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Gynaecological Oncology Pooled Public Surgical Lists
Gynaecological Oncology Pooled Public Surgical Lists
Hunter New England Area Health Service
Abstract
This paper describes the process of pooling the Gynaecological Oncology public surgical lists at the Hunter New England Centre for Gynaecological Cancer (HNECGC) in an attempt to improve access to surgery for women listed on the 30-day clinical urgency category.
It describes how the three Gynaecological Oncology surgeons pooled their waiting lists and operated on women in order of clinical priority, without preference to surgeon, on available theatre lists.
Aim
To improve access to surgery for women with Gynaecological Cancer and achieve the national benchmark for those whose clinical condition warrants surgery within 30 days.
Nature of the Problem
Women with Gynaecological Cancer whose clinical condition warrants surgery at John Hunter Hospital within 30 days have historically not received surgery in compliance with national benchmarks. Women are placed on the waiting list under the care of a clinician and wait for the appropriate theatre list to become available. The three Gynaecological Oncologists have individual operating lists, with some waiting lists longer than others, causing an extended wait for surgery for some women. Women are informed that they require surgery within 30 days and contact the unit when this has not been arranged.
Extent of the Problem
National benchmarks for access to elective surgery have been set in A New Direction for NSW – State Health Plan - Towards 2010.
For women diagnosed with Gynaecological Cancer whose clinical condition warrants surgery within 30 days, this benchmark is set at 100 per cent.
The Clinical Service Framework for Optimising Cancer Care in NSW 2003 states the maximum acceptable time between decision to operate and surgical procedure is two weeks.
The NSW Cancer Plan 2004-2006 also aims to provide access to specialised cancer treatment services for cancer patients in an optimal and timely manner.
The HNECGC has not been able to meet these standards for some time. In a three-month period (February - April 2007) the average waiting time was 34 days with a range of 3 to 182 days.
A high percentage of Gynaecological Cancer patients in the 30 Day clinical urgency category have exceeded the allocated waiting time (Graph 1). This is detrimental to the patient both psychologically and physically as it can allow for progression of disease. Patient complaints to the service, patient representative and health department illustrate the anxiety caused by this extended wait.
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Graph 1: Total Number patients exceeding 30 Days waiting time
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Strategic Importance
The NSW State Health Plan and the Hunter New England Area Cancer Service Plan 2006-2010 both include improved equity of access to services as a major strategic goal. The measure of success documented in the Cancer Services Plan is waiting time against benchmarks. Therefore, the improvement of the waiting times for Gynaecological Cancer patients on the 30 Day clinical urgency category sits within the future strategic direction of both Hunter New England Health and NSW Health.
Planning and Implementing Solutions
The staff of the HNECGC held a planning day in January 2008. This meeting included all medical, senior nursing, allied health and administration staff of the service, as well as Service Manager of Obstetrics and Gynaecology and Director of Gynaecology at John Hunter Hospital.
At this forum the waiting list was one of the major service issues discussed. The waiting list had long been a problem for the unit and there was an urgent need to rectify the problem, as benchmarks or patient needs were not being met.
It was suggested that by combining the waiting lists of the three Gynaecological Oncologists the surgical waiting time and timely access to surgery could be improved. This was agreed in principle and it was decided to trial the combined waiting list to assess if any improvement in waiting time could be made.
The combining of the Gynaecological Oncology Waiting list was commenced in February 2008. This meant that patients were operated on in order of priority by the surgeon available. The women were given the option to wait for a particular doctor if they wished, but the majority felt they preferred to have their procedure done in an appropriate time frame. This excludes private patients as they are operated on in the private system.
At the time of allocating a surgery date, the Clinical Nurse Consultant would explain to the women that they would be operated on by the surgeon allocated for that day, all of whom were qualified Gynaecological Oncologists. Women are now told at their initial consultation that they will be operated on in order of priority by the surgeon available.
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Graph 2: Number patients exceeding 30 Days (Ward Stay Patients only)
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Outcomes and Evaluation
The combination of the Gynaecological Oncology waiting list has had a very positive impact (seen Graph 2 and 3), as the HNECGC currently has no patients waiting for surgery on the 30 Day clinical urgency category.
All patients on this category are now able to be given a surgery date within 21 to 30 days following their initial consultation. In the three-month period (February – April 2008) the average waiting time was 29 days with a range of 5 to 62 days. All results are summarised in Table 1.
This had not been achieved at the HNECGC since its inception without having to obtain extra theatre time from the department of surgery. This has also had a positive impact on the women diagnosed with Gynaecological Cancer as they have a treatment plan established at initial consultation, allaying the anxiety that accompanies waiting.
The HNECGC is now meeting the National Benchmarks for Access to Elective Surgery for the patients on the 30 Day clinical urgency category and is working towards the Cancer Institute’s goal of maximum acceptable time between decision to operate and surgical procedure of two weeks.
Postoperatively, the women are under the care of the operating surgeon, who also takes responsibility for developing any future treatment plans. Continued follow-up of the patient and management of their outpatient care is also undertaken by the operating surgeon allowing for continuity of care. The GP or referring doctor is kept informed of treatment decisions and plans throughout the care pathway.
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Graph 3: Percentage of Ward Stay Patients Exceeding 30 Days
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Table 1: Summary of results |
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| Time period | No. of cases | No. > 30 days | Average waiting time | Waiting time range |
| 2007 pre-intervention |
14 | 7 | 34 days | 3-182 days |
| 2008 post-intervention |
13 | 2 | 29 days | 5-62 days |
Sustaining Change
This improvement will be sustained by the continual monitoring of the Gynaecological Oncology waiting list by the Clinical Nurse Consultant (CNC). This will be discussed at the fortnightly team meeting and future planning days.
Another process that has also been adopted to assist with decreasing the waiting list is the accurate review of external referrals received by the HNECGC. This was an issue as 60 per cent of surgery was on benign patients in a tertiary Gynaecological Oncology centre. This review is undertaken by the Clinical Nurse Consultant in collaboration with the Fellow and Staff Specialist, ensuring that each patient seen at the HNECGC is appropriate for the service. GPs are informed of the criteria for referral to the HNECGC and if their patient is referred on to the general gynaecology service.
Future Scope
This project could be applicable to other NSW Health services or settings to help improve surgical waiting times. The only criteria necessary is the agreement of all surgeons involved and the requirement for thorough documentation and communication about each patient’s condition and treatment plan.
References
- NSW Health (2006) A New Direction for NSW – State Health Plan - Towards 2010.
- NSW Health (2003) The Clinical Service Framework for Optimising Cancer Care.
- HNEAHS (2004) HNE Area Cancer Service Plan 2006-2010.
- NSW Health (2003) The NSW Cancer Plan 2004-2006.
Project Team
Dr Anthony Proietto
Dr Geoffrey Otton
Dr Kenneth Jaaback
Ms Amanda Fitzgerald
Ms Jenny Rutherford
Contact
Acting Area Quality Manager, Clinical Governance
Hunter New England Area Health Service
Phone: 02 6767 7233
