Problem
The Clatterbridge Cancer Centre (CCC) National Health Service (NHS) Foundation Trust is one of the UK’s regional tertiary (specialist) hospital trusts. We have three sites in the northwest of England: in Liverpool city centre and its suburb of Aintree, and across the River Mersey at Clatterbridge on the Wirral. CCC provides highly specialized cancer care to both inpatients and outpatients, including pioneering chemotherapy, immunotherapy, gene therapy, haemato-oncology and radiotherapy. Our catchment is 2.4 million people across Cheshire, Merseyside and the surrounding areas, including the Isle of Man.1
Radiotherapy uses ionising radiation to kill or shrink cancerous tumours. The most common technique is to direct a beam of photons (mega voltage (MV) X-rays or gamma rays) or subatomic particles (electrons or protons) from outside the body using a linear accelerator (linac) or (for protons) a cyclotron. (The alternative to external beam radiotherapy (EBRT) is to place a radiation source inside the body, eg, brachytherapy.2) Most EBRT is photon therapy, but a small number of patients receive electron beam therapy (or, for very few, proton beam therapy).3 We have 10 linacs across our three sites, 2 of which are commissioned to provide electron radiotherapy. In 2021, we administered 728 electron treatments (fractions).
At CCC, all patients receiving MV photon therapy have a CT scan to aid planning. However, the majority of our electron patients do not, since clinicians deem it unnecessary in most cases; this group is described locally as non-scanned electron patients—this is the target group for our quality improvement (QI) project, referred to simply as ‘patients’ from now on. These make up approximately 1% of our total treatment workload at CCC.
Prior to this improvement project, our electron treatment planning care pathway had a number of tasks which required manual calculations and manual data entry. The small patient numbers meant that these tasks were unfamiliar to staff, the tasks having been automated on other EBRT pathways to improve patient safety. As a result, these manual tasks caused delays, producing significant time pressures at the patient’s New Start—their appointment for their first radiotherapy treatment (first radiation fraction). Further stress and delays at the New Start arose from having to determine the required setup parameters while the patient was present and adjust the treatment plan accordingly. Amending the treatment plan, at this stage and under pressure, can also introduce inadvertent errors.
The primary aim of this project was to reduce delays at New Start, and so improve the experience for both patients and staff. We hoped that as a result of changes, 90% of New Start appointments would commence within 30 min of their allotted time by August 2021, a substantial improvement over the previous level of 33%. There would be consequent secondary impacts: reducing staff stress and increasing patient safety.
We used the Model for Improvement (MfI) and its Plan–Do–Study–Act (PDSA) cycles.4–6 This approach has been used successfully in other NHS clinical science areas: life sciences7–10 and physiological sciences.11