Q Exchange
Development of a fast-track perioperative pathway
- Proposal
- 2023
Meet the team
Also:
- James Day (Project Lead)
- Claire Cheetham
- Mark Scarfe
- David James
- Usha Nair
- Mandy Rutherford
What is the challenge your project is going to address and how does it connect to the theme of 'How can improvement be used to reduce delays accessing health and care services'?
The Pre-Operative Assessment (POA) service is a vital part of all surgical pathways. In order to conduct a safe and efficient assessment and be able to make the right decision with the patient as to their current fitness for surgery, data is collected (often as a ‘Health Screening Questionnaire’ – ‘HSQ’). The HSQ can be very long (sometimes involving up to 100 questions) taking up patient and staff time. Completing the questionnaire is particularly challenging for those who are not fluent in English, have learning disabilities or other accessibility needs. The data quality is highly variable, often incomplete and inaccurate. Taking action based on the data provided is risky, so an extra step of validating the data has to be added into the process.
What does your project aim to achieve?
Project aims:
- redesign the clinical information gathering and subsequent streamlining to best use time and skills of those using and providing services, so that the right decision for the patient can be made at the right time
- quickly and easily identify patients who can be fast-tracked for surgical scheduling in a safe and valid way
- increase capacity in POA to identify and prioritise time for patients who have more complex medical needs who can be fast-tracked into an enhanced pre-operative/prehabilitation pathway
- understand and improve how different parts of the system, including primary and secondary care, work together to meet patient needs in accessing and engaging with POA
- empower and engage the workforce and service users (experts by lived experience) to collaborate; building QI capability using improvement methods to reduce waits and improve care
- help to improve the way waiting lists are prioritised and managed, directly benefitting patient safety and flow
How will the project be delivered?
This project will use the Model for Improvement and Healthcare Systems Engineering methods.
Key stakeholders will have protected time, since a barrier to improvement efforts is often carving out ‘headspace’.
The project delivery team will include the POA Lead (project lead) and a QI Manager (among others).
Current processes and resource availability across services (primary and secondary care) will be mapped with stakeholders and issues diagnosed before changes are designed. Iterative testing (PDSA) will start small so that changes can be adapted/adopted or abandoned responsively.
Outcome measures include:
- Value/non-value added time in the POA stage of the patient journey
- Number of patients in a ‘ready for surgery’ pool
Process measures include:
- Amount of patient time taken to complete HSQ
Balancing measures include:
- Avoidable cancellations on the day (reason identified related to POA)
- Number of patients requiring repeat POA tests due to increase in time from POA to date of surgery
How is your project going to share learning?
The learning from this project will be shared widely.
Local: Trust ‘QI Stand-up’ presentation and QI Symposium
Region: ‘BOB’ System Anaesthesia and perioperative medicine meeting; ‘BOB’ GIRFT Leads meeting; ‘BOB’ HVLC meeting.
National: shared with Q members, published in Quality Improvement Journal (e.g. BMJ Open Quality/Journal of Improvement Science), shared with GIRFT for possible case study. Centre for Perioperative Care (CPOC) meeting. Royal College of GPs (RCGP) national conference.
International: Poster submission to international conferences, e.g. Institute of Healthcare Improvement Conference.
How you can contribute
- Sharing of best practice and learning from similar pathways established in other trusts.
- Learning from shared experience of Experience Based Design of similar clinical pathways.
Plan timeline
| 1 May 2023 | see attached word document for timeline |
|---|
Comments
Debbie Brazil 10 Mar 2023
Can I signpost you to the work I led at Bedfordshire Hospitals Trust on redesigning POA. Happy to have a conversation and give any hints and tips about what we did there - we implemented 17 change ideas including triaging POA patients and streaming so that patients got appropriate levels of review even at the first POA appointment.
https://bmjopenquality.bmj.com/content/10/3/e001338.info
debbie.brazil1@nhs.net
James Day 10 Mar 2023
Hi Debbie,
Our service manager and I have already been in contact with you a few months ago. Your paper was fantastic and was a good read. The developments and changes you put in were similar to some of the work we are doing here. It would be great to catch up over the phone or online.
It is reassuring that preop departments face similar challenges.
I have visited a number of departments across the country and from what I have seen there is enormous variation in practice.
This proposal we have will help to link in some of the differing sites we run in the trust and try to unify some process with this HVLC cohort of patients.
Faye Musselle 8 Mar 2023
Hi there,
I enjoyed reading through your idea and agree that a fast track process does provide many quick wins for you and the patient.
May I ask for clarification as to what the 40k will pay for? Is it to pay for the project lead or some form of additional staff?
We have talked in my trust about having a more formal fast track model for a while but currently tend to do it adhoc as necessary. Our submitted idea tackles the other end of this issue by dealing with the patients who need the longer work up earlier in the pathway (plus providing new types of pre-habilitation) and in doing so it will leave our fitness for surgery team automatically tackling our quick win patients. I wonder if this fast track process could be done without the need for additional investment by separating out staffing from the current fitness for surgery team and ring fencing them for this role as you are not suggesting any increase in activity but more a change in the way of working?
I hope these thoughts are helpful, happy to discuss further.
James Day 9 Mar 2023
Thank you for your comments Faye.
There is a broad range of patients coming through our elective pathway. We manage the complex patients needing complex/major surgery through our current service offering prehab as indicated.
We have sped up clinical decision making for this cohort with an anaesthetic MDT with input from specialist services such as intensive care, cardiology, respiratory, haematology, renal and also includes community services. This has really helped our ability to care for patients especially on a time critical pathways. We have been running this for the last 4-5 years.
At the other end of the spectrum there is a large cohort of patients having minor or intermediate surgery who are fit and well and have no prehab needs. The project is looking at that cohort.
How can we consistently identify this population and at what point in their pathway?
If we can do this using current sustainable IT infrastructure then we can develop new pathways with support from the preoperative assessment team. This should release capacity within preop to help manage the group of patients in between. Those having non complex but major surgery and have some co morbidity but do not need prehab or complex clinical decision making. These patients are difficult to identify and develop a bespoke pathway for as they have a great deal of variation.
Comments are now closed for this post.