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Avoiding same-day cystoscopy cancellations by veterans: nurse-led education improved efficiency for cystoscopy in VA urology clinics.

Same-day cancellation of outpatient cystoscopy was recognized as a growing problem in a New Mexico Veterans Administration regional urology clinic. A multidisciplinary team initiated a performance improvement project using the VATAMMCS method to address the problem. The resulting changes in patient education significantly reduced cystoscopy cancellations and improved overall patient satisfaction.

Key Words: Cystoscopy, same-day cancellation, veteran care, VA TAMMCS, nursing education, performance improvement.


Optimizing care of our nation's veterans remains an urgent concern that has been at the forefront of the healthcare continuum in recent years. In an effort to provide excellent care for veterans appointed to a regional Veterans Administration (VA) urology clinic in the most timely manner, our urology team reviewed clinic attendance and noted that same-day cancellations for cystoscopy procedures was increasing. Same-day cancellation of procedures is a challenging problem, which is costly and delays care for other patients. A performance improvement initiative revealed that better patient education could greatly reduce cancellations.


Outpatient cystoscopy is the workhorse of the vast majority of urology clinic practices. This is certainly the case for the urology clinic at the New Mexico VA Healthcare System (NMVAHCS) in Albuquerque, New Mexico. As the only level 1A (most clinically complex) VA facility in the region, this urology clinic also services veterans from Texas, Colorado, and Arizona. In fiscal year 2015, the clinic increased the number of cystoscopy slots to meet demand and decrease the wait time for patients being scheduled for cystoscopy. The clinic performed nearly 1,200 cystoscopies last year and averaged 1,150 annually over the past three years. In a normal week, there are now 31 cystoscopy slots available for scheduling (Monday = 10, Tuesday = 6, Wednesday = 6, Thursday = 9). When we increased the number of available appointments to meet the growing demand, we began to see a troubling increase in same-day cystoscopy cancellations. Veterans were arriving for their scheduled appointment only to cancel after checking in.

Intended Improvement

The goal of this improvement project was to determine the cause of same-day cancellations and find a solution to limit the number of cancellations. Our approach was two-fold:

* Assess same-day cancellations for scheduled cystoscopies and determine the causes.

* Redesign our process as necessary to decrease cancellations as much as possible.

Literature Review

A brief literature review suggested that pre-procedure anxiety and a lack of patient education may contribute to patient cancellations of cystoscopy at the clinic. Additional literature validated the importance of quality patient education in providing excellent care and patient satisfaction, and might be important to decreasing patient cancellations. Borch and colleagues (2013) noted cystoscopy may be perceived as a very uncomfortable procedure that can elicit immense patient anxiety. Anxiety is particularly likely when the patient has no prior knowledge of cystoscopy and is informed of the procedure at the time of appointment check in. Palmer (2007) stated that anxiety levels are notably higher in patients during the pre-procedure stage of an upcoming procedure and noted that lack of knowledge about an anticipated procedure may contribute to increased anxiety, especially when a patient does not know what to expect post-procedure.

Tamura-Lis (2013) discussed the impact of effective education on the improvement of patient safety, quality care, and patient satisfaction. Weiss (2007) observed that more than one-third of American adults lack sufficient health literacy to understand and complete necessary medical procedures or treatments. Shah and Sills (2007) assessed written patient information for flexible cystoscopy as an "important adjunct to the verbal exchange between doctors and patients. Their value is dependent upon whether they contain useful information from the viewpoint of the patient and are easily understood" (p. 38).

Performance Improvement Methods

Led by the clinic nurse manager, a multidisciplinary team consisting of a registered nurse, urology health technician, and medical support assistant began the formal process of assessing the reasons for same-day cancellations. The Vision-Analysis-Team-Aim-Map-Measure-Change-Sustain (VA-TAMMCS) framework, a systems redesign improvement process of the Veterans Health Administration (VHA), guided this project (VHA Office of Systems Redesign, 2010).

VA-TAMMCS is an organizing improvement framework used to identify steps and tasks in a logical order to standardize VHA improvement work. The components of this framework as related to this project are delineated below.


The NMVAHCS urology clinic continually seeks opportunities to improve access to each of our 36 clinics. The goal of this project was to decrease the number of same-day cancellations by veterans scheduled for a cystoscopy who checked in for their appointments but cancelled and left without undergoing the procedure.


During the analysis phase of the project, just over 63% of cystoscopies were scheduled directly as a result of a primary care or emergency department consult, meaning the veteran had never seen nor spoken to a urologist or urology nurse prior to the scheduling the appointment. Nearly 37% of patients scheduled for a cystoscopy:

* Did not know they were scheduled for a cystoscopy.

* Did not know why they were scheduled for a cystoscopy.

* Did not know what would occur during a cystoscopy.

These findings were reflected with baseline data collected to evaluate patient knowledge of the intended procedure (see Figure 1). Six percent of patients scheduled for outpatient cystoscopy cancelled upon learning of the intended procedure.


An important step in any improvement project is to have the right team. Our team was composed of individuals going to do the work because they must transform the work to make sustainable changes. The team consisted of the urology clinic nurse manager, a registered nurse, a urology health technician, and a medical support assistant.


The goal was to decrease the number of same-day cancellations for cystoscopy appointments related to a lack of awareness and/or lack of education from 6% when we started the project in July 2015 to zero by the end of Fiscal Year 2015 (September 30).


Flow mapping identifies the current process, clarifying the start, end, and key decision points. Mapping was instrumental in identifying improvement areas for the ideal/future state. Current and future state maps delineate the steps involved in the project and the changes that occurred as a result (see Figures 2 and 3).

Flaws were found in our process that adversely impacted patient understanding on multiple levels (see Figure 2). Initially, the consulting clinician may not have informed the patient he or she needed a cystoscopy or of a pending urology consult. Additionally, patients were often unaware that their urology appointment would include an invasive procedure. Finally, patients usually had no education or understanding of why they might need a cystoscopy or what a cystoscopy entails. These problems led to patient anxiety and same-day procedure cancellations.

Once the primary problem of lack of patient education about urology consults and cystoscopy was recognized, the team reviewed cystoscopy patient education handouts and selected one that was easy to read and understand at a basic level. Many cystoscopy education handouts/ pamphlets are available, so we elected not to create a new handout (see Figure 4). Adding the cystoscopy education handout was a separate action in the future state planning/map, which had the greatest impact. As Figure 3 denotes, new value-added actions included team members making certain the new cystoscopy education handouts were delivered and reviewed with veterans before their scheduled appointments.


Measurement identifies whether or not changes are actual improvements. After improvements were made, same-day cancellations dropped from 6% to zero from September to October (see Figure 5).


Changes implemented as a result of the project include:

* The charge nurse is notified of all cystoscopies at time of scheduling.

* All veterans are contacted by the charge nurse and provided cystoscopy education verbally and in writing (see Figure 4) prior to their scheduled appointment.

* Veterans scheduled by urology providers or those scheduling repeat cystoscopy are offered the option to meet and discuss the procedure with charge nurse.


Processes leading to project success resulted in new roles and responsibilities for each discipline represented by the team. Every team member has responsibilities to make sure the veteran is educated appropriately from initiation of the consult through the process of the cystoscopy and follow up.

At the time of scheduling a consult-based cystoscopy, the medical support assistant now notifies the patient that he or she will be sent a letter containing cystoscopy education information and that a nurse will be in contact to discuss the instructions and answer any questions. The educational handout is placed in the charge nurse's box along with an envelope addressed to the patient. The charge nurse contacts the patient confirming receipt of the education handout and reviews the cystoscopy procedure instructions and expectations. Steps taken to educate the veteran before the procedure are documented in the patient's electronic chart. For patients scheduled in person by urology or scheduled for a repeat cystoscopy, the medical support assistant offers written educational material and the option to review with the charge nurse prior to leaving the clinic.

After the cystoscopy is completed, the health technician or nurse assisting with the procedure provides the patient with a post-procedure handout before discharge from the urology clinic. Patients are also told to expect a post-procedure telephone call the following business day to ask how they are and whether they have questions or have experienced any complications.

These new measures have led to a consistent, standardized process for all patients at the NMVAHCS urology clinic undergoing outpatient cystoscopy. In addition to providing valuable patient education that improved urologic care, urology team members feel empowered because they developed this plan and implement it daily. The resulting significant decrease in same-day cancellations has been a win-win for the urology clinic, veterans/ patients, and the NMVAHCS.


This improvement project was launched in July 2015. The project was guided by the Standards of Urologic Nursing Practice, specifically standard 5B, Health Teaching and Health Promotion, which advocates use of teaching methods appropriate to the situation and applicable to learning needs, readiness, and ability to learn. The same standard specifies that nurses should provide information to patients about any proposed therapies or procedures, including potential risks and benefits. Finally, nurses are called to seek opportunities for feedback and evaluation about the effectiveness of treatment (Society of Urologic Nurses and Associates [SUNA], 2013).

As noted above, the analysis found that a little more than 63% of outpatient cystoscopies were scheduled directly as a result of interdisciplinary consults. Thirty-seven percent of those patients either did not know they were scheduled for a cystoscopy procedure, or did not know what a cystoscopy involved or the reason for scheduling the procedure. Patients were not receiving any definitive education or information about the procedure at the time of scheduling, and 6% of those patients were cancelling their cystoscopy appointments after arriving and checking in for the procedure. Armed with this information, the team developed a process to ensure patients were not only aware of the intended procedure, but were also well-educated on outpatient cystoscopy prior to arriving at the clinic for the procedure.

Practice Changes and Recommendations

After implementing process changes, we saw an immediate drop in the number of same-day cancellations. The process and practice changes were outlined in the previous discussion. In January 2016, while reviewing whether the changes implemented resulted in sustained change, it was determined that patients could benefit from additional post-procedure education. Many patients either did not keep their educational paperwork or did not remember what to expect post-procedure. A brief post-procedure handout was developed and is now reviewed with each patient at the completion of the cystoscopy procedure (see Figure 6).


In this small but important performance improvement initiative, an important lesson was learned. As nurses and clinicians, we often assume our patients have the same knowledge and understanding of medical information and procedures that we have as professionals. We often fail to realize that many patients are not literate about medical issues and/or procedures, and they need appropriate education both verbally and in writing (Shah & Sills, 2007; Tamura-Lis 2013; Weiss, 2007). Anxiety and fear of the unknown were causing our patients to cancel their cystoscopy procedures after arriving for a scheduled appointment. Many patients had come long distances for the appointment only to opt out at the last minute, creating additional stress for them and also for the urology clinic because cystoscopy appointments were left unused.

Changes made have been sustained for the past year, and our cancellation rate remains effectively at zero. Our team found that appropriate pre-procedure education alleviates patient anxiety about the unknown, empowers patients to be active participants in their healthcare decisions, and improves access for veterans needing outpatient cystoscopy.

doi: 10.7257/1053-816X.2016.36.6.275

Acknowledgement: The authors wish to thank Kaye K. Gaines, MS, ARNP, FNP-BC, CUNP, and Jane Hokanson Hawks, PhD, RN-BC, FAAN, for their assistance in preparing this article for publication.


Borch, M., Scosyrev, E., Baron, B., Encarnacion, J., Smith, E., & Messing, E. (2013). A randomized trial of 2% lidocaine gel versus plain lubricating gel for minimizing pain in men undergoing flexible cystoscopy. Urologic Nursing, 33(4) 187-193.

ClinicalKey for Nursing. (2016). Patient education: Cystoscopy. Retrieved from http://www.nursingconsult. com/nursing/patient-education

Palmer, J. (2007). Decreasing anxiety through patient education. Plastic Surgical Nursing, 27(4), 215-220.

Shah, J., & Sill, S. (2007). Evaluation of information leaflets for flexible cystoscopy. Clinical Governance: An International Journal, 12(1), 28-41.

Society of Urologic Nurses and Associates (SUNA). (2013). Urologic nursing: Scope and standards of practice (2nd ed.). Pitman, NJ: Author.

Tamura-Lis, W. (2013). Teach-back for quality education and patient safety. Urologic Nursing, 33(6), 267-271.

Veterans Health Administration (VHA) Office of Systems Redesign (10NSR). (2010). Systems improvement framework. Retrieved from http://www. Guide.pdf

Weiss, B. (2007). Removing barriers to better safer care. Health literacy and patient safety. Help patients understand. Manual for clinicians (2nd ed.) Chicago, IL: American Medical Association Foundation.

Sharon D. Wehner, MSN, RN, is a Nurse Manager, Urology Clinic, New Mexico VA Health Care System, Albuquerque, NM.

Yvette V. Saiz, RN, is a Clinical Nurse, Urology Clinic, New Mexico VA Health Care System, Albuquerque, NM.

Harmon Woodard is a Health Technician, Urology Clinic, New Mexico VA Health Care System, Albuquerque, NM.

Debra Garcia is the Lead Medical Support Assistant, Urology Clinic, New Mexico VA Health Care System, Albuquerque, NM.

Figure 1.
GU Clinic Cystoscopy Baseline

                                 No       Yes
Did you know you were
  having a cystoscopy today?    36.8%    63.2%
Do you know why you are
  having a cystoscopy?          35.8%    64.2%
Do you know what occurs
  during a cystoscopy?          36.8%    63.2%

Note: Table made from bar graph.

Figure 4. Cystoscopy

You have been scheduled for a cystoscopy in the GU Clinic on
--at--. The clinic is located on the 1st floor of the
main hospital on the east side of the building.

Cystoscopy is a procedure that is used to help your caregiver
diagnose and sometimes treat conditions that affect your lower
urinary tract. Your lower urinary tract includes your bladder and
the tube through which urine passes from your bladder out of your
body (urethra). Cystoscopy is performed with a thin, tube-shaped
instrument (cystoscope). The cystoscope has lenses and a light at
the end so your caregiver can see inside your bladder. The
cystoscope is inserted at the entrance of your urethra. Your
caregiver guides it through your urethra and into your bladder.
There are two main types of cystoscopy:

* Flexible cystoscopy (with a flexible cystoscope).

* Rigid cystoscopy (with a rigid cystoscope).

Cystoscopy may be recommended for many conditions, including:

* Urinary tract infections.

* Blood in your urine (hematuria).

* Loss of bladder control (urinary incontinence) or overactive

* Unusual cells found in a urine sample.

* Urinary blockage.

* Painful urination.

Cystoscopy may also be done to remove a sample of your tissue to be
checked under a microscope (biopsy). It may also be done to remove
or destroy bladder stones.

You will need to give a urine specimen when you arrive. No other
preparation is needed.

Let Your Provider Know About:

* Allergies to food or medicine.

* Medicines taken, including eye drops, over-the-counter medicines,
and creams.

* Use of steroids (by mouth or creams).

* Previous problems with anesthetics or numbing medicines.

* Previous urologic cancers (bladder, prostate, kidney).

* History of bleeding problems or blood clots.

* Previous surgery.

* Other health problems, including diabetes and kidney problems.

* Possibility of pregnancy, if this applies.


The area around the opening to your urethra will be cleaned. A
medicine to numb your urethra (local anesthetic) is used.

Your caregiver will gently insert the tip of the cystoscope into
your urethra. The cystoscope will be slowly glided through your
urethra and into your bladder. Sterile fluid will flow through the
cystoscope and into your bladder. The fluid will expand and stretch
your bladder. This gives your caregiver a better view of your
bladder walls. The procedure lasts about five to 10 minutes.

After the Procedure

You will be allowed to go home as soon as you are ready. You may
have temporary bleeding and burning on urination.

You will receive a post-procedure call the business day following
your cystoscopy. Please make sure that your nurse or health
technician has the best phone number to reach you.

If you cannot urinate or if you develop fever or chills, call the
clinic or go to the Emergency Department after 4:00 p.m.

Contact the GU clinic if you have any other questions or concerns.

Source: ClinicalKey for Nursing, 2016. Used with permission from
Elsevier. Accessible with paid subscription at

Figure 6. Post-Cystoscopy Care

Post-Procedure Care

After the procedure, you may experience a burning sensation or see
small amounts of blood when you urinate. This is normal.

Drink plenty of water today and the next few days, if you are NOT
on a fluid restriction.

Contact the GU Clinic if you experience any of the following
symptoms in the next few days:

* Frequency, urgency, burning, or pain when urinating.

* You are unable to urinate or empty your bladder completely.

* Blood in your urine after 24 hours.

* Signs of infection, including fever and chills.

* Pain in your abdomen, back, or side.

Call the GU Clinic with questions. In case of an emergency, call
911 or go to the Emergency Department for assistance.

Source: Courtesy of New Mexico VA Healthcare System. Used with
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Article Details
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Title Annotation:Quality/Performance Improvement Project; Veterans Administration
Author:Wehner, Sharon D.; Saiz, Yvette V.; Woodard, Harmon; Garcia, Debra
Publication:Urologic Nursing
Article Type:Report
Geographic Code:1U8NM
Date:Nov 1, 2016
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