Problem
Echocardiography is an important diagnostic technique with high demand. Of the 15 key diagnostic tests monitored in public NHS England data, the echocardiography waiting list is the fourth largest and has the third highest number of 6-week wait breaches, which is the joint highest proportion at 48%.1 The national target set in 2008 is 1%. As of the end of September 2022, North West Anglia NHS Foundation Trust (NWAFT) had a waiting list of over 2800 for echocardiography (most being transthoracic echocardiography (TTE), but also transoesophageal echocardiography (TOE)) with 69% waiting over 6 weeks.
At the NWAFT Cardiac Investigations Department, TOE has been performed by a consultant cardiologist, a role in short supply and with multiple other commitments, so capacity has been limited. Additionally, sometimes TOE had to be abandoned due to failed intubation, and some appointment slots have been taken up with ‘failure demand’2 from inappropriate referrals. The pathway also contained many points of delay (figure 1), causing knock-on effects in other clinics and staffing.
Constrained access has lengthened patient waiting times for TOE, delaying clinical decision-making and so treatment pathways and condition management. For inpatients, it increased their length of stay in beds in our trust’s acute (secondary care) hospitals when patient flow is a particularly severe problem across the NHS.
Most inpatient referrals for TOE are ‘query infective endocarditis’ (IE), a condition that should be treated without delay to improve survival. Supporting this, an internal audit of IE at NWAFT found that long waits between inpatient referral for TOE and the TOE procedure itself (and so diagnosis) can affect patients’ prognoses. A further benefit of improved access to TOE would be some patients bypassing the inpatient TTE diagnostic service, saving departmental resources. TTE is a much higher-volume service, so an inpatient could access this more quickly. Therefore, in practice, clinicians may request a TTE even though they believe a TOE will be probably be necessary subsequently.
NWAFT’s vision is based on ‘excellent quality of care’ and ‘delivering outstanding care and experience’.3 We operationalise this through continuous service improvement and redesign initiatives, in particular, new quality improvement (QI) programmes.3
In this project, our QI approach was the Model for Improvement (MfI). At its core it has three questions: Q1: “What are we trying to accomplish?”; Q2: “How will we know that a change is an improvement?”; and Q3: “What changes can we make that will result in improvement?” to guide system exploration and plan-do-study-act (PDSA) cycles.4 The three questions guide a QI team to set aims, establish metrics and design and select change ideas to then test and refine through PDSA cycles. Revisiting the purpose, metrics and set of change ideas, the team decides whether to continue developing and testing further change ideas or to focus elsewhere. Recently, the MfI has been used successfully in another area of echocardiography,5 another physiological sciences specialism, neurophysiology,6 as well as in hospital life sciences specialisms.7–9
Our primary project aim (Q1 of the MfI) was to improve the performance of our department at NWAFT via improving our TOE provision. Within this overall aim, we had four goals (see also the driver diagram4 in online supplemental figure S3):
Improve access to TOE by reducing the waiting times to within 3 days for inpatients and 14 days for outpatients, within 6–12 months (our main intended outcome);
Improve intubation success rates, so fewer TOE procedures are abandoned;
Relieve the consultant cardiologist of the TOE clinic, so they can shift their time to other high-value tasks such as seeing patients who require clinical decisions, and to make use of the greater availability of clinical scientists;
Improve the quality of TOE reporting to meet British Society of Echocardiography (BSE) TOE guidelines.10
To try to achieve these, we tested a set of change ideas (Q3 of the MfI) arising from the broad concept of developing and refining a clinical-scientist-led TOE service. To our knowledge, there has been no previous performance analysis of a TOE service, or comparison of consultant- versus scientist-led provision, in the NHS. Therefore, if successful, an additional objective was to disseminate our findings. To assess our progress (Q2 of the MfI), we established and analysed a set of metrics. See online supplemental figure S3 for an overview of the logic of our project.