Improving turnaround times for HLA-B*27 and HLA-B*57:01 gene testing: a Barts Health NHS Trust quality improvement project

Successful demand management in diagnostic immunology testing

AIMS

We investigated whether we could have a material and sustained impact on immunology test ordering by primary care clinicians by building evidence-based and explanatory algorithms into test ordering software.

METHODS

A service evaluation revealed cases of over-requesting of antinuclear antibody, allergen-specific IgE and total IgE tests, and under-requesting of urine protein electrophoresis. We conducted a quality improvement programme to address this. We determined the most effective and efficient intervention would be to embed evidence-based and advice-based decision-support algorithms in the ordering software. Consultation with general practitioners revealed lack of knowledge and confidence about testing, and an appetite for support. We iteratively designed and implemented algorithms for the four sets of tests for the primary care practices in our catchment and made them available to other hospital trusts in our region. The ordering system now contains links to advice sheets for clinicians and their patients and to an email address for queries to the lab.

RESULTS

We observe large (36% to 88%) reductions in testing activity (workload) for the over-requested tests and large (28%-135%) increases for the under-requested test. We show that these changes are sustained. There have been no complaints from the clinicians and queries to the lab are now minimal (less than one per month on average).

CONCLUSIONS

Embedding algorithms in the ordering software can be acceptable to clinicians and have a major and sustained impact on overuse or underuse of tests. The algorithms can be replicated by other hospital trusts.

Time is a terrible thing to waste: optimising use of intraoperative monitoring practitioner time towards maximising in-house IOM service provision and reducing spend on external provision

Intraoperative monitoring (IOM) during orthopaedic and neurosurgical operations informs surgeons about the integrity of patients' central and peripheral nervous systems. It is provided by IOM practitioners (IOMPs), who are usually neurophysiology healthcare scientists. Increasing awareness of the benefits for patient safety and surgical outcomes, along with post-COVID-19 service recovery, has resulted in a material increase in demand for IOM provision nationally, and particularly at Salford Royal Hospital (SRH), which is a regional specialist neurosciences centre.There is a shortage of IOMPs in the UK National Health Service (NHS). At SRH, this is exacerbated by staff capacity shortage, requiring £202 800 of supplementary private provision in 2022.At SRH, IOMPs work in pairs. Our productive time is wasted by delays to surgical starts beyond our control and by paired working for much of a surgery session. This quality improvement (QI) project set out to release productive time by: calling the second IOMP to theatre only shortly before start time, the other IOMP returning to the office during significant delays, releasing an IOMP from theatre when appropriate and providing a laptop in theatre for other work.We tested and refined these change ideas over two plan-do-study-act improvement cycles. Compared with complete paired working, we increased the time available for additional productive work and breaks from an average of 102 to 314 min per operating day, not quite achieving our project target of 360 min.The new ways of working we developed are a step towards ability (when staff capacity increases) to test supporting two (simultaneous) operations with three IOMPs (rather than two pairs of IOMPs). Having significantly improved the use of staff time, we then also used our QI project data to make a successful business case for investment in two further IOMP posts with a predicted net saving of £20 000 per year along with other associated benefits.

Reducing first appointment delays for electron radiotherapy patients by improving the treatment planning pathway: a quality improvement project

Clatterbridge Cancer Centre (CCC) is a specialist hospital trust in England with three sites.Delay to the start of an appointment for radiotherapy, especially the first appointment (a 'New Start') is poor, both for operational efficiency and patient experience, causing stress for both patients and staff. Our aim is for the New Start to begin within 30 min of the allotted appointment time. To this end, we established another aim: for 'Final Checks' to the radiotherapy plan to be completed at least 30 min prior to the New Start appointment time.Prior to this quality improvement (QI) project, only 33% of electron-treatment New Start appointments started within the target 30 min (the average delay was 52.4 min) and only 48% of the corresponding Final Checks had been completed by their 30 min prior target.The treatment pathway for these patients was redesigned, with the aim of 90% of New Start appointments starting within 30 min of the allotted appointment time.By the end of this QI project, 69.2% of New Start appointments started within 30 min of the appointment time (with average delay reduced to 27.2 min), and 92.3% of Final Checks were completed by their 30 min prior target. We also reduced the number of safety (Datix) incidents due to plan not ready from 10 to 0. A year after the project, we have held most of the time improvements and still have had 0 plan-not-ready Datix.The largest improvement was achieved by introducing a proxy (without the patient present) 'day 0' appointment. This takes place in advance of the New Start appointment to enable earlier planning. Subsequent improvements included: automating previously manual planning calculations, making the care path consistent with other external beam radiotherapy care paths at CCC to reduce staff cognitive load and sharing key performance data with staff.

Clinical-scientist-led transoesophageal echocardiography (TOE): using extended roles to improve the service

At the North West Anglia NHS Foundation Trust, we perform transoesophageal echocardiography (TOE), a semi-invasive diagnostic test using ultrasound for high-quality heart imaging. TOE allows accurate diagnosis of serious heart problems to support high-quality clinical decision-making about treatment pathways. The procedure can be lengthy and is traditionally performed by a consultant cardiologist, who typically has multiple commitments. This constrains patient access to TOE, leading to waits from referral to test, delaying treatment decisions.In this quality improvement project, we improved access by redesigning workforce roles. The clinical scientist, who had been supporting the consultant during TOE clinics, took on performing the procedure as the main operator. We used the Model for Improvement to develop this clinical-scientist-led service-delivery model, and then test and refine it. This increased capacity and frequency of TOE clinics, reducing waits and releasing around 2 days per month of consultant time.Over five plan-do-study-act cycles, we tested six changes/refinements. Our targets were to reduce the maximum waiting time for TOE to 3 working days for inpatients and to 14 working days for outpatients. We succeeded, achieving reductions in mean waiting times from 7.7 days to 3.0 days for inpatients and from 33.2 days to 8.3 days for outpatients.TOE requires intubation; when this fails, TOE is abandoned. We believe light (rather than heavy) sedation is helpful for this intubation. We reduced sedation levels (from a median of 3 mg of midazolam to 1.5 mg) and, as a secondary outcome of this project, reduced the intubation failure rate from 13% to 0% (over 32 postchange patients).Following this project, our TOE service is usually performed by a clinical scientist in echocardiography who has British Society of Echocardiography TOE accreditation and advanced training. We have sustained the improved performance and demonstrated the value of enhanced roles for clinical scientists.

Time to be more efficient: reducing wasted transthoracic echocardiography (TTE) diagnostic appointment slots at Guy's and St Thomas' NHS Trust

Transthoracic echocardiography (TTE) is one of the most requested non-invasive cardiac imaging diagnostic modalities available in the National Health Service (NHS). There is persistently high demand, but nationally, activity has lagged, producing increasing numbers of breaches of the 6-week waiting time target. This delays patients' diagnosis and treatment.Patients attend hospital for TTE either as a clinic-linked or a standalone appointment. In this quality improvement project, we identified that the clinic-linked slots were a major source of wasted capacity due to both unbooked slots and a high rate of patients not attending their appointments (DNA).DNA is a complex issue, aggravated in our trust by many IT systems, complex clinic-booking pathways and restricted patient communication channels. We parked changing these processes, pending an imminent, unifying IT development programme. We focused instead on unused clinic-linked appointments, with the goal of reducing these from 18% (~31 of ~175 allocated each week) to 5% by the end of the 14 week project period.In close collaboration with service stakeholders, we identified that the primary root causes were related to the clinic-linked TTE booking pathway. The change idea was a 7-day rule: after reminders at 9 and 8 days prior to the clinic date, any appointment slots still unbooked by cardiology sub-specialities for patients attending clinic-linked appointments at 7 days, would be used for booking standalone TTE patients.We refined this process over two plan-do-study-act (PDSA) cycles, reducing unused (wasted) appointment slots, allocated initially to clinic-linked patients, to a sustained level of 5.1%, meaning we could now perform approximately 21 additional TTE tests weekly; we have materially increased activity without increasing capacity.This contributed to a significant reduction in 6-week TTE waiting-time breaches. Over the project, this went from 378 (30%, February 2022) to 71 (8%, September 2022) and latest data show 28 (4%, February 2023).

Lean and Six Sigma as continuous quality improvement frameworks in the clinical diagnostic laboratory

Processes to enhance customer-related services in healthcare organizations are complex and it can be difficult to achieve efficient patient-focused services. Laboratories make an integral part of the healthcare service industry where healthcare providers deal with critical patient results. Errors in these processes may cost a human life, create a negative impact on an organization's reputation, cause revenue loss, and open doors for expensive lawsuits. To overcome these complexities, healthcare organizations must implement an approach that helps healthcare service providers to reduce waste, variation, and work imbalance in the service processes. Lean and Six Sigma are used as continuous process improvement frameworks in laboratory medicine. Six Sigma uses an approach that involves problem-solving, continuous improvement and quantitative statistical process control. Six Sigma is a technique based on the DMAIC process (Define, Measure, Analyze, Improve, and Control) to improve quality performance. Application of DMAIC in a healthcare organization provides guidance on how to handle quality that is directed toward patient satisfaction in a healthcare service industry. The Lean process is a technique for process management in which waste reduction is the primary purpose; this is accomplished by implementing waste mitigation practices and methodologies for quality improvement. Overall, this article outlines the frameworks for continuous quality and process improvement in healthcare organizations, with a focus on the impacts of Lean and Six Sigma on the performance and quality service delivery system in clinical laboratories. It also examines the role of utilization management and challenges that impact the implementation of Lean and Six Sigma in clinical laboratories.

Defining and evaluating the Hawthorne effect in primary care, a systematic review and meta-analysis

In 2015, we conducted a randomized controlled trial (RCT) in primary care to evaluate if posters and pamphlets dispensed in general practice waiting rooms enhanced vaccination uptake for seasonal influenza. Unexpectedly, vaccination uptake rose in both arms of the RCT whereas public health data indicated a decrease. We wondered if the design of the trial had led to a Hawthorne effect (HE). Searching the literature, we noticed that the definition of the HE was unclear if stated. Our objectives were to refine a definition of the HE for primary care, to evaluate its size, and to draw consequences for primary care research. We designed a Preferred Reporting Items for Systematic reviews and Meta-Analyses review and meta-analysis between January 2012 and March 2022. We included original reports defining the HE and reports measuring it without setting limitations. Definitions of the HE were collected and summarized. Main published outcomes were extracted and measures were analyzed to evaluate odds ratios (ORs) in primary care. The search led to 180 records, reduced on review to 74 for definition and 15 for quantification. Our definition of HE is "an aware or unconscious complex behavior change in a study environment, related to the complex interaction of four biases affecting the study subjects and investigators: selection bias, commitment and congruence bias, conformity and social desirability bias and observation and measurement bias." Its size varies in time and depends on the education and professional position of the investigators and subjects, the study environment, and the outcome. There are overlap areas between the HE, placebo effect, and regression to the mean. In binary outcomes, the overall OR of the HE computed in primary care was 1.41 (95% CI: [1.13; 1.75]; I 2 = 97%), but the significance of the HE disappears in well-designed studies. We conclude that the HE results from a complex system of interacting phenomena and appears to some degree in all experimental research, but its size can considerably be reduced by refining study designs.

Improving the turnaround times of infectious disease markers reporting in an NHS stem cell department

The Stem Cell Donation and Transplantation Department at NHS Blood and Transplant (NHSBT) facilitates unrelated donor haematopoietic stem cell transplantations for patients with life-threatening haematological malignancies or other blood diseases. Donors must be screened for infectious disease markers (IDMs) prior to donation. The purpose of IDM testing is to assess whether the donor currently has, or previously had, an infectious disease that could be transmitted to the recipient. The turnaround time (TaT) from sample collection to the return of IDM results is important to transplant clinicians and their patients. NHSBT has a target TaT of 80% within seven calendar days. Our initial analysis showed us that we failed to meet this in any week in the previous year, and our service was neither efficient nor consistent, so there was considerable improvement potential.This quality improvement (QI) project aimed to improve the TaT of the IDM reporting service. We tested three change ideas through four Plan-Do-Study-Act (PDSA) cycles. We collected data on TaTs from our laboratory information management system (LIMS) and updated our statistical process control charts after each PDSA cycle. Over the course of the project, we reduced the mean TaT from 8.9 days to 5.5 days and increased the proportion of samples reported within the 7-day benchmark from 50% to 89%, reaching the key performance indicator (KPI) target.Conducting this project was a rewarding experience. Although we encountered unanticipated technical issues during PDSA experiments, and we found that some change plans were not as effective in improving the KPIs as we expected, the improvement by the end of the study period was substantial. This QI project enabled us to meet our TaT targets and, ultimately, help ensure that our patients receive timely transplants. It suggests that QI may have wider applications across our part of NHSBT.