A 5-year journey of improvement in a nurse-led botulinum toxin type A clinic for chronic migraine

Abstract

To enable the clinic to meet the increasing demand for botulinum toxin type A (BoNTA) treatment the clinic developed a continuous process improvement programme in 2015. The configuration of clinic setup was standardised by utilising lean techniques and patients were categorised as ‘runners’ (uncomplicated/routine), ‘repeaters’ (more time-consuming, complex) and ‘strangers’ (new patients). This enabled a standardised patient pathway with fixed appointment times. The time allocated depended on the type of patient and whether the patient could be treated in a 15-minute or a 30-minute time slot. Objectives: To measure and monitor the value created by the continuous improvement process, to refine service delivery including the efficiency and capacity of the chronic migraine clinic. Method: Data was collected at the end of each month and a trend analysis of the number of chronic migraine patient treatments was carried out. Corrective actions were taken if the number of treatments fell below the anticipated demand. We calculated the increased capacity over the five-year period based on the data collected. To determine if the increased capacity required additional human resources, we also reviewed the headache specialist nurse resources allocated for chronic migraine treatments over the same period. Results: In 2015 the clinic had a waiting list of 35 patients, with a wait time of 4-6 months. At that time there was only capacity to accommodate 28 new patient referrals for BoNTA. During the period between 2015 and 2019, the total number of yearly treatments more than doubled from 791 to 1634. The clinic, at this point, was conducted by one headache specialist nurse. An additional nurse was then employed to support the increasing demand in early 2019. After implementing the improved process the clinic was able to eliminate the waiting list. In 2019 it generated capacity to accommodate 116 new patient referrals, which was an increase of 414% compared to 2015. Conclusions: The service efficiency programme implemented in 2015 has enabled the clinic to increase capacity to meet the increasing demands in the administration of BoNTA treatment. For the first 4 years, this was achieved without incurring any additional nursing costs. In addition, because of the success of the programme, more patients with chronic migraine have benefited from accessing BoNTA treatment.