Context This quality improvement project took place at a large multi-site NHS UK trust. A multidisciplinary team was convened to measure existing practice and design and implement a change to improve efficiency and user satisfaction.

Excellent communication between clinical and laboratory teams is important for patient care. At this NHS Trust, most investigation requests are made using the electronic patient record. It is sometimes necessary to ‘add-on’ additional requests after the sample has arrived in the laboratory.

Issue/Challenge Add-on requests involved the clinician telephoning the laboratory via one telephone line; the biochemistry team member was simultaneously responsible for processing laboratory samples. The existing system was perceived to be inefficient for both clinical and laboratory teams.

This project aimed to improve the efficiency of requesting add-on biochemistry tests.

Assessment of issue and analysis of its causes

Baseline analysis demonstrated high call volume to the biochemistry laboratory, of which a significant proportion were unanswered, and low user satisfaction by both clinical and laboratory staff.

There were mean (SD) 7319 (666) call logs/month to the biochemistry laboratory March-July 2021. Of these mean (SD) 56.5 (2.76)% calls/month were unanswered or made to a line already in use.

Questionnaires responses from junior doctors and biochemistry laboratory staff indicated dis-satisfaction with the established system due to inefficiency.

These findings were discussed locally by the QIP working group and presented at divisional management level in the NHS trust.

Impact Positive impacts:

• Reduced workload for both clinical and laboratory staff

• Potential reduction in blood tests for patients due to increased ease of adding on requests

Challenges and opportunities:

• Design of the electronic patient record change with a focus on clarity and user-friendliness

• Interface with the biochemistry IT systems and usability in the lab; training of lab staff and addressing technical or process errors

• Culture change to adapt to new process, achieved through frequent multisite meetings with stakeholders

Intervention A working group was convened comprising representatives from Pathology, Information Technology, Biochemistry and Clinical teams. A new orderable on the electronic patient record was devised, wherein an add-on request is made via the patient electronic record. The change was approved by relevant local committees.

Involvement of stakeholders, such as patients, carers or family members:

Patients and carers were not involved in this project, but the MDT comprised representatives from various backgrounds and at each site within the NHS Trust.

Key Messages A new electronic system to add-on biochemistry test requests was successfully implemented as measured by process and outcome measures across three hospital sites of a large NHS Trust. We describe high uptake of the change with improved efficiency demonstrated by reduced call volume to the laboratory and excellent user satisfaction.

Lessons learnt

• Importance of early stakeholder engagement

• Value of MDT collaboration

• Challenge and reward of project lasting many months

Measurement of improvement There was a progressive uptake of the Cerner add-on orderable by clinicians, with a cumulative number of requests and participating wards. At the time of reporting, 800 requests are being made electronically each month. Incoming calls decreased by 30.5% from 6175 (July 2021) to 4291 (July 2022); unsuccessful (line engaged or not answered) incoming calls reduced by 48.9% from 3265 (July 2021) to 1678 (July 2022). Initial user satisfaction from junior doctors is high, with 74% describing the process of requesting add-ons more efficient and giving positive feedback about communicating electronically rather than verbally and being able to track to progress of each add-on.

Strategy for improvement Patient safety prioritised throughout with balancing measures such as gradual roll out to maintain smooth running of essential systems:

• Laboratory teams received training sessions and ongoing support from IT representatives of the working group.

• Roll-out communicated to clinicians using word of mouth followed by formal Trust communication channels to achieve exponential awareness so that laboratory teams could adjust to the new system.

• Availability of the electronic orderable extended from office hours to 24/7.

There was laboratory team representation from each hospital site to respond to local issues arising from variability in standard laboratory operating procedures

The working group met weekly over an 11-month period to evaluate progress from MDT perspectives and continually improve the intervention consistent with rapid cycle methodology.