The document discusses issues with endoscopy capacity and performance at 3 sites. It notes high demand, a large diagnostic backlog, and failing targets for urgent cancer referrals. Various operational issues are contributing to problems. The general manager and others are working to improve performance using quality improvement methods, including analyzing capacity and demand data with a business intelligence specialist. Their efforts include identifying constraints, increasing flexibility, and gaining additional temporary capacity. Ongoing monitoring of key metrics will be important to guide further improvements.

1. An Endoscopy Problem
20th April 2016
Authors:
Business Intelligence Specialist – Sophie Fleming
General Manager- Charlotte Timmins

2. Background
• 3 sites- 2 with JAG accreditation
• Approximately 80 new referrals per day across the
sites
• Failing 2WW performance at 50%
• Diagnostic backlog over 1,500 patients waiting over
6 weeks
• Variety of issues contributing to this chaos

3. Issues on the ground
• Poorly utilised lists
• Phone not being answered
• Stopped partial booking
• Booking by PTL
• Electronic scheduler
• Extra capacity
• Scanning referrals
• SOP / processes

4. Methods
• Improvement methodology taught by NHS IQ to
General Manager and Matron
• Walk round with NHS IQ and interviews
• LIA with admin team
• Team planning meeting
• Weekly phone calls involving Director of
Performance
• Visit to UCLH

5. Working with business
intelligence
• On the ground we knew the operational challenges,
however Sophie provided the “fact” or
“intelligence” on where we needed to focus our
next improvement.

6. What is capacity and demand?
• A process
• A set of measures
• A balancing act
It’s about making sure that the capacity you have in terms of
people/ hours/ and slots is what you need to do (demand), taking
into account other variables such as seasonal variation and drop
off for example.

7. Demand
Requests in
Bottleneck
Constraints e.g. how
fast requests can be
processed by WL Staff
Backlog
Waiting List
Activity
What we did
Capacity
What we could do
The Process

8. 500 -100
-50 +30 -50 -15 +5 320
0
100
200
300
400
500
600
700
The Measures
In this example, 180 patients
would be added to the
waiting list
500 -320 = 180
For illustrative purposes only…
Measure Description Running Total Change
Demand Additions to the WL 500
Processing constraints WL staff can only process some of the referrals in a week 400 -100
Drop off Drop Off, inappropriate referrals, DNAs 350 -50
Rebooks New patients who cancel on the day and rebooked back in 380 30
Capacity Full capacity 330 -50
Reductions Staff on leave 315 -15
Additional capacity Could be locums temporarily taken on 320 5
Activity Patients we saw 320 -180

9. 1. Control Demand
2. Control Capacity
Controlling demand is harder as it is the element that UHL has less control over; however this has
been successfully achieved by the change of a clinical pathway, i.e. CT Colon rather than
Colonoscopy.
Two key strategies for controlling capacity:-
i) look for ways of gaining capacity within the system
ii) look for ways of increasing the flexibility of the capacity
Develop and agree ways to meet the unexpected and the expected situations
that occur e.g. add more appointment slots or clinicians as needed when demand goes
up unexpectedly.
Operational solutions

10. • Use scheduling to find and ease the constraint
• Work differently - flexible hours, weekends, pre-plan and cover annual leave,
extended roles, etc.
• Bid for resources only when constraint is equipment or staff and working differently
will not help.
• Temporary solution – external provider, if the system is too broken
Ideas for increasing capacity

11. • Process Mapping – improvements can be made to any of the
points in the process including reducing demand e.g. analysis of
where and when the majority of demand is coming from.
• Modelling - models can be as straight-forward or complex as
you want to make them. Because Capacity and Demand models
are only models, they are:-
– A theoretical guide
– Reliant on robust source data (garbage in garbage out)
– No model can give an absolute assurance of waiting times

12. Some key things to know
• Understand how the pathways work
• The nuances of the data you have to work with
• Talking to people /discussing the model is key to success
• Working in silos is a recipe for disaster

13. Why All Models are Wrong
But some are useful
October 15 1987 BBC weather
forecast
“Earlier on today apparently
a woman rang the BBC
and said she'd heard there
was a hurricane on the
way”.
"Well if you are watching don't worry,
there isn't."

14. What happened
• The Great Storm of 1987 was
the worst storm in nearly 300
years.
• Winds gusted at a speed of up
to 115 miles an hour across
the UK and France.

15. What the MET Office said:
• “We had picked up that there would be this vicious storm four
or five days in advance.
• But one of the problems is that we have a computer which has a
numerical model and we use that entirely to do the forecasts.
Because it's a global model, a very small error doesn't
necessarily show up”.

16. Endoscopy Metrics
• Daily backlog – No. Waiting 6+ weeks with and without dates
• Demand vs activity delivered – are we managing to deliver more
activity than work coming through the door?
• Demand for 2ww referrals
• Waiting List Size
• On the day cancellations / DNAs
• Cancer 2ww performance

17. Endoscopy Metrics – Pictures Speak 1,000
words
0
100
200
300
400
500
600
12/04/2015
03/05/2015
24/05/2015
14/06/2015
05/07/2015
26/07/2015
16/08/2015
06/09/2015
27/09/2015
18/10/2015
08/11/2015
29/11/2015
20/12/2015
10/01/2016
31/01/2016
21/02/2016
Weekly Endoscopy Demand vs Total Activity
Total Activity Additions Less Removals (i.e., Demand)
194
0
200
400
600
800
1,000
14/12/2015
21/12/2015
28/12/2015
04/01/2016
11/01/2016
18/01/2016
25/01/2016
01/02/2016
08/02/2016
15/02/2016
22/02/2016
29/02/2016
07/03/2016
14/03/2016
21/03/2016
28/03/2016
Patients on Gastro Diagnostic Waiting list 6+ weeks Actual vs
Target
Patients on Gastro Diagnostic Waiting list 6+ weeks Target
500
1000
1500
2000
2500
3000
Endoscopy Waiting List Size (Excl Planned)
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
2WW Cancer Performance
Upper GI Lower GI

18. Future Proofing Endoscopy Services
• Increasing prevalence of cancer
• Demographic factors; The UK population is projected to increase
to 68 million by mid-2022, equivalent to an annual growth rate
of 0.6%; the proportion aged 65 or over is projected to be
around one fifth to one quarter of the population across all
regions of the UK.
• More than 750,000 additional endoscopy procedures a year will
be undertaken by 2020 – this is more than the population of
Leeds and represents a 44% increase on 2013/14 activity.
• Demand for colonoscopy and flexible sigmoidoscopy has been
reported as doubling between 2012 to 2017.
Source: - SCOPING THE FUTURE. An evaluation of endoscopy capacity across the NHS in England

19. Future Proofing Endoscopy Services
Source: - SCOPING THE FUTURE. An evaluation of endoscopy capacity across the NHS in England

20. Any questions?