Planning ahead – priorities for the future Debbie Johnston Thursday 24th January 2013, Haydock

Session - Objectives Understand the national PPAT results and key challenges your region Explore what strategies have been successful Consider your plan to address the PPAT report recommendations Identify priority areas for action Plan for your future requirements

PPAT - National Overview by Rooms

National Overview – The North

PPAT ‘Experience has shown that endoscopy services that achieve the objectives of the PPAT will sustain a low wait service without the need for waiting list initiatives and other resource intensive methods for reducing waits’

PPAT relationship to waiting times

Most Achieved Measures – Nationwide % Achieving 2.3 Waiting times monitored and reviewed at least weekly at unit and business unit/directorate level 89% 2.6 There is sufficient pooling to maintain differences in waits to less than two weeks 92% 3.3 There is a booking office that is readily accessible to patients and endoscopy staff 93% 2.5 Patients on waiting lists are booked in turn 95% 2.4 Waiting lists are restricted to three categories: 2 week wait, urgent and routine 97%

Most Achieved Measures – The North % Achieving 4.3 Start and finish times are agreed with the responsible endoscopist 86% 2.3 Waiting times monitored and reviewed at least weekly at unit and business unit/directorate level 89% 4.2 There are scheduling templates for each session agreed with the responsible endoscopist and that optimise utilisation of the list 3.3 There is a booking office that is readily accessible to patients and endoscopy staff 93% 2.4 Waiting lists are restricted to three categories: 2 week wait, urgent and routine 96% Have flipcharts for each measure and ask them to share what they specifically have in place Exercise

Key National challenges 60% of organisations do not have electronic scheduling systems to facilitate efficient booking and scheduling that enable effective capacity planning. Manual diary systems are used very widely. Manual systems do not allow collection of quality data required to inform service redesign and effective planning. 57% of services indicated that they were unable to make estimates of the demand for endoscopy in a 1-5 year time frame.

Key national challenges 53% of services reported: Poor or absent development plans in anticipation of future demands Insufficient flexibility in the job plans of endoscopists to enable backfilling of funded capacity 52% of services do not apply robustly the Appropriateness standard of the endoscopy GRS. Vetting and validation practices are not clearly defined and there is inconsistency for new and surveillance procedures 42% of endoscopy units do not routinely collect data to identify capacity constraints and to improve the productivity of the service.

Least Achieved Measures – The North % Achieving 3.6 There are one-stop clinic(s) in place providing (where appropriate) same-day assessment, endoscopy and treatment 35% 3.2 Process mapping +/- lean redesign of the booking process (involving all staff and all types of endoscopy) has been completed and acted upon. Thereafter this is reviewed annually 29% 4.4 Room utilisation data (such as start and finish times and room turnaround times) is collected, collated, reviewed and acted upon. The achievable utilisation (the percentage of scheduled time a patient is in the procedure room) varies depending on case mix and type of list. For a scheduled day case list room utilisation of 80% should be achievable.

Least Achieved Measures – The North % Achieving 4.1 Endoscopy productivity data is collected through the GRS productivity tool (or equivalent) and results analysed and acted upon to identify capacity constraints and to improve the productivity of the service 32% 5.2 There is sufficient flexibility in the job plans of endoscopists to enable backfilling of funded (i.e. staffed) capacity

Key concern Of particular concern is the lack of forward planning because there is insufficient information on which to make decisions. Business planning is generally weak Closed discussion-exercise. What are the key requirement of a business plan.

5 Commitments ….. Commitment to the patient experience Commitment to quality Commitment to timeliness Commitment to efficiency Commitment to the team What needs to change ?

What data and how?

What data and how?

What data and how?

Service Improvement Pre-assessment Skill mix Plan for the future… Know what your patients want Skill mix Patient choice Understand your service Maximising capacity Plan for the future…

Recommendations For endoscopy teams and their organisations Endoscopy team leads must work more collaboratively with their organisations and commissioners to achieve joint understanding and responsibility for the planning, business development and improvement of the service More widespread adoption of processes and IT systems for collection of data on demand, capacity, utilisation and booking. All units that are not obviously in control of their waits (manifest by long waits in HES, DM01 or GRS) should complete the PPAT online at least annually with an appropriate action plan.

Recommendations For endoscopy teams and their organisations Development plans for the workforce should anticipate future demands The Appropriateness standard of the GRS must be applied robustly. Vetting and validation practices should be more clearly defined and more consistently applied Process improvements recommended by NHS improvement should be routinely applied (Endoscopy-rapid review 2012).

What should you do next? Focus on Leadership Use available data map trends Focus on service organisation Use Tools to baseline where you are at Planning, productivity and assessment tool (PPAT) GRS Productivity tool Room utilisation Develop a more flexible Workforce Develop model pathways

“Bowel Scope” Screening: Implications for Practice Dr Neil Haslam NW BCSP QA Meeting January 2013

Presentation - objectives To understand the timetable and plan for roll out of FS screening To understand the demand from FS screening and what capacity is required: where the capacity can/should be delivered options for the endoscopist workforce

Projections of underlying growth pressure (blue line) for colonoscopy and flexi-sigmoidoscopy activity plus additional activity from cancer strategy commitments (pink line) 24

Efficacy of a once-only flexible sigmoidoscopy After 11 years of follow-up, in people who had the screening: Cumulative incidence, including prevalent cancers detected at screening, reduced by 50% for distal cancers (rectum and sigmoid colon) 33% for colorectal cancer overall Colorectal cancer mortality was reduced by 43% No sign of a lessening of effect at longer follow-up times 1 life saved per 200 people screened? 25

Improving Outcomes Flexible sigmoidoscopy (FS) is an alternative and complementary bowel screening methodology to Faecal Occult Blood (FOB) testing. …… Based on trial figures, experts estimate the programme would prevent around 3,000 cancers every year. The DH has committed to invest £60 million over the next four years to incorporate FS into the current bowel screening programme … In addition, NHS Cancer Screening Programmes will be looking at how the more accurate and easier to use immunochemical FOBt can be introduced into the programme potentially to increase uptake and to provide more accurate results.

Timeline for development 2011/12 development year for Flexi-sig 2012/13 piloting of Flexi-sig 2013/14 first wave roll out of Flexi-sig = 30% country open by 31 March 2014 2014/15 second wave roll out of Flexi-sig = 60% country open by 31 March 2015 2016 roll out complete

Preparing to deliver Flexi-sig screening One-off invitation to all people aged 55 years (with self –referrals up to age 60) Process is different to FOBt screening and screening colonoscopy delivery at local level May require some reconfiguration of large screening centres Different infrastructure and will need detailed capacity and demand planning

This is primary care? It is like primary care because Patients don’t have to attend The service has to be local and convenient The service has to be an acceptable experience Most patients are normal when examined It is relentless

Best estimate of demand The initial estimates of demand were 6000/million base population each year It is expected that in some areas uptake could be higher than originally expected and demand could be as high as 8000/million/year It will be different in different demographic areas and opt in for 56-59 year olds is an unknown quantity The pilot sites will proved more certainty Screening centres should prepare for demand between 6,000 and 8,000/year per million until pilot centres start screening

Estimating FS numbers 1.6% of population is aged 55 years For a half million population = 8000 FS invites per annum = 160 FS invites per week (50 weeks) Assume 50% uptake = 8 FS lists (80 people) per week PLUS an additional 5% referred for a screening colonoscopy ( 4 people per week)

Local delivery of Flexi-sig Innovative ways of working Potential to use community sites and ITCs (JAG approved) JAG investigating pre-accreditation of new facilities Working evenings and weekends (this age group will mostly be in employment) Must ensure flexi-sig lists are always available – cannot cancel lists when you have invited them in first place!

Proposed invitation process Screening Centre to set up FS screening clinics and appointment slots on BCSS Hub to send pre-invites (8 weeks in advance) Hub sends invites and timed appointment and reply slip (6 weeks) Enemas posted once confirmation of attendance received (up to 2 weeks before) Presumption of normality and advice to phone helpline otherwise Individual attends for Flexi-sig “Opt-in” for those aged 55 -59 Possible “opt-in” for visually impaired (60-64)

Local delivery of Flexi-sig (2) Invitations with booked appointments Will require overbooking of lists Must have capacity should everyone attend 10% may require administration of enema on site Need greater pool of endoscopists than FOBT screening SSPs to attend list Dedicated Programme manager (for BSCP and FS) increased admin role for booking of lists

FS Examination Comfort is paramount Only examine as far as comfort allows Record if sub-optimal extent or prep Entonox allowed but no sedation Only one test allowed Funding £400 per “booked” test for whole programme

Colonoscopy Referral Guidelines Any patient with a polyp >10mm Any patient with, on a histological report 3 or more adenomas An adenoma with villous or tubulovillous component An adenoma with high-grade neoplasia (dysplasia) Patients with 20 or more polyps which are >3mm, hyperplastic in appearance and above the distal rectum

The following patients may be referred for colonoscopy in the Bowel Cancer Screening Programme: Any patient with suspected adenomas, which fit criteria for removal but where this may not be appropriate at initial flexible sigmoidoscopy screening exam e.g. On anti-coagulant or antiplatelet therapy (though biopsies can be taken if required) Patient intolerance of procedure / discomfort Multiple suspected adenomas (e.g. >6), At risk of vCJD A patient with a polyp which is technically difficult to remove e.g. due to poor access, in an unstable position, or recurrence in a previous polypectomy scar

Suitablity assessment Presumed suitable Sent contraindications with invitation Suitability only assessed if subject contacts the Hub to discuss a possible contraindication Suitability initially assessed by the Hub Facility for the Hub to refer to the Screening Centre

Self referrals (Opt ins) Registered with GP linked to SC offering FS Screening Age 56-59 inclusive No FS Invitation due date Not ceased, seeking further data or surveillance No previous FS screening episode

Current workforce All accredited screening colonoscopists are automatically accredited for FS screening

Eligibility Of New Workforce Attached to Centre with an Internal Mentor Minimum of 300 lifetime lower GI endoscopies Able to remove lesions <10mm including by submucosal lift (confirmed by colleague) Able to place endoscopic tattoos Able to accurately assess the size of the lesion Skilled in lesion recognition

Application criteria Lifetime lower GI numbers > 300 Lifetime perforation rate In preceding 12 months: No of Lower GI procedures > 150 Polyp detection rate Polyp removal rate Complication rate PLUS: 4 formative DOPyS to be submitted

Formal assessment To be held in local screening centre Internal and external mentors will assess One hour MCQ DOPS or DOPyS examination of 2 consecutive cases Provisional accreditation awarded until KPIs for 100 cases signed off by external assessor

Formal assessment (2) If KPIs not reached after 300 procedures or within 9 months, provisional accreditation expires (and new application required) Unsuccessful applicants would be allowed to re-sit twice in a 12 month period Expect FS endoscopists to undertake at least 400 FS per annum

Appendix 2 Demand Capacity SC activity Link GP practices to FS sites Set up FS Screening Clinic Lists Hub activity Generate FS Invitations by site (Appt date – 8 weeks) Send FS Pre-invites (Appt date – 8 weeks) Self Referral / reopen requests Send FS Invitations Inc. appt details (Appt date – 6 weeks) Appt re-bookings / cancellations Process FS Response Slips Handle Suitability Assessment phone calls Process Decline Requests Send Reminder letters (Appt date – 4 weeks) Manage Overbooked / Under-booked FS Lists Process escalated suitability assessments Confirm FS Clinic Lists (Appt date – 2 weeks) Maintain Maps and directions to FS sites Send FS Confirmation letter (Appt date – 2 weeks) Send Bowel Prep (Appt date – 2 weeks) Send Non-Response letters (Appt date – 2 weeks) Add appt details to local PAS (Appt date – 2 days) Attend appointment

Planning For FS Screening Calculate Demand and Capacity Develop the workforce needed Plan to deliver FS locally Look for local JAG accredited facilities Appoint a dedicated Programme manager

Flexi-sig screening – How far can you go...... .......with planning, given what we currently know Billie Moores NW QA Director - BCSP

Presentation - objectives Brief overview of FS Look at projected demand Look at models of delivery Workforce issues Known, unclear, unknown

Projections of underlying growth pressure (blue line) for colonoscopy and flexi-sigmoidoscopy activity plus additional activity from cancer strategy commitments (pink line) 50

Timeline for development 2011/12 development year for Flexi-sig 2012/13 piloting of Flexi-sig 2013/14 first wave roll out of Flexi-sig = 30% country open by 31 March 2014 2014/15 second wave roll out of Flexi-sig = 60% country open by 31 March 2015 2016 roll out complete

What do we know? Colorectal cancer mortality was reduced by 43% DH have committed £60 million over next 4 years Will be part of the bowel cancer screening programme – ‘BowelScope’ Activity will be linked to current bowel cancer screening centres No bowel cancer screening centre will have enough capacity ‘in-house’ Tariff payment of £400/scope (?) 52

Preparing to deliver Flexi-sig screening One-off invitation to all people aged 55 years (with self –referrals up to age 60) May require some reconfiguration of large screening centres Different infrastructure and will need detailed capacity and demand planning Needs to convenient, local, accessible People don’t have to attend Can’t stop once started

Best estimate of demand The initial estimates of demand were 6000/million base population each year – now thinking possibly 8000/million It will be different in different demographic areas and opt in for 56-59 year olds is an unknown quantity The pilot sites will proved more certainty Screening centres should prepare for demand between 6,000 and 8,000/year per million until pilot centres start screening

What does this mean for NW? 2013 – 95,000 people will turn 55. Increase to 97,000 next year Assuming 50% uptake 52 weeks/year 12 on a list 76 – 78 additional lists/week 5% refer for colonoscopy 15 – 16 additional lists/week

Estimating FS numbers For a half million population = 8000 FS invites per annum = 160 FS invites per week (50 weeks) Assume 50% uptake = 8 FS lists (80 people) per week PLUS an additional 5% referred for a screening colonoscopy ( 4 people per week)

Proposed invitation process Screening Centre to set up FS screening clinics and appointment slots on BCSS Hub to send pre-invites (8 weeks in advance) Hub sends invites and timed appointment and reply slip (6 weeks) Enemas posted once confirmation of attendance received (up to 2 weeks before) Presumption of normality and advice to phone helpline otherwise Individual attends for Flexi-sig “Opt-in” for those aged 55 -59

Local delivery of Flexi-sig Innovative ways of working Potential to use community sites and ITCs (JAG approved) JAG investigating pre-accreditation of new facilities Working evenings and weekends (this age group will mostly be in employment) Must ensure flexi-sig lists are always available – cannot cancel lists when you have invited them in first place!

Local delivery of Flexi-sig (2) Invitations with booked appointments Will require overbooking of lists Must have capacity should everyone attend 10% may require administration of enema on site Need greater pool of endoscopists than FOBT screening SSPs to attend list Dedicated Programme manager (for BSCP and FS) increased admin role for booking of lists

What next? Talk to screening centre Workforce planning Start now Training packages in development - reply to/contact David Holt, QA Co-ordinator (david.holt@bolton.nhs.uk) First wave bids will get a decision soon Call for second wave this year Think creatively

Sanchoy Sarkar Phd FRCP Consultant Endoscopist & Gastroenterologist. Improving Capacity in Endoscopy Services “Lessons from the 3 Session Day” Sanchoy Sarkar Phd FRCP Consultant Endoscopist & Gastroenterologist.

Lecture Model Need and background (The evolving story) 3 Session Day Our Service re-design Challenges Key aspects of implementation Data on the 3 session day in practice

Models Expanding Capacity (4 to 6 sessions per Day) 3 Session Day (8.30-20.30) Extra Room (9-5) Rm1-EV Rm 2-Ev Rm 1-PM Rm 2-PM Rm 3-PM Rm 1-PM Rm PM Rm 1-PM Rm 2-AM Rm 3-PM Rm 1-AM Rm2-AM

Models Needs Extra Room 3 session day (Extended Day) Space (plant) Build Staff Equipment Staff (more) Staff (work differently) Staff (cooperation)

Royal -Activity PHASE 1 PHASE 2 Procedures 2005 2006 2007 2008 2009 2010 2011 Year

Driver’s for Change in Activity PHASE 1: Introduction BCSP PHASE 2: Abolition of Barium Enema & pending JAG Visit Waiting Time Diagnostics 9 weeks Surveillance 18months

3 Session Working in Practice Monday to Thursday 3 Sessions working (8.30 am to 8.30pm) Changed Capacity to 63 Sessions 300 procedures per Week OGD/COLON/BCSP/EUS/In-patients 3 Rooms; Usual- colon + in-patient + other

Advantages Increase Capacity with Limited Plant Staff Advantages Nursing Staff- Day off during week Endoscopists- Session off during the week Evening List Better working environment Patient Advantages Patient choice Convenience OGD after Work Colonoscopy All prep on day of procedure Rarely DNA

Patient Preference V. Willing Don’t Mind Unwilling Willing 85% of patients don’t mind or are willing evening lists

DNA Rates

Full Booking A B

Challenges- Staff, Staff & Staff!!

Challenges Staff: Work Life Balance/Mind Set Nurse Work Pattern Doctors Work Pattern Workforce- Manpower Finance (Manpower)

Solutions Leadership: Credibility & Determination Engage (Trust Board- Ground Level), Buy In, Work together Financially Plan (Business Case) Workforce Flexibility & Planning

Successful Implementation Workforce, flexibility & Job Planning Endoscopists - Consultant Endoscopists - Nurse Endoscopists/Nurse Colonoscopist - Endoscopy Fellow - New Consultants - Annualised Contracts Endoscopy Service Manager (8A) Nurse Educator/Deputy Manager (7) Band 6 & coordinators x4 Admin Manager (6) Endoscopy Nurses Expansion A&C Staff HCA/Decontamination In-patient Coordinator (6) List Scheduling Support

Successful Implementation Workforce & Job Planning List Scheduling Well Controlled (Diagnostic in Evenings) Less points Flexible & meet needs – Pooling & Segmentation Share Lists & Competencies Dedicated In-patient lists & Coordinator Admin Manager (lynchpin) Support

National SpR INTERVIEW SPRS Interviews Colleague UGI MDT /ERCP-A/L for 1 wk Radiologist-EUS-FNA/ERCP-Off Sick-long-term Consultant Endoscopist A/L- 1 wk- Does GA List Consultant Endoscopist course 1 day Nurse Endoscopist A/L 1wk Surgeons on A/L SS Away 2 Days National SpR Interviews INTERVIEW SPRS NHS IMPROVEMENT

Day-Case List Utilisation

Successful Implementation Workforce & Job Planning List Scheduling Support Endoscopist of the Day Weekly Activity Meetings Endoscopy Lead & Nurse Consultant Weekly meeting with Endoscopy Manager Endoscopy User Group Quarterly Education (Facilitator-B7, APEX, Nurse Education Sessions, TREATS)

Patients Demographics AGE GENDER

Patients Health Status Healthy Patients (ASA I) Sick Patients (ASA III or IV)

Quality CAECAL INTUBATION RATE POLYP DETECTION

Safety- Adverse Events Serious: 1 respiratory arrest- Reversal Given & Crash Team called Post EMR Bleed- Patient readmission Other: Endoscopist called away for emergency- Cancelled in-patients Admin-Endoscopist Communication- Booked list & No endoscopist

Problems Lists continually over-running People getting Tired and Sickness (cover) Staff Turnover- Willing & Unwilling Starting on time of each session Covering Evening Lists (Back-fill) Coping with Unexpected- Emergencies

RLH Unit- 2004 & 2012 2004 2012 Theatres 4+1(XR) 4+1+1 Sessions 44 (9-5) 63 (8.30-8.30) Procedure 11,000 16,000 Therapeutics: Lower GI: <7% 4,000 >25% >7,500 Consultant Endoscopist 3 Gastroenterologists 6 9 Consultant Surgeons 2 Fellow Nurse Colonoscopists 1 Nurse Endoscopists 4

Happy Ever after !

Conclusions: From what I know now Get another room!! Planning; Under resourced for staffing, constant struggle- Solid maths (opportunity) Get the team right (teamwork & Skill mix) Workforce Flexibility & Job planning Scheduling (Shared lists-competencies) Support & communication

Thank You Sanchoy.Sarkar@rlbuht.nhs.uk www.liverpoolgastroenterology.nhs.uk

Endoscopy Demand and capacity: Where are we now? Dr Neil Haslam Haydock PPAT Meeting January 2013

Presentation - objectives To understand the up coming demands on endoscopy To understand how to maximise endoscopy capacity Understand what Trusts will look for in a business case to expand services

Projections of underlying growth pressure (blue line) for colonoscopy and flexi-sigmoidoscopy activity plus additional activity from cancer strategy commitments (pink line) 91

Waits Jan-April 2012

Waits June-Sept 2012

Current Demand

Demand For Bolton PCT

Quick Demand Planning for 2018 OGD 1.8% of pop FS 0.8% of pop Colon 1.4% pop Average DGH (300,000) 5400 OGDs 2400 FS 4200 colons

Post-PPAT Plans − Created detailed action plans to improve productivity − Instigated different ways of working, with a particular focus on pre-assessment − Reviewed online tools − Commenced weekly formal planning meetings in place of ad hoc reactive management − Reviewed productivity, 7 day service & reporting systems − Met with managers to improve efficiency of unit and reduce waste and standardise room utilisation − Helped others to develop their services via SHA role, publications in frontline gastro etc… − Completed a baseline PPAT and committed to review regularly − Reviewed demand and capacity for BCSP and how this could be managed better  Each regional group has committed to organising a follow up workshop in each region in the next 12 months  The JAG has agreed to use the PPAT objectives framework during assessments for accreditation and maintenance of annual accreditation

PPAT Key Recommendations: Units 1. Endoscopy team leads must work more collaboratively with their organisations and commissioners to achieve joint understanding and responsibility for the planning, business development and improvement of the service 2. More widespread adoption of processes and IT systems for collection of data on demand, capacity, utilisation and booking. available 3. All units that are not obviously in control of their waits should complete the PPAT online at least annually with an appropriate action plan 4. Development plans for the workforce should anticipate future demands 5. The appropriateness standard of the GRS must be applied robustly. 6. Process improvements recommended by NHS improvement should be routinely applied (Endoscopy-rapid review 2012)

PPAT Key Recommendations: Commissioners 1. Commissioners need to better understand the impact of endoscopy on clinical outcomes and the future demand for endoscopy, particularly from bowel cancer screening 2. They should work with endoscopy teams and provider organisations to agree future demand and make plans for meeting it 3. Should demand to see evidence of effective vetting against guidance and of high productivity

PPAT Key Recommendations: JAG 1. The JAG should use the PPAT objectives framework during JAG assessments for accreditation and maintenance of annual accreditation 2. The JAG should train its assessors to be able to review the evidence of effective planning and high productivity 3. JAG accreditation should not be held back if a service does not have its waits completely under control provided it has achieved high scores on the PPAT that can be validated by JAG assessors. 4. The JAG should assess the appropriateness item more robustly at the time of accreditation and perhaps require level A (rather than level B) for future accreditation

Drivers For Change Best Practice Tariff Any Qualified Provider (AQP) Loss of 5% of Tariff if non-JAG Accredited Any Qualified Provider (AQP) NHS Choices Flexi Sig Screening PPAT or equivalent to be included in GRS

What Have We Done? Is there a problem? What has helped/worked? What are the barriers?

Endoscopy Review -Emerging Learning- Endoscopy Tips Lisa Smith National Improvement Lead NHS Improvement

Aims of the session Set context of the work with 23 sites Update on where we are and what we hope to achieve To highlight some top tips we found To allow you to self score against ‘top tips’ Determine future support sites may need (Sign up to e-bulletin)

Context Asked to look at capacity ahead of the bowel cancer awareness campaign Understand the issues & challenges sites were experiencing Identify opportunities to increase capacity through improved productivity (no detrimental impact to quality) Look at both the clinical & admin processes Identify innovative solutions to some of the challenges currently experienced by many sites Share our experience and learning from the world of improvement

Review approach – site selection Identified 14 sites from reviewing DM01 returns & profiling the waiting lists over the last year – some with rising waits / some not Not an exact science, but confident we had a range of sites, those that had waiting list issues and those that seemed to be in control & meeting targets 14 visits in 3 weeks – one day on site Output - report for each site & publication for the wider NHS

What do we know? Huge amount of work has already been done Overwhelming increase in referrals (43% reported by one trust) Workforce issues remain: Staff working extremely hard & over a long period of time Staff working weekends & evenings to clear backlog Extended working days 8am – 9pm / 3 session days 6/7 day working Innovative solutions to the most common challenges

NHS Improvement Staff Locations Fiona B Lisa C Hannah D Janine E Elaine 1 Wrightington, Wigan and Leigh NHS Foundation Trust 2 The Pennine Acute Hospitals NHS Trust 3 Royal Bolton Hospital NHS Foundation Trust 4 Central Manchester University Hospitals NHS Foundation Trust 5 Bradford Teaching Hospitals NHS Foundation Trust 6 Mid Staffordshire NHS Foundation Trust 7 Peterborough & Stamford Hospitals NHS Foundation Trust 8 James Paget University Hospitals NHS Foundation Trust 9 Hinchingbrooke Healthcare NHS Trust 10 The Ipswich Hospital NHS Trust 11 Milton Keynes Hospital NHS Foundation Trust 12 Luton & Dunstable NHS Foundation Trust 13 Gloucestershire Hospitals NHS Foundation Trust 14 Kings College Hospital NHS Foundation Trust 15 Guy’s & St Thomas’ NHS Foundation Trust 16 South London Healthcare NHS Trust 17 Surrey & Sussex Healthcare NHS Trust 18 Royal Cornwall Hospitals NHS Trust 19 Royal Devon & Exeter NHS Foundation Trust 20 Portsmouth Hospitals NHS Trust 21 West Sussex Hospitals NHS Trust 22 Brighton & Sussex University Hospitals NHS Trust 23 East Sussex Healthcare NHS Trust Sites: A 5 B 2 3 1 4 NHS Improvement Staff Locations Endoscopy 2012-13: Agreed Sites 1 C 6 8 7 D 9 E 10 11 13 12 2 14 15 16 17 23 20 21 22 19 18

Review approach - method Met with the key people on site, exec lead, clinical lead, unit manager etc Walked the clinical process from a patients perspective Went through the admin process in detail Looked for service improvement opportunities Process issues (admin, clinical, decontamination) Leadership: (nurse leadership, ops management, clinical engagement & leadership) Service improvement – understanding & capability (including information & data) Listened to the staff

What did we find? Delays to start times of lists Delays in the middle of lists, Waiting for scopes, interpreters, bleeps & interruptions Over runs & under runs Lists not being fully utilised 40 sessions lost in one month at one Trust Poor communication results in lost opportunities to flex job plans & training lists Annual leave policy in place but not adhered to High DNA rates – due to complex admin processes - 16% at one trust Cancellations on the day – anti-coagulation issues, co-morbidity drug issues Phones not answered in department/patients can’t get through to cancel /change appointments Information on the above not fed back to staff therefore not tackling the issue

What else? Points system - used as a guide but can also be a barrier Wide variation in number of points per session & length of session Always more points on a list at weekends Roughly reflects process time Need to account for changeover time Must not squeeze procedure time (risk of compromising on quality gains) There are opportunities for productivity gains

1. Understand your service Understand and know your Demand Capacity - utilisation rates Activity DNA rates Do you know where you are losing capacity?

Typical data

2. Know what your patients want Over and above your twice yearly surveys: Voice of the patient/referrer – comment cards NPS – Friends and Family test Use of patient diaries (map the emotional journey!) Use the patients to shape the service – Endoscopy User Group Make improvements as a direct result of patient comments Feedback your improvements to patients – make it visible Patient choice Direct booking GP referral – straight to test Do patients get enough notice? Phone lines/staff to answer queries and take calls from patients Pre-assessment Reduces DNA’s/cancellations One stop (two stop) Nurse led Patient information/DVD Consented at same time

Traffic Summary for Endoscopy Total Calls Total Calls Ans Total Calls Busy Total Calls Unans 34 7 27 32 5 20 37 6 31 36 28 10 18 29 23 24 9 22 1 15 301 66 234

3. Maximise capacity Flexible workforce – pooled lists Contingency plan for dropped lists Annual leave policies for all staff A pool of endoscopists on whom you can draw (rotational registrars, research registrars, GP’s, associates etc.) An escalation policy Nurse led: Consent Cannulation Discharge Nurse endoscopists: Upper and lower procedures Backfill for consultants Audit start/stop/interruptions to lists with reasons for delays Conduct a changeover times audit – how long should it take? – wide variation Process timings – how long are patients in the department?

Areas for improvement start & stop times Whips Cross – audit December 2011 Monitored electronically and by nursing staff List started on time – 32% Mean delay – 21mins Main reasons for delay – Staff delay – 45% Patient Late – 25% Scope delay – 20% 4 months later – April 2012 List started on time – 50% Mean delay – 11 mins Main reasons for delay Patient late – 50% Over running list 30% Scope delay 20%

  Day 1 Reason Day 2 Day 3 Day 4 Day 5 Day 6 Scheduled start time Actual start time Scheduled finish time Actual finish time Variance Totals for Room 1 AM Totals for Room 1 PM Total Variance Room 1 Daily total for Room 1 Totals for Room 2 AM

Start & Stop Times Audit Utilisation of Rooms: Overall 68.4 % total utilisation

4. Plan for the future Long term planning Expand your capacity in a sustainable way – unlikely to be WLI/affording IS services Model your demand – IMAS tool Take into account future service developments/new procedures/work from out of area – is there a business case/SLA? Inform CCG’s of any rise in demand (Use NICE/MoM) ? Evening sessions/3 session days/ 7 day working options before capital builds

5. Make endoscopy important Make the Trust consider endoscopy to be a priority – work with exec lead Raise your profile and that of future demands/ potential income generation – secure support from your information team Work with commissioners and share the good things you are doing Integrate into board/PTL/bed meetings issues and improvements from the unit

Where are we now? Sites progressing well 2 workshops held lots of guest speakers who have improved their service Sites have showcased their achievements so far – poster display Creating a competitive edge! Lots of PDCA cycles taking place

New Appointments Appointed 3 new National Clinical Advisors Mark Welfare, Consultant Gastroenterologist , Northumbria Healthcare Trust Ed Seward, Consultant Gastroenterologist, Whipps Cross Hospital Tim Trebble, Consultant Gastroenterologist, Portsmouth Hospital NHS Trust Associate – 1 day per week Harriet Watson, Colorectal Nurse Consultant, currently at Dorset , moving to Guys & St Thomas

Clinical Advisors Areas of Focus Help us to work on “ straight to test” – drawing on their collective experience Clinical Leadership Link into Cancer Networks Develop models to increase capacity in a sustainable way i.e. 3 session days / 7 day services

Share & support & Next steps Recognise we are only working with 23 sites (the challenges are probably similar) Supported 10 PPAT workshops – to get the message out to non-test sites Happy to share any tools, templates, presentations and our experiences Lots of contacts where improvements have been implemented and work well Website/Publications/Workshops/Buddying sites/e-bulletin Working with the Institute on “Productive Endoscopy”

Rapid Action! Do Now: key areas of focus Really understand your capacity & demand data Perform start/stop audits – make the results visible Look at how many dropped lists you have per week – and challenge the reasons Collect how many points are actually booked onto each list Understand the real reasons for DNA’s/cancellations

Rapid Action! Do Next: key areas of focus Count the number, duration and reasons for interruptions to lists – drill down to the detail Changeover between patients audit – agree a gold standard and measure yourselves against it Complete process timings template – how long are patients in the department for? Implement daily huddle – to foster a culture of problem solving ‘on the hoof’

Rapid Action! Do Later: key areas of focus Look at workflow – patient/staff/kit/information – quantify motion Remove unnecessary vetting, consenting, cannulation, discharge by consultant Review work plans - nurse endoscopists & succession plan with HR/Business Manager Instigate weekly capacity meetings

Happy for you to sign up to our free e-bulletin Thank you Lisa.smith@improvement.nhs.uk www.improvement.nhs.uk/diagnostics/endoscopy Happy for you to sign up to our free e-bulletin