Urology Outpatients – Treatment Clinic
Microsystem Improvement Case Study
Summary
Nurses and admin staff in Urology Outpatients worked together to turn a ‘hectic clinic’ into one that is calmer, more
organised, and more timely for patients. They re-organised the patient mix in each clinic and gave appropriate times
for each appointment type.
The resulting benefits are:
•
A 50% reduction in the number of nurses required to run the service. This nursing capacity is being used in
other services within the department
•
The last patient on every list during the trial was seen on time or early
Background
Treatment Clinic is a nurse led service in Urology
Outpatients providing around 80 treatments per week
and runs most days. Many of the patients are on longterm follow-up so are well known by the team.
There was dissatisfaction with the way the clinic ran,
largely due to the way patients were scheduled. Some
clinics would have few patients on and others would
be overbooked. This made it hard to plan nursing
requirements in advance and there would often be a
surge of patients in the middle of a clinic.
Assessment
An improvement team formed, with representatives
from the nursing team and reception. Previous
activity data was reviewed to understand how many
of which treatment type were required each week. A
staff survey was completed to gather input from staff
on their feelings about how the clinic ran and to gain
ideas for improvement.
Diagnosis
Through regular meetings, each profession built their
understanding of each other’s roles and explored
alternative ways of delivering the service.
It became clear that the standard appointment length
of 10 minutes created many of the problems as a third
of all appointments take longer than this, some of
which take around 30mins. A new schedule was
developed based around the typical time required for
each treatment type, including time for writing up
patient notes. Typically because clinics ran late,
writing up notes was left until all patients had been
seen. It was agreed as preferable to write up each
patient as the clinic progressed. Because the majority
of the patients are well known and attend regularly,
the team had a deep understanding of patient needs
and could plan accordingly – a longer slot for a patient
in a wheelchair, for example.
The new schedule grouped treatments together to
decrease variation, allowing the nurses to plan their
work better and get into a flow. In order to maintain
patient choice, most treatment types are still available
each day. With more accurate appointment lengths,
appointments were spread more evenly through the
session to stop a bottleneck of patients in the middle
of clinic. The booking rules were also changed to not
allow overbooking. An extra clinic on Friday morning
was prepared that they could overflow and book into
if required.
These findings and proposals were shared in a big
meeting with the wider nursing and reception teams
to bring them up to date with the work the
improvement team had been doing and to seek
feedback ahead of a trial of the new schedule.
Treatment
The new schedule was initially trialled on Wednesday
afternoon clinic only. A small trial allowed the team to
test the new booking processes and appointment
lengths without having a significant impact if the
changes weren’t an improvement. Different staff
were deliberately rostered on to this clinic each week
to capture the broadest experience of the new clinic
and gain feedback. Feedback showed this clinic was
now running much smoother, so the new schedule
was implemented for the whole week and patients
moved over to this new schedule.
One month after full implementation the feedback
was: “The last patient on every list has been seen on
time or early”.
The new schedule delivers the same number of
treatments but now only requires seven nurses per
week compared to 14 previously - halving the nursing
cost per treatment and allowing this nurse capacity to
be used in other parts of the service.