18 weeks - focus on cardiac diagnostics project - national priority projects 07/08 summary document

NHSNHS Improvement

HEART

STROKE

CANCER

DIAGNOSTICS

Heart Improvement

18 Weeks - Focus onCardiac DiagnosticsNational Priority Project

Focus on Cardiac Diagnostics is a national priority project of the Heart ImprovementProgramme focusing on reducing the waiting times for all non-invasive diagnostics andachieving the maximum wait of two weeks.

The projects ran over the period June 2007 to March 2008.

Key learning from the project is available in the following formats:

1. Project summaryThis document includes a description of the national project, supporting informationgained throughout the period of the project and key learning from the project.

Project summaries include issues to address, actions taken and key results/outcomes fromthe 20 hospital/departmental sites participating in this work.

Contact details are included to provide additional information with regular updatesavailable on the website at: www.improvement.nhs.uk/heart.

2. Presentations at National Conference 8 May 2008Copies of presentations from the speakers at the conference are available on thewebsite www.improvement.nhs.uk/heart

3. Web based resourcesProject team members found this a very useful opportunity to share learning across thedifferent project areas. These are now available to share on the improvement website at:www.heart.nhs.uk/priority_projects

These are categorised into three chapters:1. Improving Capacity, Demand and Flow2. Workforce and Changing Roles3. Communication and Information

Content includes:• Improvement stories• Job descriptions• Templates• Questionnaires• Survey examples

Additional information will be included as it becomes available and existing materialsregularly updated.

Further information and updates email: [email protected]

318 Weeks - Focus on Cardiac Diagnostics

ContentsIntroduction

Key Learning

Project Summaries

Reduction in Cardiac Diagnostic Waiting Times - Surrey & SussexHealthcare NHS Trust

East Lancashire NHS Hospitals Cardiac Diagnostics Project

Cardiac Diagnostics Improvements - Royal Surrey County Hospital

Focus on Cardiac Diagnostics - University Hospitals of MorecambeBay NHS Trust

18 Weeks - Focus on Cardiac Diagnostics - Ashford & St Peter’sNHS Trust

Mid Yorkshire Acute Trust Cardiac Diagnostics Project

Making a Difference to Physiological MeasurementDiagnostic Services – Achieving 18 Weeks - Heatherwood &Wexham Park NHS Trust

Reducing Cardiac Diagnostic Waiting Times to Meet the 18 WeekTarget - Milton Keynes Hospital NHS Foundation Trust

Reducing Echo Waits to Two Weeks - Queen Elizabeth HospitalNHS Trust, Kings Lynn

Technical Cardiology – Improving Access to Diagnostic Services -Southampton University Hospitals NHS Trust

Project Team

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www.improvement.nhs.uk/heart

4 18 Weeks - Focus on Cardiac Diagnostics

Introduction


This project was a natural follow on fromthe work with the Department of Health(DH) to develop “Transforming CardiacDiagnostics”. The DH project gathered awealth of information on the currentposition, and produced a guide containinggood practice, innovation, and advice oncommissioning, workforce, technology andservice improvement.

The Focus on Cardiac Diagnostics Projecthas taken the work done on that documentthrough to practical implementation anddelivery with a number of hospitalsfocussing on their cardiac physiologydepartments.

Aim and scope:The aim was to:

• reduce the waiting times for all non-invasive diagnostics – in particular thewaiting times for echocardiography –beyond the existing 18 week trajectory(six weeks by 31 March 08), aiming toachieve a wait of two weeks by 31March 2008 in the participating sites

• reduce in-patient waits (particularly forecho) to same or next day service

• help all trusts meet the six weekmilestone by March 2008 (by sharinglearning via the 30 cardiac networks)

• Improve awareness and engagement ofdoctors and senior managers in cardiacphysiology and associated workforceissues.

The project worked with 20 hospitalsites/departments in nine cardiac networksoverall and in particular with 17 hospitalsites/departments in six cardiac networks,for an intensive period. A range of qualityimprovement methodologies were used tobring about accelerated improvement.Individual projects were aligned with the


particular hospital and network’s own 18week strategy. Five workshops were heldwhich offered help in developing practicalskills in service improvement and sharedideas and good practice. Participating siteswere expected to work with their networkand with the NHS Heart ImprovementProgramme team to spread the learning toother sites within the network.

In order to be accepted as a project site, anumber of criteria had to be met:

• Identification of hospital site/diagnosticsdepartment with commitment from thatorganisation to work on the project untilMarch 2008 and be a demonstration site

• Agreement of senior cardiac physiologistto work on the project and to participatein service improvement activity, datacollection and analysis

• Commitment of dedicated networkproject manager resource of one day perweek

• Commitment of a consultant cardiologistfrom the site to be the clinical‘champion’

• Commitment of attendance at a minimumof four action learning set workshops forsenior cardiac physiologist and networkproject manager

• Identification of a spread strategy withinthe network

• Contribution to the development ofproducts and other communication mediawhich will evidence sustainableimprovement

• Legitimately report the gains whereimprovement is measurable.



Anticipated Outcomes:• Improved utilisation of capacity• Reduction of waiting times• Streamlined clinical and administrativeprocesses

• Improved patient and staff satisfaction• Production of a final report detailing thelearning, outcomes and achievements.

Recorded outcomes (based on officialDH data available for nine sites only –August 07 – Jan 08)• All sites who worked actively on theproject showed a marked reduction inwaiting times. (see table below) – inproject sites, the numbers waiting overthree weeks reduced by 69% comparedto 50% nationally

• Projects showed a substantial reduction innumbers waiting for echo (in project sites,the numbers waiting reduced by 25%compared to nationally 9% reduction)

• Case studies from the projects have beenuploaded to the 18 weeks website

• A large number (148) of changes andimprovements have been recorded andshared via the web based resource.

Summaries:The following summaries give an overviewof the work of some of the projects. . Moredetailed information, including improvementstories, reports, policies and procedures isavailable in a web based resource at:www.heart.nhs.uk/priority_projects/focus_on_cardiac_diagnostics/diagnostics.html


Project Sites

Non Project Sites

National Figures

Aug 07 Feb 08

2341

% Reduction

Total on waiting list

36571

38912

1664

32134

33798

29%

12%

13%

Aug 07 Feb 08

1344

% Reduction

Numbers waiting over 3 weeks

15777

17121

248

6850

7098

82%

57%

59%

Key Learning



• Leadership is crucial to success – management,consultant or senior physiologists have shownleadership in successful projects

• Data – only when you have sound data aboutyour demand, capacity, activity, staff, andclinics can you understand your service

• Engage all the team (including seniorclinicians) to avoid anyone feeling threatenedby change, ensuring that good ideas fromstaff are included. Good communication at alltimes really helps

• Go for a one-stop approach wherever possible• Administrative processes are key to good flow• Look at all aspects of capacity, for example,clinical templates and timings and machineuse

• Review and address issues around workforceand skill mix

• Demand management (not just reduction) isneeded to reduce variation

• Don’t forget the inpatient work – it needsscheduling

• Don’t forget the patients – their views areimportant and helpful in designing the service

• Use texts and phone reminders to reduceDNAs

• Use your PAS or departmental systemeffectively – get help to do this.

In working on these projects we have beenstruck by how the application of simple serviceimprovement tools can bring about bigimprovements. The effectiveness of doing veryfocused work in a relatively small departmenthas been surprising. There is still much to bedone – to not only share these messages but toencourage the application of the learning morewidely. Cardiac diagnostics departments are stilloften the ‘backwater’ of cardiology and cardiacphysiologists profile needs to be raised. Let’sensure we continue to “focus on cardiacdiagnostics” in our future work.


Summary of key learning from Focus onCardiac Diagnostics Projects



Project Summaries


Issues to address• Delays in the process of booking

appointments. Process mapping revealedmultiple steps in the booking process. Thesesteps were variable length of time and therewere multiple queues. Some tests werebooked up to 10 days after referral date andup to seven days of received date.Appointments were not always booked indate order

• Wasted capacity was identified. Demandand capacity studies revealed that not all slotsfor appointments were booked. For example,with echocardiograms, an average of 27 slotsper week were identified as not utilised.Appointment templates did not always reflectworking hours of staff

• Clinic templates were carved out for inpatient, outpatient, urgent etc. This led tomultiple queues

• Highly skilled staff were performingduties that other staff could undertake,for example, sonographers were not onlyperforming and reporting on echocardiogramsbut also telephoning porters and wards,printing repeat test results, or receivingtelephone calls regarding patient requests

• Waiting lists not validated and managedby staff. No one person accountable forvalidation of wait lists or ensuring demandmatches capacity on a weekly basis. Staff didnot generate their own waiting reports noranalyse findings. Patients with long waitingtimes were not flagged up to managers

• DNA rates higher than the nationalaverage. 2 – 25% per test. Average 11%.

• Staff did not work as a team. Staff did notrotate roles, within a specialised field, and theyoften worked in isolation of others.

Baseline positionWaiting times July 07Echocardiograms 6 – 8 weeksExercise Tests 4 – 6 weeksCardiomemo 4 weeks24hr ECG 4 – 6 weeks24hr BP 2 weeks

DNA ratesAverage 11%2- 25 % per testDemand for each test was greater than capacity.

Reduction in Cardiac Diagnostic Waiting TimesSurrey and Sussex Healthcare NHS TrustEast Surrey and North Sussex Cardiac Network

Actions taken• Reduced the number of steps in booking

process for all tests. All tests are nowbooked on the day of receipt of referral.Appointments are primarily booked on onehospital site

• Implemented new clinic templates.Simplified new schedule by separatinginpatient and outpatient schedule. Urgent slotsremoved. Adjusted ratio of inpatient tooutpatient slots to meet demand. Adjustedtemplates to reflect working hours of all staff.Utilised an additional second echocardiogramroom for booked outpatients, portablemachine was used. More in-patients scannedin the department, rather than on the ward.Patients scanned on ward were identified astaking longer than those scanned in room

• Implemented echocardiogram assistantrole to improve patient flow through thetwo echocardiogram rooms. This role wasutilised to triage all referrals for level ofurgency, telephone wards to check patientavailability and prepare patients before andafter test. This role was undertaken bycardiographers on a rotational basis andessentially increased time of sonographers toundertake more echocardiograms

• Designated a person responsible forvalidation and management of wait lists

• Demand and capacity studies identifiedadditional kit and manpower required toreduce wait times

• Telephone DNA survey undertakenidentified that the main reasons for non-attendance were due to either to:a) The patient not receiving an

appointment letter due to incorrectaddress on database or due to delays inpostal system, as reported by patient or,

b) The appointment not cancelled by thehospital, when either consultant nolonger required investigation or patienthad already had test at another hospital oras an inpatient. These accounted for 69%of DNAs



As a result the following changes weremade:

a) Changes to the booking processes– All patients encouraged to bookappointments at time of clinicappointment– All other requests booked on day ofreferral received– If letter is required to be sent out – allletters are sent out a minimum of 14 daysprior to appointment date– If appointment date within 14 dayspatients are telephoned– All patients details are checked on database via outpatient clinic– All planned appointments put on waitinglist and letter sent out 6–8 weeks priorto appointment

b) Review of DNA policy andappointment letters reviewed – Allpatients are telephoned if they DNA. Oneappointment then if the patient DNAspatient is referred back to referrer

• Patient satisfaction survey identified thatpatients primarily wanted choice inappointment bookings rather than beingsent appointment. This led to the casebeing made for administrative support for atelephone booking line.

Key results/outcomes• Wait times for all tests reduced withoutadditional manpower or kit

July 07 Mar 08Echocardiograms 6-8 weeks 3-4 weeksCardiomemos 4 weeks 2 weeksExercise Tests 4-8 weeks 4 weeks24hr ECG 4-6 weeks 3-4 weeks24hr BP 2 weeks 2 weeks

• DNA rates for tests were reduced from0-25% per test to < 8.5%

• Reduced backlog of echocardiograms by222 patients, with no additionalmanpower or kit, by implementation ofcardiac assistant role and redesign of clinictemplates

• Capacity now closely matches demand.Echocardiogram wasted capacity reducedfrom 27 to 3 slots per week on average

• Prior to implementation of changes –wasted capacity 27 slots per week.

Contact informationSue Cottle, Service Improvement ManagerEmail: [email protected]




Issues to addressEast Lancashire Hospitals NHS Trust serves apopulation of approximately 500,000 people.In August 2007, the inpatient and outpatientcardiology services were spread across the twoacute hospital sites (Royal Blackburn Hospital (RBH)and Burnley General Hospital (BGH). In addition,RBH and BGH offered a direct access service forEchos, ECGs and 24 hour tapes to primary care;whilst at Rossendale General Hospital (RGH) anECG service was offered to both primary care andthe mental health trust.

In November 2007, the trust underwent a majorreconfiguration of clinical services. The plannedresult was for one of the acute sites to continue todeal with all emergency work, (RBH) whilst theother major site dealt with planned , elective work.The effect on cardiology services was that coronarycare and inpatient cardiology would be based atone site only (RBH) whilst diagnostic services wouldcontinue to be offered at all three sites.

This change coincided with the opening of a newcardiac catheter laboratory (CCL) at RBH and therecruitment of three new interventional cardiologyconsultants. However, there was no furtherplanned investment in cardiac physiologist (CP)recruitment.

Problems specific to the diagnostic departmentincluded a lack of appropriate administrativesupport at BGH; an absence of a unified, electronicsystem for real time mapping of activity; a surfeitof unfilled vacancies across all sites; the actualdemand on the service had not been quantified,and hence the change in demand following theservice reconfiguration could not be anticipated.

It was difficult to determine what the actualwaiting time for a diagnostic procedure was as noconsistent system existed to allow proper analysis.However, the waiting times for an echo at eitherRBH or BGH were known to be “in excess” ofthree months.

Actions taken• Demand mapping was performed, in order toquantify the various sources of investigationrequests

• Process mapping of both departments

• The implementation of a PAS based electronicsystem across RBH and BGH whichincorporated real time analysis of waiting times,allowed validated coding of activity undertaken,which in turn led to the generation of accurateinvoices

• Implementation of a TOE service• Implementation of a pacemaker insertion service• Increased administrative support• Workforce skill mix analysis and planning• Recruitment to vacant post• Redesign of administrative procedures• Rationalisation of the service available from RGH• Locum to clear backlog• Extension of ATO roles

Key results/outcomesThe departments had no robust electronicsystem, therefore had no idea of how manyecho patient’s were in the system at any onetime. The graph below shows the number ofpatients waiting for an echo. Note: Electronicsystem was introduce in October/November.

East Lancashire NHS Hospitals Cardiac Diagnostics Project:From Three Months to Three WeeksEast Lancashire Hospitals NHS Trust (Royal Blackburn Hospital, BurnleyGeneral Hospital, Rossendale General Hospital)Lancashire and South Cumbria Cardiac Network


• Waiting time for an echo now stands at underfour weeks at both sites

• Electronic system can map demand on a realtime basis

• Extension of ATO role• New TOE and pacing service• National target of six weeks wait for diagnosticsachieved 31 March 2008

• Team development programme

Contact informationJennifer WattsEmail: [email protected]


Issues to address• Waiting times for cardiac tests varied fromthree or four weeks up to 13 weeks.Echocardiography had some of the longestwaits and a backlog of 249 patients

• The booking process was coordinated througha central bookings service; this meant thatcardiology had less influence/control over theprocess

• There was a large amount of rescheduling bypatients and the hospital, and a higher DNArate (up to 25%) than the target

• Capacity was insufficient to meet the demandfor some tests while for others lack ofequipment was the main concern

• Templates did not reflect all the work actuallyperformed

• Some sessions for echo had four patientsothers six, this needed standardising.

• Skilled technical staff were regularly involvedwith administrative duties

• There was not enough equipment forambulatory monitoring.

Actions taken• Process mapping to look at the wholepathways for all tests

• Redesigned the administration department tobook all tests within cardiology instead of acentral bookings office

• Examined demand and capacity for all clinics.• Adjusted templates to ensure enough slotswere available to meet the demands.

• Added extra clinics where required• Examined workforce and recruited wherepossible

• Utilised a locum to clear echo backlog• Changed bookings process so patients arephoned for an appointment. Introduced directaccess to make bookings

• Devised plan to move towards one stop wherepossible

• Adjusted IT systems to capture all work, andmade ambulatory monitoring templatesflexible

• Bought new equipment for the department• Revised technicians job descriptions to ensurethat those inappropriately on a band five weremoved to a six.

Key results/outcomes• Ordinary echo reduced to 0-2 weeks byNovember

• Other tests for ambulatory monitoring are allwithin three weeks (most within two weeks)with further adjustments to make to reachtwo weeks.

• Reduced DNA rate• Less waste• Greater control of bookings.

Cardiac Diagnostics Improvements: Two Week WaitsRoyal Surrey County HospitalWest Surrey Cardiac Network


Echo backlog at start of project

Contact informationClaire JohnsonEmail: [email protected]

DNA rate for 24hr Tape – nowmaintaining at 7%

• Dispatch of CIU results to take place twicedaily 11.30am and 4 pm. This has led toimproved patient flow and has potentiallyimpacted on reduced length of stay forinpatients.

• Medcon link was implemented across all sitescentralising reporting and accessing resultsand images. This improves reportingturnaround and impacts on overall efficiency.

• Daily waiting list management ensures allavailable slots are filled at mutually agreedshort notice.

• Trialled flexible working days to extend use ofEcho machine.

• Extra portable echo machine was acquired forFGH.

• Addition of recently BSE accredited cardiacphysiologist.

• Successful bid for British Heart Foundationechocardiography student.Employed bank echo physiologist to covershort absence notice and sustain short waitingtimes.

• Commissioned independent sector to performexcess echo waiting list to reduce back log andallow service redesign and ensure capacity anddemand were balanced.

• Extra stress testing slot on each sessionimproved capacity and maximised resources.

• Support of services by a nurse led position andfunding secured for a substantive post.

• Daily capacity management of Ambulatorymonitoring, hook-up and analysis.

• Senior physiologists to dispatch normal openaccess results with guidelines and supportfrom the consultant cardiologists. Thisreduces demand on the cardiologists and morefully utilises the highly skilled physiologyworkforce.

• Role redesign by training assistant technicalofficers in ambulatory hook-up reducesdemand on the highly specialised physiologyworkforce.

• Opening Friday sessions for ambulatorymonitoring hook up and arranging return ofmonitors to ward over the weekend increasescapacity and reduces overall waiting times.

• Introduction of One Stop at Royal LancasterInfirmary and Westmorland General Hospital.Aim to implement at FGH in May 2008.

• Workforce and skill mix review completed forcardiac physiologists.

Issues to addressUniversity Hospitals of Morecambe Bay NHSTrust consists of three sites, which cover an areaof 1000 square miles. Each Cardiac InvestigationUnit (CIU) worked in isolation as cross-siteworking appeared an inefficient use of staff timeand historically was rarely performed leading tostaff and site isolation. Waiting times for CardiacInvestigations was over 18 weeks and this wouldinevitably impact on achieving the 18-weekreferral to treatment time for cardiac and non-cardiac pathways. A private sector company hadbeen commissioned to reduce the echo waitingtimes from 20 weeks and this highlighted theneed for service improvement and attainmentand sustainability of short waiting times forcardiac diagnostics. The trust already had plansto introduce one-stop clinics to aid reduction inwaiting times on the patient pathway.

Maximum waiting times for echocardiography inMay 2007 was 47 weeks.

Actions taken• Process maps performed at each site.• Demand data collected over 4 weeks.• All cardiac diagnostics waiting times

measured.

This resulted in:• Redesign of administrative staff workingpatterns to ensure all clinical sessions werecovered.

• Aim to reduce DNA rate and increase patientchoice by implanting trust policy by arrangingmutually agreed appointment times.

• Patients were encouraged to bookappointments directly with the CIUdepartment introducing and increasing patientchoice and potentially reducing DNAs.

• To reduce length of stay for inpatients,diagnostic tests, that were suitable to beperformed as outpatients, were requested andappointments given prior to discharge. Thiscould not have been achieved without shortwaiting times and has led to an increase inpatient choice as well as overall efficiencyimprovements.

Focus on Cardiac Diagnostics: Maximum Two Week Waits AchievedUniversity Hospitals of Morecambe Bay NHS Trust (Royal LancasterInfirmary, Westmoreland General Hospital, Furness General Hospital)Lancashire and South Cumbria Cardiac Network



• Sustainability score and report produced.• Communication plan and stakeholderinvolvement identified.

• Cross Bay, multiple site working for cardiacphysiology staff ensured all diagnostic sessionswere covered and improved efficiency ofservices across the trust.

Key results/outcomes• Sustained two week wait for all

diagnostics• Cross site working• One stop clinic implementation• Reduced DNA rate• Impacts on overall 18 week targets.

Results: Waiting times



include graph and text bulletsunder issues to address

Contact informationLauren ButlerEmail: [email protected]

Results: Number of patients waiting

18 Weeks - Focus on Cardiac DiagnosticsAshford and St Peters NHS TrustWest Surrey Cardiac Network

Issues to address• Echo waiting list and wait times: Echo waits>12 weeks with high inpatient demand andbacklog for echo = > 350. High DNA rate forecho

• Rapid access chest pain clinic waits > 5 weeks– target not met

• Data collection• Booking• Inaccurate waiting list• Inconsistent booking process

Actions taken• Project team established July 2007• Project plan and time line developed• Service improvement tools and techniquesapplied – process mapping, demand &capacity, data analysis and collaborative teamwork

• Base line data collection to establish currentwaiting list and times for diagnostics and chestpain clinic

• Validation of waiting lists• Audits – DNA, workforce and patientsatisfaction questionnaire

• Departmental workshop to review findings andengage all members of department in serviceredesign

• Training on booking system – prism to includeupgrade

• New Inpatient echo guidelines – circulated toall wards and on intranet

• New clinic templates for echo and ETT• New echo clinic on ward to increase capacityand utilise equipment to its full capacity

• Recruitment of second receptionist• Securing of SHA funding for trainee posts• Successful BHF bid for trainer across Surreyand Sussex

• New associate practitioner post• Chest pain clinic – new booking systemthrough central booking. New documentationto include referral form, outcome letter andpatient information leaflet. Name change tochest pain clinic to avoid confusion with RACand subsequent launch. All documents sentelectronically to GPs

• Nurse led chest pain clinic pilot in progress –to increase capacity.

Key results/outcomes• Accurate data collection and improved waitinglist management

• Improved booking and DNA management• Staff trained in booking and haveunderstanding of importance of 18 weektargets

• Echo waits down to all within six weeks andmajority within 2-3 weeks (included TTE, TOEand bubble studies)

• Echo waiting list down from 350+ to 170which meets capacity

• Increased echo capacity from 89 slots perweek to 150 which is > then recommendedcapacity

• Designated IP slots – improved IP managementtherefore IP waits < 48hrs

• Chest pain clinic – 100% patients seen < 2weeks for last quarter Jan – March 2008

• Prism upgraded to version 7• PAS/Prism link in progress• New treadmill purchased to increase capacity• SHA trainee funding secured for 2008/9• Recruitment for BHF Trainer post in progress.

The diagram below demonstrates reduction inwaiting list during project. This includes allroutine patients with booked and pending anappointment.




The diagram below demonstrates the reductionin waits times with significant change from startof project. There was an increase in patientswaiting >6 weeks in January due to reducedcapacity. February saw the introduction of theextra clinic hence reduced waits > 6 weeks.

Special thanks to all the members of the teamfor their commitment and hard work which hasmade the project a success and in particular, DrIan Beeton, Consultant Cardiologist, Ashford &St Peters NHS Trust.

Contact informationAlex Bennett (Service Improvement Manager)Email: [email protected]



Issues to addressThe acute trust had three sites providing noninvasive diagnostics. There was little coordinationacross the sites, who operated as separatedepartments. The three teams had not metpreviously as a single group. Waiting times wereexcessive with problems maintaining 13 weekwaits for echocardiography. Managers wereusing patient tracking and booking any potential13 week breeches causing new referrals to waitlonger.

The staff were very demoralised and felt bothundervalued and penalised by the trust. Aprevious piece of work had resulted in the lossof three posts across the sites which made staffvery wary of involvement in this project.Waiting times for tests were the worst in theregion and the trust had all the long waiters forechocardiography regionally and were underpressure from the Yorkshire and Humber SHA.This was on top of issues with invasivediagnostics. The departments did not offer staffcover to other sites to help maintain capacity.

Actions taken• We organised a cross site meeting by closingthe department on a Friday afternoon andinviting all staff to attend a meeting “offtrust”.

• Everyone attended and we arranged follow upmeetings in December and February tomaintain momentum.

• We undertook a staff survey to canvassopinions on current issues around bettercoordination of services cross trust and staffmorale. This will be followed up by a secondsurvey in early April 2009 to assess anychange.

• 202 patients completed a patient survey oftheir views on current services at each of thethree sites.

• Each site set up methods to collect demanddata and use this to better plan capacity toreduce and sustain improved waits.

Key results/outcomes• The cross site meetings generated greatenthusiasm which was harnessed to engagestaff in tackling the problems of waiting times.Currently 70% of tests are undertaken within14 days of referral and no patient is waitinglonger than 4 -5 weeks unless through choice.This is a remarkable improvement in such ashort time.

• The staff have established a mechanism for thesites to cross cover absence. This uses thedemand and capacity work which allowsweekly assessment of where capacity is at riskand the department heads liaise to ensurepotential lost capacity is minimised.

• The patient survey was very appreciative of thestaff and their level of service which wasreported to the staff. Issues arose aroundaccess and other trust issues which werehighlighted to management.

• The staff survey provided a good baseline ofstaff feeling. This will be compared to a repeatsurvey to assess any changes. It was importantto undertake this survey as staff originally feltundervalued particularly by the trust and veryseldom do we stop to ask their views. It isclear that this has helped with staffengagement which will be tested using thesecond survey.

• The feedback helped departmentalmanagement secure funding for a newphysiology post (will be a trainee with band 6post when qualified). This is a major success asthe trust has had no trainees for several years.

• The success of this work has alloweddiscussion on wider issues and further work onimproving referral and booking processes aswell as scoping “one stop” clinics is alreadyplanned for early April 2008.

Thanks to all staff and managers for theirefforts. It is they that have delivered success inthis work.

Contact informationGed OliverEmail: [email protected]

Mid Yorkshire Acute Trust Cardiac Diagnostics Project:70% of Tests Achieved Within 14 DaysMid Yorkshire Acute NHS Trust (Dewsbury District Hospital, PinderfieldsGeneral Hospital – Wakefield, Pontefract General Infirmary)West Yorkshire Cardiac Network



Issues to addressHeatherwood and Wexham Park NHSFoundation Trust is unique in that it is amultisited trust. The trust serves a population ofapproximately 500,000 in an area with a highprevalence of coronary heart disease. Over thelast 4–5 years we have developed our servicesand repatriated the work that was traditionallydone in a tertiary centre.

We had a large problem in long waits for alldiagnostic tests.

Actions taken1. Data & validation• Validating date – Implementation of a‘gatekeeper’ to ensure referrals are correctlycategorised

• Validation of backlog leads to slots,identification and improved referral criteria.

2. Demand & capacity• Regular review of demand and capacity led toincreased efficiency

• Admin staff informed of building waits leadingto ‘flexing’ of clinical sessions to preventbacklog

• Cross site scheduling and daily capacitymanagement

• Reviewed referral guidelines for both trust anddirect access from GPs.

3. One-Stop• One-stop model rolled out to five sites• Introduction of Saturday one-stop clinic to cutdown backlog.

4. Booking• Improved booking for booking management• Referral form reviewed with RTT and follow upstatus

• Electronic booking form redesigned• Improved booking for echo improves flow• Week by week review of booking systemaccommodates fluctuations in referral patterns

• Clinic templates redesigned• Rolled out electronic triaging for outpatientreferrals – request tests on same day oftriaging electronically.

5. New kit/kit use• Increased use of portable echo machinereduces wait and inpatient stay

• Additional 24 hr ECG, 24hr BP monitors andevent recorders procured that have increasedefficiency

• More efficient daily use of ECG/BP monitors(including Saturdays).

6. Reduction in waiting times• Echo, ETT, 24 ECG and BP monitors, eventrecorders waits down to two weeks.

7. New services• Electrophysiology clinic to start in May 2008• Heart failure clinic (One Stop) to start inJune 08

• Cardiac synchronisation through echo to startin August 2008.

8. Workforce and changing roles• Saturday clinics for OPD work and otherdiagnostic tests

• Staggered working hours – change accordingto needs of service and to make efficient useof equipment.

9. Workforce reviews and changing roles• Skill mix in cardiac physiologists encouragedthrough support in BSE accreditation

• Overseas recruitment• Successful bids from SHA for student cardiacphysiologists, currently two SHA funded andone trust funded.

• Review of establishment in March 08 due torapid expansion if service.

10. Admin and reception staff• Receptionists validate waiting lists• Multiskilled receptionists – undertake senioradmin role, trains other staff local and cross-site, booking, collects data, demand andcapacity management and receptionist.

11. Patient information and communication• Comments box available in unit• Patient and Public Information forum to reviewaccess to cardiology

• Patient representative in LEAN project on heartfailure.

Making a Difference to Physiological MeasurementDiagnostic Services – Achieving 18 WeeksHeatherwood and Wexham Park NHS Trust (Wexham Park Hospital,Heatherwood Hospital, King Edward Hospital, St Marks Hospital)South Central Cardiac Network



12. Staff communication/information• Active encouragement for staff to ‘buy-in’ tochanges and improvements

• Team committed to achieve the 2 weeks targetfor diagnostics.

13. Guidelines and documentation• New ‘one’ request form for all cardiology tests• Guidelines posted on intranet• Guidelines reviewed in Oct 2007 andincorporated at back of new form.

14. Electronic communication/information• Encouragement of electronic referral withinTrust rolled out

• Looking into reporting into MEDCON.

Key results/outcomesWaiting times for most of the tests are withintwo weeks.

Electrocardiograms (ECGs)• All GP practices in East Berks have ECGmachines and perform their own ECGs. Thedepartments at Wexham, Heatherwood and StMarks have physiologists to provide an ECGservice to patients in secondary care. Wherethere is no physiologist cover, nurses aretrained to perform ECGs in clinics and on thewards.

24 hr Ambulatory ECG and BP monitoring• Direct access to GPs whose patients require 24hour monitoring. This is supported by robustreferral criteria. Once the result has beengenerated, it is sent back to the GP.

• The same is offered to secondary care patients,this time with the result being sent back to thereferring consultant within the trust.

• Extra 24 hr Ambulatory ECG monitors werepurchased in Sept 2007 that have helped inclearing the backlog and has been able tomaintain the wait within <2weeks.

Event monitoring• Patients are referred from secondary care.They have a monitor fitted for seven days andthen return the monitor for analysis. GPssupported with “Invest to Save” projectsfor monitoring in primary care (still inplanning stage).

• Extra event monitors were purchased inSeptember 2007 that have helped in clearingthe backlog and has been able to maintain thewait within <2weeks.

Transthoracic and TransoesophagealEchocardiography• The echocardiography department providescardiac ultrasound imaging for patients fromall specialities within the trust. In addition totransthoracic echocardiography,transoesophageal echo is also performed. Atpresent we perform around 6,500 echoes peryear over four sites. The majority of cardiologyclinics over four sites are covered with “OneStop” echocardiography.

• Provision of a direct access echo serviceto GPs, again supported by robust criteria asdiscussed with the lead cardiologist. Resultsare sent back to GP with technical report anda conclusion for easier interpretation.Ongoing work between secondary andprimary care to support education to GPs ininterpreting results.

Pacing Follow-Up• Around 2,000 pacing patients are receivingfollow up. Many were repatriated from thetertiary centre (single/dual chamber andcomplex devices) and the others from newimplants.

• To cope with the demand, we are currentlyholding pacing clinics on a daily basis with acomplex device clinic on a Friday which isconsultant/physiologist led.

Exercise Tolerance Testing• Service provided to inpatients, outpatients andas “One Stop” to support the Rapid AccessClinics and Chest Pain Clinics.

Contact informationSuzanne Burrows; Usha BalasubramaniamEmail: [email protected]: [email protected]



Issues to addressWaiting times for cardiac diagnostic tests neededto be significantly reduced in order to achievethe 18 week target, which was implemented inApril 2008.

It was recognised that cardiology impact onother specialties and so reductions needed to bemade and be sustainable.

Actions taken• Initial validation of waiting lists• Development of action plan, with monthlymilestones

• Use of additional lists• Firebreak clinic every eight weeks• Working patterns redesigned to ensuremaximum utilisation of resources

• LEAN project started in June 2007• Patient pathways streamlined• Implementation of Cardiology Action Team toensure there is continuous improvement.

Key results/outcomes• Waiting times have been reduced toapproximately two to four weeks for tests

• New ways of working have been implemented• Staff have ownership of targets andachievement of these.

Contact informationAlison GowdyEmail: [email protected]

Reducing Cardiac Diagnostic Waiting Times to Meet the 18 Week TargetMilton Keynes Hospital NHS Foundation TrustCentral Southern Cardiac Network



Issues to addressWork started on reducing echo waits in July2005 with monthly capacity and demand figuresinforming progress. By July 2006 the wait hadfallen from 25 weeks to six weeks. But here itreached a plateau with a lack of ideas toimprove the service further without spendingmoney.

At July 2007 the wait for echo was six weeks.Monthly capacity and demand continued to berecorded.

Actions takenA generic support worker, band 3, wasemployed for a year.

Duties include:• 50% administration: manning the receptiondesk, booking appointments face to face withpatients and completing patient paperwork.

• 50% patient support: helping dress andundress, checking personal details, givinginformation and generally ensuring theequipment was ready for use.

The new position released the departmentalclerk to:• move from a postal appointments system to atelephone system as waiting times fell

• spend time checking clinic lists to be sureevery slot is filled, even at very short notice.

Key results/outcomesEcho wait dropped to three weeks byNovember 2007.

Regrettably this was not sustained due to:

• a newly appointed additional consultantincreasing the workload by 30% and

• the loss of two full-time echo technicianswhich we have been unable to replace.

We are now confident that we can deliver atwo week wait:• given the cardiac physiologists and assumingwe will be able to retain the generic supportworker.

Contact informationJane McQuadeEmail: [email protected]

Reducing Echo Waits to Two WeeksQueen Elizabeth Hospital NHS Trust, Kings LynnAnglia Cardiac Network



Issues to addressAs a department with generic/specialist workingand a high productivity level per staff member,the introduction of diagnostic targets imposedincreased pressure on a service which alreadyhad a very fragile balance between servicedemand and capacity.

Historically, interdependence on resourcesbetween specialist divisions (echo,cath lab, EP,implantable devices) meant that service pressurein one area impacted on other service areas. Thisbeing the case it was apparent thatimprovement in one area was also likely to havebeneficial impact. With this in mind, a wholeservice review was undertaken and the issuesdemonstrating commonality addressed. Theseissues were surrounding:

• clinic organisation• workforce• administration• information technology• equipment utilisation

(*some of the processes listed were in placeprior to the start of the project but werecontinued in support of the project).

The baseline position at the start of this project:• Diagnostic waiting times not achieved e.g.echo waits:- inpatients up to five days- outpatients 17 weeks- open access echo 30 weeks

• Insufficient capacity for timely implantabledevice follow-up

• Significant delays in processing results• Unnecessary duplication of administrativefunctions

• Sub-optimal use of equipment -availability ofequipment affecting service provision –equipment downtime affecting diagnosticwaiting times

• Lack of training time to develop staff inspecialist areas, especially EP.

Actions takenClinic organisation• Weekly review of capacity versus availableworkforce to ensure optimisation of clinic time

• Introduction of manufacturer specificimplantable device clinics to utilise supportfrom industry (at no additional cost) and freeup clinical physiologist time for training

• Triage of all requests to ensure appropriateclinic allocation/appropriateness of referral

• Agreement for ad hoc waiting time initiativeclinics outside of normal working hours tosmooth out any unplanned variations in theservice provision.

Workforce• Implementation of a rolling trainingprogramme with a supporting infrastructure inthe form of a dedicated clinical tutor (plusclinical skills laboratory)

• Staff appointments from overseas organisedusing:- expertise from HR department- specialist agency- teleconferencing- competency framework

• Utilisation of an improved skill mix with theappointment of HCAs

• Improved inpatient capacity throughemployment of a dedicated porter.

Administration• Centralisation of the administration support toprovide improved backfill in times ofsickness/holiday etc (therefore removing thetime commitment required by the clinicalphysiologists to manage the administrativestaff)

• Allocation of ownership of specificresponsibility to a named administratorcreating better continuity of tasks.

Technical Cardiology – Improving Access to Diagnostic ServicesSouthampton University Hospitals NHS TrustCentral Southern Cardiac Network



Information technology• All requests made and results recorded vianewly developed module(designed by clinical physiologists inconjunction with corporate information team)linked to hospital administration system

• Acquisition of database supporting remotedata management

• Acquisition of a digital archiving system tofacilitate echo review without having to tie upecho machine.

Equipment• Introduction of extended working days tooptimise equipment use

• Investment in two portable echo systems.

Key results/outcomes• Reduced echo waits- inpatients seen in 24-48 hours- outpatient waits two to three weeks- open access waits six weeks

• Increased capacity for patients withimplantable devices on remote follow-up fromeight slots per clinic to 24 per clinic thereforefacilitating appropriate follow-up intervals

• Zero vacancies on clinical physiologist posts asof 19 April 2008 – staffing levels willfacilitate improved training time

• All other diagnostic procedures performedunder six weeks and diagnostic waiting timessustained

• Streamlined administration service - reducedDNA rates

• Improved access to patients results forreferring clinicians reducing duplication ofresult processing and reducing queries for theadministration staff.

Contact informationKaren TaylorEmail: [email protected]


Project Team



National Team Members

Julie HarriesDirector, NHS Improvement

Linda BinderNational Improvement Lead, NHS Improvement

Sarah Armstrong-KleinNational Priority Project Manager

Dr Mark DancyNational Clinical Chair

Dr Strat LiddiardNational Clinical Lead

Project Managers andSenior Chief Physiologists

Lancashire and South CumbriaCardiac Network:Project Managers:Lauren Butler, Jennifer Watts, Julie Seed

Senior Chief Physiologists:Kay Smith (Morecambe Bay)Gill Corteen (East Lancashire)

West Yorkshire Cardiac Network:Project Manager:Ged Oliver

Senior Chief Physiologists:Jill Tinkler (Dewsbury)Nichola Firth (Pontefract)Linda Pilling (Pinderfields)

Anglia Cardiac Network:Project Manager:Susan Toogood

Senior Chief Physiologist:Jane McQuade (Kings Lynn)

Bedfordshire and HertfordshireCardiac Network:Project Manager:Penny Thomas

Senior Chief Physiologist:Huseyn Ahmet (Bedford)

Project Team

South Central Cardiac Network:Project Managers:Usha Balasubramaniam, Peter Loomes

Senior Chief Physiologist:Suzanne Burrows (Heatherwood and Wexham Park)

Project Managers:Alison Gowdy, Peter Loomes

Senior Chief Physiologist:Chris Barnas (Milton Keynes)

Project Managers:Karen Taylor, Kim Waterman

Senior Chief Physiologist:Diane Gardiner (Southampton)

Project Managers:Sophie Jordan, Tracy Gwyther

Senior Chief Physiologist:Lisa O’Dowda (Portsmouth)

Surrey Cardiac Network:Project Managers:Alex Bennett, Sue Cottle, Claire Johnson

Senior Chief Physiologists:Rachel Danvers (Surrey and Sussex)Gill Tyrrell, Audrey Kemp (Royal Surrey)Suzanne Brooks, Satpaul Purwaha (Ashfordand St Peters)

Leicestershire, Northamptonshire andRutland Cardiac Network:Project Manager:Ben Knight

Senior Chief Physiologist:Lorraine King (Kettering)

North Trent Cardiac Network:Project Managers:Sarah Halstead, Nicola Bolam (Sheffield)

Dorset and Somerset Cardiac Network:Project Manager:Frances Aviss, (associated project)



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NHS Improvement

NHS Improvement is a newly formednational improvement programmeworking with clinical networks and NHSorganisations to transform, deliver andsustain improvements across the entirepathway of care in cancer, cardiac,diagnostics and stroke services.

Formed in April 2008, NHS Improvementbrings together the Cancer ServicesCollaborative ‘Improvement Partnership’,Diagnostics Service Improvement, NHSHeart Improvement Programme andStroke Improvement into oneimprovement programme. With over eightyears practical service improvementexperience in cancer, diagnostics andheart, NHS Improvement aims to achievesustainable effective pathways andsystems, share improvement resources andlearning, increase impact and ensure valuefor money to improve the efficiency andquality of NHS services.

©NHS Improvement 2008 | All Rights ReservedPublication Ref: IMP/heart0003

18 weeks - focus on cardiac diagnostics project - national priority projects 07/08 summary document

Health & Medicine