You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

quality improvement

How do you improve services for Children

24 Feb, 13 | by Ian Wacogne

A paediatric tweeter, @kunbab (named with permission) working at intern/SHO level remarked on their frustration with the process of improving things in a workplace.

They’d done something very simple; their patient had needed a referral, and so they’d emailed this referral to the relevant consultant.  However, when their boss heard about this, the boss insisted on a paper based referral also.  The howl of frustration of @DrRanj was genuine.  Why, he asked, (and I paraphrase) do I need to revert to using such an archaic mechanism of communication when email is so much better?

I could see at least two of the sides here.

On the one hand, I got my first email account in 1995, which, while not at the birth of the internet, was pretty soon after the toddling period.  It’s hard to remember what a delight it was to get email in those days, and how terribly modern it felt.  Now, 18 years later, it has become all things; a way of getting spam, a way for people to efficiently and rapidly transfer the responsibility for their problems and anxieties to you, a helpful way to share information in an asynchronous way.  I couldn’t be without email, but I’m not quite sure how to live with it either…

Emailing referrals, then, makes perfect sense.  It is at least as reliable as any paper based system, faster, more direct, allows easier clarification.  Nearly every other form of communication has moved over to the electronic side – I hardly ever get a “memo” any more – so why not referrals?

The other side?  Well, this is where I’m part of the problem.  To describe this I need to tell you about how I handle patient test results.  I warn you, this will appear seriously irrational – but I would be surprised if you all have totally rational systems.

  • Results on inpatients:  I review these entirely via the electronic results system, which is rapid, reliable, and complete – meaning definitive.
  • Results on inpatients after they’ve been discharged from hospital:  I send myself an email to remember to chase the result which is usually done on our electronic results system.
  • Results on outpatients:  I wait (passively) for the paper version of the result to come across my desk, at which point I act on it – it is the trigger for me to re-remember the patient journey.  In a sort of time and motion (Getting Things Done)  sense, I’ve previously moved things as far forwards as I can, and I then forget about the task until the next decision point arrives.

Writing it down like this highlights for me how not clever it it all is.  But.  It works.  It appears to be safe.  There are latent errors in the system, of course – I can’t see the paper results I don’t get back – I don’t get triggered to review results that I haven’t had on outpatients.  But it mostly works with minimal errors for me.

Writing it down makes me think that I’ll try to redesign the process for me.  But what I can’t do is redesign the process for everyone immediately – because they’ll all have similar but subtly different systems which will need modification to continue to be safe; if I pressed a big button stopping results from being printed at all, I’d break hundreds of other people’s processes.

And that’s why we can’t just start emailing the referral letters.  Yes, it is old fashioned, and daft, and based on technology at least as weak as the newer technology, but people have ways of working with it.

So, how do we get to the point where younger doctors can be involved in change projects – where they can understand how to improve things for patients?

With the help of Bob Klaber, we’ve been developing a series for ADC E&P on Quality Improvement, which is just this, and more.  We have, coming through, a series of excellent papers with good, real world examples of how people got things done, and we’d like, subsequently, to develop a section for people to publish short (3 – 500 word) articles about improvement projects that they’ve been involved with.

Questions then:

  • – does this interest you?
  • – do you have projects that you’d like to contribute?

Edit:  Right, so I got the original tweeter wrong, which I’ve updated in the tweet; thanks for  @DrRanj for pointing out that it wasn’t him, and apologies for taking him down an experience grade or two…

Also:  to clarify, I’m not saying that my way of doing stuff is the right way.  It is just that there are some reasons for doing it this way which I will have to re-work if I do it a different way.  So, time spent understanding why people do things the way they do them is never wasted…

ADC blog homeapage

ADC Online

Education, debate, and meandering thoughts on child health, using evidence and research.Visit site



Creative Comms logo

Latest from Archives of Disease in Childhood

Latest from Archives of Disease in Childhood