Radiotherapy Toolkit In collaboration with Cancer Services Collaborative Cancer Action Team Version 2 Last updated 10.01.03 Working Version 5.1 CONTENTS BACKGROUND……………………………………………………………………………………………….. 3 AIMS AND OBJECTIVES OF THE TOOLKIT……………………………………………………………… 4 AIM……………………………………………………………………………………………………………. 4 OBJECTIVES………………………………………………………………………………………………….. 4 KEY CONTACTS……………………………………………………………………………………………… 4 DEFINITIONS………………………………………………………………………………………………….. 5 CHALLENGE ONE: IDENTIFY STRATEGIC SUPPORT AND CLINICAL LEADERSHIP……………. 6 CHALLENGE TWO: UNDERSTAND THE CURRENT SERVICE - MAP AND ANALYSE PATIENT PROCESSES………………………………………………………………………………………………. 7 CHALLENGE THREE: WORK TO IMPROVE THE PATIENT/CARER EXPERIENCE……………….. 10 CHALLENGE FOUR: BEING CLEAR ABOUT ACTUAL DEMAND……………………………………... 13 CHALLENGE FIVE: UNDERSTANDING BACKLOG……………………………………………………... 16 CHALLENGE SIX: ACCESS AND PATIENT CHOICE…………………………………………………… 19 CHALLENGE SEVEN: REDESIGN THE PROCESS……………………………………….……………. 21 CHALLENGE EIGHT: COLLECTING THE DATA AND MONITORING PROGRESS………………… 21 OTHER USEFUL SOURCES AND DOCUMENTS……………………………………………………….. 24 APPENDICES…………………………………………………………………………………………………. 25 Key contacts The team, which has been established to develop and take forward the recommended approach outlined within this toolkit, includes: Angie Craig, CSC Radiotherapy National Project Manager Email: email@example.com Tel: 0116 2225112 Mobile 07900 223352 Peter Kirkbride, CSC Radiotherapy National Clinical Lead Email: firstname.lastname@example.org Tel: 0114 2265000 Trevor Roberts, CSC Radiotherapy National Clinical Lead Email: Trevor.email@example.com Tel: 0191 2194280 Barbara Zutshi, CSC Regional Facilitator, South East Email: firstname.lastname@example.org Tel: 07900223136 Claire Henry, CSC Associate National Director Email: email@example.com Tel: 0116 222 1415 Sue Bates, Programme Manager, Cancer Action Team Email: Sue.Bates@gstt.sthames.nhs.uk Tel: 020 7960 5886 Background The Cancer Services Collaborative (CSC) is working with cancer networks across the country to redesign services, cut waits and improve experiences for patients and carers. The goal of the CSC is: “To improve the experience and outcome of care for people with suspected or diagnosed cancer by improving the way in which care is delivered” The NHS Cancer Plan states very clearly that new investment in staff and equipment needs to be accompanied by reform. Many of the improvements made as part of the CSC programme have been achieved with relatively little new resources. The main focus has been time and support so that teams can look at the way care is delivered and see how these systems can be improved. This has shown that it is possible to reduce waiting times for diagnosis and treatment, that care for cancer patients can be booked at every stage of their journey and that patient experience of care can be greatly improved by their involvement. As the CSC programme has progressed, key parts of the patient journey have been highlighted as major bottlenecks, one of which is radiotherapy. A national project has been established to address the unique problems in this area. As a programme, we are acutely aware of the problems facing cancer patients when they need radiotherapy. Long waits and poor communication are commonly reported problems from both patients and referring services. We are also conscious of the impact working towards government access targets could have on radiotherapy services. Radiotherapy is a complex, multi-step process, involving many staff groups and access to limited resources (staff and equipment). Before attempting to redesign any service it is essential to establish what the current situation is. Often, the perception of what is happening within the service is based on limited data, which can often mask the real situation. Access to radiotherapy depends on many factors, not least the availability of linear accelerators and trained staff to operate them. Initiatives to increase both the number of treatment machines and staff will eventually ease the pressure, but new ways of working are also necessary. Traditionally we have used activity data and waiting times to indicate how hard our service is working. As an indicator of the amount of work done, activity figures are a good measure. Their drawback is they give no indication of the current demand for the service, any fluctuations, or the available capacity to perform the activity. The activity may have been performed easily within the working day, or the day may have had to be extended, or ad-hoc overtime worked to cope. A waiting list can form over a very short period in time if the routine service is disrupted, or variations in demand occur. If a waiting list is constant, it is just acting as a delay buffer to patients trying to access service. This toolkit has been designed to help teams look across the whole treatment system to identify the true constraints in the process and explore how we can better understand the demand on our services, it’s complexity and how that affects our capacity and waiting times. The radiotherapy project focuses on a number of measures can be undertaken to identify the real situation: Map the patients journey through radiotherapy (identifying any constraints) Identify the true demand for the service Identify the actual capacity you have available Are they balanced? Look at demand management and streamlining before creating extra capacity Form an action plan for redesign 3 The first stage began in January 2002, with teams invited to bid for £6K to fund a 2 month snap-shot of capacity, demand backlog and activity data. This was to inform a redesign action plan for their service. 45 out of 54 UK radiotherapy departments, covering 33 out of 34 cancer networks in England took part. The work is co-ordinated nationally by a steering group, with the focus very much being team driven. We have held 3 well attended workshops to date, providing opportunities for radiotherapy teams to meet and share their progress/problems, benchmark and collaborate on common issues. The project is also linked to nominated CSC regional and network personnel, plus regular open forum conference calls for support. Utilise other initiatives: College of Radiographers/DOH education and professional development (EPD) pilot Changing Workforce Programme – Accelerated Development Programme for Radiography Booking Programme – Access, Booking and Choice Cottier review of radiotherapy services Cancer Action Team – Peer Review Process Cancer Dataset implementation National patients survey Local initiatives Aims and Objectives of the toolkit Aim To improve Radiotherapy Services for patients by giving radiotherapy teams the skills to map, analyse, streamline and redesign their processes, in partnership with the Cancer Services Collaborative (CSC) programme and other local modernisation initiatives. Objectives 1. To establish high level support for service redesign 2. To map and analyse the patient process (including referral pathways) 3. To ensure the patient experience is the focus of service delivery 4. To define, group and time patient templates (using the Health Resource Groups-HRGs) 5. To identify the issues around access and patient choice 6. To undertake a demand and capacity audit. 7. To develop and implement an action plan for service redesign 8. To use methods of measuring: to monitor the impact of any service redesign to detect changes in demand and complexity of workload and plan for its impact This toolkit sets out the recommended approach. Associated tools are provided in electronic format to assist in the data collection, data analysis, and effective e-communication of the emerging themes. The toolkit is set out as series of challenges, which if followed, will enable departments to gather clear data about service demand and complexity. This, in conjunction with service mapping, will highlight areas‟, that would benefit from service or process redesign. 4 Definitions Demand The number of referrals being made to the service. Demand measures need to be comprehensive capturing all referrals to the service, including new patients, replans, emergency and subsequent treatments. Complexity Groups similar patient based activities into common process templates to allow a measure of the impact of combined activities on global departmental workload (using common HRG templates is recommended) Capacity Resources available in terms of equipment, space, staff and skills to operate the equipment/run the facilities Bottleneck The spot in the patient pathway where hold-ups occur. It is used when the cause of the hold-up is not yet clear Constraint The “thing” holding up flow of activity and causing the bottleneck Carve Out Practice of “protecting” slots on lists for particular appointment types. For example protecting slots for emergency patients, whole sessions allocated to individual consultants, etc. Backlog Is the number of patients for which referral has been made, but the patient has not yet been treated. Activity Refers to the work done, often expressed as the number of patients treated or exposures given. To allow comparison of any data, it needs to be collected (or converted) into a common unit. The unit suggested is time. Therefore, a representative, easily achievable time value should be assigned to each step/process in the patient pathway/template. Process times should be based on what is comfortably achievable for the majority (80%) of patients and grouped by HRG template. Eg. For a simple + simulation patient The treatment step would be similar if the patient was having a hip, chest or breast treated. The treatment time is from when the staff call / greet the patient until the patient leaves the room Ignore the very quick and very long patients (eg hoisted / wheelchair / unwell) and base the time for that template / process on what happens most or 80% of the time Details on how to establish this time mathematically, and how to calculate demand, capacity, backlog and process templates are shown in the following challenges. 5 Challenge One: Identify Strategic Support and Clinical Leadership One of the keys to successful service improvement is: 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 Appendix one provides a template that may be helpful in identifying and gaining commitment from key stakeholders and sponsors in your organisation. This is important if the work invested in your service improvement project is to result in sustainable improvements in patients access, improvements working conditions for staff in the unit, and better data to inform future service development. Some key areas you may need to establish: Who is identified as the Clinical and Managerial Lead for Radiotherapy services? Are they able to make change happen? Is there local support to aid service improvement – for example, Local Modernisation Review Lead, Clinical Audit, IT, Booked Admissions, Cancer Services Collaborative, etc? Is it possible to get an executive or non-executive director to act as “sponsor” for Service Improvement? Is there a radiotherapy user group in place (as per peer review 5.23) Does the membership reflect the key stakeholders – including senior management, clinicians, radiography, etc.? Are there clear terms of reference for that group? How does action planning and progress with service redesign get on to the agenda? Does the group influence Trust planning priorities? Peer review (5.23) There should be a group for the department which includes, at least, a Medical Physics Expert*, a superintendent therapy radiographer and a clinical oncologist, which meets regularly to agree to and record proposed new or changed treatment techniques on behalf of the department. Membership of the group and Terms of Reference of the group, are both agreed by the head of service. *As defined by the Ionising Radiation (Medical Exposures Regulations 2000 (IRMER 2000) a Medical Physics Expert is one possessing a Physics Degree and with six year experience in radiotherapy. 6 Challenge Two: Understand the Current Service - Map and Analyse Patient Processes Referral mapping Patients access the service from many referral points. In understanding current demand, it is important to ensure a comprehensive referral map is identified that reflects accurately all points of referral into radiotherapy. Identifying the radiotherapy referral map The first step in detailing a comprehensive referral map is to: Clarify ALL the Trusts/hospitals that refer into your service. Identify any groups of patients for which you receive referrals on a regional, national or out of network basis (eg. CHART, TBI) Have ALL entry points for Radiotherapy referrals been clearly identified? Consider for example: What type of GP referrals exist, if any? What types of outpatient referrals are made (from where, who)? What types of in-patient referrals are made (emergency, out of hours, others)? Do the referrals come into a single central point? Is there a pattern to the receipt of referrals (eg day of the week)? How are follow-up/recurrence patients “referred”? N.B. it is important to identify if radiotherapy is performed in areas other than the main radiotherapy department (eg. satellite superficial units). All referrals need to be captured for the demand data to give meaningful information for current and future service planning Appendix 2 provides an example of presenting a referral map. This allows key stakeholders to check that all referral routes are reflected. Mapping the existing patient pathway Process mapping, although a simple exercise is one of the most powerful ways for a multi-disciplinary group to identify and understand the real problems in a service from the patient‟s perspective. Analysis by the NHS Modernisation Agency has shown that: Typically, 30 to 70 per cent of the work in a patient process doesn‟t add any value for patients; Around 90% of the errors, duplication and delay in patient processes are at the point of “hand-off” – where responsibility for the patient is handed from one professional, department or agency to another. Up to 50% of the steps in a typical NHS patient process involves a “hand-off”; Usually, no-one is responsible for the patient‟s journey through the care process and patients often receive care which is fragmented and subject to delays. How to construct a process map for your project: The objectives of this are to: Help everyone to understand what the patient is currently experiencing; Identify the stages in the process causing the problems in relation to achieving NHS cancer plan targets and wider NHS targets. 7 Preparation: Define and agree how to capture the process for the different groups of patients being mapped; Subdivide the patients into groups according to complexity of the process (using HRG groups - see challenge 4). There will be common parts to the map with some stages where it needs to be captured separately for each group defined. Define and agree what the first and last step of the process is – for radiotherapy to obtain a complete picture the process starts at point of referral to the Oncologist through to follow-up; Be careful not to limit the scope unnecessarily; Identify all staff groups within the scope of the process being considered, including support staff, administrative staff, and clinical staff; Invite representatives of those staff groups who are part of the patient process to map the process including relevant staff working in the referral Trust/department; Involve representatives of patients and carers who use the service; Support can be provided from your local Cancer Services Collaborative or Trust Modernisation team. Alternatively, contact the National Cancer Services Collaborative team for advice and further contact details (see page 3). Resources: Time allowed depends on the scope of the process to be mapped and the method used; Post it notes Flip chart Flip chart pens Methods: Either one or two ½ days, no more than 2 weeks apart with same participants (two facilitators (minimum) -one to map process and one to note comments, issues, etc). All staff groups represented. Each individual (or one person) maps their bit of the process and brings to a review meeting to establish true and entire process. All staff groups represented. Mapping the patient process Record on post-it notes who does what to the patient Example 1 Surgeon/physician tells patient they are to be referred to an oncologist 2 Patient goes home to wait 3 Appointment letter delivered by post to patient 4 Patient arrives at hospital 5 Clinic clerk receives patient and checks details 6 Oncologist examines patient 7 Etc 12 Patient attends for simulation 13 Etc There are bound to be variations so record what happens „80% of the time‟ Concentrate on what happens to the patient. Don‟t get side tracked by what happens to a referral form or request card – these are other processes, which need to be mapped, just don‟t get bogged 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 passed from one person to another (handoff)? What is the approximate time of each step? What is the approximate time between each step? What is the approximate time between first and last step? 8 Where does the patient have a wait or have to queue? Where are there waiting lists in the system? How many steps add no value to the patient? (Ask the patients) Where are the problems for patients – what do patients complain about? Where are the problems for staff? At the stages when there are the longest delays: Ask „why?‟ 5 times to get to the real reason for the delay Map that part of the process in more detail Watch and shadow patients in this part of the process Map the relevant parallel process, which may have caused the delay. Parallel processes include: The route the referral letter takes from when the patient is told to when the patient receives the appointment in the post The planning process when the patient is not in attendance ie the production of masks, shielding blocks, computer plans How space is allocated on the treatment unit At the end of the process mapping event: Agree next steps Identify specific areas for further study Collect data where necessary Allocate specific actions Organise sessions where ideas for improvement can be generated and tests of those ideas planned There may be some obvious actions that everyone agrees with and improvements could be made straight away. Just do it! Tips: Keep the group focused on the objective – current patient process and problems Process maps can get very long – use the back of a cheap roll of wallpaper Once a group has mapped the patient process, check it out with others who were not able to attend the event and with patients Photograph the main steps and make a large transportable photo board to take around with you to demonstrate the problems Back up the map with actual data Information Map the information/support you give to patients: Who gives it and at what stage? Are there any duplications or contradictions? Are there any gaps? Find out what patients want and need While a group is mapping the process there will be lots of comments, thoughts and ideas. Don‟t loose them. Note them on a separate flip chart but move on with the job in hand – mapping and analysing the patient process. Opportunities for streamlining the process Can you run processes in parallel rather than sequence? Can you reduce hand-offs between staff groups? Can you remove unnecessary steps in the process? Can you re-order the process to reduce repetitive steps (like re-scheduling)? 9 Challenge Three: Work to improve the patient/carer experience Working as part of a CSC project offers an opportunity to explore the patient experience in a meaningful and constructive way. Rather than focusing specifically upon issues to do with patient satisfaction, teams are now being encouraged to explore all domains of the patient experience and to actively involve patients and carers, as key agents, in setting the agenda for change across cancer services. Clearly, patients‟ views pertaining specifically to radiotherapy services will comprise an important component of this work. The following section contains an outline of the CSC approach that has been developed to take this work forward over the coming months. Whilst this approach has been formed with all cancer patients in mind, it can very readily be applied to improving the experience of those patients who have received, or are receiving, radiotherapy treatment. The approach There are 3 key parts to this work: i generating the ideas for improving the patient experience ii implementing the changes iii measuring the changes Generating the ideas for improving the patient experience The main focus of work to improve the patient/carer experience will involve networks and project teams working in partnership with patients and carers to set the agenda for change across the CSC programme and cancer services. It is proposed that this work is taken forward by engaging patients and carers in a process of: a. identifying core patient issues to be addressed at a local level to improve the patient experience b. generating or identifying possible solutions/change options that could be implemented at a local level to address the core patient issues There are a number of ways in which this can be achieved (in order of preference/value): Network or trust-based discussion groups. One-to-one interviews (patient journey stories) Suggestion boxes/feedback systems Patient questionnaires (only as good as the questions asked) These forums should provide a mechanism for patients, and their representatives (who can reflect the wider views of the cancer community), to begin to work in partnership with professionals, identifying issues and generating possible solutions for change to be taken forward. Where possible, existing patient focus groups (Network, Trust, Department or Locality based) should be used / incorporated. Use should also be made of any previous patient surveys, including the locally derived data from the National Patients Survey. Resource pack To assist with this work, a resource pack has been produced. This comprises two booklets. Booklet one contains a series of pre-identified issues, put forward within the broader context of cancer care and treatment, that patients may wish to be addressed in order to improve their experience of having cancer. The issues have been organised under the following sub-headings: 10 Access to care: waiting times Information, support, communication and understanding Involvement, dignity and respect and attitude of health professionals Co-ordination, continuity and discharge Pain Hospital environment/location of services Booklet two contains a list of „evidence-based‟ solutions/change ideas that could be implemented locally to address each of the issues contained within booklet one. The issues and possible solutions included within these booklets have emerged from a literature review conducted by the Patient Experience Project Team. To obtain copies of these booklets, please contact your network team, or the CSC national patient experience team. It is anticipated that these two booklets could be utilised at a local (network or trust) level to facilitate or develop the process of involving patients, in partnership with professionals, in setting the agenda for service change. This work could be taken forward in a variety of different ways – one example is set out in the box below. Example one: A Network-based (generic) discussion group is set up , or the CSC patient issues and proposed solutions booklets from the agenda of an existing meeting or meetings. The participants are sent a copy of the two booklets in advance of the meeting and are requested to identify three core issues to be addressed at the local level (from booklet one). The participants are also asked to review the possible solutions for change (contained within booklet two) that could be piloted to address the core issues already identified. During the meeting the participants will be encouraged to identify additional local issues and possible solutions that are not included within the booklets. After the session an action plan will be formulated, containing the priorities (as agreed by the discussion-group participants) to be taken forward, with key timescales against each. In addition to these two booklets, other locally produced resources could also assist with this work. For example, it is likely that work to map the patient pathway at trust or project level will have flagged up locally relevant gaps and priorities for changes to the way in which services are organised and delivered. Given that patients and carers may wish to base their views and opinions upon current evidence in terms of service delivery, the findings of this work could also be presented to patients. Mapping the information and support flow Alongside this, teams are also encouraged to undertake a mapping exercise to identify the information and support offered to patients/carers at key points in the care pathway. This work would be extremely valuable, given that the provision of information (written and verbal) and support across the care pathway are likely to be priority issues identified by patients. It is recommended that the findings of this work also be presented to patients and carers in order to elicit their views about the information and support that is currently offered. Tumour-specific templates (based upon the ideal patient journey) have been developed to assist teams in taking forward work to map the provision of information and support across the care pathway. Copies are enclosed within the CSC Patient and Carer Experience Toolkit. 11 Implementing the changes Once the relevant patient group(s) and project team have identified which change(s) they wish to implement to improve their service, this should be included in the normal team project action plan and reporting, ie: Initial testing work recorded and shared via PDSA (plan, do, study or act stage) reporting in the monthly reports - to enable teams to share and learn from each other Once the change is implemented, an implemented change/good practice form should be submitted with the next monthly report, complete with any supporting protocols, documentation, information leaflets. Details of the original situation, the change implemented and the resulting impact should be assessed and quantified, where possible. Please highlight any implemented changes that have directly evolved from patient involvement, to allow us to pull up and share these more easily. Evaluating the changes To ensure that implemented changes produce sustainable improvements for patients, they should be evaluated at a later date. Many changes fail to be sustained for a variety of reasons: Projects move on and further develop – therefore the change may become obsolete or have developed further Systems are not put in place to ensure change is sustained once initial project activity abates Change is related to, or motivated by, project team and lacks service buy in and/or support. There is little evidence to support the impact of the change for the service and patients. The development of initial implemented changes highlights the success of any project in service improvement. The lack of systems and service support should be tackled by good project management and hand-over skills. The issue of lack of evidence to support the impact can be resolved by ensuring all implemented changes are appropriately evaluated (by patient surveys, waiting times monitoring, etc) to demonstrate their effect and embed practice with teams. 12 Challenge Four: Being clear about Demand - Complexity and Templates Many radiotherapy services have experienced rising workloads. However, most services do not have systems to accurately capture the routine demand for their service. To obtain a true picture of demand for your service, it will be necessary to undertake demand data collection, as described below. As a starting point it is vital to establish an accurate referral map, as described in challenge 2. Once the referral map has been agreed to reflect all referral routes to your service, the next stage is to record all referrals received and their complexity (example in appendix 4). You will need to include any outlying departments that undertake radiotherapy, and a system for capturing abortive, emergency, inpatient and same-day clinic referrals for treatment. It may be helpful to include a member of your Trust, department or network information team. They may be able to help in establishing a system for collecting data on a longer-term or routine basis. Expressing demand To make meaningful demand and capacity comparisons, it is important to express both in the same quantities. The suggested value is TIME. Total demand (in time) = number of referrals x time taken to complete process To identify the time taken to complete the process a series of process templates need to be developed. Developing a process template Identify the start and end-points of the complete process (and the individual steps) Patient Pre-treatment Treatment consultation preparation Agree the key activities undertaken for the whole process (as above) and for each step, eg: Pre-treatment - Any mould room preparation Simulation Plan preparation and checking Dosimetry and checking Any treatment verification or simulated set-ups Patient information The suggested HRG process templates are contained in Appendix 4a Follow a sample of patients through each step, recording the time taken to complete the task. Identify the most common / 80% time taken to complete each step of each process Try to keep the number of process templates to a minimum by grouping similar processes together, as the HRG definitions defined process templates. Remember to include all steps and patient treatments (eg 25 fractions @ 15 minutes per treatment = 375 minutes of treatment for that patient) Calculating demand Using the expressing demand equation, calculate the total demand for your service from the data you have collected (referrals and process template times) Total demand = cumulative total of demand time for each process Eg. Simple template = 10 referrals x 30 minutes” = 300 minutes Simple + simulation template = 20 referrals x 80 minutes* = 1,600 minutes etc. 13 “30 minutes = 10 minutes set-up 10 minutes patient information 5 minutes calculation and checking Single treatment @ 5 minutes *80 minutes = 10 minutes simulation 10 minutes calculation and checking 10 minutes patient information 5 treatments @ 10 minutes each Total demand for this service = 1,900 minutes Total demand, however is not a useful currency as it does not identify what different types of capacity we need to run a service. By using the demand collection templates (appendix 4) and accurately timing the HRG templates (appendix 4a), we can use the data to tell us what different types of capacity we need. From the examples above: 1,900 minutes of total demand requires 100 minutes patient set –up 200 minutes of simulation 300 minutes of patient information 250 minutes of calculation and checking 1,050 minutes of treatment The electronic spreadsheet and reporting template will automatically calculate the demand per section, on completion of the demand and template timing information. This data can also be used to compare performance against Cancer Plan and JCCO /Peer Review waiting times standards. Longer term monitoring Knowing the existing demand on services allows us to respond in the acute situation. However, monitoring demand and complexity over time can give us far more information than what the current demand and complexity of our service is. It can also show us: changes in the complexity of the workload over time seasonal and annual trends in demand rising and falling areas of work Having accurate data on the complexity of the workload (via the timed HRG templates) we can begin to undertake more realistic service planning activities. For example: 1. With current departmental practice, breast patients fall within the complex HRG template (simulation, computer plan and verify). The department wishes to change the protocol to include CT – the complex + imaging HRG template (simulation, CT scan, computer plan and verify). Using current demand data and the timings for the CT component of the complex + imaging HRG template, a reasonable prediction can be made of the “extra” CT capacity required. 2. The department is considering reducing fractionation schedules for palliative lung cancer patients from 10 fractions to 4. Using the relevant template, the reduction in treatment time could be predicted and treatment capacity released identified (which could give enough capacity for the department to take part in extended fractionation trails – quantified from the relevant template) 14 Analysis of the demand Do you have any unnecessary demand? Can you manage the demand? Can your service respond to fluctuations in demand? Can the fluctuations in demand be reduced? How does the demand for your service compare to your available capacity? How does demand compare to similar services? Do you have referral and treatment protocols? Do your patients flow through a streamlined system? Do you have a DNA and cancellation policy? Can you identify processes that can be done away from constraint areas, eg key equipment/staff, etc. 15 Challenge Five: Capacity, Activity and Backlog – making useful comparisons True demand and capacity studies require ongoing, routine measurement of demand, capacity, activity and backlog. However, most capacity and demand studies in healthcare to date have focussed on single step patient processes, such as endoscopy, radiology or outpatient visits. Radiotherapy is different. The processes that patients go through generally involve many visits and steps. The first radiotherapy toolkit attempted to get teams to undertake a traditional capacity and demand study with the following results: Collecting the data was extremely time-consuming Establishing capacity and activity was difficult in areas where staff are not directly linked to equipment, eg mould room, planning, dosimetry, checking and patient information activities Broad comparisons of service demand, capacity, activity and backlog were meaningless as over- capacity in one area could mask a serious capacity shortage in another area Establishing demand, capacity, activity and backlog measures for each sub-section was felt to be a mammoth task – teams began to concentrate on what they felt were key areas (not necessarily the true constraint) We needed a different approach to enable teams to collect a manageable and meaningful level of data and concentrate on using this to inform improving the service for patients. The key to this for radiotherapy services is using accurate demand and complexity data to establish: you have the required capacity to meet demand (and cope with the demand variation) at all steps activity levels needed to meet the demand the time/capacity required to work off any backlog If you are routinely monitoring the complexity and demand for your service, capacity, activity and backlog comparisons need only be undertaken to establish balance, quantify a situation or assess the impact of any service change. Capacity Capacity is the amount of resource available to provide the service, ie. a composite of equipment, space, staff and skills available for that period of time. If one of the elements required to provide the service is missing, you do not have the capacity. Discrepancies arise because there is a key difference between planned and actual capacity. Example: The simulator is staffed between the hours of 8.30am and 5pm – planned capacity= 8.5hrs Medical staff sessions 9 –12.30 and 2-5pm - actual capacity = 6.5 hrs Demand and complexity data can give us much more accurate information about what types of capacity we need at the various points in our system. To establish whether your systems have the required capacity to meet the demand and its complexity, you will need to undertake a comparison. From our demand calculations (challenge four) Simple template 30 minutes = 10 minutes set-up 10 minutes patient information 5 minutes calculation and checking Single treatment @ 5 minutes Simple + simulation template 80 minutes = 10 minutes simulation 10 minutes calculation and checking 10 minutes patient information 5 treatments @ 10 minutes each 16 Weekly demand per template HRG template Monday Tuesday Wednesday Thursday Friday Simple 1 0 2 4 5 Simple+sim 5 3 5 2 0 Weekly demand in time per section Section Monday Tuesday Wednesday Thursday Friday Patient set-up 10 min 0 min 20 min 40 min 50 min Simulation 50 min 30 min 50 min 20 min 0 min Patient 60 min 30 min 70 min 60 min 50 min information Calculation + 55 min 30 min 60 min 40 min 25 min checking Treatment 255 min 150 min 260 min 120 min 25 min The electronic spreadsheet and reporting template will automatically calculate the demand required per section, on completion of the demand and template timing information. This data can then be used to compare against the capacity available. Variation One of the difficulties facing radiotherapy services is variation in demand (and sometimes, capacity and activity) and the impact this has. From the table above, it can be seen that the capacity needed at each step varies on a daily basis. To enable us to truly match capacity and demand on a daily basis, we would need an extremely flexible service, or large amounts of “free” capacity. The temptation is to take an average of the weekly, monthly or annual demand and set our capacity at that level. For example (from the table above): Average weekly calculation + checking demand = 55+30+60+40+25 = 42 minutes 5 This means that on Tuesday, Thursday and Friday we would have the required capacity to meet the demand on that day (with some waste). We would be short of capacity on Monday and Wednesday, which would lead to a build-up of work. Setting the capacity at the right level The way to set capacity to minimise waste and ensure we reduce the opportunity of building a waiting list is to set the capacity at 80% of the variation in demand. Example (using the demand data as above) Demand varies from 60 minutes (top value) to 25 minutes (lowest value), therefore the variation in demand is 60 – 25 = 35 minutes 80% of this variation is 35 x 80/100 = 28 minutes Setting the capacity at 80% of the demand 28 +25 (lowest value) = 53 minutes This means that there would be enough capacity to meet the demand on the same days as above, but with a much narrower gap between the lack of capacity and demand on Monday and Wednesday, reducing the risk of work building up. 17 Opportunities for redesign The following questions can help in highlighting things that affect/reduce available capacity: When is maintenance done? How flexible are staff? Can staff be moved, multi-skilled or streamlined? What reduces your planned capacity? Is capacity planned/scheduled when everyone is available? Are you booking your capacity too far in advance? Can the system flex to match variations in demand? Remember to look at opportunities for looking at reducing any inappropriate demand and also any ways of reducing it‟s daily variation. Sometimes, a room/area utilisation audit can give vital clues about what is affecting capacity – where and why it is unused, constraints reducing available capacity, etc. Backlog If there is a wait time for your service, in order to quantify how long this would take to work off, or monitor it during a period of demand management / increased capacity, the backlog burden for the various sections would need to be quantified from the demand plus template timings. The electronic reporting spreadsheets will automatically calculate the demand in time for each section. You will have to identify how much of that demand is waiting. Validate the waiting list, separate out those patients who are not scheduled to start until after completing adjuvant chemotherapy or hormone therapy and any that no longer require treatment Identify the number of referrals waiting Time it takes to do the request x the number waiting = time necessary to clear the back log (as in the demand time per section example previously) Analysing the data: Are the number on the waiting list stable, increase or decreasing? Are waiting times stable increasing or decreasing? Test out innovative ways of eliminating backlog. Any initiative to reduce backlog/waiting list will not provide a long-term solution if the system that produced the delay is not changed. Activity These methods could also be used to identify any variations in departmental activity you wished to explore. Although activity measures are used in commissioning services year on year, it is important to be aware that activity data gives no real indication of actual demand for any service. Activity measures only tell us the volume of work done in the identified time period. However, if you are redesigning processes and you feel one outcome is likely to be improved efficiency then trend data on activity over time may be useful. Try to record activity in units which are comparable to demand and capacity data, i.e. time. 18 Challenge Six: Access and patient choice The following extract is taken from the Modernisation Agency National Booking Programme Introduction The NHS requires a standard definition of what constitutes a booking for appointments and admissions to health and social care services. The National Booking Programme has progressed greatly both in terms of spread throughout England and in increased knowledge and skills about booking since the first pilots in 1998. The definition has been revised twice since 1998 and required further revision based on feedback and evidence of improvements from teams within health and social care. This revised definition will continue to support NHS Organisations and teams to provide improved access to health care for patients and enable choice through booking. Background The NHS Plan gave a commitment that, by December 2005, along with reduced access times all patients and their GPs will be able to book outpatient appointments and inpatient elective admissions at a date, time and place that is convenient to the patient. Until September 2002 a patient could only be considered to be booked if the health care provider was able to offer booked appointments and/or admissions during or within one working day of a mutual agreement of the decision to refer. This mutual decision was made by the patient and health care provider/practitioner. The concept of partial booking was introduced widely in the „Step by Step Guide to Improving Outpatient Services‟ (July 2000). The National Booking Programme has recommended implementation of partial booking for those specialities with longer waiting times for example six months for in- patient or day surgery care. It, when implemented using redesign, has emerged as a very effective method of providing certainty and choice for patients and in addition has delivered organisation benefits such as reduction in DNA and patient cancellation of appointments which are also seen when adopting full booking. Until now partial booking has not been included as a „booking‟. Booking A booking is the result of a process where the patient and health care provider/practitioner agree a convenient and clinically appropriate date and time for their appointment, treatment or intervention.. Patient choice For an appointment, treatment or intervention to be considered booked the patient must be able to, agree/choose a date within a range of dates available at the hospital or other service provider. When a patient needs to be seen urgently (within 2 weeks if cancer is suspected) it is expected that the range of dates will be smaller than those offered for a routine service. However, even in these circumstances, it needs to be clear to the patient that they can choose to wait longer if that is what they want. Time scale There are two elements to a booking and these are determined by time. Health care providers will have an objective to redesign services so they are able to offer booked appointments and/or admissions during or within one working day of the mutual agreement. Patients can choose to confirm or book their appointment outside of the agreed time-scales, if this is the case the appointment can be classed as fully booked and waiting time can be calculated from the time the patient chooses to confirm or book their appointment or admission. This type of booking is most effective where the waiting times for an appointment or admission are six months or less. Where waiting times are six months or above, it is more appropriate to redesign services to support partial booking. This is the scenario where a patient is advised of the total indicative waiting time for access to a service and arrangements are agreed for contact to be at a reasonable time before that date. During this contact the patient is able to choose and confirm their appointment or admission. Both the patient choice and time scale criteria will need to be met for an appointment or admission to be classed as booked. 19 The definition of a fully booked appointment or admission is therefore: The patient is given the choice of when to attend. For full booking the patient is given the opportunity to agree a date at the time of, or within one working day of the referral or decision to admit. The patient may choose to agree the date when initially offered or defer the decision until later. The definition of a partially booked appointment or admission is therefore: The patient is given the choice of when to attend. For partial booking the patient is advised of the total waiting time during the consultation between themselves and the health care provider/practitioner. The patient is able to choose and confirm an appointment or admission approximately four to six weeks in advance of their appointment or admission date. As waiting times are reduced health care providers will examine the potential to move from partial booking to full booking. Multiple Booking Many organisations are now able to offer patients increased certainty and choice by offering booked dates for care or treatment across the whole patient pathway. Booking can be counted at each point in the pathway where a clinical decision is made about subsequent treatment for example: GP referral and booking into a clinic decision to investigate further and booking into diagnostics for example radiology. decision to operate and booking onto a theatre list decision to refer and booking into a Tertiary Centre decision to discharge from one organisation and booking into follow up care decision to commence a course of treatment/investigation and booking for each attendance to that treatment or investigation. Change for Improvement. Booking appointments or admissions represents a significant change within the NHS. It is important to recognise that booking is part of a change process which aims to significantly improve the care and services we provide to patients. The process or pathway within which booking is part should be one that is designed around the patient and based on good practice. To ensure this, each process or pathway that is to incorporate booking should be examined. Redesign of the process should be undertaken if when examined it is found not to be designed around the patient or based on good practice. For example, patients are often able to agree a date and book for a follow up appointment. Emerging evidence is demonstrating that not all follow up appointments are being carried out in the most appropriate place or by the most appropriate person. Some follow up appointments are not necessary. This process is not centred around the patient nor can it be considered good practice. Booking must not be counted if it is within a process that has not been examined. Data Recording The NHS, through the National Booking Programme has been recording booking data since 1998 and this will be augmented by National data collection, in due course. This review and agreement of definitions will both provide clear advice on what a booked admission or appointment represents and ensure a national standard for those booked admissions and appointments. Lynne Maher Director National Booking Programme, December 2002 20 Challenge Seven: Redesign the process and look at new ways of working Focus on the patient. Avoid processes, which are arranged around the needs of staff departments or organisations, at the expense of patient care. Think about: - What is the most appropriate care? Who is the most appropriate person to give the care? When is the most appropriate time to give this care? Where should this care ideally take place? Re-designing to match demand and capacity Can you effectively and appropriately reduce or manage demand? Resolve capacity problems at the appropriate point in the system Deal with constraints Reduce all unnecessary waits and delays (delays that are not due to a lack of capacity) Reduce/eliminate batching. Do the work when it arrives rather than waiting. Estimate the number of queues (groups of patients waiting) and the amount of time and effort required managing those queues. Reduce the number of hand offs Reduce the number of follow up appointments Reduce the number of visits patient make to the hospital and/or the amount of time they spend waiting around at the hospital on each visit Eliminate any backlogs waiting lists Match capacity and demand Identify new ways of working In generating options for change, thinking about new ways of working is key. You may want to link into the national “EPD strategy Changing Workforce Programme” and their Toolkit to assist in this work. The term new ways of working covers four types of change: Moving tasks up or down a traditional uni-disciplinary ladder (eg radiographer-led planning, the use of helpers/assistants, etc) Expanding the breadth of a job (eg the healthcare support worker taking on both auxiliary and patient carer roles) Increasing the depth of a job (eg radiographer on-treatment review, limited prescribing powers) New jobs (eg combining tasks in a different way. Co-ordinator roles have emerged to manage complex referral processes and decrease hand-offs in some services) There are many examples of innovative practice across the country that have achieved improvements in the care that patients experience. In addition to the types of changes identified above, the following may be useful to consider: Is it possible to distinguish between complex and simple work? Are the same clinicians doing both? What is the impact of specialist versus mixed lists? Is it possible to design two processes with different practitioners and administrative processes – one for simple and one for complex procedures? Are there opportunities to introduce new roles which offer greater flexibility in covering lists, moving between sites, working across boundaries, releasing time for use elsewhere (eg 21 picking up consultant simple follow-up work freeing the consultant to do more planning or see new patients)? Are there staff who want to develop specialist expertise? Are there opportunities for developing new administrative roles, focused on pulling the patient through the process of care, co-ordinating each stage of that patient‟s journey? What opportunities exist for support worker roles? What training and education will assist in developing a new range of competencies that address constraints identified? What help can the local workforce development confederation offer? 22 Challenge Eight: Collecting the data and monitoring progress Recognising the challenges of collecting radiotherapy data, we have slimmed down the amount of data required to the minimum level, concentrating on demand and the complexity of patient pathway. The data collection tool is available as an Excel spreadsheet, with some basic data analysis built in. If you require any help at any point with understanding, or interpreting the data you have collected, please do not hesitate to contact a member of the national team. The thrust of the data collection is to inform service redesign and monitor the impact of any changes you make. It is just one tool we use in our aim of improving radiotherapy services. However, it has become apparent that routine monitoring of demand and complexity data allows much more timely detection of the shifts that occur in referral patterns and changes to treatment regimes or delivery that would not become apparent through activity or patient number monitoring. Timely detection allows shifting practices to become more easily incorporated into our routine service delivery and longer term planning at an earlier stage. This, hopefully will help to avoid the current situation of catch-up (with equipment) and coping (by delivering what some consider sub-optimal treatment fractionations to cop with limited capacity with growing complexity and demand). Efforts need to be made to make the data collection as easy as possible. Where teams have access to patient management/scheduling systems, some data can be pulled (using reporting tools) for these systems. Work is ongoing nationally with the systems manufacturers to alert them to teams data needs. However, each system varies and before any data collection is undertaken manually we would advise speaking to your IT department and/or system administrator to enlist their help where possible - the data may already be available or easily attained. Secondly, we are aware of the Cancer Plan target for referral to treatment of 62 days (for those patients receiving their first treatment). As this target will apply to only a small proportion of those patients receiving radiotherapy, the collection of this data, and marrying up with the referral date /information could become elaborate and time consuming. That is why we have tried to make our dataset/datasheets meaningful to the service by incorporating data on all patients to give a complete picture. We strongly advise that you collect only the data items in our spreadsheets that apply to your service. Most Cancer Networks/Trusts will be looking at data matching for Cancer Dataset submission across a series of providers. Once again we would advise speaking to your IT/Trust and/or Network Information departments for advise on how they are managing locally. An excellent network wide guide is available form the Yorkshire Cancer Network (contact the national team for details) Targets The radiotherapy project does not have any targets, other than to improve the service delivered to patients. However, in order to benchmark your service, and show the impact of any improvements made, the data collection / analysis will automatically compare to the existing CSC, Cancer Plan and JCCO targets: RCR Minimum Good practice emergencies/urgent within 24 hours Palliative within 14 days within 48 hours Radical within 28 days within 14 days st CSC initial referral – 1 treatment 62 days (by April 2003) st Cancer Plan diagnosis – 1 treatment 62 days (by 2005) st Urgent GP referral – 1 treatment 62 days (by 2005) 23 Other Useful Sources and Documents Cancer Services Collaborative (2001) Redesign: a tool kit. Service Improvement Guide. National Patient Access Team, Modernisation Agency Cancer Services Collaborative (2001) Patient Information: Service Improvement Guide. National Patient Access Team, Modernisation Agency Cancer Services Collaborative (2001) Radiotherapy: Service Improvement Guide. National Patient Access Team, Modernisation Agency Cancer Services Collaborative Patient carer toolkit Cancer Services Collaborative handbook Modernisation Agency - Twenty-seven principles for redesign National Booked Admissions Programme (2001) Ready, Steady, Book: A Guide to Implementing Booked Admissions and Appointments for Patients. Modernisation Agency National Patient Access Team (2000) Variation in NHS Outpatient Performance. A Step-by-step Guide to Improving Outpatient Services. Department of Health Peer Review Cancer Assessment Standards: Cancer Action Team NHS cancer plan A survey of radiotherapy services in England 1999 DOH Radiotherapy HRGs Definition Manual, version 3.1 (December 2001); NHS Information Authority www.nhsia.nhs.uk NHSIA / DSCN – Cancer dataset www.modern.nhs.uk/cancer: Modernisation Agency web-site - find out about other redesign programmes / projects and to access further training. www.doh.gov.uk/cancer : DOH web-site 24 Appendices Appendix 1 Strategic direction/support Appendix 2 Radiotherapy Referrals: Understanding Patient Access Appendix 3 Patient view tool Appendix 4 Radiotherapy Demand Data Collection spreadsheet Appendix 5 Radiotherapy template timings spreadsheet Appendix 6 Draft radiotherapy ideal journey Appendix 7 Radiotherapy report form Appendix 8 Good practice proforma Detachable appendices Appendix 9 CANCER WAITING TARGETS – A GUIDE Appendix 10 DSC Notice: 22/2002 National Cancer Waiting Times Monitoring 25 Appendix One: Strategic Direction Ownership and Links It is essential that the redesign process as ownership within the Trust and is not see as a standalone project, this requires teams to identify key stake holders within an organisation and ensure that there is close integration with other areas. Signed up to process and Post Holder Post Holder name implementation of change Chief Executive Lead Clinical Oncologist Lead Physicist Directorate/ Service manager Radiotherapy unit manager Nominated CSC Project Manager Booked Admission Manager Network Management Team 26 Patient Appendix 2 – referral map Surgeon / Surgeon / Surgeon / Physician Physician Physician Speciality Speciality Speciality 3 MDT 1 MDT 2 MDT Referral to cancer centre Patient registration st 1 patient oncology consultation Radiotherapy planning Pre-treatment preparation Patient treatment Patient discharge Patient treatment Patient review/follow-up Patient discharged 27 Demand collection sheet <500K Simp Multiple Emerge Radic Palli Yes No v le planning ncy al ative If we want to manage the process better we need to map the demand and identify the fluctuations - We can then begin to find out what causes the fluctuations and whether we can influence them. Where possible, all data items are compatible with NHSIA Cancer and CSC data sets. Indicates data items collected for new patients by CSC/NHSIA datasets. Please liase with your cancer network, CSC and IT teams for this Indicates items mandatory for Cancer data-set (see appendix of radiotherapy toolkit) * Indicates mandatory items for this data-set - to enable monitoring of progress towards CSC, Cancer plan and JCCO/Peer Review targets. Indicates data item unique to this dataset. This item is to encompass patient delays, eg for healing, prior programmed treatment (chemo or hormone therapy), etc. The grey shaded boxes are optional data items to help with any demand sub-categorisation/ bottleneck you may wish to collect as a department. Extra rows can be added to suit your needs. Click on the number column to the left of the table, go to "insert" and select rows. You can also add extra columns, to suit local need in a similar manner. <Month> Days Waited Date GP/1st Diagn NHS Date of Source patient Date Consult Decisi Ready Date 1st Ready to Start date *Treat *num *emerge *HRG Area Treat Comm Ready 1st Diagno referra referra osis Numb decisi of RT ID of 1st ant on to to RT OP start (telethera ment ber ncy, templ treate ment ents to Referr sis > l l date (ICD er on to oncolo number Oncol treat start appt treatment py/brach Booke of radical, ate d unit / Start > al > Treatm receiv code) refer gy ogy date proce (non- date ytherapy d fracti palliativ modali Start Treatm ent ed to an referra OP ss consulta (planning treatment ons e ty ent approp l appt date nt) complete) course) riate (Cons cancer ultant) special . ist Radiotherapy process templates (HRGs) At each step, insert the time taken for the majority (80%) of patients to have their process completed eg. treating both fields of an Anterior/posterior patient takes 10 minutes for most patients (from entering to leaving the treatment room). * Some patients may need to be allocated more than one template, eg planned 2 field breast (complex), plus boost (simple) *Booking (choice of appointment negotiated with patient within 24 hours of decision to treat/proceed) of each step could be annotated for each template as achieved < 500Kv Simple Simple +sim Complex Complex+Imaging Tech support Multiple planning 1 2 3 4 5 6 7 Time time time time Time time time Taken taken taken taken taken taken taken Oncology OP appt Oncology OP appt Oncology OP appt Oncology OP appt Oncology OP appt Oncology OP appt Oncology OP appt inform patient inform patient inform patient inform patient inform patient inform patient inform patient manual calc manual calc simulation simulation simulation simulation simulation check check manual calc Computer plan CT scan impression impression data entry data entry check check Simulation fit fit inform patient inform patient data entry Verify Computer plan localisation localisation 1st Treat 1st Treat inform patient data entry check CT scan CT scan no. fractions no. fractions routine treat routine treat 1st Treat inform patient Verify computer plan computer plan total treat" total treat" no. fractions routine treat 1st Treat data entry check check Review Review total treat" no. fractions routine treat inform patient tech support Verify Review total treat" 1st Treat verify data entry Review no. fractions routine treat data entry inform patient total treat" inform patient 1st Treat Review no. fractions 1st Treat routine treat total treat" Time for routine treatment, multiplied by number of treatments (not including 1st treatment), no. fractions total treat" Plus 1st treatment time (may be different due to enhanced checking/patient communication) routine treat Point at which patient may need replanning total treat" Review Point at which patient may repeat pathway as part of replanning Review c1c85d76-30d8-45b6-9a69-f4bf9600c980.doc 29 of 34 c1c85d76-30d8-45b6-9a69-f4bf9600c980.doc 30 of 34 Cancer Services Collaborative Radiotherapy Date report submitted Report Month (activity period) Project team/Trust/ Network/ Region Project Manager Clinical Lead Contact Details Population served – Hospital Network Project Trust Number of new cancers per annum Slice: Aim Statement: Roll out aim: Definition of Measure Target Baseline Achieved Comments c1c85d76-30d8-45b6-9a69-f4bf9600c980.doc 31 of 34 Plan, Do, Study and Act Cycles (PDSA) Was the need for the intended outcome /implemented change Description of current work Intended Outcome/Implemented Change identified by Patient/Carer Yes/No Implemented Changes Was the change Planned Evaluation Date identified by Description of change Situation before change Situation after change & Method of Evaluation Patient/Carer (Patient/Carer changes only) Yes/No Other progress this month Issues and challenges Key actions for next month including proposed solutions Team self-assessment score I would like a conference call on Subject By (date) Pro fforma tto captture iinfformattiion ffor Pro orma o cap ure n orma on or Cancer Serviice Collllaborattiive Cancer Serv ce Co abora ve case sttudiies case s ud es Background Name of CSC project, Trust Cancer Network Name, email address and phone number of project manager or other appropriate contact at project level Date that change was implemented Date that case study was last validated Details of improvement What was the problem? How was it identified? Which change ideas were tested and worked? What were the implemented improvements and how do they benefit patients? How many patients has this impacted on? What is the situation now? Is the improvement sustainable? How are patients involved in identifying the problems or solutions and evaluation?