Context This three-cycle quality improvement project was led at Hull University Teaching Hospitals NHS Trust by two foundation trainees, both co-chairs of the Junior Doctors’ Forum (JDF), with the aim of improving doctors’ working conditions and patient safety.

Issue/Challenge Specialty referrals are core tasks for junior doctors and vital to patient care. Doctors reported frustration at a lack of cohesive referral routes. Concerns of patient safety, delayed referrals, and time-intensive processes were escalated to the JDF.

Assessment of issue and analysis of its causes

Baseline survey of junior doctors (n=45) revealed that juniors were not confident in making referrals, and 51.1% of juniors reported typically taking longer than 10 minutes to identify the correct route of referral. The average time reported to make a complete referral was 30 minutes. Specialty registrars (n=13) were surveyed about receiving referrals. The average proportion of referrals reportedly received through incorrect routes was 29.6%. Overall both groups agreed that a referrals guide would be beneficial. These results were presented to trust management at the JDF.

Impact We created and circulated a Referrals Guide, containing contact details for most specialties in the trust, to aid juniors in making urgent, non-urgent and outpatient referrals. Cycles two and three demonstrated that the Referral Guide saved juniors time and increased confidence in making referrals.

The proportion of juniors spending longer than 10 minutes to identify the correct route of referral decreased from 51.1% at baseline to 35% in cycle three. The proportion of juniors spending longer than 30 minutes per referral decreased from 35.6% to 15%. Mean reported time to make a referral decreased from 30 minutes to 26 minutes. 93.3% of juniors who used the Referral Guide felt that it saved them time, with the mean reported estimated time saved per referral 10.3 minutes. 13 of the 15 juniors who used the guide (86.7%) felt that it increased their confidence that a referral would be received by the intended team. Median reported beneficialness of the referrals guide (where 1 = not at all beneficial, and 5= extremely beneficial) was 5 in cycle three. 14 of 15 (93.3%) responses agreed that the Referral Guide made referrals easier. 13 of 15 juniors (86.7%) and 5 of 6 specialty registrars (83.33%) felt that it increased patient safety.

Intervention This project demonstrates that junior doctors can successfully take on leadership roles and are in a great position to identify issues and create solutions, and are therefore a great group to be involved in leading improvement projects. This project is easily reproducible by doctors other trusts.

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

No patients were directly involved in this project.

Key Messages This is a quick and cost-effective intervention that improved juniors’ perceptions of referral-making. It also demonstrates that junior doctors can have a meaningful impact on hospital pathways to directly improve junior doctors’ experience of key tasks. This is also a great example of how the JDF can be used as a force for improvement. We hope this will inspire junior doctors to continue to use their JDF to escalate issues and ideas, and inspire junior doctors to take on leadership roles within the JDF and lead improvement projects.

Lessons learnt Limitations of this study include low survey response rates and lack of awareness of the Referral Guide. The results are also reliant on self-reported timings and confidence ratings. Further studies looking more objectively at referral timings and patient safety would be useful, although not possible in this project.

Measurement of improvement The improvements were measured across three cycles by surveying junior doctors for self-reported timings and confidence, and surveying Specialty Registrars about the timeliness, quality, and route of referrals received.

Strategy for improvement This project started in January 2021 and the third cycle completed in July 2022. The process followed quality improvement methodology of PDSA cycles involving surveying junior doctors, acting on the feedback, and reassessing responses. In cycle one, the Referral Guide was created and piloted on JDF representatives, in cycle two it was shared with junior doctors via email and WhatsApp, and in cycle three it was uploaded to the trust intranet, with the Department of Medical Education responsible for future updates. The next cycle will trial electronic referrals, with ongoing discussions with the trust’s lead for electronic patient records.