Improving the primary care clinical testing process in southwest Scotland: a systems-based approach

Abstract

Introduction: Across all healthcare environments, inadequately specified patient test requests are commonly encountered and can lead to wasted clinician time and healthcare resources, in addition to either missed or unnecessary testing taking place.Before this work, in a general practice in Southwest Scotland, a mean value of 42% of test requests were already uploaded to ordercomms (a widely used system in general practice for designating clinical testing instructions) at patient presentation, leaving an opportunity for error and wasted clinician time/resources.

Methods: Patient appointment records were retrospectively reviewed in a general practice in Southwest Scotland to monitor the proportion of test requests already uploaded to ordercomms at the time of patient presentation.The use of quality improvement tools and plan-do-study-act cycling allowed the testing of four change ideas attributable to different 'pathways' of origin for test requests.Change ideas included increasing clinician and secondary care/docman origin test requests already on ordercomms prior to patient presentation, reducing patient origin test requests and improving the test requesting system.

Results: The percentage of test requests already on ordercomms at patient presentation increased from a mean of 42% to 89% over a 30 week test period. The use of test pre-set templates was a welcome intervention that was agreed to be made accessible to 30+ regional general practices.

Conclusion: The use of pre-set templates for clinical testing encouraged a 47% rise in test requests already uploaded to ordercomms prior to patient presentation. This saved up to 90 min of clinician time weekly and ensured patients received the correct tests at the appropriate time.Our findings supported the use of pre-set testing templates, in combination with effective information communication, and were recommended for use in any clinical environment requiring patient testing.

Keywords: Audit and feedback; Continuous quality improvement; Control charts/Run charts.

Figure 1. A process map depicted the process of how test requests arose in primary care. Four distinct pathways were identified and colour coded, with one core ‘desirable’ pathway. Pathways informed change ideas. The process map was included to demonstrate the complexity of the issue and give an idea of the approach used by the quality improvement team.

Figure 2. Change idea 4 targeted improving the test requesting system within practice. Three change ideas were tested: producing and introducing templates of tests per clinical scenario, expanding this repertoire, subsequently making it available at a health board level.

Figure 3. The mean percentage of tests already on ordercomms at the time of patient presentation in general practice. The percentage increased from a mean 42% to 89% by the project end. The most valuable changes tested to achieve this aim included the creation and distribution of pre-set templates of tests per clinical scenario.