Too Long to Wait
18 August 2015 Last updated:
21 August 2015
Too Long to Wait
The prevalence of Gestational Diabetes Mellitus ( GDM ) and Type 2 Diabetes ( T2D ) in the Canterbury area has been increasing over the years and this trend is expected to upsurge with the new reference range for diagnosing GDM introduced in 2015.
The combined maternity and endocrine outpatient clinic at Canterbury Hospital with its current resources will be unable to accommodate the rising number of episodes of care provided to pregnant women with GDM or T2D . This project addresses an urgent need to improve systems and processes and realign its resources to ensure that pregnant women attending the clinic receive optimal and timely care.
Download a poster from the Centre for Healthcare Redesign graduation, August 2015.
To improve the quality and continuity of care provided to women with GDM or T2D in the antenatal outpatient clinic at Canterbury Hospital and primary health care setting.
- Optimal and timely care provided to pregnant women with GDM / T2D in the Canterbury area.
- Improved health outcomes during and after pregnancy.
- Improved cost efficiency and appropriate use of resources.
- Improved job satisfaction and job efficiency.
Project started: 1 July 2014
Project status: Implementation - solutions to identified issues have been designed with an implementation plan in place. Some solutions have been implemented.
The incidence of diabetes including GDM and T2D has increased markedly over the past ten years. The number of endocrine episodes of care for women with GDM and T2D attending the Canterbury Hospital maternity outpatient service has tripled from 798 episodes in 2003 to 2,453 episodes in 2013.
Approximately 18.5% of 1,800 women who had given birth at Canterbury Hospital in 2013 had a pregnancy complicated by GDM or T2D , which is well above the NSW state average of 5.6%1.
The rapidly rising numbers of women with GDM or T2D attending the clinic have resulted in:
- increased waiting times at the maternity outpatient clinic
- limited appropriate clinic space to provide endocrine consultations
- time constraints placed on the actual visit as there is a constant need to expedite the visit by the health care professional
- decreased staff satisfaction.
- New Referral ( GDM ) system: the referral form is used by general practitioners in primary health care and internal departments within Canterbury Hospital to complete and fax to the antenatal clinic to standardise and streamline the referral process of pregnant women with GDM or T2D . It is envisaged the form could be used as an online form when the maternity services at Canterbury Hospital moves to online referrals in the future.
- New appointment system for the combined maternity and endocrine clinic: manual and paper based appointment booking system has been replaced by electronic appointment system using the scheduler. This enables full data collection as well as efficiency in appointment modifications. The time slot appointment system has also been replaced by sequential numbering stem with cap number for the morning and afternoon clinics.
- Appointment system for the clients has been re-visited: specific appointment times have been replaced by giving the women time bands to attend the clinic, this also allows the women to determine themselves when they could arrive to the clinic within a morning band or an afternoon band, e.g. 9 am to 11.30 am and 1 pm to 3 pm.
- Promote Sydney Local Health District GDM screening protocol in general practice and disseminate GP Newsletter: aimed at improving general practitioners’ awareness of the new reference range for diagnosing GDM that was introduced in 2015 and to provide general practitioners with a clear algorithm to follow for GDM diagnosis.
- Streamline system of clinical documentation for pregnant women identified with GDM or T2D and coordination of GDM or T2D appointments: Using the new referral template and development of a flowchart has led to improved consistency and communication amongst the multidisciplinary team within the antenatal area.
- Escalation plan completed for endocrinologist and diabetes educator service enhancement: this will ensure the flow of the combined maternity and endocrine clinic will not be impeded due to unforeseen absence of leave.
- Obstetric doctors: commencing clinic sessions on time for both the am and pm sessions – this has assisted with the flow of women through the clinic.
Solutions to be implemented
- Implementation of electronic medical record for the endocrine team: this will enhance communication and aid data collection.
- Telephone incoming call queuing system for antenatal reception: aims to improve current system, enhancing public relations and staff efficacy.
- Implementation of diabetes ( GDM / T2D ) guidelines for antenatal outpatient: provide consistency of care and support the flow of the low risk GDM clinic.
- Implementation of low risk GDM run by midwives: this will support the continuity of care, provide breastfeeding and labour preparation information to women with GDM or T2D . It will also reduce the number of attendees who currently attend the combined maternity and endocrine outpatient clinic.
- Implementation of a thyroid clinic for pregnant women: this will allow a majority of pregnant women to participate in their model of antenatal care (midwife clinic, midwife group practice or antenatal shared care with general practitioner) with the periodic outpatient visit to the thyroid clinic. It will also reduce the number of attendees (pregnant women with thyroid issues) who currently attend the combined maternity and endocrine outpatient clinic.
- Combined maternity and endocrine outpatient clinic, Canterbury Hospital
- Primary health care general practice clinics
Established as a collaborative project between Canterbury Hospital and Central and Eastern Sydney Primary Health Network (formerly Inner West Sydney Medicare Local).
- Diabetes NSW
- Agency for Clinical Innovation Centre for Healthcare Redesign
Some of the initiatives have been trialled and piloted before rolling out.
Outcomes will be evaluated using pre-project evaluation methods including time in motion study, audits, patient experience trackers, interviews and focus groups.
Intra-project evaluation as per July 2015.
- Reduction in clients waiting time by 11 mins (80 minutes down to 69 minutes).
- Increased client satisfaction with the wait time by 9% (according to patient experience tracker question 'I am happy with the length of time I spend at the clinic': Pre-project response was 48%; intra-project response was 57%.
- No change in the timely referral or screening for women by local medical officers for those women at risk of developing GDM .
- Increase in the uptake of GDM women having a glucose tolerance test three months after the baby, from 35% increasing to 58%.
- Marked increase in the compliance of midwifery staff entering glucose tolerance test results and complications in pregnancy within the electronic medical record (eMR) as evidenced by eMR audits.
- Reduction in the complaints to the midwifery unit manager relating to appointment times and lengthy wait time from six per month to nil.
- Centre for Epidemiology and Evidence. 2012. New South Wales Mothers and Babies 2010. Sydney, NSW Ministry of Health.
- Ali,FM; Farah,N. O’Dwyer,V. et al. 2013. The impact of new national guidelines on screening for gestational diabetes mellitus. Irish Medical Journal 106 (2) 57 – 58.
- Anderson, R, Carmacho, F. and Balkrishnan, R. 2007. Willing to wait? The influence of patient wait time on satisfaction with primary care. Biomed Central. Published online Feb 28 http://www.ncbi.nlm.nih.gov/pubmed/17328807
- Babour, L. 2014. Unresolved controversies in gestational diabetes: implications on maternal and infant health. www.co-endocrinology.com 21(40) August 264-270.
- Committee on Practice Bulletins - Obstetrics. 2013. Gestational Diabetes mellitus. Practice Bulletin no. 137. Obstetrics and Gynaecology Vol 122 (2) Part 1 406 – 416
- Flack, J; Ross,G.; Ho,S. and McElduff,A. 2010. Recommended changes to diagnostic criteria for gestational diabetes: impact on workload. Australian & New Zealand Journal of Obstetrics & Gynaecology, 50: 439-443.
- Jones, SM and Wilson,C. 2010. Audit on outcome of midwife-led gestational diabetes care. British Journal of Midwifery December Vol 18 (12) 786-789.
- Liw, ML, et al. 2013. Preventing Type 2 diabetes after gestational diabetes: women’s experiences and implications for diabetes prevention interventions. Diabetic Medicine, March, 986 – 993.
- Lomangine, K. 2012. Post pregnancy management of gestational diabetes: a missed opportunity? Clinical Nutrition Insight, Nov pp 8-9.
- McMullen and Net land, P.A. 2013. Wait time as a driver of overall patient satisfaction in an ophthalmology clinic. Clinical Ophthalamology (7) August 20, 1655 – 1660.
- Mrfet, GO, Allen,P and Hingston, TJ. 2013. Maternal and neonatal health outcomes following the implementation of an innovative model of nurse practitioner-led care for diabetes in pregnancy. Journal of Advanced Nursing August 1150-1163.
- Nankervis, A and Conn,J. 2013. Gestational diabetes mellitus – negotiating the confusion. Australian Family Physician 42 (8) August 528-531.
- Petrovic,O. 2014. How should we scree for gestational diabetes?. Current Opinion, 26 (2) 54-60.
- Rogers,K and Hughes,C. 2010. Recognising the risks: the midwife’s role in identifying women at risk of gestational diabetes. MIDIRS Midwifery Digest 20:2 179 – 182.
- Samoa Donkor, W.and Obed, S.A. 2012 Waiting time and women’s satisfaction at an antenatal clinic in Ghana. African Journal of Midwifery and Women’s Health. Jan-Mar (6) 1, 7-12.
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