Delivering Quality and Value

Focus on: Cataracts

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Document Purpose Best Practice Guidance

ROCR Ref: Gateway Ref: 9873

Title Focus on: Cataracts

Author NHS Institute for Innovation and Improvement

Publication Date 14 May 2008

Target Audience PCT CEs, NHS Trust CEs, SHA CEs, Foundation Trust CEs, Medical Directors, Directors of Nursing, PCT PEC Chairs, NHS Trust Board Chairs, GPs, Opthalmic clinicians

Circulation List

Description This document is one of a series of documents produced by the NHS Institute for Innovation and Improvement as part of our High Volume Care programme. Produced by the Delivering Quality and Value Team, the aim of the Focus on series is to help local health communities and organisations improve the qualityand value of the care they deliver.

Cross Ref High Volume Care: Update

Superseded Docs n/a

Action Required n/a

Timing n/a

Contact Details NHS Institute for Innovation and ImprovementCoventry HouseUniversity of Warwick CampusCoventryCV4 7AL

www.institute.nhs.uk

For Recipient’s Use

Clinical

Contents:

1. Introduction

2. Our approach

3. The recommended pathway

4. The key characteristics of high quality cataract care

5. Measures for improvement

6. Benefits of following the pathway

7. Next steps

8. Further information and resources

9. Acknowledgements

Appendices

01

Cataract is a common conditionwhich causes gradual loss ofclarity in people’s vision. TheWorld Health Organisation hasestimated that over 18 millionpeople are blind due to cataract1,representing 48 per cent of totalworld blindness.

Mainly affecting elderly people,cataract can have widerconsequences for individuals andcan affect people’s ability to goabout their normal lives, oftenleading to social isolation.

Cataract surgery is now the mostcommon surgical procedureundertaken in England, witharound 300,000 operationsperformed annually in the NHS.With increasing life expectancyand an expanding elderlypopulation, the incidence ofcataract and, therefore thedemand for surgery continues torise.

What is care like now?

Cataract care in England has beenan excellent arena for service

modernisation. The Departmentof Health’s Action on Cataracts2

publication and the Royal Collegeof Ophthalmologists’ CataractSurgery Guidelines3 have greatlyassisted ophthalmology units inimproving quality and standardsfor cataract patients.

Following publication of theseresources, the day case rate forcataract surgery has increasedfrom 88 per cent in 2000-01, to 96per cent in 2006-07.

However, from our recentobservations, there is still amarked variation in the waycataract care is delivered acrossthe country, with many unitsidentifying potential areas forimprovement in their existingpathway.

In developing Focus on: Cataractswe have worked closely with NHSophthalmology units to identifythe key characteristics of highquality and efficient care forcataract patients.

These key characteristics arebased on our observations of bestpractice adopted byophthalmology teams acrossEngland. It is intended to helpanyone involved in the cataractpathway improve their serviceand reduce variation in practice.

We have also explored the extentto which existing guidance has

been applied in practice(including Action on Cataractsand the Cataract SurgeryGuidelines) and sought to identifyany issues or barriers that may behampering the implementationof such improvements. In additionto this, we also looked for furtheropportunities for qualitydevelopments in the delivery ofcataract care.

There are great challenges andopportunities for all thoseinvolved in opthalmic care. Tomeet these challenges and takeadvantage of the opportunitieswill take focused and plannedeffort. It will mean: lookingclosely at your current cataractpathway and taking time tocompare it not only with existingguidelines, but with therecommended pathway and keycharacteristics explored later inthis document.

02

1 World Health Organisation, ‘Prevention of blindness and visual Impairment’www.who.int/blindness/causes/priority/en/index1.html

2 Department of Health, ‘Action On Cataracts: Good practice guidance’ (2000)www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4005637

3 Royal College of Ophthalmologists, ‘Cataract Surgery Guidelines’ (2004)www.rcophth.ac.uk/docs/publications/CataractSurgeryGuidelinesMarch2005Updated.pdf

‘Due to the high volumeof cataract activity, anyimprovements in qualityand efficiency will havehuge benefits to patients,ophthalmology units andacute trusts.’

‘Cataract surgery is nowthe most common surgicalprocedure undertaken inEngland, with around300,000 operationsperformed annually in theNHS.’

1. Introduction

03

Delivering quality and value incataract care

Payment by Results (the system ofpaying hospitals according to thenumber or complexity of casestreated) is now firmly embeddedwithin the NHS and plays a majorrole in financial planning withinNHS organisations.

The Payment by Results system isbased on a national tariff - a pricelist for activity. The national tariffis calculated using nationalaverage costs (reference costs) as

reported annually by every NHStrust. Reference costs arecollected on a full ‘absorption’basis meaning that they includeall costs associated with providinga treatment such as staff,materials and equipment.

The national tariff is publishedannually in December andimplemented from the followingApril. In this way NHS trusts andPCTs can use the tariff to informtheir local financial and serviceplanning.

Each procedure or treatment hasits own Healthcare ResourceGroup (HRG) code and a nationaltariff. There are three HRGsassigned to cataracts: B13, B14and B15 with the majority beingperformed under B13. The tablebelow shows the annual volumeand the associated tariff for eachHRG.

HRG code HRG name Elective spell tariff(2007/08)

Annual volume(2006/07)

B13 Phakoemulsification cataractextraction and insertion of lens

£720 269,745

B14 Non-phakoemulsificationcataract surgery

£825 2,951

B15 Other lens surgery lowcomplexity

£665 16,848

Figure 1: Baseline tariff payments and activity for cataracts in NHS England

Outpatientspeciality code

Outpatientspecialty name

Adult firstattendance

tariff(2007/08)

Adult follow-upattendance

tariff(2007/08)

Annual adult first attendance

volume(2006/07)

Adultfollow-up

attendancevolume

(2006/07)

130 Ophthalmologyoutpatients

£103 £49 1,615,978 4,621,097

Tariffs are also assigned to outpatient appointments as shown below:

About the Focus on seriesThis document is one of a series published by theNHS Institute for Innovation and Improvement aspart of our High Volume Care programme.Produced by the Delivering Quality and ValueTeam, the aim of the Focus on series is to helplocal health communities and organisationsimprove the quality and value of the care theydeliver.

The areas we are focusing on in the programmehave been selected because: they are high volume(and therefore high consumers of NHS resources),they show variability in their use of resources andthey represent a range of clinical areas.

To find out more about the programme and theFocus on series see the Delivering Quality andValue pages at: www.institute.nhs.uk

04

The graph below (Figure 2) setsout NHS organisations’ referencecosts against the national tarifffor the main cataract procedure,B13.

These figures again highlight thepotential for improvement thatcan be made by streamlining thecataract pathway.

Figure 2: NHS organisations’ reference costs against the national tariff for cataract procedure B13 (elective)

‘This means that: 57 percent of organisations havecosts in excess of thenational tariff of £720 forcataract procedure B13.’

NB data does not include excess bed days and has been adjusted to account for market forcefactors. Reference cost data is based on Finished Consultant Episodes (FCEs) and tariff data isbased on spells and therefore not directly comparable.

Questions to be answered within your Trust:

• How do your costs compare with the tariff?

• What reference costs were submitted by your trust for cataract surgery? (HRGs and outpatients)

• Are staff aware and involved with cost improvements?

• Do your local costs properly reflect resource usage across HRGs and services?

HRG B13 - Phakoemulsification Cataract Extraction and Insertion of Lens

05

2. Our Approach

At the NHS Institute we arecommitted to co-producing ourproducts with frontline NHS staff.We invite clinicians, managersand patients from inside the NHSto work with us as part of ourproject teams. We also workclosely with a range of NHS staffand organisations to ensure thatthe people who we want to useour products are able to influencetheir design as much as possible.

Site selection phase: During thecourse of this project we visited anumber of organisationsspecifically to look at the cataractpathway. We worked with nineophthalmology units acrossEngland each with differentconfigurations and differentperformance profiles andincluding two private providers.

As well as spending time at eachunit observing the cataractpathway (following patientsthrough their journey fromreferral to aftercare) weinterviewed more than 100 staff and patients. TheAcknowledgements section at the end of this document lists and thanks the organisations with which we worked.

Visit phase: Visits to the siteswere conducted over one or twodays. Our activities included a mixof pathway observation and semi-structured interviews. We alsoconsidered how organisationswere using information to aidclinical and non-clinical decisionmaking.

Our discussions involved a rangeof professionals within thecataract pathway includingophthalmologists, optometrists,orthoptists, pre-assessmentnurses, theatre staff,anaesthetists, day case managers,ophthalmology operationalmanagers, booking andadministrative staff as well aspatients themselves.

Post visit phase: Following ourvisits we consolidated andvalidated the knowledge we hadgathered. Working with frontlinestaff at a co-production event, wewere able to review and agreethe recommended pathway forpatients with cataracts and startto identify the fundamentalprinciples and characteristics thatunits need to embrace in order todeliver this pathway successfully.In the course of this work we also consulted numerousprofessional bodies and voluntaryorganisations about our findings.

Our aim:

This document aims tohelp local healthcommunities andorganisations improve thequality and value of carefor cataract patients. Itcontains the keycharacteristics for a highperforming, qualitycataract service along withcase studies and measuresfor improvement.

The aim is for thesecharacteristics to bewidely adopted across theNHS so that cataractpatients have a highquality experienceirrespective of where theyreceive their care.

06

3. The recommended pathway

Undoubtedly the national daycase rate for cataract surgery hasimproved significantly to anaverage of 96 per cent rangingfrom around 74 per cent in a fewunits to as high as 100 per cent inseveral others.

However, during our recentobservations we found significantvariation in how cataract care isdelivered betweenophthalmology units. For instancesome cataract patients spend onlyone-and-a-half hours at theophthalmology unit on the day ofsurgery, compared with up to sixhours in other units.

As a result units are stillcombining aspects from thetraditional model of cataract careand the recommended model,resulting in:

• delays

• duplication

• and waste within their existingpathways.

Many units appear to focus theirimprovement efforts on only oneaspect of the patient pathway(e.g. the pre-assessment stage),meaning there is still scope forfurther improvements across theentire pathway.

However, as the highest volumesurgical procedure for most acutetrusts, any improvements madetowards the recommendedpathway would generate hugebenefits in both time and costsavings, as well as providing amore patient-focused service.

Our observations and discussionsduring site visits, together withextensive feedback fromstakeholders during co-production, have enabled us toidentify the key characteristics ofthe recommended care pathwayfor cataract patients.

The following tables compare thetraditional and recommendedpathways for the management ofcataract patients across the wholecare pathway.

‘the national day case ratefor cataract surgery hasimproved significantly toan average of 96 per cent’

We do not expect thatunits will be following thetraditional pathway in itsentirety but that they willbe able to identify one ormore areas within thisthey could improve upon.

07

Referral:

Traditional (up to 2 weeks) Recommended (immediate)

Step 1: Patient visits optometrist (including highstreet opticians)

• No specific information as to whether the patienthas lifestyle problems due to cataract or whetherthe patient understands the risks and benefits ofsurgery and wishes to consider it

• Complete GOS18 generic referral form and sendto GP

Step 1: Patient visits optometrist (including highstreet opticians) and is referred directly to hospitaleye service

• Discuss risks and benefits of surgery (providepatient information leaflet and consentinformation)

• Discuss patient lifestyle

• Ensure patient wishes to proceed with surgery

• Offer choice of provider

• Complete bespoke cataract referral form,including refraction, and send to hospital eyeservice with a copy to the patient, GP and PCT

Step 2: Patient visits GP and refers patient to hospitaleye service

• Send GOS18 form and details of past medicalhistory to hospital eye service or bookappointment via Choose and Book

Benefits

• saves unnecessary visit to GP

• saves administrative time of GP generating Choose and Book referral

• direct referral leads to shorter waiting time for surgery (appointment can be sooner as non-valueadded steps are removed from the referral process)

• accurate bespoke referrals from optometry eliminates wasted visits to hospital eye service for thepatient and saves unnecessary worry – this may reduce cataract referrals by up to 40%

• higher percentage of correct referrals saves unnecessary clinic visits freeing up space for otherpatients.

08

Booking:

Traditional (up to one week) Recommended (immediate)

Step 1: Booking team

• Referrals allocated

Step 1: Booking team

• Direct booking into cataract clinic (no or limitedvetting)

Step 2: Consultants

• Referrals vetted by consultants

Step 3: Booking team

• Booking into general clinic

Benefits

• saves unnecessary administrative time

• speeds up time taken to generate appointment

• frees up clinicians’ time as no (or limited) vetting of referral letters is required

• reduces the number of patients booked into a general clinic and then returning for pre-assessmenton another date.

09

Pre-operative assessment:

Traditional (3 hours) Recommended (1.5 hours)

Step 1: Patient sees nurse 1

• Measure visual acuity, pupil reactions andintraocular pressure & perform biometry andfocimetry

Step 1: Patient sees either nurse, optometrist ororthoptist

• Measure visual acuity, pupil reactions andintraocular pressure & perform biometry andfocimetry

• Discuss past medical history

• Discuss current medications

• Complete observations

• Provide patient information leaflets (includingconsent information for patients to reviewbefore consent is signed)

• Agree day case

• Discuss anaesthetic options

• Dilate pupils

• Investigations only if indicated

Step 2: Patient sees nurse 2

• Discuss past medical history

• Complete observations

• Discuss current medications

Step 2: Patient sees ophthalmologist

• Slit lamp examination (including fundus)

• Decide appropriateness for surgery

• Discuss desired post-operative refractive statuswith the patient (including current type ofspectacle correction) to enable the choice of lensimplant

• Identify 2nd eye surgery where appropriate

Step 3: Patient sees nurse 3

• Perform biometry and focimetry

• Perform auto-refraction

• Perform ECG and blood tests

Step 3: The following should be performed by theophthalmologist or a suitably trained nurse,optometrist or orthoptist as seen in Step 1

• Complete bespoke cataract consent form(patient reads consent information)

• Complete pre- and post-operative drugprescriptions

• Complete admission documentation

• Arrange INR test for one week pre-operatively

10

Traditional (3 hours) Recommended (1.5 hours)

Step 4: Patient sees ophthalmologist

• Slit lamp examination

• Measure intraocular pressure and pupil reactions

• Agree type of admission

• Discuss anaesthetic options

• Dilate pupils

• Fundus examination

• Decide appropriateness for surgery

• Complete consent using standard trust consentform (time is spent writing common risks onform every time as there is no specific cataractconsent form)

• Discuss desired post-operative refraction

Step 4: Patient sees booking team

• Offer patient choice of dates for surgery and forpost-operative follow-up appointment

Step 5: Patient sees nurse 4 / booking team

• Complete admission documentation

• Fixed date for surgery

• Provide patient information leaflet

Benefits

• only one pre-operative assessment visit provides better service for patients and frees up clinic time

• reduces the number of steps and handovers a patient encounters during their pre-assessment visitand therefore the amount of time the patient spends in hospital

• suitably trained professionals performing most tasks frees up ophthalmologist’s time

• pre-assessment visit ensures that everything is ready for the day of surgery (e.g. consent, choice oflens, INR test, 2nd eye listing, post-op drugs and post-op appointment).

11

Traditional (6 hours) Recommended (1.5 hours)

Day unit

Step 1: All patients arrive at the beginning of a list(nil by mouth following trust policy)

Step 1: Patient arrives at staggered or semi blocktimes and meets ‘primary nurse’ who follows thepatient through the journey including theatres(patient eats and drinks normally)

Step 2: Nurses dilate patient’s pupil in the day unit Step 2: Patients dilate their pupil at home or onarrival

Step 3: Review admission documentation Step 3: Review admission documentation

Step 4: Examination of the eye by operatingophthalmologist

Step 4: Recording of observations (blood pressure,pulse)

Step 5: Complete consent form with operatingophthalmologist

Step 5: Ophthalmologist or appropriately trainednurse marks eye and confirms consent

Step 6: Operating ophthalmologist chooses lensimplant

Step 6: No undressing

Step 7: Operating ophthalmologist marks eye Step 7: Patient walks to anaesthetic room

Step 8: Recording of observations (blood pressure,pulse)

Step 9: Ophthalmologist completes post-operativedrug prescription and sends to pharmacy

Step 10: Total or partial undressing

Step 11: Trolley or wheelchair patient toanaesthetic room

Day of surgery:

Ideally, the operating surgeon should be in the position to meet their patient at pre-operativeassessment to discuss refractive expectations and to choose lens implants for the patient ahead of theday of surgery. This will minimise delays and reduce last minute patient cancellations on the day ofsurgery.

12

Anaesthetic room

Step 1: Monitor patient with ECG, pulse oximetryand blood pressure

Step 1: Patient gets onto operating chair / trolleyand is positioned comfortably for surgery

Step 2: Venous access Step 2: Monitor patient with pulse oximetry

Step 3: Anaesthetic given Step 3: Anaesthetic given

Step 4: Patient wheeled into theatre on trolley andtransferred onto operating table (using up to fourmembers of staff)

Step 4: Patient wheeled into theatre accompaniedby primary nurse

Theatre

Step 1: Position patient Step 1: Monitor patient – pulse oximetry and withhand holder

Step 2: Monitor patient – ECG, pulse oximetry,blood pressure

Step 2: Perform operation

Step 3: Perform operation Step 3: Patient walks from theatre to day unit (iffit enough)

Step 4: Transfer patient using pat slide from tableto trolley (using four members of staff and risksinjury to staff)

Step 5: Trolley or chair patient to recovery area forobservations

Step 6: Operating ophthalmologist writesprescription for post-operative medication

Traditional (30 minutes) Recommended (0 minutes)

Recovery

Step 1: Wheel patient to recovery No stop in recovery

Step 2: Monitor patient with observations (bloodpressure, pulse)

Step 3: Transfer patient by trolley or chair to dayunit

13

Traditional (1 hour plus) Recommended (30 minutes)

Day unit

Step 1: Monitor patient with observations (pulse,blood pressure)

Step 1: Monitor patient with observations (pulse,blood pressure)

Step 2: Await drugs from pharmacy Step 2: Reviewed by nurse for discharge (post-operative patient information and post-operative appointment date already given at pre-assessment, and post-operative drops alreadydispensed from pharmacy)

Step 3: Patient’s eye examined by ophthalmologist/ nurse on slit lamp

Step 4: Post-operative information given topatient by nurse

Step 5: Post-operative appointment arranged viabooking team

Benefits

• less observations needed

• no need for patients to go to general recovery – this can be unpleasant for patients and it reducesstaffing costs

• staff time freed up by omitting unnecessary moving and handling of patient

• shorter stay in day unit reduces pressure on nursing staff and helps them care for patients better.

Traditional Recommended

Step 1: 24-hour follow-up with ophthalmologist Step 1: 2-4 week review by nurse, optometrist orophthalmologist

Step 2: 2-4 week review by ophthalmologist Step 2: 4-6 weeks patient attends localoptometrist

Step 3: 4-6 weeks patient attends localoptometrist

Benefits

• avoids 24 hour post-operative visit for the ‘routine’ patient which is more convenient for the patientand saves clinic time.

After care

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4. The key characteristics of high qualitycataract careThrough our observations andwork with NHS partners we havefound the followingcharacteristics to be the keyfeatures for delivering bothquality and value care forpatients undergoing cataractsurgery.

After the explanation of eachcharacteristic there are casestudies from frontline teams andsuggested improvementmeasures.

These key characteristics aregrouped and presented in twomain categories:

• overarching characteristicswhich are common to theentire pathway

• pathway specific characteristicsrelating to the main steps in therecommended pathway:

•• referral

•• booking

•• pre-operative assessment

•• day of surgery

•• after care.

15

Worcester Cataract Clinic is partof the Worcestershire Acute NHSTrust and operates out of theWorcester Royal Hospital andKidderminster Treatment Centre.The centre won a Beacon Awardin 2000 for its friendly andefficient cataract service. At thattime more than 100 consultantsand staff from the UK andIreland visited the departmentfor lectures and live surgerysessions.

The clinic has run a four-visitbilateral sequential cataractsurgery service for the past threeyears resulting in significantsavings to the health economy inWorcestershire. For every 1000patients with bilateral cataractsthere is a potential saving of1000 outpatient appointmentsover the most efficientconventional system.

The service is patient focusedand based on a set offundamental principles whichincludes the concept of treatingpeople from the point of viewof wellness not illness.

The clinic believes, for instance,that if a patient’s blood pressureis acceptable at the pre-op clinic10 weeks before it does notneed to be tested again.

‘We don’t treat cataractsbut treat people withvisual disability caused bycataract – there’s animportant difference’explains Paul Chell, ClinicalDirector

‘We regard patients asbeing well and we respecttheir involvement in theirrefractive outcome. Forexample, if a patient isaccustomed to monovisionin contact lenses then wefeel that option should beoffered as an outcome fortheir cataract surgery.’

The pathway also offers:

• one-stop cataract assessmentand diagnostic clinic

• one pre-operativeappointment for both eyes

• the creation of a refractiveplan for each patient

• a length of stay of 90 minuteson the day of surgery

• improved privacy – with noneed for patients to undress

• one follow-up appointmentfor both eyes

• open access to clinic forpatients post-operatively

• one opticians visit and onepair of glasses for both eyes.

Results:

Audits show that the inter-operative complication rate isless than six per thousand forthe department as a whole. Thisreduces the number ofoutpatient clinic attendances asintra-operative complicationsnot only increase the risk of apoor visual outcome but alsodoubles the number of patientvisits.

Case study‘We treat people, not cataracts’

Overarching characteristics of an ideal cataract care pathway

Key characteristic 1:The pathway is ‘fit forpurpose’

The best performing units havedeveloped pathways which arespecifically designed for highvolume day case cataract surgery.

Examples of this include:

• developing bespoke cataractconsent forms

• developing protocols that arespecific to cataract surgery (suchas allowing patients to eatbefore surgery).

‘We don’t treat cataractsbut treat people withvisual disability caused bycataract – there’s animportant difference’

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Key characteristic 2:The service has a highdegree of autonomy

Ophthalmology is a uniqueservice and the best practicepathway for cataracts has manyspecific requirements which aredifferent to other surgicalpathways.

As a result ophthalmology unitsbenefit enormously from beingable to devise and adopt policiesand procedures that reflect thevery different nature of thisextremely high volume surgicalspecialty.

For instance, manyophthalmology units use a trust-wide generic patient consentform. But consent could beobtained more appropriately andmore efficiently using the

bespoke cataract patient consentform devised by the Royal Collegeof Ophthalmologists (see Section8 - Further information andresources).

Cataract surgery is the largestvolume surgical procedure inmany acute trusts and, therefore,by giving ophthalmology unitsincreased autonomy will enablethem to implementimprovements more easily anddevelop a pathway tailoredspecifically to the requirements ofcataract patients.

We have observed that thoseophthalmology units with a highdegree of autonomy within atrust find it easier to develop acataract pathway which delivershigh quality efficient care.

Key characteristic 3:Data and information areused effectively toenhance decision making

Greater financial authority andresponsibility may enable eyedepartments to develop new andbetter services. Clinicians shouldbe aware of Healthcare ResourceGroup (HRG) costs and tariffsincluding the costs of instruments

and pre- and post-operativedrops. All staff can help inidentifying potential costimprovements.

Thresholds on a variety of clinicalareas are being appliednationally. For instance, duringour visits we observed thresholdsimplemented by a PCT which ledto a considerable reduction onthe number of cataractprocedures listed. As this hasbeen a recent adjustment to theservice it is too early to judge themerit of this new practice.However, although there are nonationally agreed guidelines,ophthalmology units need tounderstand the implications totheir service if thresholds areimposed locally.

Audits should also take place on aregular basis (e.g. rate ofoptometrist referrals for cataractthat actually require surgery,reasons for unplanned admissionsand cancellations).

‘Ophthalmology unitsbenefit enormously frombeing able to devise andadopt policies andprocedures that reflect thevery different nature ofthis extremely highvolume surgical specialty’

Key characteristic 4:Multidisciplinaryteamwork is key

Ophthalmologists, optometrists,orthoptists, pre-assessmentnurses, theatre staff,anaesthetists, day case managers,ophthalmology operationalmanagers, booking andadministration staff all worktogether to make improvementsto the cataract pathway. Thewhole team should be aware ofthe entire patient journey (ideallyhaving observed it firsthand) sothat a consistent message is givento patients and carers.

The ‘do it once, do it well’principle is useful here. Each partof the pathway needs to becompleted by someone who isappropriately trained.

Having confidence in individualmembers of the team opens upnew possibilities for theexpansion of roles. For instance,during our observations some

surgeons expressed a lack ofconfidence in the pre-assessmentstage and felt ocular examinationnecessary on the day of surgery.

This can lead to delays in startingand finishing lists and canprevent the unit from staggeringthe arrival times for patients. Thiscan be avoided by:

• ensuring staff have the correcttraining and support

• close working between pre-assessment staff and theoperating surgeon which helpspromote confidence in all stepsof the pathway leading up to,and following surgery.

‘Having confidence inindividual members of theteam opens up newpossibilities for theexpansion of roles’

17

The problem caused by increaseddemand for cataract surgery butwith no additional theatre timeor staffing has led to thecreation of a new and flexiblerole within the Ophthalmic Unitat Norfolk and NorwichUniversity Hospital NHS Trust.

The role of associate specialistwas created by re-grading thestaff grade. The move hassignificantly increased cataractcapacity and throughput in theunit and has achieved thisentirely within the existingtheatre sessions and without theneed for extra staffing.

A database is kept of all theannual leave booked by all themedical staff in the unit and amonthly timetable is produced.This allows the associatespecialist to identify and pick uptheatre lists and clinics whichwould otherwise be left vacant.The system is particularly usefulduring school holidays whenmany theatre lists wouldotherwise be unfilled due toconsultant absence.

Working closely with secretaries,theatre managers, bookingclerks and the outpatientmanager the associate specialistplays an important role inhelping the unit target areas ofneed and minimise wastedtheatre time.

The associate specialist prioritisestheir time by picking up theatrelists in Norwich and Cromer firstand then booking in clinics forthe sessions they are notrequired in theatre.

On theatre sessions there is nocase selection or cherry pickingof more straightforward cases,and there is normally still timefor the associate specialist tocarry out some teaching ofjunior doctors.

Results:

In the first year afterimplementing the new role:

• wasted theatre slots werereduced by 85 per cent and anextra 1000 cases were carriedout

• overall an average of 1500more cataract operations peryear are carried out

• a specialist registrar wouldnormally do over 100outpatients sessions per year(roughly 1800 outpatientslots). The flexible associatespecialist is able to do thatnumber in addition to all theextra cataract work. Whencataract numbers werereduced in 2006-2007 due toPCT restrictions on patienteligibility for surgery thenumber increased to 170 clinics(over 3000 outpatient slots).

Case study Flexible theatre cover; reduced waste

The move has significantlyincreased cataract capacityand throughput in theunit and has achieved thisentirely within theexisting theatre sessionsand without the need forextra staffing

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Key characteristic 5:Patient flow is optimisedand waste and duplicationeliminated

The number of patient handoversthroughout the pathway needs tobe reduced. For instance, somepatients can see up to sevendifferent individuals (includingfour different nurses) during theirpre-assessment visit while otherssee only three professionals intotal.

To support high throughput lists,the ideal set-up of anophthalmology unit would be asa discrete (or self contained) unitwithin the trust. A ‘cataractcentre’ containing its ownoutpatient rooms, day unit andtheatres is an ideal way tofacilitate patient flow.

Careful thought should be givento how patients flow through thesystem with any steps that don’tadd value being eliminatedaltogether. For instance, the day

unit should be close to theatresmaking it easier for patients towalk to and from surgery. Someunits have to trolley patients longdistances taking up time andresources and often creatingdelays.

Ophthalmology units willundoubtedly have restrictions tomajor layout changes so the basiccomponents would be adedicated day unit and theatreclose together. The one-stop pre-assessment team should also belocated in one area withinoutpatients. Much can still beachieved without the need tohave a completely self-containeddepartment.

Key characteristic 6:Patient information isconsistent, timely andaccessible

Patient information should berelevant and consistentthroughout the whole patientjourney. This should begin at the

start of referral and involve aninformed discussion between thepatient and optometrist of therisks and benefits of cataractsurgery.

This allows a reduction in thenumber of inappropriate referralsand makes for a more efficientpre-assessment clinic. But it doesrequire close links betweenreferring optometrists andproviders.

Information also needs to beprovided in an accessible format,such as audio tapes that patientscan listen to at home beforesurgery. See Section 8 - Furtherinformation and resources for theRoyal National Institute for theBlind’s ‘See it Right’ Guidelines.

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Referral: key characteristics

Key characteristicDirect referral is used tosave patient and clinictime

Bespoke cataract referral formscan filter out patients who areuntroubled by cataract or do notwish to proceed with surgery atthat time.

The form should trigger adiscussion with the patient aboutthe risks and benefits of havingsurgery. It is through thisdiscussion that agreement withthe patient can be sought toproceed with referral tosecondary care for treatmentoptions.

The referral form should cover:

• refraction

• visual acuity

• intraocular pressure

• significant symptoms (e.g. nightdriving)

• co-morbidity of the eye

• relevant medical history fromopticians (e.g. mobilityproblems, requirement for ainterpreter) in conjunction withpast medical history from theGP if required.

Copies of the form need to begiven to the patient, GP, PCT andhospital eye service.

An example of a bespoke cataractreferral form can be found inAppendix 1 at the end of thisdocument.

Optometrists are the preferredprofession to provide thisinformation. Although a fee isoften incurred for direct referralsthere are potentially overallsavings as patients do not need tosee their GP and unnecessaryreferrals to the hospital eye clinicare reduced. However, many PCTsdo not currently have the fundingavailable for direct cataractreferral schemes.

Where it can be achieved thedirect referral pathway should beimplemented alongside aneducation programme tointroduce optometrists to theophthalmic department criteriafor cataract surgery.

In addition:

Consistent information from allhealthcare professionals helps tomanage patient expectationsright throughout the pathway -beginning with their visit to theoptometrists. A leaflet includinginformation about the risks andbenefits and the consent processshould be given to patients at thisfirst visit.

The optometrist should also haveinformation about all providers ofcataract surgery giving thepatient choice of provider fortheir operation.

Regular audits of optometricreferrals should take place, andfeedback given to referringoptometrist to improve thestandard of the service.

20

Surrey PCT has developed apathway that is allowingoptometrists to refer patientsdirectly to the cataract clinic.

The scheme requires theoptometrist to undertake aneducational lecture with localophthalmic surgeons. Thisinvolves explaining the criteriafor cataract extraction and therisks of cataract surgery. Theoptometrist is then able todiscuss in detail the option ofcataract surgery with patientshelping them decide whether ornot to proceed with the hospitalreferral.

If, on visiting the optometrist,cataract is found, referral is onlyconsidered if the patient isnoticing an effect on theirlifestyle. Then:

• the patient is informed of therisks of loss of vision fromcataract surgery

• if the patient wishes toproceed the referral is made

• an assessment of angle closureis made and documented(enabling clinic staff to dilatethe patient’s pupils prior toseeing the ophthalmologist)

• the patient is given aninformation leaflet aboutcataract and the operation

• the optometrist also hasinformation about the choiceof local providers for cataractsurgery – meaning the patientcan choose their provider

• the bespoke cataract form isfilled in and five copies aremade - one each for theoptometrist, patient, GP, thehospital cataract clinic and thePCT for remuneration.

The optometrist receives £25from the PCT for each referralregardless of whether thepatient progresses to surgery ornot. In cases where more than10 per cent of an optometrist’sreferrals refuse surgery whenseen at the hospital eye service

the optometrist is required to re-attend the training lecture.

Initially there were severalsimilar schemes across the healthcommunity. These have nowbeen brought together in oneconsistent system where thedocumentation is all the same.

Results:

• audit information from onecataract clinic found thatbefore the set up of thebespoke cataract referralscheme 50 per cent ofcataracts referred did not haveany indication to have surgery

• after the introduction of thescheme the conversion rate tocataract surgery in the cataractclinic increased to 90 per cent.

Case studyDirect referral from optometrist to cataract service

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Booking: key characteristics

Key characteristicDirect booking issupported by bespokereferral systems

Direct booking into a cataractclinic from the bespoke referralform offers the most streamlinedsolution. Using information fromthe bespoke form booking staffcan book patients into the correctone-stop pre-assessment clinicwithout the need to involve otherprofessionals.

This reduces the need forclinicians to ‘vet’ referrals. Limitedvetting should only occur forcases with co-morbidities.

Alternatively, patients can begiven a choice of dates and timesfor their outpatient appointmentthrough the Choose & Bookelectronic referral system.

For optimal waiting listmanagement a robust policy forDNAs (did not attends) needs tobe in place and followed.

‘Direct booking into acataract clinic from thebespoke referral formoffers the moststreamlined solution’

22

Pre-operative assessment: key characteristics

Key characteristicPre-assessment isstreamlined,comprehensive and avoidshandovers

From our observations, the time apatient spends at pre-assessmentvaries from one and a half hoursto three hours. The shortest timewas achieved in a one-stop clinic(as outlined in Action OnCataracts) where the patient onlyhas one visit prior to surgery.

It was achieved by theprofessionals listed belowundertaking the following:

Nurse / optometrist /orthoptist

The following steps should beperformed by the same individualmember of staff to avoidhandovers:

• measure visual acuity, pupilreactions and intraocularpressure & perform biometryand focimetry

• observations

• past medical history

• discuss current medications

• patient information leaflets(including consent informationfor patients to review beforeconsent is signed)

• investigations (if required)

• agree day case - if patientdeviates from the ‘normal daycase’ pathway follow strictinpatient criteria

• discuss anaesthetic options

• pupil dilation.

Note: auto refraction isunnecessary at this point as theinformation has already beenprovided by the optometrist.Undertaking this examination atthis stage is a duplication.

Although The Royal College ofOphthalmologists CataractSurgery Guidelines clearly statesthat there is no benefit inperforming ECGs or blood teststhere are still a small number ofunits currently carrying outunnecessary ECGs.

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24

Biometry is a natural extendedrole for orthoptists using manyof the skills they already have.

Recognising this the UniversityHospitals of Leicester NHS Trustis using orthoptists to carry outbiometry at its cataract clinicssaving time for both patientsand clinicians.

Orthoptic undergraduatetraining already covers theanatomy and physiology of theeye in detail: ophthalmologyinvestigative techniques,refractive error and, of course,binocular vision. These are theareas that need to be fullyunderstood in order to carry outsuccessful biometry and forsatisfactory post-op outcomes tobe achieved.

In addition, orthoptists routinelytake an ophthalmic and medicalhistory from patients - other keyskills needed in cataract clinics.According to the trust the onlyadditional training orthoptistsrequire is in the use of theequipment (the keratometer andA scan, and, more recently, theIOL Master).

At Leicester two seniororthoptists were initially trainedby medical staff and cascadedthe knowledge to the rest of the

orthoptic team. Regularcompetency assessments arecarried out to ensure standardsare maintained.

An added advantage of theextended role is when binocularvision problems are identifiedfor the first time duringbiometry. With orthoptistscarrying out the test these canobviously be addressed at thesame appointment.

The British and Irish OrthopticSociety has produced adocument, CompetencyStandards and ProfessionalPractice Guidelines for theExtended Role of the Orthoptist(2006). See Section 8 Furtherinformation and resources.

Case studyBiometry could be an extended role for Orthoptists

Biometry is a naturalextended role fororthoptists, using many ofthe skills they alreadyhave

25

Ophthalmologist

• slit lamp examination includingfundus examination – or,alternatively, this can be carriedout by a suitably trainedprofessional (e.g. nurse,optometrist, orthoptist)

• decide appropriateness ofsurgery

• discussion with the patient ofthe desired post-operativerefractive status - this avoidscomplex discussion and decisionmaking immediately beforesurgery which can be distressingfor the patient

• identify second eye surgerywhere appropriate.

Note: Ideally, the operatingsurgeon should examine thepatient. This is best performedonce at pre-assessment and notleft until the day of surgery orduplicated. This is more practicalnow that the time between pre-assessment and surgery is shorter.

Ophthalmologist orsuitably trained nurse /optometrist / orthoptist

The following should beperformed by the same individual

member of staff (ideally the samemember of staff as in Step 1) toavoid handovers:

• consent should be obtainedthrough a bespoke consentform specifically for cataractpatients

• the consent form should clearlystate the risks and benefitsassociated with cataract surgeryand should be pre-printed

• pre-operative drug prescriptionsshould be completed duringthis visit on a pre-printed form– this helps minimise delays onthe day of surgery and could beundertaken by the nurse actingunder Patient Group Directives

• standardised post-operative eyedrops should be prescribed inthe initial pre-assessment visitand patients educated on howto instil them

• patients unable to self medicateshould be identified andcontingencies put in place tosupport them - this streamlinesprocesses on the day of surgery

• specific requirements (e.g.translation, transport) on theday of surgery are identifiedand arranged in advance

• admission documentation forthe day unit should becompleted at this point in theprocess, in advance of the dayof surgery and reviewed onarrival for surgery

• the INR test should be arrangedin the community one weekbefore surgery - this avoidswaiting for results on the dayof surgery and the possible riskof cancellation.

Information required atassessment:

During our observations therewere many examples where trust-wide policies produced largeamounts of unnecessary work.These steps did not add value tothe process.

Patients in one trust, for example,had to undergo a DVT riskassessment, a nutritional levelassessment as well as a bed sorerisk assessment before cataractsurgery.

Far from adding quality to theprocess these constraints may welldetract from it by reducing thetime staff have to discuss relevantissues and concerns with thepatient.

Booking team

Patients are offered a choice ofdates and times for theiroperation and follow-upappointments.

Remember: Do it once, do it well

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As well as dealing with a vastthroughput of patients since itopened in 1993 the CataractTreatment Centre at SunderlandEye Care Infirmary has alsotaken positive steps to helppatients understand each stageof their care journey.

The unit has introduced a simpleand informative plan of carethat patients can use when theyreturn home following pre-assessment, surgery and aftertheir post-operativeappointment.

Working together to devise thebooklet patients and staffagreed that the informationshould describe care from pre-assessment right through to postoperative clinics. Knowing whatwill happen to them in advanceallows patients and carers tomake arrangements, for instancewith transport or organisinghelp with drops.

The booklet also supports thepre-assessment process by:

• giving patients and carers atake-away resource so theydon’t have to retain all theinformation given to them onthe day

• enabling staff to signpostinformation in the booklet sothey don’t have to repeatinformation and instructions.

Dates for surgery and all otherappointments are clearlyidentified on the front of thebooklet thus giving patients a

useful ‘at-a-glance’ record. Theplan also gives contact numbersin case the patient experiencesany problems or needs advice. Care has also been taken overthe font size of the booklet,setting it at N18 – a size whichmost patients with visualimpairment are able to read.The booklet’s yellow colour alsocontrasts with the print to givehigh definition and ensure easierreading.

The booklet is professionallyprinted and reviewed yearlywith patients.

Results:

As well as patients and carersbeing better informed thebooklet has helped reducecancellations and forgottenappointments leading to betterutilisation of clinics and theatrelists.

See appendix 2 for the Plan ofCare booklet.

Case study‘Plan of care’ booklet supports the whole cataract pathway

‘Knowing what willhappen to them inadvance allows patientsand carers to makearrangements, for instancewith transport ororganising help withdrops’

Newcastle Upon Tyne HospitalsNHS Foundation Trustintroduced nurse led consent in2002 following the Departmentof Health’s ‘Consent Policy’earlier that year. The Trustalready had a fully nurse led pre-assessment clinic – so expandingthe role to include takingconsent was seen as a naturalmove and a good way tosupport continuity of care forpatients.

With all nurses now leading theconsent process the consentform is signed by the patientand the nurse and remains inthe medical notes. This is thenreadily available on the day ofsurgery when the nurse obtainsthe second signature.

Results:

• the process frees up 10minutes per patient ofconsultant time

• it provides a better patientexperience as the nursing andconsent aspects of treatmentand care can be discussed atthe same time

• patients are offered a choiceof dates and times for theiroperation and follow upappointment.

Case studyNurse led consent

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There is wide variation across NHSorganisations in the total lengthof time a patient is in hospital fortheir cataract operation. In someunits this is done in an efficientand timely manner and takes nolonger than one and a half hours.In others a patient can stay for upto six hours without any addedvalue.

For operating lists to be efficientit is important to have a memberof staff who is responsible for theflow of patients through the list.This role is best undertaken by ananaesthetist or theatre sister who,assisted by the use of a TVmonitor, can assess how theoperation is progressing andprepare for the next patientaccordingly.

Key characteristicDay of surgery processesare streamlined

What this means in the day unit:

• a primary nurse remains withthe patient throughout thesurgical pathway fromadmission to discharge thusimproving continuity of care

• dilation is done at home ordirectly on arrival

• arrival times are staggered -patients prefer this and it helpsminimise pre-operative waiting.However, semi-block arrivaltimes will also facilitate theatreflow and reduce the number ofpatients the nurses are lookingafter at any one time

• warfarin levels are taken aweek prior to the day ofsurgery

• admission documentationalready completed at pre-assessment is reviewed

• observations are recorded(blood pressure, pulse)

• consent is confirmed withophthalmologist or nurse

• the eye is marked byophthalmologist or nurse (whowill remain with patient intheatre) – this allows the list toflow with staggered arrivaltimes without removing thesurgeon from the theatre. (SeeSection 8 Further informationand resources for the ‘CorrectSite Surgery’ Guidelines)

• undressing is not necessary aspatients wear a cap and atheatre gown over their clothesand good draping techniquesare used to avoid iodine ontheir clothes

• the majority of patients areable and happy to walk to theanaesthetic room therebyavoiding the use of trolleys andchairs - this reduces patienthandling and risk of back injuryand helps free up staff normallyinvolved in patient transport.

Day of surgery: key characteristics

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In the Cataract Treatment Centreat Sunderland Eye Infirmarypatients benefit from knowingthat the nurse who does theirpre-assessment will be the sameindividual who accompaniesthem right throughout thesurgical pathway.

During assessment the namednurse involves the patients inmaking decisions about theircare, offering them choices ofdates and helping them thinkabout other issues such as homecircumstances, transportarrangements and anaesthesia.

The nurse then places thepatient on the operating list andensures that they will be presenton the day of surgery to lookafter their patient.

On the day of the operation thenurse positions the patient forsurgery and holds the patient’shand throughout.

Being this close means the nursecan keep talking to the patientand quickly deal with anyproblems, whether this is justreassuring them or somethingmore practical such as adjusting

air flow so the patient does notget breathless or start to panic.

This has several benefits:

• the patient knows who will belooking after them duringsurgery and they are confidentthat they will see a familiarface - this is very important topatients who are elderly asthey are often anxious abouthow they will cope during theoperation, whether they willbe able to lie still duringsurgery and whether they willfeel any pain

• the one-to-one care makes thepatient feel they are the onlyone that matters – they areless anxious and oftenpresume they are the onlypatient on the list

• a trust builds up between thenurse and patient with thenurse becoming more sensitiveto the patients needs and ableto detect when the patient isanxious and needs increasedreassurance

• there is less repetition whichmakes the patient feel theyare being listened to and nothanded from one member ofstaff to the next.

Results:

• there are no handoversthereby reducing the chancesof mistakes

• patients cope well withsurgery and are quickly readyfor discharge

• nursing staff have increasedjob satisfaction - staffmotivation is high withreduced sickness levels andreduced staff turnover in theunit.

Case studyPrimary nurse stays with patient across whole journey

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‘The one-to-one caremakes the patient feelthey are the only one thatmatters – they are lessanxious and oftenpresume they are the onlypatient on the list’

What this means in theanaesthetic room / pre-operativearea:

The anaesthetic room is essentialfor the smooth running of acataract list. This enables moretime to be spent getting thepatient comfortable and readyfor theatre without wasting timeduring the theatre slot.

Specifically:

• the patient is positionedcomfortably on operatingtrolley / chair

• saturation monitoring is theonly monitoring required

• anaesthetic is given:

•• with sharp needle anaesthetictechniques - an anaesthetistshould be present at all times(refer to The Royal College ofOphthalmologists CataractSurgery Guidelines)

•• with topical anaesthesia andblunt cannula techniques – ananaesthetist presence is notessential as long as at leastone member of the theatreteam is qualified in AdvancedLife Support.

Notes:

• The Royal Colleges ofOphthalmologists andAnaesthetists do notrecommend routine bloodpressure checks or ECGs intheatre

• venous access is notrecommended by the RoyalCollege of Anaesthetists inpatients undergoing topical orsub-tenons anaesthesia.4

What this means in theatres:

Dedicated cataract lists can leadto greater efficiency andthroughput. A minimum of six orseven operations can beperformed on a list includingtraining lists. High volume listsare regularly achieving at leastnine.

High volume lists are regularlyachieving up to nine or tenoperations a list. It is importantthat the complexity and thelength of surgery are taken intoaccount when deciding on thenumber of cases on a list.However, standardisation of theentire pathway can help efficientrunning of lists.

Other specific things to considerinclude:

• saturation monitoring is all thatis required during surgery

• the ‘hand holder’ is an excellentway to monitor patientexperience and wellbeing aswell as helping reduce anxietylevels - in some units this role isundertaken by volunteers

• standardisation in types ofinstruments surgeons use willhelp the scrub nurses knowwhich instruments the surgeonwill need and will make settingup between cases easier

• some units find it efficient totrain the scrub nurse to drapethe patient and to fold or loadthe intra-ocular lens prior toinsertion

• peri-operative drugs and post-operative drops should be pre-printed to save surgeon timeduring the theatre list - ideallythese should be prescribed atpre-assessment to save patientswaiting for drops to bedispensed on the day of surgery

4 The Royal College of Anaesthetists and The Royal College of Ophthalmologists, 2001. Local Anaesthesia for Intraocular Surgery.www.rcoa.ac.uk/docs/rcarcoguidelines.pdf

30

• units are moving towards theElectronic Patient Record (EPR)but in practice most unitscontinue to use a combinationof electronic and paper records- a rational approach to thismay help reduce duplication. Inunits where the process isnearly all paperless there maybe great benefits from makingthe final push and becomingcompletely paperless.

• the level of nursing staff intheatres and the day unit varies- the most efficient model weobserved was:

•• 3 staff in theatres

! 2 scrub nurses and 1 runner

•• 3 staff in the day unit

! 3 primary nurses / unit staffrotating through theatres andday unit.

What this means in the day unit:

After the operation, if the layoutpermits, the patient should walkto the day unit thus avoidingfurther unnecessary patienthandling. If needed, considerusing a wheelchair.

A single set of post-operativeobservations (blood pressure,pulse) can also be performed,avoiding a stop in recovery.

Other specific things to considerinclude:

• standardise post-operativemedication between surgeonsordered at pre-assessment - thisenables pre-packed, post-operative drugs to be availableimmediately ready for discharge

• providing two bottles of post-operative eye drops avoids anunnecessary visit to the GP forpatients needing another bottle

• some units are no longer usingeye shields after surgery, or forpatients at night, without anapparent increase in post-operative complications

• in many eye units the patientsare reviewed post-operativelyby trained nurses for discharge

• unless a patient hadcomplicated surgery or is inpain a slit lamp examination isnot required and adds littlevalue - this enables patients toleave the day unit sooner byreducing unnecessary waitingand time spent in the hospital

• ideally a patient should bedischarged within 30 minutespost-operatively - the samenurse discharging the patientshould ensure patienteducation is given includingemergency 24-hour contactdetails

• date and time of post-operativeappointment (agreed at pre-assessment) should beconfirmed.

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After care: key characteristics

It is usual to arrange a singlepost-operative visit at two to fourweeks. This can be done in anumber of ways. The majority ofpatients are reviewed in hospitalclinics and in some units nurses oroptometrists perform this role forroutine cases.

However, some patients are stillbeing routinely reviewed 24hours post-operatively regardlessof whether there has beencomplicated surgery. This isunnecessary and means anothervisit for the patient. Otheralternatives to hospital reviewhave successfully been set upusing local optometry services.

Important features of the post-operative review include:

• visual acuity measurement

• auto-refraction to screen forrefractive surprise

• eye examination

• discussion of post-operativeresults

• management of post-operativerefractive error

• collection of outcome data

• listing of second eye

• refraction by optometrist - thisshould occur four to six weeksafter surgery when the patienthas stopped using their eyedrops and has been dischargedfrom the eye clinic. In cases ofsecond eye operation refractionfollows the second operation.

Note: Most surgeons and patientsprefer to ensure that the first eyehas fully recovered beforeadvising for second eye surgery.In line with the 18-weeks policythe clock officially starts when apatient is fit and ready for thesecond of a bilateral procedure.To keep up to date with 18-weekrequirements visit:www.18weeks.nhs.uk

The second eye pre-assessmentcan be performed over thetelephone by a nurse (and achoice of date offered forsurgery) for uncomplicated cases.Some units proceed to second eyesurgery without a post-operativevisit for the first eye.

32

Newcastle Upon Tyne HospitalsNHS Foundation Trust hasintroduced telephone pre-assessments for second eyepatients.

Originally every patient wouldhave to come back for anotherpre-assessment appointment atthe hospital before their secondeye operation even if it was onlya few months since their firsteye surgery.

As well as placing a burden onstaff time and resources this wasan unnecessary step for thepatient and inconvenient if theyhad to travel long distances.

Now patients book their secondeye operation date at their post-operative visit and nurses phonepatients to check their detailshave not changed since their lastoperation.

Results:

• considerable time and resourcesavings for the department

• an improved experience forpatients.

Case study2nd eye telephone pre-assessment

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5. Measures for improvement

Through our observations weidentified a need and desire infrontline staff and managerialteams to understand currentperformance in their cataractservices and compare thisperformance to local and nationalbenchmarks.

Data to help identify potentialimprovement opportunities incataract pathways was alsohighlighted as a key need. Well-performing organisations that wevisited had a good understandingof their own performance androutinely used data to drivequality and safety in their local

services as well as to assess theimpact of any changes theymade.

The measures offered here arenot in any way prescriptive. Theaim of using these metrics is to:

• improve the quality andeffectiveness of care and thepatient experience

• decrease the variation incataract pathways

• stimulate thinking and helplocal organisations considertheir own position in terms ofspecific cataract processes.

They should also be used inconjunction with 18-weeksmeasures.

Local services will want toprioritise the use of thesemeasures to reflect their ownlocal circumstances. Agreementwill also need to be reached onhow frequently this informationis collected and what level ofdetail is sought.

34

Pathway Step Measure Aim

Referral percentage of optometristreferrals for cataract thatactually require surgery

> 90%

Booking percentage of referrals directlybooked into cataract clinicwithout being vetted

> 80%

Pre-assessment percentage of patients not pre-assessed on day of initialconsultation

< 10%

Pre-assessment length of time at pre-assessmentvisit

target 1 1/2 hours

Day of surgery length of stay from admission todischarge

target 1 1/2 hours

Day of surgery utilisation figures for cataracttheatres

> 90%

Day of surgery number of cases per week 70 per theatre (if 10 operatinglists per week)

After care patient satisfaction surveys quarterly

After care percentage of patients using 24-hour helpline vs patientsattending eye casualty

locally agreed

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6. Benefits of following the pathway

There are fewer visits to hospitaland pre-operative and day ofsurgery visits are shorter:

• patient flow is improved

• variability in the process isreduced. This results in:

•• increased activity

•• better use of capacity(resources for inpatientoperations and emergencycare are freed up)

•• patients being treated faster

•• shorter waiting times.

Patient expectations aremanaged and satisfaction isimproved:

• consistent information isprovided about the medicalcondition, the options formanagement and what toexpect from treatment

• patients have choice andcertainty over dates for hospitalappointments and over theoperation date

• patients are not referredunnecessarily to the pathway

• access to well designed facilitiesimproves the patient experience

• well trained staff provideconsistency of care

• patients are able to return totheir own homes sooner

• risks of hospitalisation, e.g.through hospital-acquiredinfection, are reduced

• effective pre-assessment andbooking processes reducecancellations.

There are significant financialbenefits:

• reductions in the length of stayand standardisation ofprocedures and equipment allreduce costs

• productivity is increasedthrough reducing variations inthe process

• waste is reduced and resourcesare freed up e.g. fewer lastminute cancellations.

Surgical reputation is enhancedthrough improvements in quality:

• opportunities for marketing arecreated in the new, competitiveNHS environment

• staff and patient satisfactionincrease.

Team working and the workingenvironment improves:

• the multidisciplinary carepathway achieves a sharedvision and purpose

• a high quality mindset isdeveloped in staff.

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7. Next steps

The advice and ideas offered inthis report are based on ourobservations of practice withinophthalmology units. Althoughthese practices are delivering highquality care and value for moneyit should be recognised that theymay not be the only way ofachieving these. However, webelieve they will offer usefulguidance and direction to anyoneseeking this goal.

To improve services we adviseorganisations to use this guidanceand take the following steps:

• map your current pathwayagainst the recommendedpathway for cataracts andexisting guidelines

• identify areas of delays, waste,duplication and savings in yourcurrent pathway

• generate a local plan forimprovement.

While this document offerssuggestions to care providers andcommissioners on how they canoptimise their own provision ofcare it is only a first step. Weknow units will need practical,relevant tools that will help themmake these improvementshappen.

We want to hear from you...

We genuinely welcome and valueyour contribution to our work. Ifyou have comments or would liketo be involved in any way pleaseget in touch with us at:

Delivering Quality and ValueTeam at: cataracts@institute.nhs.uk

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8. Further information and resources

This is just a small selection ofsome of the best links andresources to help you improveyour cataract pathway:

Action on Cataracts: goodpractice guidance (2000),Department of Health:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4005637

Cataract Consent Form Template,The Royal College ofOphthalmologists:http://www.rcophth.ac.uk/docs/publications/published-guidelines/consentform04.pdf

Cataract Surgery Guidelines (2007- updated), The Royal College ofOphthalmologists: http://www.rcophth.ac.uk/docs/publications/CataractSurgeryGuidelinesMarch2005Updated.pdf

Commissioning Cataract Surgery– an outline of good practice(2004), The Royal College ofOphthalmologists:http://www.rcophth.ac.uk/docs/publications/published-guidelines/CommissioningCataractSurgery-April2004.pdf

Competency Standards andProfessional Practice Guidelinesfor the Extended Role of theOrthoptist (2006). The British andIrish Orthoptic Society:www.orthoptics.org.uk/BIOS_Competencies_Standards_-_Extended_Roles_-_Master_Handbook.pdf

Correct Site Surgery, NationalPatient Safety Agency & TheRoyal College of Surgeons (2005):http://www.npsa.nhs.uk/patientsafety/alerts-and-directives/alerts/correct-site-surgery/

Local Anaesthesia for IntracularSurgery, Royal College ofAnaesthetists and Royal Collegeof Ophthalmologists (2001):www.rcoa.ac.uk/docs/rcarcoguidelines.pdf

‘See it Right’ guidelines (2006),The Royal National Institute forthe Blind’:www.rnib.org.uk/xpedio/groups/public/documents/PublicWebsite/public_seeitright.hcsp

Understanding Cataracts (patientinformation leaflet), The RoyalCollege of Ophthalmologists:http://www.rcophth.ac.uk/docs/publications/patient-info-booklets/UnderstandingCataracts.pdf

Association of Ophthalmologists:www.aoo.org.uk

British Medical Association (BMA)Ophthalmic Group Committee:www.bma.org.uk

Eye Care Services (Department ofHealth):www.dh.gov.uk/en/Healthcare/Primarycare/Optical

Royal National Institute of BlindPeople (RNIB):www.rnib.org.uk

The College of Optometrists:www.college-optometrists.org

The Royal College ofOphthalmologists:www.rcophth.ac.uk

United Kingdom and IrelandSociety of Cataract and RefractiveSurgeons:www.ukiscrs.org.uk

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9. Acknowledgements

We wish to offer our sincere thanks to everyone who has contributedto this project. In particular, we would like to thank the patients andstaff who gave us an invaluable insight into their work and practice.

The trusts we visited were:

Buckinghamshire Hospitals NHS Trust Capio Healthcare UKCity Hospitals Sunderland NHS Foundation Trust Leeds Teaching Hospitals NHS Trust Moorfields Eye Hospital NHS Foundation Trust Netcare Healthcare UK Newcastle Upon Tyne Hospitals NHS Foundation Trust Norfolk and Norwich University Hospital NHS Trust University Hospitals of Leicester NHS TrustWorcestershire Acute NHS Trust

We would also like to thank the following organisations for theirvalued contribution to this work:

Association of Ophthalmologists British Medical Association (BMA) Ophthalmic Group Committee Eye Care Services (Department of Health)Royal College of Nursing Royal National Institute of Blind People (RNIB) The College of OptometristsThe Royal College of Ophthalmologists United Kingdom and Ireland Society of Cataract and Refractive Surgeons

39

Appendix 1 - Example of a Bespoke CataractReferral Form

40

Appendix 2 - Sunderland Eye Care Plan

41

42

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44

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