Alice Malpas CT1 Natasha Corballis FY1 James Paget University Hospital Learning To Make a Difference Project Aims To improve rate of referrals by faxed copy of an OGD report to the patient pathway coordinators PPC of suspected upper gastrointestinal GI malignancy by 100 wit ID: 1047095
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1. Referrals to the Patient Pathway Co-ordinator Following Suspected Malignancy at OGDAlice Malpas (CT1)Natasha Corballis (FY1)James Paget University HospitalLearning To Make a Difference
2. Project Aim(s)To improve rate of referrals (by faxed copy of an OGD report) to the patient pathway co-ordinators (PPC) of suspected upper gastrointestinal (GI) malignancy by 100% within a 4 month period.According to hospital guidelines OGD reports should be faxed to PPCPPC reported this did not happen.Manual searches/random referrals from UGI CNS/ConsultantsJames Paget University HospitalLearning To Make a Difference
3. Action PlanningActPlanStudyDoWhat are we trying toaccomplish?Increase same day faxed referrals to 100% in a 4 month period.How will we know that achange is an improvement?Patient pathway co-ordinator - time and energy saving. More reliable referral method.What changes can we makethat will result inimprovement?Reminder to all endoscopists.Posters in endoscopy suite.Fax number easily availableName and ShameAlter structure of endoscopy report.James Paget University HospitalLearning To Make a Difference
4. Learning To Make a DifferenceProcess mappingJames Paget University Hospital
5. Driver DiagramJames Paget University HospitalAim: To improve faxed referrals to the patient pathway co-ordinators (PPC) of upper gastrointestinal (GI) malignancy by 100% within a 4 month period.Learning To Make a Difference
6. Gastroenterology Meeting (27/2/14), email to all endoscopistsEndoscopy Unit Meeting (11/3/14)Members of MDT (Admin, Nurses, Surgeons, Clinicians)Yellow laminate (May 14)Posters of guidelines and fax numbers (June)Tests of Change James Paget University HospitalLearning To Make a Difference
7. RunchartJames Paget University HospitalInitial Audit PeriodGastro Meeting Endoscopy MeetingYellow Reminder FormsReminder PostersLearning To Make a DifferenceMedianFOLLOW SOP FOR UGI MALIGNANCY
8. What difference has beenmade?Endoscopy staff more aware of guidelinesMay – 50% faxed referral rateJames Paget University HospitalLearning To Make a Difference
9. Next Steps What do we plan to do next? Posters around Endoscopy unit giving clear guidelines in bold print, eye levelEmail all consultants not complying with guidelines specifying what was not done.What do we need?Cooperation from endoscopy staff and principle endoscopy consultantWhat has been the learning?Without full cooperation, implementing change is difficult.Multi-disciplinary involvement – priorities differ.Quality improvement methods are more effective than one-off audit.James Paget University HospitalLearning To Make a Difference
10. Team MembersDr Williams (Gastroenterology Consultant)Dr. A Malpas (CT1)Dr. N Corballis (FY1)James Paget University HospitalLearning To Make a Difference