Quality Improvement Science can be successfully used to implement an online self referral initiative for an NHS Musculoskeletal Physiotherapy service

Purpose

To use Quality Improvement (QI) science, for the implementation of a patient self referral initiative “go2physio”. The initiative took place over 12 months.

An online patient self referral form and pathway was implemented
at scale within 12 months, which patients valued.
At the end of the 12 month initiative
the Statistical Process Charts demonstrated 53.9% of referrals from the 90 day collaborative 3 GP practices were via “go2physio”, with 24.6% from across all 45 GP practices city wide.

Approach

The Model For Improvement (MFI) methodology was employed addressing the 3 key questions:

 

  1. What are we trying to accomplish?
  2. How will we know that a change is an improvement?
  3. What change can we make that will result in an improvement?

 

The framework utilised small scale tests of change using the Plan, Do, Study, Act (PDSA) format. A 90 day improvement collaborative took place which involved 3 GP surgeries, 5 NHS Musculoskeletal (MSK) Physiotherapists, 1 secondary care administration booking staff member and 2 service users. A measurement strategy was formulated with the main outcome measure: the percentage of referrals to physiotherapy received via “go2physio”. To deploy changes at scale and implement “go2physio” across the city a QI approach called the wedge and spread model was adopted.

Outcomes

  • An online patient self referral form and pathway was implemented at scale within 12 months, which patients valued.
  • At the end of the 12 month initiative the Statistical Process Charts demonstrated 53.9% of referrals from the 90 day collaborative 3 GP practices were via “go2physio”, with 24.6% from across all 45 GP practices city wide.
  • There was no overall increase in total referral numbers. Existing provision was able to accommodate all referrals. There were no observed changes in wait times or non-attendance rates to the service.
  • Analysis of feedback from the 90 day collaborative team had an overwhelming theme (55%). This theme showed the most valuable element to be collaboration and discussions between professions and staff members. Quotes from the collaborative included: “Successful change takes successful measurement” “PDSA cycles are key to measure change” “enjoyed listening to other people's ideas” “importance of data collection” “enjoyed learning from all different areas”.

 

QI science methodology, namely MFI, is a robust technique to drive service redesign, particularly over a short time frame. The 90 day collaborative approach can be a valuable tool that can support clinical leaders. The 90 day collaborative fostered multi-professional learning, promoting communication across primary and secondary care. Iterative multiple small scale PDSA cycles drove fast paced change ideas ensuring confidence was built with the solution prior to wide sale implementation. Learning from both success and failure was accepted within this framework. The introduction of an online patient self referral to a well-established NHS MSK Physiotherapy service can be an efficient addition. More evidence of the use of QI tools, following the guidelines by the Standards for Quality Improvement Reporting Excellence (SQUIRE) is urgently required. QI capabilities need to be prioritised otherwise frameworks like the MFI will remain underutilised and relatively unknown.

Cost and savings

The project cost £66,676.00 to run for the 12 month initiative.

The QIPP process along with the Department of Health (2011) has shown savings of £25,207 per 100,000 of population of people as a result of reducing GP contact, unnecessary prescribing and diagnostic imaging.  However cost savings were beyond the scope of this initiative.

Implications

  • Illustrates and advocates effective utilisation of QI science methodology within the Physiotherapy field.
  • Self referral to a well-established NHS MSK Physiotherapy service does not change the wait time or non-attendance rate.
  • Patients are keen to self refer to a NHS MSK Physiotherapy service via an online form. Digital innovation is crucial for future patient self referral initiatives.

Top three learning points

  1. QI knowledge and tools can unlock successful and sustainable service redesign.
  2. The use of the 90 day rapid cycle of improvement collaborative fostered multi-professional learning, promoting communication across primary and secondary care which has gone beyond this initiative.
  3. Leadership is vital on any improvement initiative and leading an improvement project requires a combination of technical skills, facilitation skills and personal qualities. 

Fund acknowledgements

Salford CCG innovation fund.

Additional notes

This work was presented at Physiotherapy UK 2019 and has been published by NHS Improvement as a case study Jan 2019.

Please see the attached Innovations poster below.

For further information about this work please contact Gabriel Ford.

 

Reference(s):

Middleton K. Give patients direct access to physiotherapy. British Medial Journal. 2016 Jan 5;352:h6844.

Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP. The improvement guide: a practical approach to enhancing organizational performance. John Wiley & Sons; 2009 Jun 3.

Ogrinc G, Mooney SE, Estrada C, Foster T, Goldmann D, Hall LW, Huizinga MM, Liu SK, Mills P, Neily J, Nelson W. The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration. BMJ Quality & Safety. 2008 Oct 1;17(1):i13-32.

The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement. 2003.

Dixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant literature. BMJ Qual Saf. 2012 Apr 28:bmjqs-2011.