Case study summary
Tinkers Lane Surgery in Wiltshire was experiencing a large number of unused nursing appointments, due to what it suspected were incorrect appointment booking processes. To tackle what was causing the problem, the practice took part in the Productive General Practice (PGP) Quick Start programme, delivered by NHS England’s Sustainable Improvement team. The programme is part of the support available through the General Practice Forward View. The practice has 8,500 registered patients. At the time of participating in the programme it had three GPs, four practice nurses and two healthcare assistants.
To work through the Common Approach module from PGP Quick Start, and identify whether there was any unhelpful variation in the way reception staff were booking nursing appointments. This would subsequently help the team develop a consistent approach to the process, minimise errors and maximise the number of appointments used.
Identifying the problem
An anonymous survey was undertaken with all nursing and reception staff to understand their perceptions of how many errors were being made when booking appointments, and the length of time patients had to wait for an appointment. The results showed there were fewer mistakes than originally expected; however it became clear that every squeezed-in appointment made a big impact on the nursing team, and they had little confidence in the booking process. As a result, the nurses were booking almost 50% of the appointments themselves.
Working together, the reception team, nurses and healthcare assistants created a driver diagram (a cause and effect diagram), to identify what the real cause of the problem was. They found that while staff booked appointments in slightly different ways the real problem was the template being used on SystmOne, which the team had put in place to make booking simpler!
The template structured appointments in different coloured blocks depending on their type e.g. clinics for vaccination, flu jabs, blocks of time put aside for smears etc. When booking a new appointment reception had to search for the next available slot of that particular type, rather than the next free nursing slot. This was the reason why slots were going unused and in some instances, resulted in some appointments having to be booked a month in advance.
Making the changes
The problem was discussed with the reception and nursing teams, both of whom were supportive of making improvements. The booking template was reviewed and the following changes made.
- The majority of appointment slots were opened up and no longer restricted to specific types unless it was necessary e.g. the practice had to continue taking blood tests in the morning.
- Appointments were to be booked either one after the other or either side of breaks, to allow space for longer appointments such as spirometry that can take up to 45 mins.
At the end of each appointment nurses would give slips to the patient to hand to reception with details of the next appointment that needed to be booked in.
- Previously 63 nursing appointments a month were being unused. Over a year this equates to a wastage of 210.5 hours, or more than 26 full days of nursing time that now have the potential to be released.
- The survey demonstrated the quantity of work that the reception team were handling and this recognised their effort.
- Patients have more flexibility when booking appointments, including evening and early morning appointments that were previously restricted to a specific type.
- The surgery has also implemented a new telephone system as a result of the feedback, which has improved the service to patients and the productivity of the reception team.
- Get everyone involved, actively listen and work through the issues together.
- Undertake the work without a blame culture – this is about continuous improvement, learning from mistakes and making things better for practice staff and patients.
- Access the external support that is available, having someone from outside the practice coming in to help you makes you commit to the work and putting time aside to do it.
Charlotte Gorman, Practice Manager, Tinkers Lane Surgery