Grampians Region Colonoscopy Access Project
This project aim was 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 was 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 timely colonoscopy.
This project was dubbed the Colonoscopy Access Project (CAP) and was completed in March 2026.
Overview
Over an 18-month period, the CAP has delivered a comprehensive, multi-stream review of colonoscopy access across patient, primary care, and health service perspectives, providing clear evidence base for ongoing system reform.
- Co‑design with key stakeholders
- Baseline analysis of the current state of referral pathway
- Patient journey mapping
- Solution design
- Implementation of targeted improvements.
A key strength of this project has been the collaboration between patients, the primary care network (WestVicPHN), and public healthcare services (Grampians Health – Ballarat).
Key Themes
Referral inefficiency and fragmentation
Inconsistent, manual referral processes and limited tracking were identified as primary contributors to delays and duplication across the referral pathway.
Communication and patient navigation gaps
Variability in communication and health literacy challenges impact patient readiness, experience, and engagement with care.
Digital fragmentation
Lack of interoperability between key systems drives administrative burden and inefficiency.
Primary care as a critical lever
Strengthened GP engagement improves screening participation, referral quality, and downstream demand management.
Limited data visibility
Prior gaps in real-time data and reporting constrained operational and strategic decision-making.
Workforce and coordination constraints
Capacity limitations and reliance on manual coordination functions remain key system risks.
Key Achievements
- Implementation of a real-time colonoscopy dashboard, now embedded in operational planning
- Increase in National Cancer Screening Register (NCSR) integration across Grampians region general practices
- Development and implementation of colonoscopy surveillance guidelines to support appropriate demand management
- Establishment of an Endoscopy Planned Care Navigator Pilot model
- Ongoing planning for Endoscopy specific e-Referral template
- $500,000 in funding provided across the Victorian Integrated Cancer Services (VICS) network, with 7/8 regions receiving funding to improve timely access to colonoscopy for public health services (see further details below).
Implications and next steps
The project confirms that timely access to colonoscopy requires coordinated system reform, including:
- Implementation of e-Referral and digitally integrated pathways
- Expansion of patient navigation and coordination models
- Ongoing primary care engagement and education
- Sustained investment in data capability and system interoperability
Key initiatives (Endoscopy e-Referral specific template, Endoscopy Planned Care Navigator Pilot model) are progressing through the GICS work program to support sustainability and scale.
We sincerely thank both Deakin University, and Western Victoria Primary Health Network, leads and all stakeholders for their significant contributions to this project and its outcomes.
Poster Presentation at the ACCN Innovations Showcase
This project was presented as a digital poster at the Australian Comprehensive Cancer Network (ACCN) Showcase on Thursday 3 July 2025.
VICS CAP funded projects
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.
