Pathway modelling at Exeter Genito-Urinary Medicine (GUM) clinic

South West PeninsulaRenal and Urogenital
Start Date: 1 Oct 2015


The genito-urinary medicine (GUM) service in Exeter sees over 18,000 patients per year, with high rates of documented sexually transmitted infections (STIs). Providing efficient care to all patients at all times has always been a challenge. The clinic is proposing to streamline the asymptomatic patient pathway to reduce demand on senior staff time, dramatically reducing patient waiting time and improving the impact of screening on public health.

At the clinic, long wait times due to high and unpredictable patient numbers are compounded by bottlenecks accessing appropriately skilled staff and properly equipped rooms.  This can lead to walk-in clinics being ‘capped’ or to patient walk-outs. Dissatisfaction with these service deficiencies has been documented in patient feedback surveys for several years running and remains an ongoing issue.

From a financial perspective, the service is compensated on a payment by results basis, with a flat tariff for new/rebook patient episodes and reduced rates for follow-ups.  When walk-in clinics are capped due to insufficient appropriately trained staff or room availability, this limits income.

The clinic wishes to respond to these issues by implementing a set of service improvement measures; specifically they are proposing to create a separate fast-track system for asymptomatic patients, using self-triage and with Health Care Assistants managing the full episode of care, rather than doctors or senior nurses.

To inform these potential service changes, they would like to use modelling methodologies to provides measurable outcomes, as well as providing a baseline for future scenario simulation. Such modelling would be one aspect of a set of assessments used to analyse service changes. The benefit of using modelling is that any potential outcomes of changes to the system configuration or patient pathway, can be investigated without making changes to the actual system.

Aims and objectives

The aim of this project is to evaluate how the possible re-design of the current configuration and patient flow at the GUM clinic in Exeter could influence patient waits and staff workload.

What-if scenarios have been identified by clinicians and these include changes such as re-arrangement of opening times (or scheduling in general terms); different forms of triage, e.g. paper-based, clinician-led or online-based; service integration options; changes in workforce allocation; and self-check-in of patients.

Based on these scenarios, the specific objectives of this project are to:

  1. Investigate which other key performance indicators (KPIs) exist besides ‘standard’ ones such as patient waits or workload/number of did-not-attends. This is based on an analysis of available data sets. The data can be used to describe the status quo and to parameterise a discrete event simulation model.
  2. Design a pathway model capturing current pathways and patient flows at the clinic. The pathway will be visualised using a dedicated flowchart modelling language and also flowchart software.
  3. Develop a discrete event simulation model capturing the current situation at the GUM clinic. This model can then be used to perform a number of what-if analyses capturing changes to KPIs.
  4. Investigate, using the simulation model, the likely changes to the workflow and the effects in terms of KPIs. This will look at different pathway re-design options that have been identified by clinicians. Possible changes include; different opening times, online-triage, or self-check-in.

Project activity

  • Problem Structuring Methods to develop pathway maps and to identify key aspects for change. Conducted in liaison with clinicians at the GUM clinic. Pathways will be visualised using software and will include dedicated pathway modelling languages such as Business Process Modelling Notation.

  • Descriptive statistics/data analytics will be used to evaluate the status quo of the clinic (using MS Excel as well as commonly used statistic software such as R, Stata, or MatLab).

  • Developing a pathway simulation model using Simul8. This might require visualising the pathway using MS Visio ahead of building a Simul8 model.

Anticipated outputs and next steps

It will be possible to track which options of service re-design have been favoured by the clinicians and how this has influenced the decision making process. As the project aims to quantify the likely changes in KPIs, we can potentially monitor any ‘true’ change in terms of a dedicated data analysis, e.g. after six months.

The initial project will focus on the Exeter clinic and in particular on modelling current workflows. The first set of what-if analyses could possibly open the door to; (a) look more generally at pan-Devon services or even UK in general; (b) look at the impact of demography and future changes, or; (c) extend the range of what-if-scenarios for the Exeter clinic in order to develop this as a vanguard site. In the context of these options, opportunities for extension of work through grant funding could be explored.

Dr Sebastian Rachuba