Improving Waiting Times for a Scottish Hospice Breathlessness Intervention Service

1. Context Ardgowan Hospice provides specialist palliative care to people with life limiting illness in the Inverclyde locality, part of NHS Greater Glasgow & Clyde, Scotland. It serves a population of approximately 81,500 people offering a wide range of both in-patient and out-patient services to meet the palliative care needs of the local population. As part of a wider service evaluation, the hospice has adopted improvement science methodologies to improve the referral pathways for patients requiring specialist palliative care. This included examining the wait times from referral to service start dates for all services. One service identified for improvement was the Breathlessness Intervention Service (BIS). 2. Problem Breathlessness is a complex symptom of advanced disease. It can manifest in patients with a variety of illnesses, including cancer, chronic obstructive pulmonary disease (COPD) and heart failure [1]. Breathlessness is a distressing, and complex symptom that can profoundly affect a person’s life, leading to loss of independence, increased distress and reduced quality of life [2]. Evidences suggests, in conjunction with optimised medications, teaching people self-management techniques and offering psychological support can improve physical well-being, personal coping strategies and quality of life [4,5,6]. However, the baseline median wait time from referral to service commencement was 19.5 working days. The aim of this improvement project is to reduce the median wait time from 19.5 days to 11.5 days by June 2016. 3. Assessment of the Problem and analysis of its causes Run charts were used to identify and display the trends in the available data on the wait time from referral to service commencement from Jan- Sept 2015. In addition, the current referral pathway was process mapped and cause and effect diagram co-produced with staff. 4. Intervention Key areas for improvement identified were the lack of staff and the difficulties getting people to the hospice for assessment. Changes ideas identified were to include the wider multidisciplinary team within BIS, and offer home visits for people who were housebound or on continuous oxygen. 5. Strategy for change We are currently running PDSA test cycles offering home visits and evaluating the patient experience between hospice versus home assessment. Multidisciplinary team colleagues have been identified to deliver the service and are receiving training on current best practice on breathlessness management. Staff meetings are held fortnightly to share progress and discuss future developments. 6. Measurement of improvement The outcome measure is the time taken from referral to service start date. This information is collated monthly by the team data analyst. In addition, patient and carer interviews are being undertaken post-assessment. The interview data is being organised into themes and shared at the staff meetings to reflect on the changes being made to ensure no negative outcomes are being experienced following a test of change. Final results are not available. Early indications are that the aim of the project to reduce the wait time from referral to service start date from 19.5 working days to 11.5 working days is achievable, and patients and carers have a positive experience being assessed in their own homes. 7. Effects of change Current evidence suggests engaging with staff and enabling them to identify areas of improvement has led to positive changes to the breathlessness service at Ardgowan Hospice. Staff have worked together to find solutions using existing hospice resources and now offer a service to people who are housebound, a known barrier to accessing services. 8. Lessons Learnt This project is still in progress. One anticipated challenge is the level of resource required from the wider team to sustain change over time. 9. Messages for others Inclusion at all stages of the project thus far has facilitated and motivated staff to embrace quality improvement methodologies in a positive manner. Enabling staff to work with patients and carers to develop the service and has given meaning to the need for change and put person-centred care at the heart of this project. 10. Describe how you have involved patients, carers or family members in the project Brief interviews were undertaken with patients referred to the service following initial assessment. Notes were taken and summary points agreed. These notes were arranged into themes using a framework and used to reflect and inform the development of new change ideas. 11. Declare any conflicts No interests of conflict to declare. 12. Ethics approval Ethical approval was not required for this project.