Grampians Region Colonoscopy Access Project
This project aims to explore timely access to colonoscopy for people after a positive (FOBT) result.
In August 2024, GICS received Federal Government funding to explore timely access to colonoscopy.
The project aim is to explore concordance with Clinical Practice Guidelines for timely access post a positive Faecal Occult Blood Test (FOBT) result within the Grampians region, and to identify priority areas and activities to improve access to timeline colonoscopy.
This project has been dubbed the Colonoscopy Access Project (CAP).
Overview
The project will have focus across three streams Patient, Primary Care, Tertiary Health Services perspectives and aims to:
- Streamline and expand referral pathways to improve equitable and timely access to colonoscopy for National Bowel Cancer Screening Program (NBCSP) participants
- Improve compliance on colonoscopy reporting to the National Cancer Screening Registry
- Reduce the stage of disease for patients at diagnosis through earlier detection of disease enabled by the NBCSP.
Over the duration of the project we will be engaging with key stakeholders across the region to identity current issues across the streams, work through feasible solutions and to increase compliance to the National Cancer Screening Registry.
Project Update
April 2025
Over the past 4 months the Project Leads have undertaken an extensive Diagnostic/Discovery phase of the project focusing on both Primary Care and Tertiary Health Services and to understand the current state of referrals (from GP to Health Service and the Health Service journey), triage and waitlisting for procedure.
Across the Grampians Region there is 8 regional hospitals, with Grampians Health (Ballarat) being the only public theatre list hospital to accept referrals from multiple agencies including Primary Care, Specialist Clinics and internally (from Ward/Emergency Department) for Endoscopy services. All ‘other’ Regional hospitals within the Grampians Region whilst having Endoscopy theatre lists are managed and booked by Private Specialist rooms or funneled through from Grampians Health (Ballarat site). This has led to the Project Leads not being able to capture reliable and accurate data on number of procedures, CRC diagnosis, referral waitlist timeframes completed at the regional hospital sites outside Grampians Health (Ballarat).
Based on this, a deeper dive exercise was conducted for Grampians Health (Ballarat) of which a full mapping exercise of the referral pathway journey from presenting to GP (via NBCSP or presenting symptoms) was completed. This exercise identified pain points and critical issues that impacted and delayed the referral processing for patients to be waitlisted and made ‘ready for care’ for Colonoscopy procedure. These pain points and critical issues were also identified as part of the Discovery co-design workshop.
Overall, for public referrals, it was documented that the Optimal Care Pathway (OCP) timeframe to procedure recommendations were not being met regardless of reason the patient was being referred for Colonoscopy (NBSCP or presenting complaint). It was identified as part of the mapping that the categorisation of referrals were accurate and did meet the Colonoscopy Categorisation Guidelines 2017, however the time from acceptance of referral to triaging of referral did not met the Planned Surgery Access Policy 2024 guidelines.
The Primary Care stream diagnosis review, led by the Western Victoria Primary Health Network (WVPHN), highlighted the challenge of patients accessing a Primary Care professional and the wait periods associated to a high pressurised and stretched system. Primary care clinics in the Grampians region were sent opt in surveys to gather their understanding of the NBSCP and NCSR, the survey identified that GPs regularly discussed opportunistically with patients Bowel Cancer Screening, with some confidence in using the National Cancer Screening Register to access the NBSCP kits under Alternative Access Model to Bowel Screening.
A critical component of the diagnosis phase was to undertake two co-design workshops and bring identified key stakeholders together to discuss current state and future state. The workshops were held in December ’24 and February ’25 and focused on Discovery – pain points and critical issues and Solutions – what does future look like by identifying high value, high impact solutions.
At conclusion of the diagnosis phase and co-design activities, a number of recommended solutions have been proposed and mapped out across Primary Care and Tertiary Health Care with the aim to improve timely care to Colonoscopy:
- System enhancements to software used for Referral management
- Increase to National Cancer Screening Register (NCSR) registrations, usage and reporting
- One accessible data report – compiling a number of data sets to bring into one visual real-time report
- Development of eReferral template (specific to Colonoscopy)
- Management of Surveillance Scopes – Health Services & Primary Care
- Planned Care Navigator model to coordinate and manage referral journey from triage to waitlisting and ready for care.
The third stream of this project, Patient perspective is being undertaken by Deakin University with ethics currently being sought to commence their diagnostic phase of the project. Further updates will be available in the next few months.
Project Lead
Poster Presentation at the ACCN Innovations Showcase
We’re pleased to share this project was presented as a digital poster at the Australian Comprehensive Cancer Network Showcase on Thursday 3 July 2025.
VICS CAP Funding Recipients Announced
A $500,000 funding allocation was budgeted, within the Commonwealth funding provided to GICS, for the VICS network. This funding is aimed at providing opportunity for scaling and spreading service improvement activities implemented in the Grampians region, across the state to public health services, who are similarly reporting significant delays in access to colonoscopy.
An Expression of Interest process was undertaken in May 2025 with 13 applications received. Applications were reviewed ranked against the below criteria:
- Ability to define robust methodology and project aims
- Ability to define the size and scope of the problem
- Demonstrates alignment with the aims of the Colonoscopy Access Project
- Applicable to the needs of priority populations
- Organisational readiness
- Feasibility of delivering sustainable outcomes of the project on time and on budget.
In June 2025, a review panel assessed submissions with the Project Steering Committee endorsing recommendations for the funding of 6 projects listed below:
This project is associated with the Implementation of a standardized e-referral system and waitlist dashboard for all suspected colorectal cancer patients, ensuring that criteria and appropriate workup are in place to prevent the
system from being overwhelmed.
It will further investigate the benefits to introducing a dedicated regional colonoscopy triage nurse and integration of prehabilitation and ERAS principles for colorectal cancer (CRC) patients undergoing surgery as the first line of treatment.
This project involves a collaboration between metropolitan and regional Integrated Cancer Services and seeks to enhance the effectiveness of
the NBCSP and the overall access to and quality of colonoscopy services by fostering consistently high-quality procedure delivery and seamless, accurate
data reporting.
This will contribute to earlier detection of cancers, reduced bowel cancer incidence and mortality, promote equitable access to high-quality procedures across diverse settings including rural communities, and decrease the likelihood of patients presenting with advanced disease or via emergency pathways. With the additional impact of supporting governance compliance with National Safety and Quality Health Service Standards (NSQHS) and health service accreditation as well as reassuring Executive and Board that the clinicians working in their health service are providing safe and high-quality patient care.
This scoping initiative aims to identify the root causes of delays to colonoscopy and treatment across the Loddon Mallee and implementing feasible service improvements based on data and stakeholder consensus with particular reference to patients from underserved populations.
Implementation of the SeNT electronic referral management system will transition referral pathways from paper-based to electronic, significantly improving the timeliness and quality of care provided to patients undergoing colonoscopy following a positive NBCSP result.
This project considers the challenges of low income patients and seeks to clarify public referral pathways for GPs, differentiating AWH’s free public clinics from VMO-associated pathways that incur costs for the same services.
The project involves configuration of referral templates, internal system integration, staff training, and collaboration with Murray PHN and BPAC Clinical Solutions, who are otherwise funding the remaining cost of the project.
This project includes three components:
Digital Integration and Automation
Continue the use of Personify Care – a digital platform that streamlines pre-procedural triage and gathers patient information directly, supporting the safe bypass of initial outpatient appointments The development of a dynamic digital colonoscopy dashboard that integrates referrals and procedure data to.
Expansion of the Direct Access Colonoscopy Nurse role
Provide tailored support and follow-up for patients at high risk of falling through the cracks – including those from low socioeconomic backgrounds, rural and regional locations, culturally and linguistically diverse communities, and Aboriginal and Torres Strait Island groups. Offer navigation support using culturally safe practices and health literacy-sensitive communication strategies and closing the loop between primary care, specialist follow- up, and public hospital colonoscopy services.
Targeted outreach and access pathways for under-screened communities
Partnering with local Aboriginal health services, community organisations, and regional referrers to support culturally safe referral pathways. Offering digital and
telephone-based triage options to reduce the burden of travel and system navigation, especially for patients in regional and remote areas.
Peninsula Health seeks to improve the pre-endoscopic and post-endoscopic care of patients with a positive Faecal Occult Blood Test (FOBT+) within the National Bowel Cancer Screening Program (NBCSP) by expanding two recently introduced initiatives:
Expanding the Nurse-Led FOBT+ Clinic
The Nurse-Led FOBT+ Clinic is a weekly multi-disciplinary ambulatory care service that streamlines the pre- endoscopic work-up and administration for patients referred with a positive FOBT. Patients are seen by a trained outpatient nurse within 7-days of their referral being received who undertakes a comprehensive protocol-driven pre-endoscopic assessment, which is supported by a Consultant Gastroenterologist. Endoscopy booking staff are present at the clinic to provide individualised procedural instructions and allocate a date for the procedure at the one appointment. Introduction of this service has improved the
30-day colonoscopy completion rate for patients referred following a positive FOBT+.
Integrating a Nurse-Led Post-Endoscopy Review Pathway
The Nurse-Led Post-Endoscopy Review Pathway is a standardised pathway to systematically review histology results following endoscopic procedures and to communicate this, along with management recommendations, to the patient, the referring physician and the National Cancer Screening Register.
