East General Hospital is one of a large number of regional trusts that together make up the National Health Service (NHS) of the United Kingdom.
One of the areas targeted by the UK government as in need of change in the NHS is the cataract diagnosis and treatment procedure. Cataract surgery—a 20-minute procedure—represents 96% of the ophthalmology workload. Traditionally, cataract diagnosis and treatment involved a long series of visits to various specialists, beginning with the optometrist (local commercial optician). Whilst the optometrist has sophisticated equipment and can easily detect cataracts, they are not medical professionals. Therefore,
they would diagnose “suspected” cataracts and refer that patient to his or her General medical Practitioner (GP). The GP, not being an eye specialist would generally rely on the diagnosis of the optometrist and forward the patient to the hospital for a brief consultant appointment. On confirming cataracts, the patient was scheduled for a physical examination with a nurse in order to confirm their suitability for the operation. When all of these visits were complete the patient would be placed in the queue for obtaining a date for the cataract surgery—in many trusts, lead-time being over 12 months. Post-surgery, another visit to the consultant was scheduled and then the patient was finally referred back to the optometrist for spectacles. In all, then, it took patients at least six visits and often well over a year to have a routine, 20-minute, outpatient, surgical procedure and, thus, a new reengineered cataract diagnostic and treatment process was seen as potentially beneficial.
A designated member of the hospital’s “transformation team” was assigned to facilitate the change process. The team was unique to this particular hospital, whose remit was to facilitate organizational change, both identifying where change might provide most benefit and encouraging buy-in from relevant groups. The transformation team member identified knowledge sharing as a key priority and used their own personal contacts to gather together a group of eye experts from both the hospital and the community to discuss ways in which to cut surgery lead times and improve patient satisfaction. Members of the cataract team included the head nurse in the eye unit, a hospital administrator, general practitioners, a set of optometrists from the local community, and a surgical consultant who was instrumental in championing the change process. Because the group did not meet on a day to day basis, meetings were held in the evening to facilitate attendance.
Minutes, flow charts and other necessary documentation were produced by the transformation team member and distributed after each meeting for comment.
At the outset meetings were rather “difficult,” with each member defending their own position. But, with repeated meetings, the specialists involved began to share information about their current roles and procedures more openly.
Based on a more collective understanding, plus an increased awareness of the competencies and skills of the various groups involved, they were able to begin to see alternatives to the traditional process. In doing this, each individual in the team drew upon his/her own experience and knowledge, but also used their personal networks to find out what was happening in other hospitals.
A number of changes to the existing process were made. Non-essential visits to the general practitioner; the consultant and the nurse were eliminated and, instead, optometrists were empowered to decide if a patient needed cataract surgery. In doing so, they were required to fill out a detailed form—developed by the project team—that provided the consultant with specific information about the nature and severity of the cataract, and to call the hospital and book a time for the patient’s surgery. For their additional responsibility, the optometrists were given extra training and received a small
financial incentive. The preliminary pre-operation physical was replaced with a self-diagnostic questionnaire that each patient was required to fill out and return to the hospital before surgery. This questionnaire was again designed by the project team (based on forms used elsewhere). Immediately before surgery, nurses telephoned each patient to check details and answer any questions. Post-operation consultant appointments were also replaced with follow-up telephone calls. The new cataract procedure resulted in a number of efficiency gains. Lead times were radically reduced from over 12 months to six to eight weeks. In addition, theatre utilization rates improved and, most importantly, according to follow-up phone conversations, patient satisfaction improved dramatically.
The new cataract process significantly altered roles and responsibilities, particularly for the optometrists, who could now diagnose and directly refer patients. This process, however, was not entirely straightforward, and significant knowledge sharing was needed, in particular among the consultants and the optometrists so that the optometrists could learn how to make diagnoses that were acceptable to consultants. The consultants also provided optometrists with regular feedback on the patients they had referred and answered their questions. For example, one optometrist explained that at times he had needed to clarify issues with the consultant and claimed that this would be very difficult for consultants who had not been involved in the cataracts project because they did not trust the optometrists to have the required expertise:
While there were many advantages of the new system there were also pockets of resistance. Previously, theatre scheduling had been done by each consultant’s secretary but this secretarial support had been centralized, and theatre scheduling allocated to a new administrator. The secretaries resisted, insisting that they were “far too busy” to be assigned to more than one consultant. In order to overcome this problem, one of the nurses on the project team contacted a friend in another hospital that had successfully introduced a centralized secretarial pool and took the secretaries to see it working. While this helped weaken the resistance, it did not eliminate it. For example, initially the administrator in charge of theatre scheduling was not provided with the schedules from the secretaries and therefore was unable to perform her role.
However, when it became clear that this was not going to be acceptable, the secretaries revised their strategy and all sent their schedules in together, so that the new administrator was overwhelmed by the workload. As one project member put it, “they were wanting her to sink.”
There was also resistance from some local optometrists. For example, the transformation team member recounted the story of an optometrist with a large local practice who refused to participate. As luck would have it, the transformation team member happened to need a new pair of spectacles and so decided to visit the reluctant optometrist and sang the praises of the new cataract procedure throughout her eye exam. By the time her spectacles were ready, the optometrist had reconsidered his position.
While the redesigned cataract process was considered to be highly successful in the hospital where it had been developed, the diffusion of this newly designed process to other hospitals was extremely problematic. For example, in one hospital which had been sent the paperwork about the new process in East General Hospital, the idea had been rejected because it was seen as “too radical.” Indeed, even within East General Hospital itself, consultants who had not been involved in the reengineering project still assumed that optometrists could not properly diagnose cataracts and continued to want to see all patients themselves to make the diagnosis.
Recognizing these problems, significant effort was put into capturing and disseminating user-friendly documentation, and “blueprints” (referred to as the “Roadmap”) for implementing the new “best practice” cataracts treatment process in other hospitals. However, these were having relatively little impact. Faced with this, the transformation team hosted a number of networking events aimed at explaining and illustrating the process “live” to members of other hospitals. Whilst this generated significant enthusiasm at the events themselves, still relatively little happened and, two years on, East General Hospital remained the only one to have implemented the new process.