The North Tees and Hartlepool Clinical and Support teams Integration project (CSI: North Tees) was initiated following an investigation into an unexpected death. One of the contributing factors to delays in care was that communication between clinical and diagnostic areas was inadequate and led to a delay in the patient receiving the appropriate diagnosis and treatment. The death is an extreme example, but we felt that there were multiple examples of inefficient communication that impact on patient care and experience and potentially lead to delays in diagnosis, treatment and discharge. We formed a ‘steering’ group of representatives from clinical areas, diagnostic services (pathology and radiology) as well as the education department to try and identify specific barriers to communication and develop workable solutions. The focus of the project is to improve all bidirectional communication (verbal, written and electronic) between clinical and diagnostic areas and is intended to be an on-going process.

To ensure that the issues and solutions we identified reflect the reality of everyday working, we sought to engage different staff groups to tell us where the problems are and then empower them to come up with and implement their own solutions. Information-gathering events were conducted in a variety of locations, including clinical and diagnostic areas as well as communal areas such as the canteen and the education centre. From these we obtained 116 responses from a variety of staff groups. These suggestions were divided into common ‘themes’ (‘verbal and team communication’, ‘resources’, ‘appointments and other information’, ‘pathways’, and ‘communication between electronic systems’). By far the largest proportion of suggestions fell in to the ‘verbal and team communication category’ (57%). The key messages gathered from this project so far is that there is a shared concern across the hospital about inadequate communication. In addition, feedback from the laboratory staff and healthcare scientists was the feeling that there is also a lack of mutual understanding of each other’s job roles.

The biggest obstacles facing the CSI: North Tees project include engagement from the different staff groups and achieving and sustaining behavioural change. In terms of engagement, we are encouraged by the multiple professional responses, indicating a widespread desire to improve the quality of communication and thereby patient care. Engagement with surgical and intensive care teams seems to require a different approach as responses were fewer. The steering group is looking at ways to address this. To try and sustain a change in behaviour we are directly asking the staff groups themselves to develop and take ownership of solutions, rather than issuing them from above.

We are currently in the process of facilitating sessions with different staff groups to use quality improvement methodology (‘PICK’ charts) to empower them to identify specific solutions that they are then able to implement through PDSA (Plan-Do-Study-Act) cycles. An example of this came from the session with medical registrars, who selected to try and solve the (common) complaint from radiology and pathology staff about the lack of clinical information on electronic investigation requests. Their solution was using the medical registrar team to ‘model’ appropriate requesting behaviour as well as promoting this at handover meetings, with a focus only on the emergency admissions unit (EAU) initially, during April 2017. The metric they chose to assess the impact was to analyse the mean number of words in a sample of investigation requests from before and after this period, with an increase in word count being a surrogate marker for improved information. The clinical information from 2981 radiology exam requests performed by EAU for the top four radiology modalities (CT, Plain Film, Ultrasound, and MRI) in February and April 2017 was analysed. Although we had buy-in from the medical registrars, the initial analysis so far has not demonstrated a statistically significant improvement (p=0.18). The next step of the PDSA cycle is to identify whether this behaviour can be better promoted or an alternative solution can be found.

We are planning further sessions with different staff groups, as well as new starters, such as Foundation Programme doctors joining in August. We are introducing sessions, including a laboratory tour, onto the shadowing programme to try and engender mutual understanding and appreciation of each other’s job roles.