ResearchPad - bmj-quality-improvement-report Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[Reducing readmissions and improving patient experience following urological surgery, through early telephone follow-up]]> Readmission from urological surgery is common, with a readmission rate for day case surgery of 3.7% and 26% for robot-assisted cystectomy. Readmission to secondary care and representation to primary care are both expensive and preventable. This project aimed to reduce both and also enhance the care of patients following urological surgery in a large tertiary referral centre, within the National Health Service. A retrospective telephone follow-up (TFU) survey was set up in the early postoperatively period to measure reattendance and readmission rates and perception of care received. Patients were also asked to suggest how improvement could be made. Quality improvement tools were used to optimise and review the methods and timing of TFU. TFU was initiated as a strategy to enhance care and reduce readmission rates. Phone calls were targeted to occur between 48 and 72 hours following discharge. During the intervention period, 484 phone calls were attempted with 343 being successful. Reattendance rates were reduced by 13% and patient satisfaction improved by 19.6%, following TFU. This intervention also generated additional income for the organisation and enhanced patient satisfaction in the early postoperative period.

<![CDATA[All change: a stroke inpatient service’s experience of a new clinical neuropsychology delivery model]]>

Adults presenting to stroke services are frequently faced with the challenge of adjusting to a different life following a stroke. Difficulties often include cognitive impairments, such as memory deficits, attention and language difficulties, and mood disturbances such as anxiety and depression. It has been highlighted that psychological care for this group is just as important as physical rehabilitation. Psychological expertise may therefore be required for the multitude of problems that occur after a stroke. UK National guidelines recommend routine assessment and management of mood and cognition after stroke. The aim of this study was to evaluate a new stroke clinical neuropsychology service developed by the Department of Neuropsychology and Clinical Health Psychology, in order to meet the needs of stroke survivors and their families referred into a large acute hospital. This involved using a different skill mix of staff across one post delivering a service in an acute inpatient stroke unit. This model was evaluated and results revealed that the model delivered increased patient access to neuropsychological support, an expansion in provision of clinical work, along with positive multidisciplinary team feedback. This finding is key as where resources are limited, clinical services may benefit from adopting a ‘skill mix’ model to meet the varying needs of their patients in a timely manner. This model serves to raise the value of psychology to medical services.

<![CDATA[Reducing acute kidney injury incidence and progression in a large teaching hospital]]>

Acute kidney injury (AKI) is a common syndrome that is associated with significant mortality and cost. The Quality Improvement AKI Collaborative at Salford Royal Foundation Trust was established to review and improve both the recognition and management of AKI. This was a whole-system intervention to tackle AKI implemented as an alternative to employing separate AKI nurses. Our aims were to reduce the overall incidence of AKI by 10%, to reduce hospital-acquired AKI by 25% and to reduce the progression of AKI from stage 1 to stage 2 or 3 by 50%.

From 2014 to 2016, several multifaceted changes were introduced. These included system changes, such as inserting an e-alert for AKI into the electronic patient record, an online educational package and face-to-face teaching for AKI, and AKI addition to daily safety huddles. On 10 Collaborative wards, development of an AKI care bundle via multidisciplinary team (MDT) plan, do, study, act testing occurred.

Results showed a 15.6% reduction in hospital-wide-acquired AKI, with a 22.3% reduction on the collaborative wards. Trust-wide rates of progression of AKI 1 to AKI 2 or 3 showed normal variation, whereas there was a 48.5% reduction in AKI progression on the Collaborative wards. This implies that e-alerts were ineffective in isolation. The Collaborative wards’ results were a product of the educational support, bundle and heightened awareness of AKI.

A number of acute hospitals have demonstrated impactful successes in AKI reduction centred on a dedicated AKI nurse model plus e-alerting with supporting changes. This project adds value by highlighting another approach that does not require a new post with attendant rolling costs and risks. We believe that our approach increased our efficacy in acute care in our front-line teams by concentrating on embedding improved recognition and actions across the MDT.

<![CDATA[Testing of the ‘Always Events’ approach to improve the patient experience in the emergency department]]>

Maintaining quality of care and meeting patient expectations in the face of rising demand within emergency departments (ED) is a significant challenge for clinicians. This study tested the Always Events (AE) approach as a means to identify AE’s relevance to patient care in the ED and act on this to address patient concerns. The project team looked to identify aspects of care patients would like to see improved within the minor injuries stream (MIS). Following triage, patients typically have presentations that do not require admission and require a single interaction with a clinician. Interventions seeking to improve patient experience were created and impact was monitored using patient feedback using a quality improvement (QI) framework.

AEs were identified via convenience sampling using a short semistructured survey questionnaire. Patients were asked ‘What should always happen in the Emergency Department?’ Communication and information provision regarding how the department worked were identified as key themes. Two interventions, an educational poster and a video campaign, were designed and implemented. Improvement was assessed via convenience sampling of patient questionnaires using a 5-point Likert scale and free-text responses.

Initial patient satisfaction levels regarding information provision stood at 80%, rising to 88% after our poster intervention and 92% by the end of the video intervention. Understanding of how the ED functions was initially 83% in the baseline sample before rising to 86% following poster and video interventions. Patient questionnaires indicated that information provision directly from staff was variable throughout the study period.

Implementing the AE approach in the MIS has improved patient experience. Our poster intervention had the greatest benefit regarding patient understanding of the ED and information provision. This project has also indicated that the AE method can be successfully combined with a QI tool and applied in the ED to address patient needs.

<![CDATA[Reducing inappropriate antibiotic prescribing in upper respiratory tract infection in a primary care setting in Kolkata, India]]>

Inappropriate antibiotic use is a key factor in the emergence of antibiotic resistance. The majority of antibiotics are prescribed in primary care, where upper respiratory tract infection (URTI) is a common presentation. Inappropriate antibiotic prescribing in URTI is common globally and has increased markedly in developing and transitional countries. Antibiotic stewardship is crucial to prevent the emergence and spread of resistant microbes. This project aimed to reduce inappropriate antibiotic prescribing in URTI in a non-governmental organisation’s primary care outreach clinics in Kolkata, India, from 62.6% to 30% over 4 months. A multifaceted intervention to reduce inappropriate antibiotic use in non-specific URTI was implemented. This consisted of a repeated process of audit and feedback, interactive training sessions, one-to-one case-based discussion, antibiotic guideline development and coding updates. The primary outcome measure was antibiotic prescribing rates. A baseline audit of all patients presenting with non-specific URTI over 8 weeks in November and December 2016 (n=222) found that 62.6% were prescribed antibiotics. Postintervention audit over 4 weeks in April 2017 (n=69) showed a marked reduction in antibiotic prescribing to 7.2%. An increase in documentation of examination findings was also observed, from 52.7% to 95.6%. This multifaceted intervention was successful at reducing inappropriate antibiotic prescribing, with sustained reductions demonstrated over the 4 months of the project. This suggests that approaches previously used in Europe can successfully be applied to different settings.

<![CDATA[Training: improving antenatal detection and outcomes of congenital heart disease]]>


This study describes the design, delivery and efficacy of a regional fetal cardiac ultrasound training programme. This programme aimed to improve the antenatal detection of congenital heart disease (CHD) and its effect on fetal and postnatal outcomes.

Design setting and participants

This was a prospective study that compared antenatal CHD detection rates by professionals from 13 hospitals in Wales before and after engaging in our ‘skills development programme’. Existing fetal cardiac practice and perinatal outcomes were continuously audited and progressive targets were set. The work was undertaken by the Welsh Fetal Cardiovascular Network, Antenatal Screening Wales (ASW), a superintendent sonographer and a fetal cardiologist.


A core professional network was established, engaging all stakeholders (including patients, health boards, specialist commissioners, ASW, ultrasonographers, radiologists, obstetricians, midwives and paediatricians). A cardiac educational lead (midwife, superintendent sonographer, radiologist, obstetrician, or a fetal medicine specialist) was established in each hospital. A new cardiac anomaly screening protocol (‘outflow tract view’) was created and training on the new protocol was systematically delivered at each centre. Data were prospectively collected and outcomes were continuously audited: locally by the lead fetal cardiologist; regionally by the Congenital Anomaly Register and Information Service in Wales; and nationally by the National Institute for Cardiac Outcomes and Research (NICOR) in the UK.

Main outcome measures

Patient satisfaction; improvements in individual sonographer skills, confidence and competency; true positive referral rate; local hospital detection rate; national detection rate of CHD; clinical outcomes of selected cardiac abnormalities; reduction of geographical health inequality; cost efficacy.


High levels of patient satisfaction were demonstrated and the professional skill mix in each centre was improved. The confidence and competency of sonographers was enhanced. Each centre demonstrated a reduction in the false-positive referral rate and a significant increase in cardiac anomaly detection rate. According to the latest NICOR data, since implementing the new training programme Wales has sustained its status as UK lead for CHD detection. Health outcomes of children with CHD have improved, especially in cases of transposition of the great arteries (for which no perinatal mortality has been reported since 2008). Standardised care led to reduction of geographical health inequalities with substantial cost saving to the National Health Service due to reduced false-positive referral rates. Our successful model has been adopted by other fetal anomaly screening programmes in the UK.


Antenatal cardiac ultrasound mass training programmes can be delivered effectively with minimal impact on finite healthcare resources. Sustainably high CHD detection rates can only be achieved by empowering the regional screening workforce through continuous investment in lifelong learning activities. These should be underpinned by high quality service standards, effective care pathways, and robust clinical governance and audit practices.

<![CDATA[Multidisciplinary approach to improve the quality of below-knee plaster casting]]>


In our trauma unit, we noted a high rate of incorrectly applied below-knee casts for ankle fractures, in some cases requiring reapplication. This caused significant discomfort and inconvenience for patients and additional burden on plaster-room services. Our aim was to improve the quality of plaster casts and reduce the proportion that needed to be reapplied.


Our criteria for plaster cast quality were based on the British Orthopaedic Association Casting Standards (2015) and included neutral (plantargrade) ankle position, adequacy of fracture reduction and rate of cast reapplication. Baseline data collection was performed over a 2-month period by two independent reviewers.


After distributing findings and presenting to relevant departments, practical casting sessions with orthopaedic technicians were arranged for the multidisciplinary team responsible for casting. This was later supplemented by new casting guidelines in clinical areas and available online. Postintervention data collection was performed over two separate cycles to assess the effect and permanence of intervention.


Data from the preintervention period (n=29) showed median ankle position was 32° plantarflexion (PF), with nine (31%) inadequate reductions and six (20%) backslabs reapplied. Following Plan-Do-Study-Act (PDSA) 1, ankle position was significantly improved (median 25° PF), there were fewer inadequate reductions (12%; 2/17) and a lower rate of reapplication (0%; 0/17). After PDSA 2 (n=16), median ankle position was 21° PF, there was one (6%) inadequate reduction and two (12%) reapplications of casts.


Following implementation of plaster training sessions for accident and emergency and junior orthopaedic staff, in addition to publishing guidance and new protocol, there has been a sustained improvement in the quality of below-knee backslabs and fewer cast reapplications. These findings justify continuation and expansion of the current programme to include other commonly applied plaster casts.

<![CDATA[Improving service user self-management: development and implementation of a strategy for the Richmond Response and Rehabilitation Team]]>

Community rapid response and rehabilitation teams are used to prevent avoidable hospital admissions for adults living with multiple long-term conditions and to support early hospital discharge by providing short-term intensive multidisciplinary support. Supporting self-management is an important service intervention if desired outcomes are to be achieved. A Care Quality Commission inspection of the Richmond Response and Rehabilitation Team in 2014 identified that self-management plans were not routinely developed with service users and reported this as requiring improvement. This quality improvement project aimed to develop and implement a self-management strategy for service users and for 90% of service users to have a personalised self-management plan within 3 months. The quality improvement intervention used the Plan-Do-Study-Act model comprising: (1) the development of a self-management plan, (2) staff education to support service users to self-manage using motivational interviewing techniques, (3) piloting the self-management plan with service users, (4) implementation of the self-management plan and (5) monthly audit and feedback. Evaluation involved an audit of the number and quality of self-management plans developed with service users and a survey of staff knowledge and confidence to support service users to self-manage. Following implementation of the intervention, the number of self-management plans developed in collaboration with service users increased from 0 to 187 over a 4-week period. Monthly audit data confirmed that this improvement has been sustained. Results indicated that staff knowledge and confidence improved after an education intervention. Quality improvement methods facilitated development and operationalisation of a self-management strategy by a community rapid response and rehabilitation team. The next phase of the project is to evaluate the impact of the self-management strategy on key service outcomes including self-efficacy, unplanned and emergency hospital admissions and early discharges.

<![CDATA[Primary care scribes: writing a new story for safety net clinics]]>

The spread of electronic health records systems (EHRs) poses challenges for both patient and provider care experience. Limited research suggests that scribes offer potential benefits to productivity and clinician satisfaction in emergency health and specialty settings. We conducted this evaluation of trained volunteer scribes for primary care clinics serving a diverse, low-income population in a US safety net system, which implemented a new EHR 2011–2014. The scribe programme trained and managed scribes for 51 providers (25% participation) from 5 of 12 San Francisco Health Network primary care clinics. We evaluated the programme using four measures. Providers reported spending less time out of clinic completing notes after sessions with scribes versus sessions without scribes (14.0 min vs 30.2 min, p<0.01). The rate of incomplete EHR notes at 72 hours was not significantly different for clinics using and not using scribes (16.9% vs 16.7%, p=0.4). Mean visit length using EHR-recorded provider cycle time was shorter for sessions with scribes (24.0 min), compared with sessions without scribes (26.4 min, p<0.01). Patients at clinics using scribes were as likely to recommend their provider (74.5%), compared with patients at clinics not using scribes (74.3%). Limitations of our evaluation include selection bias and possible confounding by clinic- and provider-level factors. In a safety net primary care system, trained volunteer scribes were associated with improved clinician efficiency and experience and no difference in patient satisfaction.

<![CDATA[Using the plan-do-study-act approach to improve inpatient colonoscopy preparation]]>

Poor inpatient colonoscopy preparations can provide multiple challenges to healthcare providers and patients alike. Poor preparations can make the colonoscopy difficult to perform, and can require the procedure to be repeated. This can in turn lead to greater costs, longer length of stays, less patient satisfaction and worse outcomes. The aim of this quality improvement project was to decrease the rate of poor inpatient colonoscopy preparations using the plan-do-study-act approach. Inpatient colonoscopies at our institution from a 3-month span (November 2016 to January 2017) were evaluated, and found to have a 19% rate of poor preparations. A multiphase intervention programme was then conducted to improve the quality of these preparations. This intervention programme was threefold, and involved (1) direct education to physicians and nursing staff on the preparation process and its importance; (2) the implementation of an electronic order set within our electronic medical record (EMR) to standardise and simplify the process of ordering colonoscopy preparations; and (3) patient education in the form of a handout explaining the steps and importance of a good preparation. Through these interventions, we were able to bring down our rate of poor preparations over a 3-month average from 19% to 4%. Specifically, the implementation of an electronic order set within our EMR resulted in the greatest impact. Our interventions can be replicated at other institutions in order to decrease the rate of poor preparations, and thus result in better outcomes for patients, providers and healthcare facilities.

<![CDATA[Prevention of acute kidney injury through accurate fluid balance monitoring]]>

Acute kidney injury (AKI) is associated with increased patient morbidity, mortality and an extended hospital stay. The financial burden to the National Health Service is high and it can affect up to one in five inpatients. Optimal fluid balance management is essential for the prevention of AKI and this can be particularly challenging in the patient with trauma. Our aim was to reduce the rate of AKI in patients with traumatic injuries in the regional trauma centre.

We developed new fluid balance charts and documented how well these were completed. The number of AKI alerts per month was calculated on our pathology system. Scenario training was delivered at handover meetings and an e-learning tool was designed at three levels: healthcare assistants; nurses; and medical staff, dietetics and pharmacists. Educational posters were placed in clinical areas and patient information leaflets produced. Junior doctors were regularly informed of AKI rates on the ward.

The number of AKI alerts on our trauma ward declined from 50 in January 2016 to 19 in November 2016. The mean monthly rate of AKI fell 33% following the invention (P<0.001). Completion of fluid balance charts improved; 6 hourly urine output documentation increased from 36% to 68% and running 1 hourly output increased from 80% to 96%. Calculation of total daily fluid balance rose from 12% to 72%, before decreasing to 32%. This highlighted the need for continued encouragement.

Improved fluid balance monitoring led to a reduction in the prevalence of AKI in patients admitted to this trauma centre.

<![CDATA[Improving the workflow of nursing assistants at a general hospital in Japan]]>

Transferring non-specialised tasks from registered nurses to nursing assistants may help registered nurses focus on specialised tasks. Optimising the workflow of nursing assistants by making their tasks more efficient may improve problems associated with the shortage of registered nurses. The nursing assistants at our hospital were stressed about referring inpatients to outpatient specialty clinics. Therefore, we initiated a project to optimise the referral process and reduce the time spent by nursing assistants on this task, with the collaboration of physicians, registered nurses and administrative assistants. The Training for Effective & Efficient Action in Medical Service–Better Process (TEAMS-BP) method, which was developed by modifying the Japanese Training Within Industry–Job Method, was used for the optimisation process. TEAMS-BP teaches users how to break each task down into its individual components, to scrutinise the details, and then to develop new processes by eliminating, combining, rearranging and simplifying tasks. At baseline, each referral took 10 min and was performed 39 times over 10 days in six wards. The first TEAMS-BP cycle did not yield satisfactory results for the nursing assistants. In the second TEAMS-BP cycle, participants included inpatient and outpatient physicians, registered nurses and administrative assistants. As a result, we changed the referral process from paper to electronic records and streamlined referrals that were ordered by inpatient physicians to outpatient physicians. The use of this method saved the equivalent of 175 hours of nursing assistants’ time per year at no additional cost. If we had been able to define the referral process as an interdisciplinary task and show the merits to each department from the beginning, we may have been able to form the interprofessional team in the first TEAMS-BP. Improving the efficiency of nursing assistants can allow other professionals to focus on their specialised tasks more effectively.

<![CDATA[Initiative to improve the cardiogenic safety of antipsychotic medication in community mental health patients]]>

Serious mental illness is reported to reduce a patient’s life expectancy by 15–20 years. This disparity is thought to be related to lifestyle factors, access to healthcare, poor health monitoring and the common use of antipsychotics, which can cause serious metabolic and cardiogenic side effects. Therefore, to reduce the risk of cardiac complications, both national and local guidance recommends annual ECG monitoring for patients on antipsychotics. Unfortunately this monitoring is not completed consistently at Manchester Mental Health and Social Care Trust, especially within community mental health teams. A small team of healthcare professionals conducted a quality improvement (QI) project from June 2015 to May 2016 with the aim of addressing this deficiency in care. A multidisciplinary approach was used to implement improvement in four key areas. Awareness of the need for monitoring, patient engagement with this process, identification of patients requiring monitoring and access to ECG equipment were all addressed as separate primary drivers for change over an 8-month period using a ‘Plan Do Study Act’ model of QI. Outcome, process and balancing measures were gathered monthly to track progress and improvement following the application of change. Compliance with annual ECG monitoring nearly doubled throughout the course of the project from 43% in June 2015 to a peak of 83% in February 2016. Improvement appeared to be sustained as the percentage of patients receiving the required monitoring remained significantly higher than baseline even after no further change interventions were being implemented (76%, 71%, 77%, March, April, May 2016). This QI project has shown that improvements can be made and has documented a recipe for how this change was achieved.

<![CDATA[Improving OSA screening and diagnosis in patients with hypertension in an academic safety net primary care clinic: quality improvement project]]>

Obstructive sleep apnoea (OSA) is more prevalent in patients with hypertension (HTN), and associated morbidities include stroke, heart failure and premature death. In the Internal Medicine Clinic (IMC), over 70% of the patients had a diagnosis of HTN and obesity. We identified a lack of OSA screening in patients with HTN. The aim of this quality improvement (QI) was to increase OSA diagnosis to 5% from the baseline rate of less than 1% in patients with HTN between the ages of 18 and 75 years over 6 months at IMC. We used the Plan-Do-Study-Act (PDSA) method. The QI team performed root cause analysis to identify materials/methods, provider and patient-related barriers. PDSA cycle included: (1) integration of customised workflow of loud Snoring, Tiredness, Observed apnea, high blood Pressure (STOP)-Body mass index (BMI), Age, Neck circumference, and Gender (BANG) OSA screening tool in the electronic health record (EHR); (2) physician education of OSA and EHR workflow; and (3) completion of STOP survey by patients, which was facilitated by nursing staff. The outcome measure was the percentage of OSA diagnosis in patients with HTN. The process measures included the percentage of patients with HTN screened for OSA and the increase in sleep study referrals in hypertensive patients with STOP-BANG score of ≥3. Increase in patient wait time and cost of sleep study were the balance measures. Data analysis was performed using weekly statistical process control chart. The average increase in OSA screening rate using the STOP-BANG tool was 3.88%. The significant variation seen in relation to PDSA cycles was not sustainable. 32% of patients scored ≥3 on the STOP-BANG tool, and 10.4% had a confirmed diagnosis of OSA. STOP-BANG tool integration in the EHR and a team approach did not result in a sustainable increase in OSA screening. OSA diagnosis was increased to 3.3% in IMC patient population within the 6-month period. The team identified multiple barriers to screening and diagnosis of OSA in the IMC.

<![CDATA[Improving best possible medication history with vulnerable patients at an urban safety net academic hospital using pharmacy technicians]]>


Best possible medication history (BPMH) enhances the care of safety net patients, especially those with limited English proficiency and limited health literacy who are most vulnerable to medication error during the hospital admission process. Our large urban academic safety net centre faced numerous barriers to achieve BPMH among hospitalised patients including communication barriers that increase the time and complexity of eliciting BPMH, frequent provider turnover at our training institution and lack of an electronic health record (EHR) medication reconciliation tool to facilitate BPMH collection and monitoring.


Leveraging opportunities afforded by the US federal incentive EHR programme, our multidisciplinary team designed an EHR-facilitated medication reconciliation programme by which pharmacy technicians engaged newly admitted patients and their caregivers at the bedside to develop and electronically document the BPMH.


Prior to this intervention, pharmacy technicians had no role in BPMH. Providers collected home medications documented on paper notes without a consistent methodology. With each plan–do–study–act (PDSA) cycle since the programme began, the goal was to increase the per cent of BPMH completed by a pharmacy technician. Individual PDSA cycles targeted either the pharmacy technicians by expanding their pool of eligible patients or provider engagement with the pharmacy technician workflow.


By optimising not only the health information technology platform but also the operational processes, the programme achieved a nearly 80% generation of BPMH completed by a highly trained pharmacy technician, surpassing its intended goal of 50% BPMH completion by a pharmacy technician on admission.


An EHR-facilitated tool improved BPMH at an urban academic safety net hospital using pharmacy technicians.

<![CDATA[Improving combined contraceptive pill/oral contraceptives prescribing in general practice]]>


Eighty per cent of contraceptive care occurs in the general practice setting. UK Medical Eligibility Criteria provides clear guidelines for the safe provision of appropriate contraception. The Faculty of Sexual and Reproductive Health and the National Institute for Health and Care Excellence offer further recommendations for initiation and continuation of the combined contraceptive pill/oral contraceptives.

Method and analysis

Using the Egton Medical Information Systems database of an inner city, average size general practice we performed a retrospective analysis of combined contraceptive pill/oral contraceptives consultations to identify areas of substandard prescribing. Through three subsequent improvement cycles we demonstrated that the safety of combined contraceptive pill/oral contraceptives prescribing could be enhanced by consistent application of UK Medical Eligibility Criteria. By encouraging general practitioners to promote safe sex and use local long-acting reversible contraception options we were able to enhance the quality of consultations as dictated by national guidelines. Regular education and use of an amended EMIS template (to include UK Medical Eligibility Criteria) enabled us to improve both the safety and quality of community-combined contraceptive pill/oral contraceptives prescribing in a sustainable fashion.

<![CDATA[A local quality initiative to improve follow-up times for patients with heart failure]]>

Introduction Heart failure is the most common cause of hospital admission in patients >65 years and around 50% of patients will be readmitted within 6 months. Inability to achieve timely outpatient follow-up may contribute to the high rates of avoidable rehospitalisation for this group of patients. Canadian guidelines recommend patients with heart failure should be seen within 14 days of discharge.

Methods An audit demonstrated that less than half of advanced heart failure patients were being followed up within 14 days. In an effort to improve postdischarge follow-up in our heart function clinic, we used process mapping and applied a series of iterative changes to the appointment booking system using Plan–Do–Study–Act cycles to reduce waste and standardise.

Results The primary outcome measure, tracked over a period of 20 months, was percentage of patients booked within 14 days. At baseline, 37% of patients were seen within 14 days. After our series of interventions related to streamlining and standardising the appointment booking process, 77% of patients were seen within 14 days and 100% of patients were seen within 21 days.

Conclusion The changes made to the appointment booking process were reproducible, sustainable, effective and required no additional resources or funding.

<![CDATA[Improving the patient booking service to reduce the number of missed appointments at East London NHS Foundation Trust Community Musculoskeletal Physiotherapy Service]]>

The East London National Health Service Foundation Trust (ELFT) Community Musculoskeletal (MSK) Physiotherapy Service had reported a high rate of non-attendance at scheduled appointments. This was leading to delayed access to treatment for patients and a reduced capacity for service users, as well as a waste of clinical resources. The aim of this quality improvement project was therefore to reduce the percentage of missed appointments within this department. This study was undertaken by the ELFT community MSK service, with support from the ELFT Quality Improvement team. To begin with, patient complaints were explored; these indicated that the main reason for missing appointments was due to issues with the patient booking service. Baseline data were initially collected for both new referrals and follow-up patients. The proposed changes were then introduced, which included text message reminders, first via a manual platform and then via an automated system. Ongoing data were recorded to note the effectiveness of these changes. Following the intervention, non-attendance of newly referred patients reduced by 43.35% (23.76%–13.46%) after both cycles. Non-attendance of follow-up patients reduced by 44.14% (23.74%–13.26%) after the second cycle alone. By listening to the opinions of service users, it was possible to improve the patient booking system and the flexibility of appointments. This resulted in a reduction in the percentage of appointments missed. These changes will continue to be monitored within this department to ensure sustainability but there is also now potential for similar interventions to be trialled in other health service departments.

<![CDATA[Improving the rates of electronic results acknowledgement at a tertiary eye care centre]]>


Hundreds of thousands of tests are performed annually in hospitals worldwide. Safety Issues arise when abnormal results are not recognized promptly resulting in delayed treatment and increased morbidity and mortality. As a result Singapore’s largest healthcare group, Singhealth introduced an electronic result acknowledgement system. This system was adopted by the Singapore National Eye Centre (SNEC) in February 2016. Baseline measurements show that weekly numbers of unacknowledged results ranged from 193 to 617. The current standards of electronic results acknowledgement posts a significant patient safety hazard.


Root cause analysis was performed to identify contributory factors. Pareto principle was then used by the authors to identify the main contributory factors. We employed the rapid cycle improvement Plan-do-study-act (PDSA) strategy to test and evaluate implemented changes. Changes are implemented for 2 weeks and data collected prospectively. The data is analyzed the week after and the following PDSA actions are decided and instituted the following week. 3 PDSA cycles were undertaken in total.


The first PDSA cycle focused on raising awareness of the problem at hand, the number of unacknowledged results drastically decreased during the 1stweek of implementation of our PDSA from 617 to 254. The second PDSA cycle targeted the lack of knowledge of doctors involved in the electronic result acknowledgement process. There was a trend downwards near the end of the cycle which continued through the week after. The third PDSA cycle targeted individual doctors and provided individual remedial training. Second line doctors were also equipped to better handle abnormal results. There was significant improvement with the number of unacknowledged abnormal results dropping to <5 a week.


Multiple factors were identified to contribute to the low compliance to electronic acknowledgement of results. The role doctors play in the issue at hand was paramount and required careful handling in a professional manner with multiple reminders and emphasis on the importance of acknowledging and acting on the results.A significant improvement in the rates of acknowledgement of abnormal results was demonstrated with clear benefits to patient safety. Interventions can be replicated when implementing similar systems to other areas of healthcare.