New order

Using Lean methodology to reconfigure referral pathways and reduce Dermatology outpatient waiting list by 40%

Timeline

2020-2021

Team

Mater Dermatology

Challenge

In 2020, despite repeated waiting list initiatives, the Dermatology outpatient waiting list at the Mater was at 3,736
and growing.

The average time to be seen for an urgent patient was 81 days while patients with more routine conditions were waiting over two years.
“It’s like we’re caught in a tsunami of patient referrals”
Dermatology Consultant, 2020

Outcome

A whole systems approach was adopted to explore this problem in a root and branch review using Lean Six Sigma methodology.

Over the following year, the team implemented a series of changes to internal processes including a new centralised triage and booking system to help ensure that all capacity in the system was utilised.

Impacts

40% reduction in the waiting list from 3,736 in September 2020 to 2,228 in June 2021
Average waiting time for ‘urgent’ referrals reduced from 81 days to 41 days
All ‘soon’ and ‘routine’ patients were given an appointment within four and six months respectively

Process

In August and September 2020, Mater Transformation worked closely with the Dermatology team to carry out an analysis of waiting lists and a deep dive on referral processes.

This included desk top exercises, ‘Gembas’ (observational studies) on triage and booking processes as well as ‘Voice of the Customer’ interviews. 
This data was synthesised, visualised and presented over the course of a week long Value Stream Analysis (VSA) event where the team came together to collectively make sense of the information.  From here, the major gaps and opportunities for the service were teased out, and a roadmap was developed identifying the key areas for change.

Insights that emerged from Lean analysis:

Variation

Patient wait times for appointments varied significantly depending on which consultant they were referred to.

Harnessing capacity

A lack of overall visibility of capacity resulted in appointment slots being held in case urgent skin cancer referrals came in. Sometimes these slots then went unused.

Opportunity for ‘5S’

An audit of the waiting list revealed a significant amount of duplicates and invalid referrals, which presented an opportunity—a recalibration of the waiting list using through the ‘5S’ method - ‘Sort, Set in Order, Shine, Systemise and Sustain’
These insights informed the design of the new centralised referral and booking systems.

This provided the team with a better operational grip, which then allowed clinic restructuring and other initiatives to optimise capacity.
Five separate waiting lists led to imbalanced distribution of patient referrals
A new model for managing referrals was introduced that allows a central point of oversight
A new model for managing referrals was introduced that allows a central point of oversight

What’s happening now?

While these system changes had a major impact on waiting lists, the rate of referrals coming in to Dermatology is increasing significantly year on year due to increases in skin cancer prevalence and population growth. With this projected increase in volume of referrals, there is a clear need to move away from an over reliance on hospital specialists and rethink how skin conditions are managed across the system.

One key learning from the Dermatology VSA was that General Practitioners (GPs) receive very little training in skin conditions. A key challenge is the fact that dermatology is a highly visual and tactile field. There is a limit to what learners can gain from textbooks and lectures, even with high quality photos. Teaching therefore traditionally relies on the learner seeing real patients. However it is not practical for large volumes of trainees to attend clinics for extended periods in order to gain the exposure they need.

To address this, we connected Mater Dermatologists with the Medical Device Design group at NCAD and together they have developed a novel, high-fidelity suite of teaching aids. No other teaching tools currently available on the market offer this level of fidelity in terms of visual and tactile features. We anticipate that they will increase confidence and competence in the management of common skin conditions among practicing GPs as well as undergraduate and postgraduate trainees.
Read more about this initiative:  Sim-U-Skin
Sim-U-Skin.