Context This Project was carried out in an outpatient department. The change affected the care of patients in outpatients.
Problem The paper method of recording patient outcomes resulted in missing outcomes. The form had potential for error, mistakenly taken by patients, completed incorrectly or illegibly. This causes in delays patient care. There was no simple way to find the outcome. A lot of time and resources were used, consultants were emailed about patients seen months ago, notes requested to find out what the next step should be.
Assessment of problem and analysis of its causes A weekly data report was produced to track the number of missing outcomes. This was done by searching PIMs (the live database by which inpatient and outpatient activity is recorded), identifying patients who were not assigned an outcome such as 20-discharge to GP, 03- Watchful waiting.
The outpatient management team were involved in meetings and service managers were engaged to try to identify solutions.
Weekly emails were sent to service managers. Results of analysis were presented at a meeting to consultants and managers.
Intervention An electronic version of the outcome form was created. This created a permanent, clear record of activity, enabling the next steps of patient care to be identified and carried out.
The electronic outcome form on EPR (electronic patient record) replaced the paper form. The form was not changed, the same information was recorded (Figure 1). A new search was created to cross reference electronic forms for patients who have not been updated on PIMS and distributed to the reception to complete.
Study design A prospective study looking as missing outcomes as the roll out was in progress.
Strategy for change A phased roll out schedule was devised. Specialities launched weekly over 3 months. Prior to this we presented at forum. We asked service managers to email their teams instructions to complete the form. We gave demonstrations. We ensured the reception staff knew how to access the form and input the data into PIMs and in some areas we ordered equipment (e.g double screen). We attended clinics ensuring clinicians knew how to use the form. This took up about 5 min of clinic time. We were available to staff for queries with the form. After 5 weeks, we did a trust wide change. Posters were put in clinical and office areas. Flow sheets were made for staff to follow.
Opportunities were given for feedback. Comments have been used to create an updated form.
Measurement of improvement The measure of change is that previously there was no simple way to see what decision was made in clinic, now it can be accessed on EPR immediately after being entered. There is no longer an uncertainty whether an outcome has been decided. If it isn’t there then it has not been done.
Effects of changes This change has created a more robust way to record an outcome. There is a permanent record and an audit trail. Patients can benefit from this as there are fewer delays in their pathway.
Lessons learnt We learnt that a structured approach is needed to implement such a change. The importance of a team meeting weekly to discuss the next steps was vital.
Message for others The main message is that a permanent record of the patient consultation is important to improve care as it helps all health professionals easily access this decision and minimises delays. This change makes patient outcomes accountable and protects the patient and the clinician.