Background
Methods
The TRaCKED study
Settings
General practice study ID | Number of patients registered | Number of full time equivalent general practitioners (GPs) | IMD code rankinga
| Clinical management system |
---|---|---|---|---|
Practice 1 | 23,727 | 7.3 | 15,066 | SystmOne |
Practice 2 | 7059 | 6.3 | 871 | EMIS |
Practice 3 | 5914 | 3.0 | 13,866 | EMIS |
Practice 4 | 27,430 | 12.3 | 8447 | EMIS |
Phase 3: Selection and refinement of proposed solutions
Practice 1 | Practice 2 | |
---|---|---|
Initial Phase 3 meeting | GP ×6 Nurses ×2 | GP × 2 Lead receptionist ×1 Practice Manager X1 |
Working group meeting 1 | GP ×2 | GP ×1 PM × 1 |
Working group meeting 2 | GP ×2 | GP ×1 PM × 1 |
Phase 4: Evaluation phase
Focus groups
Analysis
Results
Phase 3: Selection and refinement of proposed solutions
Issue | Proposed solutions | Solution (those implemented in italics) | |
---|---|---|---|
Practice 1 and 2 | Practice 1 | Practice 2 | |
1. Delay in access to phlebotomy | 1) Reconfigure appointments to meet demand. 2) Increase the hours of phlebotomists. 3) Train existing staff in phlebotomy to provide support for phlebotomists. |
Employed additional HCA
Extended clinic to the afternoon
|
Trained existing staff in phlebotomy.
Kept additional appointments free
|
2. Receptionists reporting clinical information | 1) Support data protection act compliance by receptionists 2) Training for receptionists in how to communicate potentially sensitive information 3) Improving access to teleconsultations with GPs 4) Greater clarity in the script provided by GPs |
The importance of the accurate communication of result information was raised with reception staff.
|
Receptionists instructed to advise patients that there may be results outstanding.
The number of teleconsultations with GPs was increased.
|
3. Lack of routine communication of results | 1) via SMS 2) via letter 3) via email |
Selective use of SMS.
|
Selective use of SMS.
Letters routinely sent to patients with abnormal results advising them to book/keep their appointment.
|
4. Lack of patient awareness of the communication pathway | 1) Poster on wall in waiting room 2) Information leaflet for patients detailing tests ordered and the means of retrieving their results embedded within clinical management system. |
Information leaflet for patients printed and distributed by GPs.
| Issues with software provider meant it could not be achieved within the timescale of the study. |
5. Delays for patients seeking results via telephone | 1) Precise time slot for calling for results 2) Separate phone line for results 3) Call waiting | Patient demographic deemed unsuitable. | New telephone system recently procured. |
6. Lack of an alert for delayed or missing results | Alerts embedded in the clinical management system issued if: 1) The result has not been returned by the laboratory 2)The result has not been seen by GPs 3) The result has reached patients | The technical development needed could not be achieved within the time scale. | Would not commit to improving existing system with laboratory services out for tender |
What we still want, as a practice, is for our nurses, who are much better qualified, not to be doing stuff like that – that’s just an expensive use of nurses’ time, so we’re trying to move towards HCAs for as much as we can. – FP1 (male) Practice 1
We’ve just employed a new HCA – virtually full-time – well, it should be about three or four days…we’re doing phlebotomy morning and afternoon, that’s something that’s changed. – FP1 (male) Practice 1
The receptionist has just finished her competencies; she’s actually going to cover home visits for our HCA when she’s on leave next year which is the first time we’ve ever had that, so yeah, the teams expanded, it’s giving us a bit of flexibility. – PM (female) Practice 2
We save appointments for the day so there’s a slot the Doctor can utilise rather than sending people away. – PM (female) Practice 2
We’ve discussed this just this week actually… they don’t have any out of house training. It’s all in-house training. [They’re doing a receptionist training day at the BMI in June] which is a good idea…we’ve got a couple of new receptionists that I think would benefit from that. – FP1 (male) Practice 1
I think the main thing is to remember to write what you want the receptionist to say to the patient, and actually write the words – then there’s no confusion. – FP1 (male) Practice 1As partners and doctors, we talked about the importance of having a clear result to communicate to the patient and the staff know that they’re allowed to say what’s written in the box but not anything in brackets that’s for our benefit. That has definitely been reiterated recently. – FP2 (female) Practice 1
I think there’s definitely room for training; I think it’s just finding time to do it. Honestly, we are just running and tripping over ourselves at the moment and we have been doing now for the last eighteen months, never known anything like it. It started in the new year last year usually we have a lull, and in that lull I do all sorts of things because it’s definitely quieter, we haven’t had that period, we didn’t get it last year, we didn’t get it this year, and I doubt we’re going to get it next. – PM (female) Practice 2
Receptionists don’t know if that’s the only result or one of six so our staff are trained to say “Well this result’s back and that particular result is normal but obviously we don’t know how many the doctor ordered”. – PM (female) Practice 2
We felt it’s not a good idea to enact as policy for a lot of reasons to do with confidentiality. If you put your phone down and I text it to you …it’s a visible sort of thing. – FP2 (female) Practice 1
Phone numbers can change, and phones can be lost. If you don’t know their phone is lost and you don’t know they’ve not got the message, then that comes back to us. – FP2 (female) Practice 1
It’s a good idea … You could set the system up so that ‘normal - no action’ was an automatic SMS….The more that we can do here without involving receptionists, the receptionists are just… you know it is always chaotic in reception. – FP (female) Practice 2
The patient would need to know which results to expect so that they can tick them off themselves. – PM (Female) Practice 2
It is surprising how many do have email addresses. And email addresses are less likely to change as often as mobile phone numbers. So actually email is probably the better, safer way, than even text messages. – PM (Female) Practice 2
We looked at abnormal results…If we had an appointment we didn’t write to them because we just wrote on the results: “Discuss with doctor in appointment”. Patient then with an abnormal B12 did not come up and attend the appointment because they cancelled it, and because they cancelled it, it went off the system and it wasn’t identified as an issue until it was picked up on a medication review nearly a year later. – FP (female) Practice 2
In the letter for patients we are going to say: “If you already have an appointment please keep it”. I know they’ve got an abnormality... needs to be seen...check that they’ve got an appointment. Normally I’d have done nothing; they just don’t know the test was abnormal. It’s going to cost a fortune in writing to people but medico-legally…? – FP (female) Practice 2
I think something to hand to the patient to remind them of their responsibility to ring up for the results is a good idea. – FP2 (female) Practice 1We need this message: “It’s important that you contact the surgery” and then “See Lab Tests Online for further information on the implications of your test”. So those two are really good. – FP (female) Practice 2
You have to click on the form, bring the form up, and then print it, so it’s an extra click, if you like…We have put in the bottom in bold what times to call, and you can put on what day to call as well, which I do routinely. – FP2 (female) Practice 1
If we do online lab requests we still need a letter like that, that goes to patients saying: “this is what’s being requested”… – PM (female) Practice 2
It’s all old dogs, new tricks. I mean, probably 70-80% of tests we do are on over 70’s and you’re asking them to ring different numbers to the ones they’ve been ringing for 20 years, so it sounds nice when you’ve got sort of young people sitting round the room saying ‘nothing could be simpler’, but then you’ve got an old person, who will still ring the main number, and what do you do? Just say ‘I’m sorry, this is the number…’ and then you’re just irritating people you see? – FP1 (male) Practice 1
They are queued, but they are not told “you’re fourth in the queue”, I don’t believe so…It’s called Auto Attendant that we have. With the new system, if it’s busy it will tell you it’s busy, which is one step better than before where it just rang and rang and rang. – PM (female) Practice 2
I don’t think we should waste a lot of time...[on alerts] – FP (male) Practice 1
As far as they are concerned it’s pretty bomb-proof, the front end, getting to the lab… The back end may have a bit of an issue but they won’t appreciate that the way we have, as we have reviewed it.…they’ve not been helpful EMIS, they said to me “OK, you want a change making; you’ve got to put it on the list [for voting]”. – FP (female) Practice 2
It’s an openness really that we need to look into ‘cause how many times actually in these practices has it gone wrong? We don’t know because people don’t actually share this sort of thing… – PM (female) Practice 2
Evaluation phase
Focus groups
Practice 1 (P1) | Practice 2 (P2) | |
---|---|---|
Attendees staff focus group | ||
General Practitioners (GP) | 6 | 1 |
Practice managers (PM) | 0 | 1 |
Practice nurses (PN) | 2 | 0 |
Administrative staff (AS) | 1 | 1 |
Attendees patient focus group | ||
Female patients | 3 | 2 |
Male patients | 4 | 2 |
Yeah, we’ve had quite an increase in phlebotomy [capacity] ‘cause at one stage we were up to two plus weeks wait… now the access to phlebotomy is better, [the nurses] can be freed up to do what they’re meant to do – which isn’t taking blood. – FP1 (male) Practice 1
I’ve had recent tests and I got an appointment the exact day I wanted and the exact time I wanted it. – Patient 1 (male) Practice 1
We now have people we pay to be phlebotomists…two reception staff who step in if we’re overloaded or if someone’s on holiday. – PM (female) Practice 2
Like with Mum, the doctor would say, “Go down and request an appointment for today” and then I would know that I can go to the desk and say, “The doctor’s just told me ... [to have it done to today]” and they will slot you in! – Patient 3 (female) Practice 2
Often it will be next day but I think it depends on how flexible they are…if they say, “I can only come in on Thursday at 3 o’clock”, well... – FP (female) Practice 2
-
Training receptionists to acknowledge the potential of multiple test resultsReceptionists at both practices are now instructed to advise patients there may be further results yet to be returned by the laboratory or processed by practice clinicians. At Practice 1, patients were impressed with their recent experience of receptionists communicating results.Phoned the receptionist. Good as gold: “Sorry, you’ve got one result back which is fine, the rest of your results aren’t back yet. Can you ring again between 3 and 4?” – Patient 1 (male) Practice 1At Practice 2, one of the patients we spoke to still found receptionists had difficulty relaying abnormal results.It’s fine if it’s a negative one, but if it’s abnormal it’s hard for them to give the information over the phone. – Patient 3 (female) Practice 2
-
TeleconsultationsTo help address patient anxiety engendered when receiving news of abnormal results from receptionists, Practice 2 increased the availability of teleconsultations with FPs. The practice manager commented on this growth.We’re definitely seeing an increase in teleconsultations, on average two or three each surgery with each doctor, which I know isn’t a lot, but it’s more than it was and the doctors like it. – PM (female) Practice 2Patients appreciated the increased availability of their FP via telephone.I think it’s a good thing I really do, it’s just a back-up really, just gives you that extra confidence. – Patient 3 (female) Practice 2For FPs at the same practice the benefit of teleconsultations to them was less apparent.The trouble is telephone consultations aren’t quick either, and people say “I thought I’ll talk to you on the phone and then you can save an appointment” and I think we’re not actually saving time. You can be on the phone for seven minutes. Well, the appointments only seven minutes long and they think they’ve done you a favour! – FP (female) Practice 2The practice manager also conceded that teleconsultations could only offer a limited solution due to constraints on resources.Making an appointment a week later for a telephone consultation for your results: we have no problem with that; if everybody did it? You’d sink us, again because we don’t have the capacity for that. – PM (female) Practice 2
-
Standard Messaging ServiceStaff at both practices had begun to use SMS to communicate results to patients.The younger FPs are using it. They’re not using a standardised language. I think it’s an individual thing. So they’re all sort of using it in varying degrees, but all in their own fashion. – PM (female) Practice 2It’s nice to use a text message as well. – FP1 (male) Practice 1However the Practice Manager at Practice 2 was still concerned that the patient might be unaware of multiple tests being undertaken on a single blood sample.Confidence in its use is growing, but until we can iron out what to do in the case of multiple test results then... – PM (female) Practice 2For a patient at Practice 1 the concern was if the result prompted a query from an anxious patient there would be a delay before it could be answered.I always worry with something like this. How is it going to affect the patients who also suffer with anxiety? There’s no immediate feedback path for someone who suffers with anxiety. – Patient 1 (female) Practice 2
-
Written notificationThe letter Practice 2 issues to those with abnormal results, reminds patients of their responsibility to attend appointments. One patient we spoke to at Practice 2 following this advice would book an appointment if a test had been ordered, then either cancel it or, if receiving the letter advising them of an abnormal result, attend the appointment.The office manager will always say, “Make an appointment in a week”, and then I either ring up or you’ll get a letter for an abnormal, but you’ve already got an appointment and if you don’t need the appointment you cancel it. – Patient 3 (female) Practice 2
We talked about it with the entire practice in the big group meeting and yeah, I think it has been positively received by staff. – FP3 (male) Practice 1It’s great for patients and you can also show them the important things, like whether to phone for results and the number of tests ordered…I think what we all wanted to avoid is this problem, which happens not infrequently, where people ring up and are told “everything is normal”, when in fact not everything is back, and this is the real danger, isn’t it? – FP2 (female) Practice 1
It’s an extra click, as simple as that, and it’s not [always] happening for that reason. – FP1 (male) Practice 1
I found actually it takes an extra minute or two to explain at the consultation, to explain to the patient what I’m actually doing, which I hardly…I haven’t got that time, but I was hoping it was going to help some of the communication issues at the other end, and it probably has helped on occasion. – FP2 (female) Practice 1
I think sometimes the more paperwork, the more work it can be for a patient… you’ve got to be a bit careful, haven’t you? – Office Manager (female) Practice 2[Its continued use] depends on how many people ring back for results and don’t have the leaflet because it’s completely pointless [otherwise]. I suspect it will be quite a lot of people ringing back and they won’t actually have it in front of them… But it has the potential. If it doesn’t work then we’ll have made the effort and done all we can to make sure they get the right results. – FP4 (male) Practice 1
There might be a problem with terminology. I mean, I’ve seen it before, my doctor asked me to have a kidney function test, and it’s on there as ‘the renal profile’ which is, I assume, the same thing? – Patient 2 (male) Practice
It wouldn’t just be a bit of paper given to you, it would be [the start of] a dialogue: “I’m doing this ‘cause you need that” – Patient 1 (male) Practice 1
I think it’s really good; it would remind those that had a test and so to follow it up really… ‘cause people walk out of the door and they forget. – Patient 3 (female) Practice 2From my point of view, it’s quite a useful reminder and I would look online to see what the implications of the test are. – Patient 3 (female) Practice 1
At least, when you phone through for your results you can say you know what’s missing. – Patient 2 (male) Practice 1