Storyboard Entry Form 2015
Main author: Gurpreet Singh Kalra
Email: [email protected]
Telephone: 01792 285207.
1. Storyboard title:
Setting up of HyCoSy (Hystero Contrast Salpingosonography)
service
A simple well-tolerated, non-invasive, outpatient, ultrasound scan based
procedure used to assess the patency of fallopian tubes, as well as detect
the abnormalities of the womb and the ovaries for women undergoing
infertility investigations.
2. Brief outline of context:
The HyCoSy service reduces the need for traditionally used expensive and
invasive operative procedure of Laparoscopy and dye test requiring a
general anaesthetic and admission to a hospital ward.
This innovative work with backing of good clinical evidence (1) was
undertaken in the Fertility clinic, Department of Obstetrics and
Gynaecology, Singleton hospital, ABM University Health Board, Swansea,
lead by one of the Consultant Fertility specialists Mr Gurpreet Singh Kalra
with support of the management and a fertility nurse Paula Williams. The
HyCoSy service runs as a weekly Monday PM clinic at Singleton hospital
seeing 4 patients in a clinic.
3. Brief outline of problem:
Up to about 20% of infertility in women is caused by the blocked or
unhealthy fallopian tubes (2). About 80% women will therefore have
healthy tubes. However in order to identify the 20% women with
unhealthy tubes, all women need to have their tubes tested. Traditionally
ABM University health board fertility services have only offered the
operative procedure Laparoscopy & Dye test for this.
There were various compelling reasons to consider introducing the
HyCoSy tubal testing service –

Need for providing a safer, non invasive and well tolerated
alternative method of tubal patency testing to patients in a
secondary care fertility service.

To reduce the waiting times for gynaecological surgical procedures
in the health board by replacing some with innovative non invasive
procedures.

To save costs for the NHS by replacing an expensive service with
equally effective and much cheaper service. Replacing a service
needing admission with an outpatient procedure, reducing number
of admissions and saving costs further for the NHS.

Both patient and partner get opportunity to be involved, improving
patient experience and journey through infertility management as a
couple.
Having expertise available in the fertility team, support was sought from
the management and a business case was submitted for invest to save.
4. Assessment of problem and analysis of its causes:
An analysis of the situation was undertaken and the following factors were
considered to be the drivers favouring or opposing change. Shown below
on the “Forcefield analysis” proposed by Kurt Lewin, a german sociologist,
as a useful tool to get an overview of the situation and help making the
decisions regarding a change –
5. Strategy for change:
With a very strong will to make this change of introducing a better,
cheaper and safer service, a journey was started about two years ago. As
with any change and departure from traditions the potential opposition
and difficulties were recognised. The “unfreeze change freeze” model was
chosen as the bases of strategy.
The stakeholders in the change process were identified as –
 Patients
 Clinicians
 WCH Management
 Nursing staff
 Admissions/ appointments department
There was good evidence and a strong case to make this service available
to patients. The consultant colleagues and the rest of the clinical team
were engaged by making presentations at teaching sessions. Individual
opinions and support was sought. An “invest to save” business case was
prepared with the help of management and forwarded to appropriate
authorities. Lead nurse was involved and nursing support requested. In
the current climate of austerity, the severe financial restraints were
identified as the main opposing factors.
Resource planning was done early on. The service was started on informal
bases at a smaller scale with the available minimal resources and goodwill
of the nursing team and the management, largely in the free time of Lead
consultant and the fertility nurses. Guidelines, Standard operating
Protocol, Nursing competency document and a Patient information leaflet
were prepared, circulated and approved. The consultant session was
approved in April 2014 whilst formal nursing support was put in place in
October 2014 when the service started formally.
The service has since been repeatedly advertised amongst the clinical
colleagues to encourage referrals and specific referral criteria devised.
Best practices for clinical governance including audit and risk management
have been put in place from the beginning.
Since the nurse was not experienced in the procedure, structured training
programme was put in place over first three months.
The first performance review has been undertaken after three months and
patient satisfaction survey has been started.
6. Measurement of improvement:
In the first three months Total number of procedures done in first three months – 36
Negative findings (suggesting patent tubes) – 28
Positive findings (suggesting blocked tubes) – 7
Sent for laparoscopy – 5 (14%)
(two patients not sent for surgery – both going straight for IVF)
14% rate of return to Laparoscopic procedure following HyCoSy is
quite standard and in line with prevalence of tubal disease as a
cause of female subfertility in a low risk population (12-20%).
7. Effects of changes:
1. Number of laparoscopic procedures saved – 31. With corresponding
saving of Theatre time, General anaesthetic, Admissions/
Readmissions, complications, working days off.
Projected saving of about 120 laparoscopies over one year with
corresponding and significant return on investment. That is about
25% fewer laparoscopic procedures in a year as a department as
the total number of laparoscopic procedures done by women’s
health department is about 500.
2. A gynaecological US scan is performed as a part of the procedure
giving an opportunity to assess the health of the pelvic organs.
Most importantly as a clinician is performing the procedure it is
easy to correlate clinically to any scan findings.
3. A follow up appointment is saved because a management plan is
made following the procedure, depending on the findings. A clinic
letter with findings and management plan is then dictated and sent
to the GP, the referring clinician and the patient.
4. Service is a strategic fit with potential of aiding in reducing waiting
times for surgical procedures trust wide. At the same time this
service comes at the right time when there has just been a
significant expansion in provision of fertility services with start of
WFI.
8. Lessons learnt: statement of lessons learnt from the work; what
would be done differently next time
It has been a very learning and enriching experience all the way. It has
taken time and there has been opposition to change as expected. One can
feel frustrated when things are not happening. Therefore a structured
systematic approach, working as a team and having sound bases in ethics
and good evidence is essential to stay on course.
9. Message for others:

Change is hard but don’t give up.

Aim for Innovation and high standards driven by values based on
prudent care
Clinician involvement is essential to make changes to quality of
care.
Direct/ easy communication between clinical leaders and the senior
management
Set up forums to share knowledge of successful setting up of
innovative services between different specialities and across health
boards
Local champions to be recognised, rewarded and encouraged.
The service if successful should form the template for transferring
best practice to other health boards.
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
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10. Please summarise how your entry reflects the principles of
prudent healthcare: http://www.prudenthealthcare.org.uk/
This service is a perfect example of a move towards prudent health
care principles. The service is meant to make the testing of fallopian
tubes safer as compared to an invasive operative procedure of
laparoscopy and dye test. The patients are therefore protected from
risks of potential complications of general anaesthetic and surgery.
There is no need for post procedure recovery period and hence no
working days are lost.
A HyCoSy is significantly less costly than a laparoscopy. It saves
theatre time as well as admissions. The waiting lists for surgical
procedures are likely to improve.
The setting up of HyCoSy has given patient a choice and has
therefore made decision making a shared but patient cantered
process. Patients who are low risk for tubal disease can choose to
have HyCoSy after being informed about the pros and cons. The
savings can then be utilised where there is a need.
References
1. Four series – 600 patients – Deichert, Dagenhardt, Venezia &
Bourne – 1994. Concordance with HSG – 83.8% to 90.5%.
Concordance with Lap & Dye – 80.4 – 92.5%
More references available. Widely used procedure in the NHS.
2. Excerpt from NICE Infertility guideline 2013,
1.3.8.2 Where appropriate expertise is available, screening for tubal
occlusion using hysterosalpingo-contrast-ultrasonography (HyCoSy) should
be considered because it is an effective alternative to
hysterosalpingography and Laparoscopy and dye test for women who are
not known to have comorbidities. [2004]
www.1000livesi.wales.nhs.uk
The NHS Wales Awards are organised by
the 1000 Lives Improvement service in
Public Health Wales.