!!

Tips

� Keep the group focused on theobjectives – current patient process andproblems

� Process maps can get very long – usethe back of a cheap roll of wallpaper


� Once a group has mapped the patientprocess, check it out with others whowere not able to attend the event andwith patients – leave on display in thedepartment and ask for comments onpost-its

� Photograph the main steps and make alarge transportable photo board to takearound with you

� Map the information you give topatients

� Who gives information and at whatstage?

� Are there any duplications orcontradictions?

� Are there any gaps?

� Find out what patients want and need

� While a group is mapping the processthere will be lots of comments, thoughtsand ideas. Don’t lose them. Note themon a separate flip chart but move onwith the job in hand – mapping andanalysing the patient process


Insights into patients’ perceptions andviews about current endoscopy servicesprovide powerful information to include inany service redesign work. The NHSModernisation Agency has a number ofkey publications to assist in thinkingthrough which approach is best suited toyour project (see section 14 for references).

In preparation for process mappingworkshops, it can be really helpful to havea number of key quotes from patients tofeed in. Two quotes are included here thatillustrate a number of important points.The first quote was taken from patientinterviews and the second quote camefrom patient diaries.

The first patient was concerned about thecost of her telephone bill. She had madeseveral phone calls to the hospital to tryto find out when her appointment was

scheduled. Each time she was passedfrom one department to another withlittle progress. The patient then decided itwas more cost effective for her to use herbus pass to visit the endoscopydepartment in person to get theinformation she wanted. This is powerfulinformation to feed back to theendoscopy team. It raises key points, fromthe patient’s perspective, about the"transparency" of existing referral routes

and clarity of current information topatients about how their appointment willbe made. These are likely to be areaswhere redesign will deliver significantbenefits to both patients and the staffwho are currently fielding inquiries fromthese patients.

The second quote raises importantquestions around consent procedures, andwhen and what type of patientinformation is given to patients.

It is also important to understand whatsort of information is given to the patientat the various key stages in the processfrom referral to clinical decision regardingpatient destination following the result ofthe endoscopic procedure(s).

� What mechanisms are being used:patient literature, taped information,

help line access, pre-assessmentinterview, video, and so on?

� Would the information currently in usepass the Plain English tests and achievea Crystal Mark™?

CHALLENGE THREE: SEEING THE SERVICE THROUGH PATIENTS’ EYES

"I got fed up with waiting for my appointment and ringing the hospital repeatedly,nobody knew what was happening so I went straight to the endoscopy unit to getit sorted once and for all…"

Elderly female, Patient Interviews

"..laid on trolley and wheeled into treatment area. Tag checked and number. Informedprocedure has 1 in 1000 chance of perforating colon! Odds don’t sound too good; rememberthese odds of failure in an aero engine would not be considered airworthy. Howeverconsequences of said puncture made to sound fairly trivial leaving me wondering why it wasmentioned among all the other things that can go wrong. Why this late in the process?"Signed consent form without glasses."

Male, Engineer British Aerospace, Patient Diaries


A CD containing the spreadsheet tool thatenables the redesign teams to recorddemand, capacity, activity and backloginformation for their departmentsaccompanies the following sections. Thesecond part of this toolkit also includes astep by step guide to help project teamsuse the spreadsheet tool.

Data Quality

As with all data collection, good quality ofinformation is crucial to the success of theproject. It is important that a member ofstaff is responsible for data collection andensuring the quality of the information.More than one individual shouldunderstand the data collection process toallow cover for annual leave and sickness.Poor data collection will result ininappropriate decisions and outcomes.The following are key to makingsustainable changes to the service:

� Good communication with all staffconcerned in data collection

� Everyone being responsible for dataquality

� Decisions seen to be taken on thecollected information

Calculations

To make meaningful capacity, demand,activity and waiting list comparisons it isimportant to express them all in the samecurrency. In this case the shared currencyis minutes of TIME. The spreadsheet toolautomatically performs all the calculationsdescribed in the text from data entered.Timings can be measured from patientwalk-throughs or stop watch studies –you should then select the timing whichcaptures 80 per cent of patients.

Using the data

This toolkit is designed to support and beused on a daily basis by endoscopyredesign projects and is not primarily areporting tool3 . The spreadsheet toolcreates graphs and tables from theinputted data and these can be exportedto other documents to support serviceredesign planning.

INTRODUCTION FOR CHALLENGES FOUR TO SEVEN

3 Those projects funded as part of the National Endoscopy Programme will be also be expected to submit the spreadsheets andprogress reports to the NHS Modernisation Agency on a monthly basis.


CHALLENGE FOUR: BEING CLEAR ABOUT ACTUAL DEMANDMany clinical teams have seen anapparent rise in activity in endoscopyservices. However, many services do notcurrently have systems in place toaccurately capture and report demand ona regular basis. Understanding the

demand for your endoscopy service iscrucial to undertaking a redesign project.If your service does not currently reportreferrals received for endoscopycomprehensively, it will be necessary toundertake demand analysis, as describedbelow. It is vital to establish an accuratereferral map as the starting point to thiswork, as described in challenge two. Oncethe referral map has been agreed toaccurately reflect all endoscopy referralroutes, the next stage is to record allreferrals received. You will need to agreewith any outlying departments thatundertake endoscopy, in addition to themain unit, a way of recording thosereferrals. Similarly, any emergency referralsfrom in-patient areas need to be recorded.

At the planning stage of this study, it isessential that you include a member ofthe Information Department who canadvise on establishing a system (electronicor otherwise) for collecting data on anongoing basis.

Expressing demand in minutes andhours:

To make meaningful demand and capacitycomparisons, it is important to express

both in the same currency; in this case theshared currency is TIME.

To express demand as a measure of timerequires the calculation shown in the box:

The constraint refers to the issue/problemholding up flow of activity and causingthe bottleneck. In endoscopy units this isusually the theatre.

Developing a process template:

The "time taken to see a patient" iscalculated by developing processtemplates for each type of request andidentifying the constraint.

Method:

� Identify start and end points of theprocedure i.e. when patient arrives inthe department through to dischargefrom the department.

� Agree how many key activities areundertaken; for example: patientclerking and consent; any pre-procedurepreparation; getting the patient into theprocedure room and positioned;carrying out the procedure; reportingfindings; patient recovery; discharge

� Follow a sample of patients througheach procedure, recording the timetaken for each step to be completed

Number of referrals x time taken to see patient at the constraint

Admission Preparation Consent Procedure Recovery


� Identify the times taken for eachprocedure from the patients sampledand select a time which would include80 per cent of patients surveyed (80:20rule).

A process template can be created simplyby using a spreadsheet.

Step 1.

From your process map identify times tocomplete each step in the process

Clerk in (reception) 2Clerk in (nursing) 15Patient gets changed 5Pre observations 2Consent 10Procedure 30Post observations 2Type up report 5Patient in recovery 45Discharge 5

Clerk in (reception) 2Clerk in (nursing) 15Patient gets changed 5Pre observations 2Consent 10Procedure 30Post observations 2Type up report 5Patient in recovery 45Discharge 5

Time (minutes)

Step 2.

Allocate a colour to each step

Time Code


Step 4.

Line up several templates so that patient waits are minimised.

Step 3.

Line up the colour steps in sequence in blocks of colour proportional to the time scale.

Step 5.

Position on time line to determine patient appointment time, optimum theatre usageand list composition.

Theatre in use

1.30 2.00 2.30 3.00

Appointment Time


Step 6.

Use process template to schedule resources and staff for the number of procedures.

Example

Clerk in (reception) 2

Clerk in (nursing) 15

Patient gets changed 5Pre observations 2Consent 10

Procedure 30

Post observations 2

Type up report 5Patient in recovery 45Discharge 5

1 clerk

1 Nurse

1 Nurse

1 Endoscopist

1 Endoscopist2 Nurses

1 Nurse

1 Endoscopist

1 Nurse

1 Clerk

6 scopes

Time Staff Equipment Rooms

1 examination1 toilet

1 changing room

1 theatre/room

1 theatre/room

1 theatre/room

1 theatre/room

1 theatre/room

(clean scope) 1 Technician 2 washers 1 room

1 bed

1 chair

Example 1:

If patients require bowel preparation in the department, and there is only onetoilet, only one patient of this type should be scheduled to be in the departmentat any one time – unless toilet capacity can be increased.

Example 2:

The number of recovery beds/chairs will influence list schedules if bottlenecks atthis stage are to be avoided.

Analysing the process template:

� Using the time required (for 80 per centof the patients) at the constraint of theprocess multiply this with the numberof referrals you have collected as part ofthe demand study. This gives youdemand expressed as time – i.e. howmuch time needs to be available in

terms of procedure capacity to dealwith existing demand

� Timings for the other process stagesgive very useful information to thinkabout the current approach toscheduling, when compared to thecapacity available.


4 The British Society for Gastroenterology and the Primary Care Society for Gastroenterology both have clinical guidelines thatprovide a useful point of reference for developing shared protocols between primary and secondary care. These can be accessedthrough the respective web sites. For details see page 43.

This exercise provides useful information inidentifying key constraints in the processrelated to available capacity – for example,availability of endoscopes, availability ofrecovery beds, equipment turn-aroundtimes, can all impact on the time taken tocomplete the procedure. Future schedulingcan then take account of all constraints,and eliminate their impact.

� When the times taken for eachprocedure are available, the next step isto calculate the actual demand figure.Take the figures derived from theexercise to capture all referrals andconvert this using the process templatetimes into demand expressed as time, asdescribed above.

The following questions may also help inanalysing the data that comes out of thisexercise:

� How will the endoscopy team and Trustidentify changes in demand on anongoing basis? If referrals increase ordecrease are there mechanisms thatallow that to be picked up? How is/willdemand be reported – daily, weekly,monthly and where will these reports goand what action will be taken, bywhom?

� What demand management strategiesare used? e.g. what referral protocolshave been agreed, are these audited,how are variations picked up and dealtwith?4

� Have surveillance and "follow-up"endoscopy protocols been subject toevidence-based review? Are thereconsistent practices across the clinicalteams in approaches to follow-up?

� How does demand for endoscopycompare with other similar Trusts?


CHALLENGE FIVE: UNDERSTANDING EXISTING BACKLOGIn addition to understanding currentdemand for endoscopy services, it isimportant to know what backlog exists inthe service. This is key in taking action toclear the backlog and determiningwhether the action that is taken willprovide a sustainable solution topreventing future backlog. It is alsoessential to have the backlog booked up-to-date before commencing bookedappointments.

To calculate the size of your backlog inunits of time, you have to:

� Calculate your process times asdescribed in section four

� Count and validate the number ofpatients waiting.

In some services, the only way of doingthis is to work with the booking clerksand manually count referrals waiting.Often central returns do not capture thedetails about the type of procedurepatients are waiting for, particularly ifendoscopic procedures are classified asoutpatients5. In addition, whereprocedures are classified as follow-up orplanned, no information is collectedthrough national published data. It isimportant that all of these groups ofpatients are counted for the purpose ofunderstanding existing backlog.

Method:

To calculate backlog you need to:

� Identify requests by type of proceduree.g. colonoscopy, flexi-sigmoidoscopy,gastroscopy etc.

� Identify the total theatre time (patient in– patient out of theatre) it takes to dothe procedure (from the process map/template)

� Identify the number of requests waiting– for all patients

� Multiply the time it takes to do therequest by the number waiting, whichgives the measure of time necessary toclear the back log

� Total the timings for all procedures

Analysing the data

� What is the data showing by categoryof procedure?

� What is the data showing by"endoscopist", if pooled referrals arenot in operation?

Dealing with backlog

Options for dealing with the backlog arelinked to knowing what is possible withinexisting capacity. Demand, backlog andcapacity data need to be consideredtogether to ensure sustainable strategiesare developed.

Number of Procedure A x time taken to see patient at the constraint = X minutes

Number of Procedure B x time taken to see patient at the constraint = Y minutes

etc for all procedures

Total time required = X+Y+etc

5 If you classify endoscopy procedures as outpatients you may need to put in place an electronic mechanism to code and enableidentification of the referrals by procedure.

Example:


Options for dealing with backlog mightinclude:

� Reducing inefficiencies, e.g. DNA rates,cancelled lists, session start times

� Validating (clerical and clinical) thebacklog on a regular basis

� Introducing changes to the working day– e.g. extended working day, threesession days, weekend working

� Additional endoscopist(s)

� Access to capacity elsewhere in the localhealth community

� More equipment

� Access to "waiting list initiative" funds(sustainability may be an issue)


CHALLENGE SIX: BEING CLEAR ABOUT ACTUAL CAPACITYIn keeping with the principles of demandmeasurement, frequently broad measuresof capacity have been used. It is essential tobe clear about potential available capacity,and actual capacity being used. Capacityincludes facilities and equipment available inaddition to the skills and staff available tooperate both equipment and the facility.The following questions can help in buildinga clear picture of available capacity:

Method:

To express capacity in measure of timerequires the calculation illustrated in the box:

Available Capacity of Facilities andEquipment:

� Where is endoscopy performed, e.g. allthrough one central unit, split site units,main theatre, day surgery, outpatientdepartment, x-ray, primary care?

� What physical capacity is available, e.g.number of theatres, accommodation forassessment, toilets, recovery chairs, andtrolleys?

� Where is out-of-hours, emergency workdone?

� What equipment is available?

� How many endoscopes and what type?

� How long does it take to clean and disinfect equipment ready for use with the next patient, i.e. the average"turn-around" time?6

� How many scopes are available for each list?

� Does equipment availability affect lists?If so, why?

� Is equipment compatible across sites?

In addition to knowing how many roomsare available, it is also important to knowhow those rooms are being used. A roomutilisation audit provides some useful datafor discussion.

Carrying out room utilisation audit:

Method

� Agree how long the audit will last, wesuggest a minimum of four weeks.

� Agree who will record the audit dataand contingencies for promptlyidentifying any missing data and takingcorrective action7.

Capacity available in the form of staffand skills:

Key items of information are:

� How many endoscopists are available

� Consultant Endoscopists – physicians, surgeons, radiologists

� Associate Specialists

� Clinical Assistants

� General Practitioner Endoscopists

� Nurse Endoscopists

� Others

Calculation expressing capacity in measure of time

Time available in theatre x staff & skills x equipment

6 British Society of Gastroenterology has published guidelines regarding the recommended number of scopes to be available forvarious types of endoscopy session. The document can be found on British Society for Gastroenterology web site,see page 43.7 See Appendix 2 for example of room utilisation sheet


� What sessions does each contribute?

� Calculate potential capacity on the basisof known usage based on history.Remember to account for holidays,study leave, existing absence coverarrangements, and so on. Also toinclude the impact of Bank Holidays.

� How are sessions staffed in addition tothe endoscopist, e.g. assessment roles,endoscopist assistant, recovery,technician roles?

� What roles do registered nurses take?

� What roles do health care assistantstake?

� What roles do technicians take?

� Is capacity "carved-out" i.e. are slotsprotected for two week rule patients,emergency in-patients, single procedurelists, urgent, soon, routine and so on

� Is there pooling of referrals, or arepatients referred to named consultantsand wait for the next available slot withthat consultant? How does this affectaccess times?

� How often are lists cancelled and why?This will also be picked up through theroom utilisation audit.

� Is the DNA rate known and accuratelymonitored?

Compare the data emerging from demandand capacity measures with existingbooking schedules. Is there a need torevise these in the light of what you havefound?


CHALLENGE SEVEN: USING ACTIVITY RECORDS TO IDENTIFY TRENDSOVER TIME

Although activity measures have had animportant role in commissioning servicesyear on year, it is important to be awarethat measures of activity give noindication of actual demand for anyservice. Activity measures only tell us thevolume of work done in the identifiedtime period.

However, if you are redesigning processes,and you feel one outcome is likely to beimproved efficiency, then trend data onactivity over time may be useful. It may beuseful to compare activity with scheduledcapacity to help identify issues within theservice, such as late starts, poorscheduling etc.

Method:

To express activity in measure of timerequires the calculation shown in the boxsimilar to that involved in countingbacklog:

It is key that all activity is captured,including any out of hours work, orendoscopic procedures carried out inother areas.

Be clear about the changes you areanticipating related to activity

� You may actually want to see reductionsin activity over time, e.g. if you areworking with key stakeholders onreferral guidelines and thresholds forreferral.

� As part of this data collection you mayalso want to consider recordingoutcome of the procedure – e.g. for adiagnostic service, what proportion ofprocedures identify pathology.

� What impact may improving access toendoscopy have on other services, e.g.access to surgery?

� Do sessions start on time? What impactdoes this have?

Calculation to express activity in measure of time

Number of Procedure A x time taken to see patient at the constraint = X minutes

Number of Procedure B x time taken to see patient at the constraint = Y minutes

Number of Procedure C x time taken to see patient at the constraint = Z minutes

etc for all procedures

Total activity = X+Y+Z+etc


CHALLENGE EIGHT: PROMOTING NEW WAYS OF WORKING

8 Information about the Changing Workforce Programme can be found on the following website: www.modern.nhs.uk

In generating options for change, thinkingabout new ways of working is important.You should include your local HumanResources Team in your communicationstrategy and involve them at an earlystage. You may also want to link into thenational "Changing WorkforceProgramme"8 and their Toolkit to assist inthis work.

The term new ways of working coversfour types of change:

� Moving tasks up or down a traditionaluni-disciplinary ladder (e.g. a consultantgiving care previously undertaken byjunior doctors in follow-up outpatients.The consultant might be more likely todischarge the patient than the juniorswho did not have the same level ofexperience and changed frequently)

� Expanding the breadth of a job (e.g. thehealthcare support worker taking onboth auxiliary and technician roles)

� Increasing the depth of a job (e.g. NurseConsultant who has discreet case loadof Inflammatory Bowel Disease patientsand also contributes to the endoscopyservice)

� New jobs (e.g. combining tasks in adifferent way. For example, theendoscopy co-ordinator role hasemerged to manage the complexreferral processes and decrease hand-offs in some services)

There are many examples of innovativepractice across the country that haveachieved improvements in the care thatpatients experience. In addition to thetypes of changes identified above, thefollowing may be useful to consider:

� Is it possible to distinguish betweencomplex and simple work? (e.g. flexiblesigmoidoscopy and colonoscopy)

� Are the same clinicians doing both?

� What is the impact of specialist versusmixed lists?

� Is it possible to design two processeswith different practitioners andadministrative processes – one forsimple procedures, one for complexprocedures?

� Are there opportunities to introducenew roles which offer greater flexibilityin covering lists, moving between sites,working across primary and secondarycare boundaries, releasing time for useelsewhere (e.g. picking up consultantendoscopist simple diagnostic work,freeing the consultant to do moreoperating or see new outpatients)?

� Are there GPs who want to developspecialist expertise?

� Can open access services be delivered insatellite sites?

� Are there opportunities for developingnew administrative roles, focused onpulling the patient through the processof care, co-ordinating each stage of thatpatient’s journey?

� What opportunities exist for supportworker roles?

� What training and education will assistin developing a new range ofcompetencies that address constraintsidentified through the diagnosticphase?

� What help can the local WorkforceDevelopment Confederation offer?

� Three plus session days

� Pooled lists



SPREADSHEET TOOL: A STEP BY STEP GUIDE TO USING THESPREADSHEET TOOL

What is the Spreadsheet Tool?

The Spreadsheet Tool is provided on a CDenclosed with this Modernising EndoscopyServices redesign guide. It is a computerbased management tool that will assistproject leads and endoscopy staff to:

� Record demand,capacity, activity andwaiting list data

� Produce tables andgraphical reportsregarding thisinformation

� Help analyse capacityand demandinformation

The role of the Spreadsheet Tool

The spreadsheet tool will make life easier.The package is used to assist project staffin their scheduling. It collates andmanipulates information at the request ofthe user that would take a great deal oftime if performed manually. It is a tool togive evidence in an easy to understandformat, to facilitate discussions forredesigning and managing your service. Itdoes not create or control projects andneither does it make any valuejudgements or decisions.

Getting Started

The minimum requirement to run this CDis Excel 97. First load the worksheet ontoyour C drive. The spreadsheet tool isdesigned to work via Microsoft Excel. Thismeans that it operates within theMicrosoft Windows environment and canbe controlled by using both keyboard andmouse. Some of the data is calculatedusing macros and the January worksheet,

therefore it is important that the Januaryworksheet must not be deleted.

When you open the spreadsheet you willbe prompted as to whether you wish toopen the workbook as it contains Macros.Always enter Enable Macros at this stage.

What is a Macro?

A macro is a function within Excel whichallows tasks to be performed by theprogramme automatically. You do notneed to understand macros to use thetoolkit. Once you have entered and savedyour monthly data you need to

� Select the month in cell B1 of graphssheet

� Return to the overview sheet and pressthe GO button

The macro will then automatically updatetables and graphs for you to view andanalyse.

Remember to always save work regularly,preferably after each section entered.


THE MAIN WORKSHEETS AND THEIR CONSTITUENT PARTSMonthly worksheets

The spreadsheet tool has a worksheet forevery month from January to December.Numerical data is entered into the areashighlighted in green. Each month isidentical in layout and consists of up tofive weeks, numbered 1 – 5. In addition, itis also split into demand, capacity, activity,waiting list, waiting list distribution,cancelled sessions, failed sessions and latestarts. Definitions can be accessed byclicking on the red triangles on the topright hand corner of relevant cells.

Data must be entered for a completemonth. If a month changes half waythrough a week that week’s data must besplit by appropriate days to form the lastweek of one month and first week of thenext. If a month starts at a weekend thenstart entering data in week one. Do notleave week one blank.

Issues Sheet

This sheet provides the user with an audittrail of significant events, inconsistenciesin data or significant/noteworthyoccurrences. It is important that these arefully documented so that at a reviewmeeting several months later changes inthe information can be discussedaccurately and knowledgeably. Enter thedate and cell reference to the informationyou are explaining and then record theissue, comment and/or action next to it.

Overview Sheet

This sheet enables project teams to entertheir procedure names and timings inminutes. In addition, there is a GO buttonto perform the macro, which calculatesand updates all the data for the tablesand the graphs.

The procedure and timing informationentered into this sheet is used to calculate

the data in the monthly sheets, graphsand tables. If procedures and timings arechanged after initial entry theyautomatically change the entire toolkit.Therefore, information should only beamended once for that workbook.

If your department has more than 11procedures then another workbook mustbe used. Do not add extra lines to thespreadsheet because the macro and thetoolkit will not work correctly.

Turn around time sheet

This sheet is used to record the room‘down time’ i.e. when there is no patientpresent.

The toolkit has been developed to assistthe redesign of endoscopy units and asignificant focus is placed ontheatre/rooms utilisation, as it is a keyconstraint. However, it is recognised thattheatres/rooms need to be ‘turnedaround’ to prepare for the next patient.The turn around sheet enables the projectteam to monitor and understand thedowntime involved in making a theatreready for the next patient. This can bedone by sampling a selected time periodthen redesigning and reviewing this partof the service regularly.

Graphs sheet

This sheet allows the user to view datagraphically by month; the user can selectthe month they wish to view. There are 17graphs available highlighting usefulmanagement and redesign informationdrawn from the monthly worksheet.


Tables Sheet

This sheet contains the tabularrepresentation of information shown inthe graphs and also contains additionalmicro level data. There are 34 tablesavailable detailing daily and week onweek information.

Table hours sheet

This sheet contains a tabular representationof information detailed in the tables sheetconverted into hours instead of minutes.There are 17 tables mirroring the ones inthe main tables sheet.

Multiple Combination Lists

Many services run endoscopy sessionswhich contain multiple combinations ofprocedures. This sheet allows the user tocalculate ‘combination list’ timings. To dothis the user should enter:

� The date the combination list took place

� Whether it is a morning, afternoon orevening session

� The number of each type of procedurethat took place in that session.

The worksheet then calculates theestimated time taken for this list based onthe timings for individual procedureswhich have already been entered by theuser in the overview sheet.

In addition, the user can enter the totaltime the list actually took, and thespreadsheet will automatically calculatethe difference between the two times(variance). If the variance is constantlygreater than 20 per cent, then the usermust reassess the calculations andassumptions made for the individualprocedure timings they have entered inthe overview sheet.


USING THE OVERVIEW SHEET The Trust name is set to Insert TrustName. This must be changed to yourTrust’s name in order to personalise thegraphs. To do this simply enter text intothe Green box (cell B1) at the top of theoverview sheet:

There are 11 procedure type slotsavailable on this sheet for users to enterthe names of their 11 most frequentlyused procedures. In addition, the usermust enter numerical values in the greenboxes under the minutes column for eachprocedure type. These timings aredependent on the times measured at eachthe individual sites (patient in and out of

theatre) and should reflect what happensto 80 per cent of patients for specificprocedure.

When more than one procedure isperformed per session you should select

the multiple combination option on thedrop down menu. Any changes toprocedure types listed on this sheet resultin automatic changes to all work sheets.

Measuring procedure times

From your process map this is the time that the theatre is used for each patient.

This is measured by timing each patient in and out of theatre.

Then identifying the time which includes 80 per cent of patients forthat procedure

If there are other events that also happen in theatre e.g. consent this may needto be included in the timing initially but the redesign programme should worktowards a more appropriate place for this to be done.


USING THE MACROIn order to update and view the monthlydata in tabular and graphical form amacro must first be run from theOverview sheet. It is recommended thatthe macro be run immediately after datais added to the sheets and saved.

Running the Macro

� Select the month from cell B1 of graphssheet.

� Return to Overview sheet.

� Click on the Go button which runs themacro.

� A progress bar will appear to informyou that the process will take a fewminutes and will show you thepercentage of progress complete.

� Once completed view the required(updated) month’s data in the Tablesand Graphs worksheets.

USING THE MONTHLY SHEETS

Recording Demand data

All the demand upon your endoscopy unitmust be entered into this sheet. It is mustbe 100 per cent complete in order to trulyreflect the demand upon the service.Demand referrals are classified

� By procedure type

� By type of referral

To enter demand data

� Select the required month’s sheet

� Click on the relevant procedure typeand day

� Enter number of referrals in numericalformat (1, 3, 5, etc),

� Enter data in to the ‘green cells’ only.The total demand per day and perprocedure is automatically calculatedand will change when numbers areentered.

Referral types

Demand referrals are separated byprocedure type and also by type ofreferral; definitions for each category ofreferral are available by clicking on the‘red triangle’ in the top right hand cornerof the relevant box.

Select month. January


Day Patients – Patients in and out in thesame day (first attendees). This includescategories such as Outpatients, Directaccess and Daycases but excludes two-

week wait suspected cancer referrals asthese are recorded separately only fordemand.

9 To avoid double counting include here only cancer two week wait referrals sent to endoscopy as a first point of entry into thesystem. You should however find out numbers of patients with suspected cancers referred for an endoscopy so that this can beincluded in any service redesign.

Day Patients Monday Tuesday Wednesday Thursday Friday Saturday Sunday Total

Procedure A 0 0 0 0 0 0 0 0

Procedure B 0 0 0 0 0 0 0 0

Procedure C 0 0 0 0 0 0 0 0

Procedure D 0 0 0 0 0 0 0 0

Procedure E 0 0 0 0 0 0 0 0

Procedure F 0 0 0 0 0 0 0 0

Procedure G 0 0 0 0 0 0 0 0

Procedure H 0 0 0 0 0 0 0 0

Procedure I 0 0 0 0 0 0 0 0

Procedure J 0 0 0 0 0 0 0 0

Procedure K 0 0 0 0 0 0 0 0

Procedure L 0 0 0 0 0 0 0 0

Total Day Patient Referrals 0 0 0 0 0 0 0 0

2-week wait referrals – All two-weekwait suspected cancer referrals9.

2 Week Referrals Monday Tuesday Wednesday Thursday Friday Saturday Sunday Total

Procedure A 0 0 0 0 0 0 0 0

Procedure B 0 0 0 0 0 0 0 0

Procedure C 0 0 0 0 0 0 0 0

Procedure D 0 0 0 0 0 0 0 0

Procedure E 0 0 0 0 0 0 0 0

Procedure F 0 0 0 0 0 0 0 0

Procedure G 0 0 0 0 0 0 0 0

Procedure H 0 0 0 0 0 0 0 0

Procedure I 0 0 0 0 0 0 0 0

Procedure J 0 0 0 0 0 0 0 0

Procedure K 0 0 0 0 0 0 0 0

Procedure L 0 0 0 0 0 0 0 0

Total 2 Week Referrals 0 0 0 0 0 0 0 0

Inpatients – Patients who are on wardsand need an endoscopy before beingdischarged. Exclude those patients who

need an endoscopy within twelve hours,these are recorded as emergencies.

Inpatients Monday Tuesday Wednesday Thursday Friday Saturday Sunday Total

Procedure A 0 0 0 0 0 0 0 0

Procedure B 0 0 0 0 0 0 0 0

Procedure C 0 0 0 0 0 0 0 0

Procedure D 0 0 0 0 0 0 0 0

Procedure E 0 0 0 0 0 0 0 0

Procedure F 0 0 0 0 0 0 0 0

Procedure G 0 0 0 0 0 0 0 0

Procedure H 0 0 0 0 0 0 0 0

Procedure I 0 0 0 0 0 0 0 0

Procedure J 0 0 0 0 0 0 0 0

Procedure K 0 0 0 0 0 0 0 0

Procedure L 0 0 0 0 0 0 0 0

Total Inpatient Referrals 0 0 0 0 0 0 0 0


Private Patients - There is also a facilityto enable you to capture private work thatmay have an impact on your ability todeliver NHS care. At the side of eachweek’s demand is the private patient box.

Enter the total number of private patientrequests for each procedure each weekthat will be undertaken in existingscheduled sessions in the endoscopy suite.(e.g. between 9am-5pm).

Emergency – All patients who need anendoscopy within twelve hours. Includeout of hours work in this figure.

Emergency Monday Tuesday Wednesday Thursday Friday Saturday Sunday Total

Procedure A 0 0 0 0 0 0 0 0

Procedure B 0 0 0 0 0 0 0 0

Procedure C 0 0 0 0 0 0 0 0

Procedure D 0 0 0 0 0 0 0 0

Procedure E 0 0 0 0 0 0 0 0

Procedure F 0 0 0 0 0 0 0 0

Procedure G 0 0 0 0 0 0 0 0

Procedure H 0 0 0 0 0 0 0 0

Procedure I 0 0 0 0 0 0 0 0

Procedure J 0 0 0 0 0 0 0 0

Procedure K 0 0 0 0 0 0 0 0

Procedure L 0 0 0 0 0 0 0 0

Total Emergency Referrals 0 0 0 0 0 0 0 0

Follow up – All patients who havealready had an endoscopy. This includesrescopes, follow-ups and plannedsurveillance patients.

Follow-up Monday Tuesday Wednesday Thursday Friday Saturday Sunday Total

Procedure A 0 0 0 0 0 0 0 0

Procedure B 0 0 0 0 0 0 0 0

Procedure C 0 0 0 0 0 0 0 0

Procedure D 0 0 0 0 0 0 0 0

Procedure E 0 0 0 0 0 0 0 0

Procedure F 0 0 0 0 0 0 0 0

Procedure G 0 0 0 0 0 0 0 0

Procedure H 0 0 0 0 0 0 0 0

Procedure I 0 0 0 0 0 0 0 0

Procedure J 0 0 0 0 0 0 0 0

Procedure K 0 0 0 0 0 0 0 0

Procedure L 0 0 0 0 0 0 0 0

Total Follow-up Referrals 0 0 0 0 0 0 0 0

Private Patients TotalProcedure A

Procedure B

Procedure C

Procedure D

Procedure E

Procedure F

Procedure G

Procedure H

Procedure I

Procedure J

Procedure K

Procedure L

Total 0


Total Demand - At the bottom of eachweek’s data the total number of referralsfor that week are calculated automaticallyand shown in the white cells.

At the right hand side of each week’s datathe total demand for each procedure byreferral category is also calculatedautomatically.

Recording Capacity and Activity data

The data sheet - The data is recorded ina room by room layout. There are amaximum of five rooms per week in total.The definitions are given for eachcategory by clicking on the red triangle inthe right hand corner of each cell. If yourunit has more than five rooms you mustuse an additional Excel workbook.

Endoscopy type - Before entering thecapacity and activity data you must definethe procedure types used most frequentlyin the Overview Sheet.

Data is split into morning and afternoonsessions and by endoscopy type. The typeof procedure can be chosen from the dropdown menu shown when clicking in thebox just below each day:

Name -The name of the endoscopist maybe entered in the row below this. This isan optional choice which the user mayfind useful.

Total Week 1 Referrals 0 0 0 0 0 0 0 0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Room 1 Sun Sun Mon Mon Tue Tue Wed Wed Thu Thu Fri Fri Sat Sat TotalAM PM AM PM AM PM AM PM AM PM AM PM AM PM

Endoscopy Type

Name

Total Capacity minutes

Session minutes available

Scheduled List Minutes

Scheduled List Minutes(initiative)

Total Scheduled Minutes

Actual Procedures Mins

Variance

Emergency Mins Used

Inpatient Mins Used

Day Patients Mins Used

Follow up Mins Used

Private Patient Mins Used

Total

CBP Mins

CBH Mins

DNA'd Mins

Total Variance

No Procedures Performed by:

Consultant

Trainee Doctor

Nurse Endoscopist

Other A

Other B

Room 1 SunAM

Endoscopy Type


Capacity - Entering minutes

Useable capacity of the room is thepotential capacity that is available for use.This must be entered, completed for eachroom available regardless of whether itwas used for that session or notirrespective of staffing resources available.This is to enable total useable capacityand usage to be plotted.

To calculate capacity in minutes

� Take the number of hours per day theroom could be used i.e. 7 hours

� Split into morning and afternoonsessions i.e. 3.5 hours each

� Multiply by minutes per hour

Example above

Session minutes available

This section is used to enter the time inminutes that the endoscopist is contractedto work, e.g. 3.5 hours session is 210minutes. Please note this figure can be thesame as useable capacity minutes.

Activity - Entering minutes

Scheduled list minutes - This sectiondocuments the number of procedureminutes scheduled. This is based on locallydefined timings for each procedure typeor combination list which have beenentered on the overview sheet.

Capacity per session = Session length (hours) x minutes per hour

= 3.5 x 60

= 210 minutes

This can be all calculated using theMultiple Combination List Sheet

Any minutes relating to Initiatives shouldbe entered separately in the appropriatecells.

Initiative minutes - These are anyprocedure minutes that are not normallypart of the service’s normal workload e.g.extra sessions on Saturday mornings or inevenings or any covering of lists due tothe absence of the routinely scheduledendoscopist.

A session consisting of four flexible sigmoidoscopies.A flexible sigmoidoscopy takes 20 minutes then

4 flexible sigmoidoscopies = 4 x 20= 80 minutes

OR

A mixed session consisting of two colonoscopies, three flexible sigmoidoscopiesand two OGDs. A colonoscopy takes 40 minutes, a flexible sigmoidoscopy takes20 minutes and an OGD takes 15 minutes then

2 colons + 3 flexi’s +2 OGD’s= (2x 40) + (3x20) + (2x15) = (80+60+30) = 170 minutes

Examples:


Actual procedure minutes - This sectioncontains the minutes of work actuallyundertaken in the session. This is basedon locally defined timings for eachprocedure type or combination list. Oncethe total number of minutes worked havebeen entered there is space for the user tosplit this data down into minutes usedand unused10.

Emergency minutes - This sectiondocuments the time used for patients whoeither need an endoscopy within twelvehours or for endoscopies undertaken out ofnormal hours.

Inpatient minutes - This section includespatients who are in a hospital bed andcannot or will not be discharged until anendoscopy has been performed. Thisexcludes patients who require anendoscopy within 12 hours.

Day patient minutes - This sectionincludes patients who are in and out inthe same day and are first attendees. Thisclassification includes daycases,outpatients, and direct access and twoweek wait cancer referrals.

Follow up minutes - This sectionincludes all patients who have previouslyhad an endoscopy. Locally these may becalled re-scopes, re-do’s, follow-ups,planned or surveillance patients.

Private Patient minutes - This sectioncontains those minutes which are usedduring the session for private patients.

Cancelled by Patient minutes (CBP) -This is the time allocated to a procedurethat has been cancelled by the patientand where the slot has not been refilled.

Cancelled by Hospital minutes (CBH) -This is the time allocated to a procedurewhich has been cancelled by the hospital.

Did Not Attend (DNA) - This is the timein minutes allocated to the procedure butthe patient did not attend for theappointment.

Recording who performs procedures

This section is used to record how manyprocedures are performed in each sessionand which professional group theendoscopist belongs to. The categoriesinclude consultant, trainee doctor andnurse endoscopist, other A and other B.These last two categories can be definedby the user if others are performing theprocedures such as GP, radiologist orregistrar.

Running the Macro

Once all five weeks’ data for the currentmonth has been entered and saved thenrun the macro

� Select the current month in graph sheetcell B1

� Return to overview sheet

� Press the Go button. This will update allthe figures in the tables and graphs.

Emergency Mins UsedInpatient Mins UsedDay Patients Mins UsedFollow up Mins UsedPrivate Patient Mins UsedCBP MinsCBH MinsDNA'd Mins

10 Unused time

CBP = Cancelled by patient, CBH = Cancelled by Hospital, DNA = Did not attend


Waiting Distribution

The monthly waiting list distribution datais entered into the second section asshown below: It is important that waitinglist data is collected on the same day ofeach month.

Recording Waiting List DataWaiting List

The two waiting list sections are for allpatients waiting regardless of the localclassification used by the Trust. These maybe classified11 as daycases, outpatients,inpatients or diagnostic tests.

Active waiters are all first attendeeswho have not had an endoscopy beforein this care episode. These are patientswho should have their endoscopy withoutany delay.

Planned are all follow up (rescopes, redo,planned or surveillance etc) patients.There will typically be a planned delay for

this group of patients. The waiting timemust be recorded from the date of theprevious endoscopy.

The numbers of patients on Active andPlanned waiting lists must be

� Recorded on a weekly basis

� Always on the same day of the week

� Recorded by procedure type

The Toolkit will automatically calculate thetotal numbers by procedure type and byclassification in each category (Active orPlanned).

Week 1Procedure

AProcedure

BProcedure

cProcedure

DProcedure

EProcedure

FProcedure

GProcedure

HProcedure

IProcedure

JProcedure

KProcedure

LTotal

WaitingListNumberat start

0 0 0 0 0 0 0 0 0 0 0 0 0

WaitingListNumberat start

0 0 0 0 0 0 0 0 0 0 0 0 0

ACTIVE

PLANNED

TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

11 There is no definitive classification of endoscopy procedures currently; however guidance is expected during 2003/4.

January First Day

Distribution of waiting times Procedure A

First Day First Follow up

Under 1 month

1month -

2months -

3months -

4months -

5months -

6months -

7months -

8months -

9months -

10months -

11months -

12 months -

13 months +

Total 0 0


Failed Procedures

This section documents the number offailed procedures, regardless of the reason.These are procedures that started but thenfor whatever reason could not becompleted. The reasons for such failedprocedures should be entered in the issuessheet.

Enter data, split into Active and Follow Upcategories, by procedure type and lengthof time waiting,

Cancelled Sessions and Late starts

In this section you should record capacitythat has been lost regardless of thereason. This may include minutes lostthrough annual leave, study leave andsessions being cut short as well as listsstarting late. The reasons for thesecancellations or late starts should beidentified in the issues worksheet.

0

0

0

0

0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Cancelled Sessions and late starts

Week 1 Sun Sun Mon Mon Tue Tue Wed Wed Thu Thu Fri Fri Sat Sat TotalAM PM AM PM AM PM AM PM AM PM AM PM AM PM

Room 1

Room 2

Room 3

Room 4

Room 5

Total

0

0

0

0

0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Failed Procedures

Week 1 Sun Sun Mon Mon Tue Tue Wed Wed Thu Thu Fri Fri Sat Sat TotalAM PM AM PM AM PM AM PM AM PM AM PM AM PM

Room 1

Room 2

Room 3

Room 4

Room 5

Total


Turn around time

This sheet allows you to record the timewhen there is no patient in the room; thiscould be for a variety of reasons e.g.getting the room cleaned, sterilisingendoscopes and preparing the nextpatient.

Sessionam/pm/evening

am

RoomNumber

1

Patientnumber

1

Time Pat.enteredtheatre

(e.g.13:00)

9:00

Time Pat.Left

Theatre(e.g.13:50)

9:15

Time Pat.Spent intheatre

0:15

Time roomprep fornxt Pat.

(e.g.13:56)

9:20

Minsroom

prepared

0:05

Time nxtpatiententeredtheatre(14:15)

9:30

Totaldowntime

0:15

Reasonsfor

delays

Patientdelay

am

Date**/**/**

01/01/2001

01/01/2001 1 1 9:30 10:10 0:40 10:15 0:05 10:15 0:05

The user needs to insert the relevant timesinto the turnaround sheet; however somefigures are calculated automatically. Theseare as follows:

� Time patient spent in theatre

� Minutes to prepare the room

� Total downtime

� The next time a patient entered theatre

All the other fields should be completedby the user on a sample basis.


GRAPHS AND TABLESThese are automatically generated fromthe data entered. To ensure that thegraphs and tables are updated you needto:

� Select the month you want in cell B1 ofthe Graphs sheet

� Press the Go button on the overviewsheet and this will run the macro

These sheets allow you to view the mostrelevant monthly information in tabularand graphical format. The followingsubjects can be viewed:

Subjects1 Demand by day of week 2 Demand by Procedure3 Minutes Demand by Procedure4 Demand by Referral Source5 Total Planned and Actual Workload Minutes by

Week6 Breakdown of Minutes Used By Week7 Breakdown of Minutes Unused By Week8 Breakdown of Minutes Unused By Day9 Procedures undertaken by Professionals By Week10 Active and Planned Waiting List Split11 Active Waiting List Distribution12 Planned Waiting List Distribution13 Macro Level Chart (1) – Showing Total capacity,

Total demand, Total Activity14 Macro Level Chart (2) - Showing Total capacity,

Total demand, Total Activity, Active waiting listand Planned waiting list

15 Macro Level Chart (3) - Showing Total capacity,Total demand, Total Activity and Total waitinglist

16 Cancelled Sessions17 Failed Procedures

Graphs

The Graphs listed below using the monthof January as an example:

Demand by day of week - January 2002 - InsertTrust nameDemand by Procedure - January 2002 - Insert TrustnameMinutes Demand by Procedure - January 2002 -Insert Trust nameDemand by Referral Source - January 2002 - InsertTrust nameTotal Planned and Actual Workload Minutes byWeek - January 2002 - Insert Trust nameBreakdown of Minutes Used By Week - January2002 - Insert Trust nameBreakdown of Minutes Unused By Week - January2002 - Insert Trust nameBreakdown of Minutes Unused By Day - January2002 - Insert Trust nameProcedures undertaken by Professionals By Week -January 2002 - Insert Trust nameActive and Planned Waiting List Split - January2002 - Insert Trust nameActive Waiting List Distribution - January 2002 -Insert Trust namePlanned Waiting List Distribution - January 2002 -Insert Trust nameMacro Level Chart (1) - January 2002 Insert TrustnameMacro Level Chart (2) - January 2002 Insert TrustnameMacro Level Chart (3) - January 2002 - Insert TrustnameCancelled Sessions - January 2002 Insert TrustnameFailed Procedures - January 2002 - Insert Trustname


CUTTING AND PASTING TABLES AND GRAPHSThe tables and graphs can be inserted intoWord documents and Power pointpresentations by cutting and pasting asfollows:

Copying graphs into Word documents

To transfer graphs into a Word document

� Select the graph by a single left click onthe mouse in the appropriate chartarea. A black line with eight small blackboxes will appear around the graph.

� Right click the mouse in the chart areaand a menu will appear

� Choose copy and a flashing box willappear around the graph.

� Go to the Word document and in anappropriate space right click with themouse

� Select paste from the menu and thechart will appear.

Copying tables into Word documents

To transfer a table into Word documentsyou should:

� Highlight the area you wish to copy

� Right click on the mouse and from thelist which appears select copy. Aflashing box will appear around thetable selected.

� Go to the word document

� Right click with the mouse where youwish the table to be placed

� Select paste; the table will appear.


Inserting Graphs into a PowerPointpresentation

In PowerPoint select the slide layoutrequired; note that not all slides offer theoption to present graphical information.This is represented by a bar chart, asshown below:

Select the style of slide required anddouble click to enter a graph. Thefollowing screen will appear:

� Copy the table relevant to the graphrequired, as described in copying tablesinto Word documents

� Paste this into the datasheet in PowerPoint.

� The graph will automatically change.

� Click outside the highlighted chart tohide the datasheet; your graph istransferred.


OTHER USEFUL RESOURCES AND DOCUMENTSGeneral.

Redesign: a tool kit. Service ImprovementGuide. Cancer Services Collaborative(2001), NHS Modernisation Agencywww.modern.nhs.uk/csc

Bowel Cancer: Service ImprovementGuide. Cancer Services Collaborative(2001), NHS Modernisation Agencywww.modern.nhs.uk/csc

Ready, Steady, Book: A Guide toImplementing Booked Admissions andAppointments for Patients. NationalBooked Admissions Programme (2001)NHS Modernisation Agencywww.modern.nhs.uk/booking

From Scepticism to support – What arethe influencing factors? Research intoPractice Programme, (2002) NHSModernisation Agencywww.modern.nhs.uk/redesign

Improvement Leaders’ guide to matchingcapacity and demand. Redesign Team,(2002) NHS Modernisation Agency(address above)

Improvement Leaders’ guide tomeasurement for improvement. RedesignTeam, (2002) NHS Modernisation Agency

Improvement Leaders’ guide to spreadand sustainability. Redesign Team, (2002)NHS Modernisation Agency

A Step-by-Step Guide to ImprovingOutpatient Services.www.modern.nhs.uk/serviceimprovement/1338/4647/guide toimproving outpatient services

Getting Patients Treated Handbook, Thewaiting List action team Handbook.www.doh.gov.uk/pub/docs/waitingl.pdf

Process mapping

Improvement Leaders’ Guide to Processmapping, analysis and redesign. RedesignTeam, (2002) NHS Modernisation Agency

The Patient’s Journey. Mapping, Analysingand Improving Healthcare Processes(2002) Sarah Fraser. Kingsham Press ISBN:1-904235-09-03

Maps and Journey’s: redesign in the NHS.(2001) Louise Locock HSMC University ofBirmingham. ISBN: 07044 2309X

Seeing through patient’s eyes

Patient Information: Service ImprovementGuide. Cancer Services Collaborative(2001) NHS Modernisation Agency

Learning from patient and carerexperiences. Second Edition CoronaryHeart Disease Partnership Programme(2001), NHS Modernisation Agency

Improvement Leaders’ Guide to Involvingpatients and carers Redesign Team, (2002)NHS Modernisation Agency

Voices in Action Resource Book, G Fletcher& J Bradburn (2000) College of Health

A guide to developing effective userinvolvement strategies in the NHS. MKelso (1997) College of Health

Web Sites

www.bsg.org.uk: Web site for British Societyfor Gastroenterology which has informationabout clinical guidelines, endoscopy trainingand broad service guidelines.

www.modern.nhs.uk: web site for NHSModernisation Agency to find out aboutredesign programmes. Includes web pagesfor Cancer Services Collaborative, NationalBooking Programme: Access, Booking &Choice, Coronary Heart Disease Collaborativeand Changing Workforce Programme.

www.primarycaresocietyforgastroenterology:Web site for the Primary Care Society forGastroenterology. Has useful informationabout GP endoscopy in primary andsecondary care and clinical guidelines forprimary care.


ACKNOWLEDGEMENTSModernising Endoscopy Services: apractical guide to redesign would nothave been created without this team whotook a basic concept and successfullydeveloped this final published version.They not only establish the nationalprogramme but also developed thisdocument and the recommendedapproach to enable teams to redesigntheir service.

Liz Allan, National Programme Managerfor Endoscopy, NHS ModernisationAgency

Sally Batley, Deputy Director for Analysis,NHS Modernisation Agency

Sue Bates, Programme Manager, CancerAction Team

Shona Brown, North London WorkforceConfederation (formerly National ProjectManager for Endoscopy)

Erika Collinson, Information Analyst, NHSModernisation Agency

Ian Greenwood, Associate Director,National Booking Programme: Access,Booking & Choice, NHS ModernisationAgency

Kam Kalirai, National Redesign Leader,NHS Modernisation Agency

Lesley Wright, National Associate Director,Cancer Services Collaborative, NHSModernisation Agency

The first wave pilot sites listed belowmade this toolkit possible by activelycontributing to the development andrefinement of this toolkit during ayearlong redesign programme.

Aintree Hospital NHS Trust

Gateshead NHS Trust,

Good Hope Hospital NHS Trust,

Lewisham NHS Trust

Mid Essex NHS Trusts

North West London NHS Trust

North Staffordshire NHS Trust

Royal Liverpool NHS Trust


APPENDIX 1 - DEFINITIONS

Activity

Backlog

Bottleneck

Capacity

Carve Out

Constraint

Demand

GP referral

Outpatient referral

Inpatient referral

Repeat endoscopy

Refers to the work done, expressed as the number ofendoscopic procedures performed

Is the number of endoscopic procedures for which referral hasbeen made, but the procedure has not yet been performed

The place in the patient pathway where hold-ups occur. It isused when the cause of the hold-up is not yet clear

Resources available in terms of equipment, space, and skillsavailable to operate the equipment and staff to run the facilities

Practice of "protecting" slots on lists for particular appointmenttypes. For example protecting slots for twoweek rule patients,whole sessions allocated to individual procedure types

The issue/problem holding up flow of activity and causing thebottleneck

The number of referrals being made to the service. Demandmeasures need to be comprehensive capturing both electiveand emergency referrals, i.e. generated both inside andoutside of the service

All referrals, including letters, faxes etc. that are generated bythe GP and result in the patient being listed for endoscopywithout being seen first. This includes two week urgentreferrals, any open access or direct access services

All referrals for endoscopy, where the patient has been seenfirst in the outpatient department prior to the decision to listfor endoscopy

All referrals for endoscopy to be carried out during aninpatient episode

All referrals for patients who require follow up endoscopicexamination; i.e. includes surveillance patients


APPENDIX 2 - ROOM UTILISATION SHEETA simple way of documenting and highlighting issues with room utilisation is to use acalendar sheet which can be coloured to denote whether a room is used or not.

Example: Code: Room in use Room not used

Room 1

1 December 2 3 4 5 6 7

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

8 9 10 11 12 13 14

15 16 17 18 19 20 21

22 23 24 25 26 27 28

29 30 31 1 January 2 3 4

1 December 2 3 4 5 6 7

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

8 9 10 11 12 13 14

15 16 17 18 19 20 21

22 23 24 25 26 27 28

29 30 31 1 January 2 3 4

Room 2



National Booking ProgrammeAccess, Booking & Choice 4th FloorSt John’s HouseEast StreetLeicesterLE1 6NB

Telephone: 0116 222 1414Fax: 0116 222 5101

Web address: www.modern.nhs.uk/booking

February 2003

The NHS Modernisation Agency is part of the Department of Health

Documents

MODERNISING ENDOSCOPY SERVICES A PRACTICAL GUIDE TO … the endoscopy... · 2011-11-11 · Modernising Endoscopy Services (MES) is a toolkit, which aims to provide a basis for multidisciplinary