Creating a one stop clinic to reduce pathway variation for patients with suspected cancer
As part of the Access QI programme, NHS Lothian’s Urology service set out to reduce the wait time from referral to diagnosis for patients with visible haematuria, or blood in their urine. They focused on this group because visible haematuria is a possible risk for cancer and these patients are considered urgent referrals.
The Urology team made detailed process maps of three common diagnostic pathways, including the median number of days waited at various steps. They also made note of any barriers or constraints in the system at various steps.

A small excerpt from pathways one and two of the original process map with detailed steps
They found a great deal of variation between wait times in each pathway, and that key differences at the beginning of each pathway were contributing to this variation. Patients on pathway one had imaging done before their flexible cystoscopy procedure, while patients on pathway two had imaging after their flexible cystoscopy. In pathway three, flexible cystoscopy was performed first and imaging was ordered later than on the other two pathways. As you can see in the diagram below, patients were reaching different stages of each pathway at very different times.

A high level view of the three Urology pathways and their median wait times
After completing their process maps, the team then surveyed 45 patients and 43 staff members to ask what they liked about the service and what they felt could be better. More than 30 patients responded that they would have preferred to have a shorter wait time or clearer communication from the service
After reviewing clinical outcome data along with the process maps and survey results, the team decided to trial a One Stop Haematuria Clinic in which patients receive cystoscopy and ultrasound imaging all on the same day. A one stop clinic can eliminate unnecessary variation between multiple pathways and significantly shorten the time from referral to diagnosis. The team completed another process map to visualise what the One Stop Haematuria Clinic would look like. They also secured a part-time ultrasonographer to facilitate this change. While the old process map was complex and branched off into three distinct and highly variable pathways, the new one was much more streamlined and straightforward.

Wait times for the three original Urology pathways compared to the new one stop clinic
After trialing the new one stop pathway, the Urology team collected patient feedback again and found that 100% of the patients surveyed were either “very satisfied” or “extremely satisfied” with their experience.
“Everything seemed to flow, surprised by how quickly I was seen in each area” – Urology patient
“The service reduced the need for follow-up consultation” – Urology patient
Preliminary results from the trial period suggest a potential resource saving for the service, as they may be performing fewer CT urograms. Lothian Urology has now adopted the one stop clinic as the model of care for patients with visible haematuria and believes this model could eventually also be used in other areas of the service. Click here to see a poster the Urology team made about this project.