Cataract Service Redesign Project Westmead Hospital

Aim

• To improve efficiency of the Cataract referrals received, such that the number of patients proceeding to surgery increases from current 40 % to 60 % by August 2020
• To reduce the current waitlist at Westmead Cataract clinic from 18 months to 12 months by December 2020.
• To reduce Did Not Attend (DNA) rates of 17% to 10 % by August 2020.

Benefits

• Reduced wait for initial appointment.
• A-Scans, Slit lamp Assessment and consent for surgery on the same day.
• Only patients requiring consent for Cataract surgery to see the ophthalmologist.
• Improved patient experience and satisfaction from the service.
• Improved attendance rates.
• Effective use of clinician time and resources on more Acute cases.

Background

Westmead Hospital Eye clinic is an Outpatient clinic that provides clinical, surgical, educational and research services. Due to the large volume of referrals the Initial Cataract assessment appointment is currently subjected to a wait of over 12-18 months. The vast majority of the patients are more than 70 years of age and various studies have shown that during this wait time the worsening cataracts could lead to falls, increased dependence on others, depression and loss of independence in this category.

Other contributing factors to the long wait time was the insufficient or incorrect clinical and social information on the referrals that affect the referral triage, leading to less than 40% of patients proceeding to surgery due to other eye conditions that require attention first. This referral quality has often led to increased wait time for people who really need to have a cataract assessment and surgery sooner. Due to the increased wait time a large number of patients did not attend their appointments or have had alternate private surgery, leading to loss of opportunity for other patients on the wait list as well as inefficient use of clinician time and resources.

By undertaking this project, we will be able to reduce wait times and improve vision outcomes and experience for patients whilst maximising utilisation of our services for the benefit of the community.

Implementation

Project initiation

Established a sponsorship and steering committee to ensure agreement on scope, monitor progress against objectives and express, model and reinforce change to direct reports.

Phase 1 of the project was formally launched with stakeholders, that included the Nursing, Orthoptic, Administrative staff and ophthalmologists of the Westmead Hospital Eye clinic.

Diagnostics

A review of current waitlist and Did Not Attend rates was undertaken during the diagnostic phase. After analysing the data and engaging administration, nursing, and managerial staff a number of service-related issues, referral issues directly related to specific root causes were addressed during the solution development phase.

Solutions

• A Cataract Streamline Pathway (CSP) that included a nurse and orthoptist led cataract assessment clinic attached to a Senior Resident Medical Officer (SRMO) clinic that was to be implemented in two phases.
• Approval of nursing assessment criteria for slit lamp examination, by the director of nursing.
• Phase 1- Three month pilot of the One Stop Cataract Assessment Clinic (OSCA) every Friday afternoon, selection of patients meeting the eligibility criteria from the wait list, telephone booking of five patients per week by administrative staff, training two registered nurses for slit lamp assessment.
• Conducting all tests such as A-scans, Ocular Coherence Tomography (OCT), Retinal Photos, Auto refraction, dilated anterior segment assessment by nurses and consent for surgery by the SRMO.
• Providing cataract information sheets to patients in the clinic and throughout the service journey. For example, consenting for surgery to post- operative requirements.
• A discharge, follow-up, and re-entry criteria to support registrar clinical decision making.
• Phase 2- Based on analysis of Phase 1, increasing One Stop Cataract Assessment Clinic (OSCA) days and patient numbers, phone calls two weeks ahead and text message reminders one week prior to appointments.

Implementation

• Formation of an implementation team consisting of clinical head of the department, nurse, orthoptist and administrative managers to ensure implementation of the One Stop Cataract Assessment Clinic (OSCA) was planned, resourced and communicated via existing organisational channels to ensure that they were sustainable.
• Providing support and training to cataract assessment nurses, written communication, and weekly feedback to head of the department and staff involved via emails.
• Conducting a patient satisfaction survey over the phone.
• Maintaining an excel spreadsheet for data analysis.

Status

Pilot Phase – The initiative is ready for implementation or is currently being implemented, piloted or tested.

Results of the pilot phase

• Total booked – 59 patients
• DNA rates reduced by 5.08%
• Attendance rates increased by 94.92%
• Patients moving to surgery increased to 71%
• Rebooking and follow up 26.79%

Dates

June to August 2020

Implementation sites

Westmead Hospital Ophthalmology Clinic

Partnerships

Optometry NSW, Agency for Clinical Innovation.

Evaluation

The plan is as outlined below:

• Develop and maintain an excel sheet to audit data for Did Not Attend rates, consent for surgery, time spent in clinic, follow up and rescheduling.
• Complete over the phone patient satisfaction survey to assess patient satisfaction on eye clinic services for cataract assessment.
• Conduct audits by CNC for compliance of nursing cataract assessments to One Stop Cataract Assessment Clinic (OSCA) criteria and providing feedback to nurses, nurse unit manager, director of nursing and clinical head of the department.

Lessons learnt

• Good sponsorship and stakeholder engagement are key – the sponsors and stakeholders really help drive the project and if you do not have them on board and engaged early it can delay your project.
• Maintain stakeholder engagements throughout the project.
• Document all steering committee meetings and send out without delays and refer to agreed terms.
• Use sponsor influence on stakeholders to steer back to project aim.

Contact

Meryl Rodrigues
Registered Nurse
Westmead Hospital
Western Sydney Local Health District 
Phone: 0403855803
Meryl.Rodrigues@health.nsw.gov.au