A one-stop clinic improvement project for postmenopausal bleeding in NHS Forth Valley

Abstract

Background

Referrals for postmenopausal bleeding (PMB) were creating a pressure point within a general gynaecology outpatient clinic in NHS Forth Valley (NHSFV) in Scotland. This project originated in concerns around delays in time from referral to diagnosis as a result of this pressure point.

Aim

The aim of this project was to test the efficiency of a process change which reduced waiting time from referral to diagnosis for patients with PMB.

Methods

Use Active Clinical Referral Triage (ACRT) and a one-stop clinic to reduce waiting lists. Quality improvement methods including data collection and process mapping were used to understand the current system. Cycles of the Plan-Do-Study-Act (PDSA) tool were applied to test the concept of introducing a one-stop clinic for PMB.

Results

Qualitative data gathered during the project showed that patients preferred the one-stop clinic. Limited quantitative data indicated the one-stop clinic design reduced PMB referral waiting time for patients.

Conclusion

Our aim was to streamline a process to reduce waiting time between referral and diagnosis for patients with PMB. This was achieved by the creation of a one-stop clinic for PMB/unscheduled bleeding on HRT (hormone replacement therapy) patients. The work to date has highlighted the efficiency of the new process and ultimately suggests the potential for a reduction in waiting times in this pathway.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Active Clinical Referral Triage (ACRT) can streamline clinical pathways. Clinicians can use ACRT to streamline local practices and reduce waiting lists.

WHAT THIS STUDY ADDS

• Demonstrates that local initiatives supported to use quality improvement methodologies and making use of established tools can effectively streamline services and improve patient journey and experience.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• We demonstrated the successful use of ACRT methodology and one-stop clinics in clinical practice, as well as the value of national programmes such as quality improvement collaboratives which can support clinicians by giving them the knowledge, tools and connections to drive service improvement.

Introduction

Background

Referrals for postmenopausal bleeding (PMB) were creating a pressure point within a general gynaecology outpatient clinic in NHS Forth Valley (NHSFV) in Scotland, to the extent that general gynaecology clinics were being converted into PMB-specific clinics to meet demand. Menopause is defined as ‘marked by the end of monthly menstruation (also known as a menstrual period or ‘period’) due to loss of ovarian follicular function.’¹ The Scottish Intercollegiate Guidelines Network (SIGN) goes on to define postmenopausal bleeding as bleeding that takes place 12 months or more after the patient’s last period, while noting that the minimum time period is debated.²

Staff were aware that PMB referrals represented a significant number of their overall workload and demand for consultant time. It was also identified that this patient group had a high ‘did not attend’ (DNA) rate. While the referrals for PMB did not have the longest waiting list within the service, staff suspected that reducing the waiting times for PMB would have a significant impact on other treatment pathways and reduce the clinical space the gynaecological service required.

Given the staff awareness of the pressure point, the team further recognised that the current model was disjointed, involving a referral by the general practitioner (GP), attendance at a clinic for assessment and then an additional clinic if the patient required an outpatient hysteroscopy (OPH). Please see Visual 1 for a graphic representation of the pathway before and after the project’s interventions. This specific patient pathway (PMB requiring OPH) was not meeting the government guideline of 62 days from referral to treatment, which further encouraged the project team to test changes to the process. At the time of developing the project, there was no separate pathway in Forth Valley for PMB or unscheduled bleeding on hormone replacement therapy (HRT), resulting in the identified bottleneck. Otherwise, the team was meeting the Scottish government guidelines of 31 days for patients waiting to start treatment, as their median waiting time for patients was 30 days.³

The team was interested in creating a ‘one-stop clinic’ for PMB. Using the Active Clinical Referral Triage (ACRT) process, their aim was to streamline PMB referrals, reduce waiting times and the time from identification of a potentially abnormal endometrium to histological diagnosis, thus reducing patient anxiety while improving outcomes and the experience of patients and National Health Service (NHS) staff.

Available knowledge

A review of the available published literature identified that there is limited evidence available on the design of a one-stop clinic to treat PMB. However, the evidence around the impact that one-stop clinics can have on reducing waiting times and improving the speed of diagnosis is positive.⁴,⁷

Specific aim

Following a literature review, the team resolved to use ACRT and a one-stop clinic to reduce waiting lists. This report captures their methodology and learning from the project. Standards for Quality Improvement Reporting Excellence (SQUIRE) reporting guidelines were used in the writing of this article.⁸

Methods

Context

The NHSFV team joined a Scotland-wide quality improvement (QI) collaborative to improve access to services and reduce waiting times, run by Healthcare Improvement Scotland (HIS). They were supported to use a QI methodology via learning and coaching sessions, project surgeries and they had access to a speciality peer network. The collaborative, called Access QI, worked with elective care services to spread the use of quality improvement methods to sustainably improve waiting times in Scotland.

Interventions

The project was launched in August 2022. The team initially involved clinical and project staff and commenced with data collection activity and process mapping, which lasted from August 2022 to January 2023.

The team were supported to process map their current and desired pathways, using templates and coaching provided by HIS. Process mapping generated a greater understanding of the current overall process which created discussion around alternative models of care and what they could look like within the current structure. These process maps are shared in Figure 1, alongside the median time spent by patients in each pathway.

The team developed a two-armed approach to streamline PMB referrals: first, to separate PMB and unscheduled bleeding on HRT referrals using an ACRT process; second, to create a one-stop clinic, with the option of offering a same-day hysteroscopy clinic.

The process of offering advice to referring GPs through the process of active triaging is referred to as ACRT.^{9 10} Offering this advice rather than an appointment can result in providing patients with faster specialist advice while avoiding a potentially lengthy wait to be seen in a specialist appointment.¹¹,¹³ In this project, specialist advice was offered around HRT treatment. Studies have shown that this method can improve both patient and GP satisfaction and lead to greater efficiencies for outpatient clinics.^{14 15}

Arm 1: data collection on separate PMB and unscheduled bleeding on HRT referrals

Arm 1 of the project ran from January to August 2023. Arm 1 involved actively vetting referrals from a cohort of patients into two streams—those with PMB and those with unscheduled bleeding on HRT. Arm 1 was guided by a Test of Change (TOC), which posited that patients with PMB were more likely to have malignancy, and that splitting the referrals would streamline operations and reduce waiting times.

Data were collected at various stages, including at the vetting stage, at the GP clinic and at the OPH clinic. Waiting time for both streams was collected, alongside (but not limited to) data on inpatient and outpatient hysteroscopy requirements, Body Mass Index (BMI), type of HRT, need for biopsies and malignancy rates; this data provided the basis of the ACRT process.

Analysis of the clinic data collected in advance of Arm 1 showed that unscheduled bleeding on HRT accounted for 40% of the overall referrals. As a member of the Access QI collaborative network, the team had access to a review of published peer review literature which concluded that users of HRT with breakthrough bleeding do not require a more urgent referral given the low risk of malignancy and therefore suggests that PMB patients not using HRT should be given higher priority (online supplemental file 1).

For the unscheduled bleeding on HRT group, the first step in the process was for the team to create a standard operating procedure (SOP) which set out their intended process and which considered relevant risk factors. This was presented to their governance team and approved. If patients in the unscheduled bleeding on HRT stream met certain risk factors, such as high BMI, they were streamlined using ACRT into the PMB stream to be seen more quickly. These risk factors were identified in the literature review.¹⁶ The team wrote to the referring GPs with the correct dosage of HRT, as this would rule out PMB which was a result of incorrect HRT dosage. The team were aware that this may not reduce the waiting times but could reduce the return rate.

The team conducted an initial data collection exercise, where they identified the median number of days patients who required hysteroscopies spent waiting for a diagnosis, starting from the point of GP referral (table 1). The team aimed to reduce the amount of time patients spent in the ‘PMB clinic to OPH’ stage, with the goal of reducing this from 29 to 1 day. Using data collected from clinics, the team measured the utilisation of OPH slots to provide an overview of the effectiveness of this intervention.

Table 1. Median number of days from referral to diagnosis.

	Median number of days
GP referral to PMB clinic	20
PMB clinic to OPH	29
OPH to pathology diagnosis	13
Total:	62

GP, general practitioner; OPH, outpatient hysteroscopy; PMB, postmenopausal bleeding.

The team collected data throughout the vetting process in Arm 1. Following analysis, the team concluded that their model, offering PMB and unscheduled bleeding on HRT clinics side by side, would be safe. Arm 1 also provided evidence in support of the literature review, which suggested that patients in the unscheduled bleeding on HRT stream were less likely to have a malignancy (online supplemental file 1).

Postmenopausal bleeding in patients on HRT: December 2022. Literature review.

Arm 2: One-stop clinics

Following the initial data collection and analysis, the team planned Arm 2, where they designed and tested a one-stop clinic. The key aim of this was to create a one-stop clinic to streamline the gynaecology PMB clinic and reduce time from clinic referral to diagnosis. This discussion produced a theory of change: that PMB to OPH waiting time could be reduced by introducing a one-stop clinic. A second SOP was created which was approved by the NHSFV clinical governance team. The first clinics ran on 8 August 2023. Figure 1 visualises the original and revised pathways.

Figure 1. Pathways and waiting times before and after tests of change.

Two clinics were run side by side, both seeing patients who had been identified as PMB or unscheduled bleeding on HRT using the vetting process from Arm 1. The two initial clinics then fed into an OPH clinic for those who required further investigations which was situated down the hall from the two clinics. The team were conscious they did not have the space, equipment and likely the patient demand to have the PMB and OPH clinics combined in a single space. The model was first organised around clinics running side by side: in the morning slot, a consultant would see the patient and conduct a history, examination, and scans if required; patients requiring hysteroscopy and who met the referral criteria were invited to attend the afternoon clinic. The team then decided that asking patients to take a full day to attend clinics was not efficient, so they changed to two PMB clinics running side by side simultaneously, feeding into a hysteroscopy clinic operating in the same office space. All took place in the same morning or afternoon session. This meant that all patients who required further investigation received them during the same half-day period, rather than being asked to return later in the day or to a later clinic.

Arm 2 Test of Change 1 (TOC1) ran for 4 weeks, starting in August 2023, during which the team used four small scale weekly Plan-Do-Study-Act (PDSA) cycles to test their theory of change; templates for this were provided by the Access QI collaborative. The team found that the outcomes from the earlier PDSA cycles, such as who should chase up results and who should write the letters and consents, were resolved as the team progressed and gained experience. The team ran an additional Test of Change 2 (TOC2) with the aim of increasing the utilisation of hysteroscopes. Table 2 shares the results from these tests of change.

Table 2. Test of change results for one-stop clinics.

	Test of change 1 (TOC1)	Test of change 2 (TOC2)
Months	August–September	November–December
Patients seen	54	47
Number of patients on PMB pathway	33	47
Number of patients with unscheduled bleeding on HRT pathway	21	0
Number requiring OPH	17	18
Percentage utilisation of OPH	71%	90%
Usage of OPH by pathway	10 PMB 7 unscheduled bleeding on HRT	18 PMB 0 unscheduled bleeding on HRT
Successful OPH	14 (3 did not tolerate)	15 (3 did not tolerate)

HRT, hormone replacement therapy; OPH, outpatient hysteroscopy; PMB, postmenopausal bleeding.

Each PDSA represented a 5-day period of running clinics as per the model identified above. The two clinics had seven patients each, feeding into six spaces in the OPH clinic. Patients who needed a hysteroscopy but could not be seen in one of the six available slots could have been seen at an outpatient clinic; however, this overflow option was not required. Each PDSA was supported by an SOP and a patient letter, which were adjusted to contain information around what would happen at the patient’s appointment. Patients were told they would be offered the option of attending the clinic for same-day testing if that was identified as necessary or attending an appointment at a later date for testing if that was their preference.

The PDSA cycles saw the team introducing two additional questions to their patient feedback questionnaire, exploring patient preferences around having investigations completed on the same day as the consultation. The additional questions used a strongly agree to strongly disagree five-point Likert scale and were phrased: “I was happy to have all investigations carried out on the day of my initial consultation” and “I would have preferred to have more time between my initial consultation and further investigation.”

Throughout Arm 2, the change ideas tested were whether the team would be successful in offering same-day outpatient hysteroscopy when patients attended PMB clinics. They also tested having two PMB clinics running side by side with a concurrent OPH clinic receiving patients from these clinics. An objective throughout the PDSA cycles was to determine the feasibility of their change ideas and to determine the number of OPH appointments that would be needed to meet demand. The team predicted three things that might occur during the trial: insufficient OPH spaces, insufficient demand for OPH spaces and that patients might prefer having their investigation on the same day. These were to be assessed against a patient satisfaction questionnaire, percentage utilisation of OPH slots and the wait time for diagnosis.

The whole clinic team was involved in making the service change: clinical and administrative staff worked together to implement ideas. For instance, the administrative staff designed a sheet to monitor the patient flow, which improved their ability to process patients and predict demand.

TOC2 ran for an identical 4-week period, starting in November 2023. The modification made for this Test of Change was that the clinics saw only patients with PMB, not patients with unscheduled bleeding on HRT. This was to maximise the hysteroscope usage. As patients on HRT are less likely to have cancer, it was decided that they could be seen at a different type of clinic. The ‘PMB clinic to OPH’ median waiting time of 29 days was unlikely to have an impact on HRT patients, as they were less likely to have a positive cancer diagnosis.

Patient involvement and feedback

In Arm 2, starting October 2023, the team recruited a patient representative via an advertisement in the outpatient clinic. A poster was placed into the clinic waiting room asking patients to join a group to improve services for patients attending the postmenopausal bleeding clinic.

The team encouraged patients to complete a questionnaire about their experience and sought to involve patients within the project group. 14 patients completed the questionnaire, with only eight of those patients completing the second page of the questionnaire, an issue that was highlighted and corrected via PDSA cycles. The findings from the patient experience questionnaire are shared in more detail in the patient feedback report, included as supplemental material. Online supplemental material 2

Patient feedback report

Involving patients within the design of Arm 2 was beneficial as it helped staff to understand the patient experience and journey. For example, the team responded to patient comments that they would prefer more time between initial consultation and later investigation by ensuring that the patient was always verbally asked if their preference was the one-stop clinic or to come back on a different day. The team gathered patient feedback using the British Society for Gynaecological Endoscopy OPH, a patient satisfaction survey form from the British Society for Gynaecological Endoscopy, a robust and verified questionnaire.¹⁷

In the course of this project, patients were involved and encouraged to contribute their views to the design of the service. It was deemed not appropriate to involve the public or patients in the design, or conduct, or reporting, or dissemination of plans of this QI report. Ethical consideration was not sought by the team, as they were not collecting any additional data on patients, and this project was determined to be quality improvement rather than research, as it did not seek to generate generalisable findings nor assign participants to control groups. Standard operating procedures (SOPs) for Arms 1 and 2 were approved by the Board’s clinical governance team.

Results

The initial objective of this project was to streamline PMB referrals and the time from identification of a potentially abnormal endometrium to histological diagnosis, thus reducing patient anxiety while improving outcomes and the experience of patients and NHS staff. This objective was adjusted over the course of the project to include the use of the ACRT process and the creation of a one-stop clinic and the development of a pathway to support patients experiencing PMB.

In Arm 1, the aim was streamlining the referral process, by using ACRT to split pathways for PMB and unscheduled bleeding on HRT. As the team improved their efficiency in vetting referrals, they were better able to process the increasing number of overall referrals and cope with the increasing demand on the clinics. However, as a result of the volume of referrals, they were unable to demonstrate a reduction in waiting times during the study.

In Arm 2, the team introduced a one-stop clinic and were successful across TOC1 and TOC2 in reducing the median ‘PMB clinic to OPH’ time from 29 to 1 day for eligible patients who choose to use the one-stop clinic, as can be seen in Figure 1. The first patient using the clinic was identified as having a malignancy, with the result that their cancer diagnosis time was reduced by 29 days. For other patients who chose to use the one-stop clinic, their waiting time for results was similarly reduced, potentially resulting in decreased anxiety. Patient feedback suggested that the one-stop clinic approach was received positively. This initial result proved to be a promising first step and a strong motivating factor for the remainder of the project.

In TOC1, there was 71% utilisation of hysteroscopes. Patients in the unscheduled bleeding on HRT clinic were less likely to require hysteroscopies, which meant that the six available hysteroscopes were not always used. The patients with PMB and not on HRT were more likely to need hysteroscopies; therefore, for TOC2, the team decided to make both clinics only PMB patients, to maximise hysteroscope usage. The changes made for TOC2 resulted in 90% hysteroscope usage. 101 patients were seen across both Test of Change cycles.

PDSA cycles were generally successful, with sufficient OPH slots and clinics running to time. Issues identified during cycles centred around communication with patients and completion of questionnaires, as well as insufficient uptake of OPH slots—between three and five of the six total slots were used. Patient satisfaction remained good throughout, and patients preferred same-day investigations, as described in the patient involvement and feedback section.

Discussion

Summary

Using the process of ACRT to streamline referrals from primary care helped reduce the number of patients waiting to be seen and ensured that the correct patients were attending clinics. The overall analysis from the QI project has shown a positive outcome, but the next step of rolling out this model to all PMB clinics within NHSFV is proving difficult because of staffing and space issues. The team has continued to run this project as a limited Test of Change and has continued to make improvements, such as the use of ultrasonographers and nurse-led clinics. This has highlighted the need for changes to improve equality of service for all patients. One strength of this study is that it adds to the sparse literature on the use of one-stop gynaecology clinics, describing in detail the process of setting up the service, including the quality improvement tools which were used.

Interpretation

The team encountered several challenges throughout the project, most of which they were able to correct or overcome, frequently by using quality improvement tools such as PDSA cycles to improve processes. Space and equipment limitations in NHSFV were a barrier to implementation of the new model. Having highlighted this issue, a review of requirements to proceed with the process was initiated and resulted in the procurement of appropriate equipment.

The process of getting the necessary data in Arm 1 was challenging and time-consuming. Certain outcomes, such as patients requiring hysteroscopy, were not being coded at point of referral. Looking at the data, the team could not easily tell which patients were going to PMB clinics and being referred onwards to an OPH clinic. The team manually cross-referenced all hysteroscopy referrals with patients attending PMB clinics. Once this problem had been identified, TrakCare was updated so that referrals could be coded properly.

A post-implementation debrief generated the reflection that collecting patient feedback prior to implementation of this pathway would have been beneficial in designing the service. Learning taken from this also suggested that, if they had gathered qualitative evidence before the design phase, they could have potentially demonstrated a greater benefit to those patients attending the one-stop clinic. However, overall, the exercise of gathering patient feedback was very positive and showed the benefits of this pathway in relation to enhanced patient experience.

Similarly, the team agreed that they would have benefitted from having a patient representative involved at an earlier stage. Having a representative allowed the team to get a different perspective on processes and patient-facing communications. Ideally, the representative would have been involved before TOC1.

Data on staff benefits were not collected systematically; anecdotally, clinicians working with the team report that the high patient satisfaction has resulted in improved staff satisfaction. Staff also provided positive feedback around the streamlining of the service, with administrative staff particularly positive around the reduction in number of appointments that needed to be scheduled and patients contacted. The local consultant body are seeking to implement a similar system for their clinics as a result of the evidence that came out of the trials.

As a small and limited Test of Change, the team have been unable to collect data over an extended period and therefore are unable to demonstrate whether this intervention can produce sustainable reductions in waiting times. Early outcomes are suggestive of improved efficiency and patient satisfaction; however, this requires further investigation. Despite this limitation, findings from this project support Friedemann Smith et al’s research on one-stop clinics reducing time to diagnosis and Mohamed et al’s improved patient satisfaction results.^{4 6}

Limitations

In any quality improvement programme, it is important to acknowledge limitations to the work. The main limitations for this study are the small scale and sample size in Arm 2, and the project mostly generated qualitative data and lacked control data resulting in limited opportunities for statistical analysis. This is largely because the project is a small Test of Change using one clinic, with the intention of scaling up the intervention if successful. This study does not include long-term follow-up of patient outcomes; however, with the intended scaling up for the intervention, this would be something to consider in the future.

Conclusion

The implementation of a one-stop clinic within the NHSFV gynaecology service proved to be a beneficial exercise and the waiting time for referral to treatment was reduced. Conducting the PDSA cycles provided vital feedback on how to structure the modified service; changes were based on the data generated by the cycles and using the ACRT process ensured that patients were being referred appropriately. By involving the whole team throughout all stages of the project, refinements could be made continuously. Taking the time to talk with patients during the project provided positive feedback on the changes being made. The processes and lessons learnt from the programme are well documented and so will enable the possibility of conducting a similar exercise elsewhere, within other departments or hospitals. By taking part in the HIS Access QI collaborative, staff were upskilled to use quality improvement methods which they can take forward to future programmes.

One of the aims of the improvement programme was to reduce waiting time from referral to treatment and this was achieved with the first patient seen in the one-stop clinic resulting in a substantially shorter time frame for commencement of treatment. This early success demonstrates the potential for further reduction in waiting times from referral to treatment.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.