Table 1

PDSA cycles for improvements to the electron (non-scanned) patient treatment care path

Cycle	Plan/predictions	Do	Study (data are mean±SD)	Act
Change idea A: introduce day 0
A1	Introduce day 0 appointment after Final Checks Predictions: Reduced pressure on staff Improved safety Improved ability to deliver New Start on time	26 Oct 2020 Amend care path on ARIA Make staff aware	OM: 11.3±11.6 min, 100% of plans ready on time and 100% of patients treated within 30 min of appointment time PM1 28.0±31.5 hours PM2 83.2±58.6 hours PM3 8.7±1.0 hours Staff not aware of day 0 appointment	Change retained Further improvements required: Final Checks should be after day 0 Attach day 0 to care path Raise staff awareness
A2	Move Final Checks to after day 0 Add staff as a resource to day 0 task Predictions: Improved safety & staff availability	01 Jan 2021 Amend care path on ARIA Check and add to care path Make staff aware	Incidents recorded: 2 booked onto incorrect machine 1 no day 0 appointment booked (Mould Room task) 2 no immobilisation document (Mould Room task) 1 no photos present (Mould Room task)	Change retained Further improvements required: Ensure Mould Room tasks completed prior to planning Avoid booking patients onto incorrect machine
A3	Add in additional Mould Room task Remove possibility for booking onto incorrect machine Predictions: Reduced delays at planning & incorrect bookings	01 Mar 2021 Amend care path on ARIA Contact IT to change booking system to only appropriate linac	OM: 19.6±30.3 min, 67% of plans ready on time and 75% of patients treated within 30 min of appointment time PM1 11.0±18.9 hours PM2 59.4±46.8 hours PM3 31.2±66.6 hours	Change retained Pinch points revealed in completion time data Further improvements required: Move day 0 appointment earlier
A4	Move day 0 to 2 days prior to treatment Predictions: Improved number of plans completed in time for New Start	28 June 2021 Amend care path on ARIA Booking Desk and Mould Room informed	OM: 26.1±27.6 min, 72% of plans ready on time and 61.4% of patients treated within 30 min of appointment time PM1 17.0±21.7 hours PM2 26.9±24.5 hours PM3 59.5±40.5 hours	Change retained Further improvements required: Electron-capable machines were seeing high usage, other linacs less heavily used. To maintain benefits of day 0: Allow it to be completed on any linac
A5	Allow day 0 task on any linac Predictions: Benefits of day 0 would be maintained, while not impacting on availability of patient appointments, despite rising workload	12 April 2022 Obtain permission (instead of under concession): work instructions updated Evaluate sustainability as COVID-19 eases	OM: 27.2±26.8 min; 92.3% of plans ready on time and 69.2% of patients treated within 30 min of appointment time PM1 12.0±13.5 hours PM2 25.0±23.0 hours PM3 47.1±42.5 hours	Performance maintained Change retained
Change idea B: make pathway more like other EBRT treatments
B1	Remove manual calculations and data input Predictions: Reduced staff’s lack of familiarity and stress, improved safety	01 Jan 2021 Implement pseudo-plan in Eclipse Plan checking questionnaires Write and distribute staff training and work instructions	No Datix incidents Care path for scanned and non-scanned electrons now similar→confusion as to which is which!	Change retained Further improvements required: Need to be able to identify plan type
B2	Add additional identification of scanned/non-scanned patient Predictions: Improved plan-‘type’ identification	31 Aug 2021 Additional clarification on immobilisation document Additional patient alerts Additional staff training	Changes are made for safety not efficiency—metrics not recalculated	Change retained
Change idea C: remove TEP Sig task
C	Remove TEP Sig step (now redundant) Predictions: Can remove TEP without issues, and so free some staff time	31 Aug 2021 Prepare risk assessment and share with Quality and Safety Committee Ensure all tasks covered elsewhere Update tick lists Remove TEP Sig task	With B2, and a downstream of New Start—metrics not recalculated	No issues detected Change retained

EBRT, external beam radiotherapy; IT, information technology; OM, outcome metric; PDSA, Plan–Do–Study–Act; PM, process metric; TEP Sig, treatment expert practitioner sign-off.