This assignment is written from the point of view of a bowel cancer project manager for one of the cancer networks in England. It gives a systems review of the service provided to bowel cancer patients and makes recommendations for improvements in quality, with a project plan to demonstrate the process for making changes.
A systems review provides a logical analysis of current processes and can highlight aspects of the service that might previously have gone unrecognised and not specifically noted.
Project plans are essential if a task is to be completed to schedule with all the relevant steps being included. Without such a plan, arrangements can be haphazard and take place in the wrong order, leading to failure in achieving the desired goals. This can have a negative impact on the delivery of quality service to patients.
The material is described in general terms in the ‘Observations’ section while the project plan, which contains specific details, is given in the Appendix.
The National Patients’ Access Team (NPAT) provides support and guidance to NHS trusts around the country in an attempt to improve patients’ experiences and outcomes.
The Cancer Services Collaborative (CSC) consists of some members of NPAT and various cancer networks (groups of trusts) in England. Each cancer network concentrates on one of five different cancers (breast, bowel, ovarian, prostate and lung), and for each of these, there is a project manager and a lead clinician (usually a consultant surgeon).
This assignment is written from the point of view of Helen, a fictitious project manager who deals with bowel cancer in the South Midlands cancer network. Helen was seconded to the project from her previous job as a colorectal specialist nurse.
As a nurse, Helen was aware of the many bureaucratic requirements in the system. For instance, any patient who was suspected of having bowel cancer often had to undergo two particular tests. These tests (a colonoscopy and a barium enema) require that the bowel be emptied (with the aid of medication) and an instrument to be inserted into the rectum. The tests are usually carried out on different days because the two departments (endoscopy and X-ray) worked independently. Therefore, the patient would be required go through the very uncomfortable experience of clearing hisher bowels twice. As a project manager, Helen could help to redesign the system so that any patient who required both tests could have them done on the same day, with only one bowel clearance required. The patient would also obtain a diagnosis more quickly.
This assignment describes how Helen identified these type of situations and set about changing the service to offer patients a better experience.
Various government documents have emphasised the need to improve the quality of patient care (HSSM 2000, Managing Service Delivery, book 1, pp 8–13). This is especially important for cancer patients as the diagnosis of cancer is often accompanied by great fear and anxiety.
Broadly speaking, outcomes for cancer patients include mortality (death rate), morbidity (degree of illness), patient experience, etc. Death and morbidity can probably be reduced by cutting delays in the patient’s journey that starts with the GP’s referral and goes down the road of the first outpatient appointment, diagnosis, treatment, etc. (Figure 1). Therefore, these outcomes were appropriate for Helen to work on (HSSM 2000, Managing Service Delivery, book 1, pp 15–16). Patient satisfaction could also be measured at various stages along the journey.
To carry out this project, various inputs were needed (HSSM 2000, Managing Service Delivery, book 1, pp 13–14). These included salaries for Helen and support staff, extra time given by the lead clinician, and office space and equipment. The output would be identifying areas for improvement within the existing service and rectifying these. The outcomes (as described above) would be measures to show that improvements were being made. These measures might show a reduced number of days between referral and the first outpatient appointment, or that a higher percentage of patients were having tests on the same day rather than on separate days. Patient satisfaction scores might show a higher percentage of patients rating their scores as four or five on a scale of five (with five indicating high satisfaction with the service). Such measurements are concrete enough to be meaningful and specific targets can be set (e.g., 90 per cent of patients with suspected bowel cancer should be seen by a specialist within two weeks of referral by the GP) (HSSM 2000, Managing Service Delivery, book 1, p 16).
Helen had to start off by obtaining the views of patients and staff on the existing service. She wanted to sample both groups because she considered them to be her ‘customers’. The patients would benefit from improvements and the staff would also benefit, because they were often concerned when they saw patient care hindered by bureaucracy.
This information could be collected in different ways (HSSM 2000, Managing Service Delivery, book 1, pp 24–26). It was felt, from informal feedback and hearsay from staff and patients, that the waiting time to see a specialist was too long, patients had to return on several occasions for different tests, and it took too long to obtain a diagnosis and start treatment. Helen developed a questionnaire for patients at various stages of the journey (e.g., in outpatients, in the X-ray department, on the ward, etc.) and negotiated with the staff in the different departments to hand out and collect the questionnaire. Staff also filled in a questionnaire.
Helen tried to organise a patients’ focus group to identify issues, but the only patients who were interested tended to be retired healthcare professionals, and they were not considered to be representative. However, a staff focus group proved useful because the staff identified problems and brainstormed ideas for reform.
Helen also carried out some process mapping to find out how long each part of the patient’s journey took: that is, a ‘service-delivery process’ (HSSM 2000, Managing Service Delivery, book 2, pp 16–20). She calculated the average time for each stage at one of the hospitals in her network (Figure 2).
The purpose of the process (HSSM 2000, Managing Service Delivery, book 2, p 19) was to achieve timely treatment for bowel cancer patients and check on their progress at the follow-up appointment. Helen was able to use this map to identify where the bottlenecks were, set targets for individual stages (and set up monitoring for them) and determine whether parts of the journey could be eliminated or combined. She worked with her lead clinician and other staff to decide on the ideal patient journey and looked at the reasons for any deviation from this (HSSM 2000, Managing Service Delivery, book 2, pp 20–21).
Helen could use process redesign (HSSM 2000, Managing Service Delivery, book 2, pp 24–26) to reconfigure the patient pathway. The GPs could fax the referral to the hospital rather sending it through the post. The hospital could immediately fax back an appointment for the patient. Rather than having separate appointments for the first outpatient appointment, colonoscopy and barium enema, the patient could have these all on the same day and start the medication for bowel clearance two days beforehand. The patient could attend the clinic again the following week for the results, and surgery could be arranged within a few days. The patient could be discharged early, so long as the district nurse and GP were willing to look after him/her, and the follow-up outpatient appointment could be brought forward. Helen had to consider all these possibilities when drawing up her project plan and how to achieve them in reality (Appendix).
Helen identified that one constraint in the system was the consultant’s time. By training the colorectal nurse specialists to see patients in the clinic and to carry out colonoscopies, capacity could be added. The revised patient pathway is shown in Figure 3.
Patient care could be improved by implementing changes such as these. The most appropriate model to consider is the ‘business model’ because Helen is dealing with ‘convenient appointments’ and ‘acceptable waiting times’ (HSSM 2000, Managing Service Delivery, book 3, p 8). The patients were already receiving a quality service from the doctors in terms of the ‘biomedical model’ (medical care), that was being monitored by the trusts’ Audit Departments. Helen’s remit was to consider the other aspects of care, as mentioned above.
The patients’ expectations are not necessarily very high (HSSM 2000, Managing Service Delivery, book 3, pp 12–13). Many people expect to wait to be given an appointment and also to wait to see the doctor on the day of the appointment. They might be pleasantly surprised if new systems were to be introduced to reduce these delays. However, documents such as the Patients’ Charter can raise expectations and show what may be perceived to be a low level of patient care.
Another question is that of equity (HSSM 2000, Managing Service Delivery, book 3, p 14). Patients with suspected cancer might be seen urgently but this is at the expense of other patients who would then need to wait for a longer time. These patients may also be critically ill, but it is more politically correct to focus on cancer than other diseases. Even though Helen was covering cancer patients, she would need to consider the effect of her changes on other patients.
Helen also had to take into account the cost of any changes, although a large budget had been allocated to cancer services. Some of the money had already been spent on salaries and office equipment. In the short-term it may cost more to put more patients through the system (as would happen if delays were reduced). However, all those patients would have required processing at some stage, and it is cheaper to treat someone with an earlier stage of cancer. If left, the cancer will advance and require more extensive and expensive treatment (HSSM 2000, Managing Service Delivery, book 3, p 15).
According to the prevention-appraisal-failure model (HSSM 2000, Managing Service Delivery, book 3, p 16), Helen is probably intervening at the prevention stage. By looking at service design and taking small steps to reduce waiting time, the risk of patients’ cancer advancing and/or patients making complaints is decreased. However, appraisal is also carried out in the form of monitoring and auditing, which is part of Helen’s job description. Failure occurs when a patient slips through the net through being delayed more and more at each stage. By the time (s)he is operated on, it might be too late to cure the cancer. This could start off as an internal failure at each delayed stage, but by the time the patient’s life is affected significantly, it becomes an external failure. Helen would anticipate that although prevention costs were relatively high, appraisal and failure costs would fall. She wished to improve systemic quality, i.e. redesigning systems to meet patients’ needs and eliminate barriers among different service providers (e.g., GP practice, outpatient department, colonoscopy suite, X-ray department, ward, etc.) (HSSM 2000, Managing Service Delivery, book 3, p 24).
It was important, therefore, for Helen to liaise with many different people in the trusts and gain their co-operation in order to provide an integrated journey for the patient (HSSM 2000, Managing Service Delivery, book 3, pp 25–6). If the patient was having a colonoscopy and a barium enema on the same day, the staff should be aware of this situation and be able to communicate with each other. For instance, the nurse in colonoscopy must ensure that the patient knows not to eat until after the barium enema, and the colonoscopy clerk can telephone the X-ray clerk to say that the patient was on his/her way.
Helen was given leeway to try out changes on a few patients at a time to see whether the changes worked. This is one of the characteristics of the CSC, in that “Plan, Do, Study, Act” (PDSA) cycles (Figure 4) can be carried out to see what is feasible, before extending improvements to the whole service (HSSM 2000, Managing Service Delivery, book 3, pp 33–35). PDSA cycles formed part of Helen’s project plan (Appendix).
Helen had to consider possible conflicting aims of process and outcome (HSSM 2000, Managing Service Delivery, book 3, pp 53–54). She might have supervised the restructuring of the service to allow a colonoscopy and barium enema to take place on the same day in the belief that it was better for patients. The outcome might show that delay was reduced for the stage of first outpatient appointment to diagnosis. However, it could be very stressful for the patient to have two big investigations, one after the other. That is where a different kind of outcome measure (e.g., patient satisfaction) is valuable.
Helen was appointed as a CSC project manager to look at service delivery to patients and redesign systems to make improvements. Improvements would also impact on staff morale.
As a result of the mapping process (HSSM 2000, Managing Service Delivery, book 2, pp 16–20), Helen identified bottlenecks in the system and she had preliminary discussions with her colleagues (doctors, nurses, radiographers, clerks) on how to reduce delays at each stage.
Helen instigated monitoring to show the number of days or weeks involved in each stage of the process. She also carried out investigations into patient and staff satisfaction. Preliminary results showed that delays were longer than government targets and that neither patient nor staff satisfaction was very high. These were the outcome measures (HSSM 2000, Managing Service Delivery, book 1, pp 15–17).
Helen took quality into consideration and she bore in mind that what she thought the patients needed was not necessarily what the patients themselves would want. She was also aware that quality must be balanced against cost.
As a result of the above, Helen was able to redesign the process and she drew up a project plan (Appendix).
Health and Social Services Management, Managing Service Delivery (2000). Milton Keynes: The Open University
The Cancer Services Collaborative (CSC) aimed to reduce waiting times between different stages of the cancer patient’s journey and to improve the patient’s experience. This project was concerned with bowel cancer in the South Midlands Cancer Network.
At the time of writing, the waiting times between key stages of the basic patient’s journey would be a maximum of:
GP referral to first outpatient appointment: 2 weeks
First outpatient appointment to diagnosis: 4 weeks
Diagnosis to start of treatment: 2 weeks
These should be achieved for 90 per cent of bowel cancer patients.
For patient satisfaction, 80 per cent of patients should be describing their care as four or five on a scale of one to five (with five being the most satisfied).
Funding of £x had already been secured from the CSC as part of a bidding process.
The key stages of the project (HSSM 2000, Managing Service Delivery, book 4, p 23) are as follows:
A Map the process of the bowel cancer patient’s journey
B Measure initial waiting times and satisfaction
C Identify bottlenecks
D Discuss possible improvements with staff in different departments at the different trusts
E Identify changes that need to be made
F Try out changes using PDSA cycles
G Achieve waiting time targets
The timescale (HSSM 2000, Managing Service Delivery, book 4, p 26) is estimated as follows:
A 3 weeks
B 4 weeks
C 1 week
D 5 weeks
E 4 weeks
F 26 weeks
G 52 weeks
These stages can be shown in a logic diagram (figure 5).
(Numbers of weeks are shown in brackets.)
A (3) C (1)
START B (4) E (4) F (26) G (52) FINISH
The path START à A à C à E à F à G à FINISH would take 86 weeks.
The path START à B à E à F à G à FINISH would take 86 weeks.
It can be seen that there was some flexibility during the start and finish times of stages A, B and C (a week’s leeway for each.)
Project Management, Reporting and Review
The project will be managed by Helen X, with support from Mr. Y, Consultant Surgeon. Helen will liaise with all groups of staff and maintain communication links.
Helen will produce monthly reports for the National Patients’ Access Team on the measures described above (HSSM 2000, Managing Service Delivery, book 4 pp 29-30). Regular meetings will be held between Helen, Mr. Y and groups of staff.
The main risk in this project is that of labour (HSSM 2000, Managing Service Delivery, book 4 p 31). The staff might not have time to implement changes (because they were so busy doing their normal jobs), or they might be unwilling to try anything new. This could be alleviated by identifying keen members of staff and negotiating with them first.