System redesign lessons from success in cutting diagnostic delays?

Liked this story from 8 January the Health Service Journal as an example of successful service redesign, in the aftermath of the Gerry Robinson TV programme on the NHS. Maybe there’s something in it that can be learned for safety systems redesign, including shift handover (see the CMO’s recent discussion on NHS safety work)?

Quicker diagnosis makes good timing

Success in cutting diagnostic delays won Blackpool, Fylde and Wyre Hospitals trust an invitation to the Number 10 summit on delivering the 18-week patient pathway last year.

The trust piloted its approach in radiography, where it reduced waiting times for routine CT scans from 46 weeks 18 months ago to a maximum six weeks today.

It has also reduced waits for urgent MRI scans from six weeks in January 2005 to between one and three weeks, and for routine MRI scans from 52 weeks to 16. And vascular ultrasound waits have dropped from 48-56 weeks in January 2005 to 16 weeks.

Chief executive Julian Hartley puts this down to three factors.

First is system reform.

‘We’ve worked closely with primary care trusts to identify alternative patient pathways for diagnostic tests, for example using new diagnostic suites in care settings and in community hospitals,’ he says.

‘It is more accessible for the patient, gives GPs the opportunity to provide services much closer to the needs of their patients and closer to where they live, which in turn means getting test results more quickly.’

Second are top-down initiatives, such as the 18-week target and the decision to concentrate on scanning.

‘A lot of waiting times were in the diagnostic element,’ says Mr Hartley. ‘These two initiatives have helped focus people’s attention on getting waiting times for diagnostic tests right down so patients can get the whole treatment plan more quickly.’

Third is service redesign. ‘The team within radiology at Blackpool has completely redesigned and streamlined the flow of work through the department,’ says Mr Hartley.

‘We took the whole system that patients experience and critically evaluated it. By doing so – by challenging customary practice – we significantly improved the capacity of the department to see more patients more quickly.’

The trust has also made use of telemedicine, sending images electronically to a company in Belgium and receiving reports back within 48 hours.

It also employs independent providers such as Alliance Medical for extra capacity.

Minimal cost

The project is all about spending the same but getting more.

Mr Hartley says: ‘Rather than paying an awful lot of money, we’ve been able to do it for minimal cost through process redesign.’

Another critical factor is the clinical champion. Consultant radiologist Graham Hoadley, a national clinical lead for radiology service improvement, oversaw the design and detailed implementation of the project.

‘Basically, our interest in the old days started when we received the report request,’ says Dr Hoadley. ‘We’re now being more proactive at both ends to get the request into the department more quickly.’

At the primary care end, GPs now use electronic request cards, which automatically download patient information. The GP has only to provide data and fax or e-mail it over. It arrives immediately, and the patient is phoned up with a choice of appointments.

‘It’s faster and it’s choice. Before, GPs had to hand write the request – often illegibly – and it was posted second class,’ says Dr Hoadley.

At the hospital, a referral to cancer services is made if a report suggests this. The GP is informed purely so he or she can intercept the referral if there is something the hospital does not know.

‘It all happens within a week. In the old days, the GP would receive the report then initiate the pathway. Now we’re pushing them through the pathway.’

Operating hours for CT and MRI have changed so the service does not close over lunchtime. MRI has been extended to cover three evenings a week. To clear a backlog, scans were carried out on Saturdays for a time.

‘We had such a terrific problem that the whole system began to fall apart,’ says Dr Hoadley. ‘Waiting lists had got to three months and rising.’

After a demand and capacity exercise, and process mapping, the trust decided to organise ultrasound differently. Office processes were improved to speed up requests. Ultrasound units lying idle in peripheral hospitals were pressed into use, which had the added benefit of making parking easier for patients. Sonographers were placed in GP surgeries.

‘Within a few months, routine waits were down to two weeks, inpatient waits down to two hours, and it cost us nothing at all,’ says Dr Hoadley.

Roles have been redesigned. ‘We have one radiographer reporting mammograms and three reporting barium enemas,’ says Dr Hoadley. ‘One of the superintendent radiographers can interpret plain films of the eyes.’

He continues: ‘Any process or system that depends on any one person is vulnerable to collapse. That’s been a problem at different stages, so we try not to have any one system dependent on a single individual.’

Morale is higher – role redesign has created career development opportunities – and recruitment and retention has improved.

Simple changes have made a difference. Offering a choice of appointment means fewer calls from patients who cannot attend. ‘All those calls go away and clerical staff are happier,’ says Dr Hoadley.

He adds: ‘I don’t think there is anyone who isn’t proud of the service we provide now.’

Revisiting improvement

Dr Hoadley stresses it is all about improvement, which is continuous.

He says: ‘We had improved ultrasound a lot by the end of 2005 but by January 2006 it was all going to pot so we had to look at it again. At the moment our problem is MRI reporting – we’re getting into difficulties again because the demand for urgent scans has risen.’

The next step is to apply the principles across the trust. Mr Hartley says: ‘The improvements have applications for other services. For example, the service redesign approach has significant implications for theatre use and for diagnostic pathways such as pathology.’