Timelier diagnoses for head and neck cancer patients through improved cancer pathway journeys

Aneurin Bevan University Health Board (ABUHB) has a target of 28 days for patients to receive a decision on how their cancer will be treated from the point of suspicion. Head and neck cancer teams struggle to achieve this, as several investigations are needed before a decision to treat. Timeliness is particularly important in head and neck cancer, with the mortality rate estimated to increase 3–5% each week a patient awaits treatment (ref 1,2).

Baseline data demonstrated the head and neck team were taking on average 62 days to provide a decision to treat. This resulted in only 19.3% of patients starting treatment within 62 days. There were inefficiencies, and the pathway wasn’t person-centred. The team decided to use a Quality Management System (QMS) approach to improve this situation with quality planning, improvement, control and assurance.

They formed a core project team consisting of two head and neck consultants, an assistant directorate manager, a cancer nurse specialist, a service improvement manager, a business support manager and a quality improvement specialist. This team committed, with the clinical director and directorate manager, to meet for one hour every month. 

The team undertook a quality planning exercise to understand the reasons for the delay. They used a lean methodology to identify waste and inefficiency in the process. The hospital database provided data on the whole system and a standardised work study helped them better understand the details at a patient level. 

The Pareto analysis identified three main areas responsible for most of the delays. The team focused the first 12-month phase on two of these areas and the second phase on the third area. For the first phase, they included stakeholders from radiology, outpatient booking clerks and patients. The second phase included patients, preassessment nurses and consultant anaesthetists. The team engaged patients through lived experience interviews, questionnaires, focus groups and an online feedback app to gain insights into their experience of the pathway.

The team conducted 12 Plan-Do-Study-Act (PDSA) tests of change.

For the central registration triage PDSA, two consultants took a sample of 50 referral letters and compared how they would triage them. They then co-designed a guide on how to safely triage and tested it with a nurse to see if it was easy to follow. They then tested it with central registration staff. 

The team conducted five PDSA cycles as part of quality improvement. Then, the guide was implemented to make the changes business as usual, with a standardised operating procedure in place as part of quality control. The five PDSAs improved time to first outpatient appointment from 8.9 days to 6.1 days. The team continue to review and report the data monthly as part of quality assurance.

Other PDSAs resulted in a 15-day reduction in waiting time for an ultrasound of the neck and reduced preassessment time from approximately 21 days to 2–3 days. 

The biggest challenges around this project were allocating time for improvement, and resistance to change from colleagues.

The time challenge was overcome by committing to an hour meeting every month. The meeting was designed to provide as much value as possible. As a result, it was well attended and often overran by 30–60 minutes as the team was so engaged. Colleagues commented it was the best meeting they attended and that they looked forward to it. 

When looking at improving a whole system, resistance is inevitable. Providing education on strategies to overcome resistance and recognising that it is part of the process helped. Also, starting on a constraint that wasn’t the most impactful but was within the team’s sphere of influence allowed the team to demonstrate effectiveness. This helped when engaging with colleagues in other areas. The team’s enthusiasm and effectiveness were infectious and made others want to take part and share in the successes.

The project resulted in the time from suspicion to decision to treat improving from 62 days to 28 days. It also improved the percentage of patients starting treatment within 62 days from 19.3% to 64%.

Staff morale also improved significantly. Before this work, they were subject to scrutiny for poor performance. They are now proud of the service they deliver. Team members have developed their skills by taking courses in quality improvement methodology and embedded the QMS monthly meeting to ensure continuous improvement. 

• The clear vision towards a common goal brought the team together with focus and determination.
• Patient voice uncovered valuable information and helped to improve the service in ways that mattered to users.
• Using PDSA cycles ensured learning and confidence in the changes being tested. However, it was important to add quality control to lock in the improvement and prevent a drift backwards.
• Many of the PDSAs that took months to complete could have been done in a few weeks if the time had been made available. Having a few teams working simultaneously but separately on the different constraints and/​or making more time available with a more focused effort could help.
• A cost effectiveness analysis calculated that quality-adjusted life years have increased by 0.67 per patient. As ABUHB treats around 150 patients with head and neck cancer per year, this equates to a value of around £2.5m (using the NHS willingness-to-treat model). The cost effectiveness analysis also estimated that 10 lives will be saved per year as a direct result of this work.
• 28 days is a key metric in measuring performance for all cancers. This is included in all National Optimal Pathways for all cancer sites in Wales. Although this aim was considered impossible at the onset, it became achievable over the course of the improvement work.

Having achieved the original aim, the team are excited to continue the work. They’re now aiming for 75% of patients to be treated within 62 days. This would align with the global aim of 75% compliance. Many of the team have taken or plan to take courses in quality improvement methodology to better understand how to obtain relevant data from the hospital’s data system. 

The QMS approach using a lean methodology for improvement has been noted by the organisation, and there is a plan to engage other cancer services in the same process. 

Hanna TP, King WD, Thibodeau S, Jalink M, Paulin GA, Harvey-Jones E, O’Sullivan DE, Booth CM, Sullivan R, Aggarwal A. Mortality due to cancer treatment delay: systematic review and meta-analysis. BMJ. 2020 Nov 4;371:m4087.

Rygalski CJ, Zhao S, Eskander A, Zhan KY, Mroz EA, Brock G, Silverman DA, Blakaj D, Bonomi MR, Carrau RL, Old MO, Rocco JW, Seim NB, Puram SV, Kang SY. Time to Surgery and Survival in Head and Neck Cancer. Ann Surg Oncol. 2021 Feb;28(2):877–885.