Safety in Practice Results Handling Change Package
Aim: 100% of all lab results will be actioned within 7 days by 9am on 1st June 2016/17
What types of laboratory test results should I focus on?
To start with the Safety in Practice initiative is focusing on the following blood tests only:
•Full Blood Count (FBC)
•eGFR
•Liver Function Tests (LFT)
•Thyroid Function Test (TFT)
How many patients
We recommend that you undertake routine audits of 10 patients every month which is not too much of an onerous activity.
Which patients
On the day of the data collection each month, run the query (available to download from and randomly pick 10 patients who had one or more of the blood tests listed above undertaken at least 3 weeks previously.
Why do this?
Hopefully you’ll quickly see the potential of the Care Bundle approach in helping you to pinpoint areas of strength and potential weakness so you can take steps to improve the system focus in the appropriate areas (e.g. ensuring reliable communication of all test results to patients).
The data you collect are entered into a Spreadsheet, where it is automatically graphed for you as a ‘Run Chart’ allowing to you to see at a glance how compliant your system is with the Bundle measures.
This will give you a much better idea of how safe and reliable your practice systems are for results handling. You can monitor your progress and focus on improving those areas identified by audit as being a potential problem. Your ultimate aim is in maintaining 100% compliance.
How does the Results Handling Care Bundle ‘measure’ system safety?
The Results Handling Care Bundle measurements are questions that are answered on a Yes, No or N/A basis. For example, if you answer Yes to ALL questions for EVERY patient in the data collection cycle then you will have 100% Bundle compliance (10 out of 10).
However, if you were to answer NO to one of the questions for a single patient but answered YES for all other questions for all remaining patients then you will have achieved 90% compliance (9 out of 10).
Therefore, we are interested in what is called an ‘All or Nothing’ approach i.e. whether ALL ordered tests for EVERY patient match to a positive answer for ALL five questions.
To illustrate further, if one patient had an eGFR, FBC and Glucose done, but only the eGFR and Glucose were viewed by a practice clinician within 2 working days of being received, then answer NO for question one of the bundle
Results Handling Audit Questions
The following questions are used for monthly auditing in practices for Results handling –
- Was a definitive decision recorded by a clinician on EACH test result within 7 calendar days of being received?
- Have the decisions for EACH test result been ‘actioned’ by the practice including appropriate recalls and tracking of the actions? (if no actions are required record at N/A)
- Was the patient informed as instructed? (If no instruction record at N/A)
- Overall Compliance
Theory of Improvement
Change ideas tested
•Update practice policy on results handling policy - expectation that all results will be annotated not just signed
•Consideration of how this will fit with patient portal
•Using standardised comments against lab results.
•Doctors to send a txt (or post letter) for all results that are normal or stable
•Result forwarded to nurse to follow-up with patient if result is not normal/stable. Comments section used to advise nurses on action desired.
•Surveyed patients as we saw them on their knowledge of our current process.
•Getting the GP team to understand how their action/ notes on a result can help the nursing team relay the GP plan to the patient in a timely fashion
•Ensure patient ‘preferred contact’ info is loaded into PMS
•Update information on ‘results process’ within HPMC for patient education
•Communication with clients at each visit, how result should be communicated: Dr & nurse & reception asked methods of communication and documented in notes in to-do task
•Made Poster in waiting-room advising clients to check for results if it has not been communicated to them within 7 days of doing tests.
•All staff took responsibility in keeping updated contact details.
•Allocating other doctors to monitor inbox of absent or locum doctors: This system worked well and all results were dealt with in appropriate timely manner
•Lead Clinician audited inboxes/results daily of any locum doctors, especially weekend staff.
•Individual feedback to doctors to not include both interpretation and action required
•Enforce inbox standards sent to doctors- “top 10 inbox messages sent to nurses that waste their time”
•Education of Drs in barriers to dealing with results in a timely manner
Benefits/Positives
•It has been motivating to see the staff buy-in in general on providing a more streamlined results handling process within the practice.
•Further implementation of PMS direct patient communication (via email and text) has ensured that we are able to see a trail of actions taken with each result within the PMS system.
•Medical staff now check inboxes prior to leaving for the day and during the day as appropriate.
•Some doctors are able to access their inbox from home to check their results.
•Alerts and recalls are being set when repeat tests are necessary.
•Patients are being informed of results earlier than before.
•Tangible benefits evident from 1st cycle – was a strong re-enforcement for continuing improvement
•Strong drivers to doctors continuing to consistently annotate and try to improve
•Awareness that what they were doing had a significant impact on both the nurses workload and on the ease of them doing undertaking their work
•Made several big changes in first cycle (annotations and clear shorter timeframes ) – with subsequent cycles mostly re-enforcing and encouraging to apply changes diligently as opposed to several cycles of smaller stepwise improvement
•Significant increase in awareness of the how the comments they make on results impacts both the ease of nurses doing their role, and on the reassurance that patients experience – previously viewed these more as comments they were making for their own recording
•Less interruptions to do with interpreting someone’s results
•Realising that we aren’t that bad, understanding that there are still improvements to be made
•Has got clinic interested in the portal
•Starting a conversation with staff and patients
•Thinking about how to go about larger scale change eg now blood taking
Issues/Negatives
•GPs are finding that it takes longer to annotate results
•Keep developing new keywords for results- perhaps too many.
•Sluggish uptake from some GP’s to utilise standard result notes and participate
•We realise there is much more to be done and probably we are not that great at actually measuring things.
Standardised Comments Fields
Clinic One
"normal"
"stable, repeat:___"
"abnormal:___"
"followed by specialist"
These are standardised across the practice for all GPs to be using. We have only specified them for use on blood tests at this stage, however some have been using them for other results (e.g. MSU/swabs etc) which is fine too.
Clinic Two
The following is a list of our current results annotation options.
The numbered ones at the top of the list are the ‘preferred options’ which are being used by the GP’s.
Clinic Three
Quick keyPress spacebar after letters / Suggested comments for INBOX results
.a / acceptable – no action required
.ar / acceptable – repeat in (insert time frame for recall or message)
.disc / non-urgent - can discuss at next visit 3/12 visit
.ex / ordered and being followed up by external provider
.inr / INR result been actioned
.life / please discuss with patient appropriate lifestyle advice
.me / note - change in medications
.n / normal
.nad / no abnormality detected
.nar / no action required
.ni / no infection
.ot / ?Otahuhu patient - forward on and send back
.sf / sample forwarded to other lab for testing
.si / similar to previous - no current action required
.st / stable – continue to monitor (add in timeframe and by whom)
.stn / stable – no current action required
.tci / patient to make appt to come in and discuss – non urgent (2 weeks)
.tciu / patient to come in to see doctor URGENTLY (identify timeframe required)
.tr / transferred - send back and to new practice
.un / unmatched - send back
Clinic Four
.n = normal
.a = acceptable
.aa= acceptable repeat in ...
.tci= to come in
.sp= test arranged by specialist
.ix= further investigations arranged
Clinic Five
Current comment options are normal, abnormal no action required add comment improved from before or gone worse ,abnormal& add comments ie plan of action