Improving endoscopy turnaround time and list efficiency through implementation of a multifaceted improvement plan

ABSTRACT

Introduction Maximising efficiency in endoscopy in the face of increasing service pressure, demand and complexity of endoscopy is imperative, particularly given the unparalleled impact of the COVID pandemic on service delivery and cancer pathways. Previous attempts to improve turnaround time through introduction of a turnaround nurse have been hindered by inadequate staffing. We aimed to improve list efficiency and improve turnaround time through the application of marginal gains theory and implementation of a multi-faceted improvement plan. Methods Data was collected from electronic patient records and audit entries made by endoscopy staff. List 'actual' start and stop times were audited against 'scheduled' times. Turnaround time was assessed by a Quality Improvement (QI) Fellow, observing the endoscopy list and collecting information in real time. Results were discussed at a departmental meeting and a 4-stage improvement plan was devised and implemented. Re-audit data was collected to determine effect. Results Preliminary audit data revealed 89% of list starts to be delayed. Lists ran beyond scheduled stop times in 73%. The improvement plan saw 1) Review and re-organisation of the nursing rota. 2) Departmental commissioning of an external 'change agent' to conduct interviews with nursing and endoscopy managers and work with the QI fellow in designing a bespoke team-building day to address communication strategies and brainstorm perceived departmental issues hindering efficiency. 3) Introduction of an in-room debrief tool, to enhance situation awareness and teamwork. 4) Implementation of a multi-modal 'Nurse-led consent' training programme, combining didactic and in-situ scenariobased simulation training, measuring and recording competence using Directly-Observed-Procedural-Skills (DOPS) assessments. Re-audit data revealed improved list finish-times (49% cf. 27%) although delays in start-times remained. Median turnaround time was 10 minutes, a major improvement from a turnaround time in 20.8 minutes in 2018. Conclusions It is recognised that single improvement interventions are unlikely to result in significant, sustainable change. The aggregation of marginal gains theory dictates that small, marginal gains can add up to a remarkable improvement. Our 4-stage improvement plan saw the implementation of a revised nursing rota and a bespoke team-building day in tandem with the introduction of a 'Nurse Consent' training programme and a novel team debrief tool. In this way, we were able to implement change, whilst simultaneously assessing and addressing staff morale, engage key stakeholders and as a result significantly improve turnaround time. We plan to streamline admission and patient preparation processes to further address delayed start times in future cycles of the improvement project.