Paul Calder | Service improvement
The right place at th
Service improvement in radiography: A new idea for the allocation of
outpatients’ appointments in a radiology department.
Sorry to see this was
only a proposal. What a
dynamic individual who
thinks outside the box and
a radio 4 listener to boot!
Karen Smith
SCoR Vice President &
second round judge
4 October 2013
Introduction
As part of the third year
BSc Diagnostic Radiography
programme at Teesside
University I particularly enjoyed
the challenges involved in
identifying a hypothetical service
improvement idea. This academic
work was presented by myself
in the form of an electronic
poster and was accompanied by a
presentation and an oral defence
to the module tutors. All of the
student ideas, including this
one, will be shared with clinical
colleagues at a later date which
may encourage departments
to take on board some of the
service improvement ideas. This
reflective piece discusses my
personal journey in undertaking
this assignment, exploring
some of the underpinning
tools and techniques of service
improvement.
Service improvement is of
particular importance as it is
outlined in many key drivers. The
Government’s long term vision
for the future of the NHS was
laid out in Equity and Excellence:
Liberating the NHS (2010).
Significant focus within this white
paper ensures that patients are
placed at the heart of every action
we take and that we continually
improve the things that matter
to our patients. Furthermore,
practitioners are entrusted and
liberated to innovate and improve
in healthcare delivery1. The recent
report carried out by Robert
Francis QC, which highlighted a
decline in professionalism and a
tolerance of poor standards in the
NHS2, has made recommendations
which can be used to improve
service delivery. Each employee
in the NHS is required to reflect
on what can be done differently
in order to contribute to a safer,
committed, compassionate and
caring service3 and thus position
the patient ‘first in all that we do’2.
Also, managers in all areas of
the NHS have increasing pressures
he right time
on their activities to make cost

This article was well organised and

savings and to run their services
within tighter financial controls
whilst, at the same time, being
encouraged to improve services
to patients. Although I identified
written in a clear and unambiguous
and considered possible areas for
service improvement through way. I enjoyed reading the paper
clinical practice, in collaboration
with my teaching hospital site and liked the introduction, and the
coordinator, I was determined
to develop an enhanced service
user experience based on research
currency of the political climate which
evidence.
My long commute into made reading very relevant to today’s
university for academic lectures
allowed me to listen to The Today NHS.
Programme on BBC Radio 4, and
I was particularly interested to Professor Pat Williams
hear an interview between John College Board Trustee &
Humphries, one of the show’s
presenters, and David A Ellis
second round judge
from the School of Psychology
at the University of Glasgow,
who had just published some
work entitled Weekday Affects on to mention in the piece that Creating a strategy programme, to become an
Attendance Rate for Medical previous studies had identified It was this discussion and my evidence based practitioner, I felt
Appointments: Large-Scale Data a number of factors that affect consequential retrieval of this confidently armed to critically
Analysis and Implications4. The DNA rate including patient age, research paper that formed review and appraise the described
discussion began with the author gender and transport options, the foundation of my service study and use it as ammunition
outlining some background but that it was not obvious improvement idea: A strategy with which to defend my service
information that the financial how healthcare providers could to improve the attendance of improvement proposal.
cost of missed appointments is so use this information in order booked appointments within my Introducing proposals for
great that even a small percentage to improve attendance as such radiology department. Having improvement inevitably involves
reduction in the did not attend factors are not under their control. identified the importance and asking people to change and can
(DNA) rate could save significant Ellis proceeded to state that the developed the skills and knowledge cause barriers and resistance5.
sums of money. David Ellis went DNA rate for the UK hospitals is through my academic development In order to minimise these risks
approximately 12% and that these
missed appointments cost the NHS

This is what real learning

an estimated £600m per year.
The Glasgow Study had looked at
appointment scheduling and, in
looking at attendance records for
over 4.5 million patients across
is all about! I was also
Scotland, they found that DNA rate
was highest for Mondays (11%) impressed by the last
and lowest for Fridays (9.7%)
and decreased monotonically over sentence ‘the prime focus
the week. This weekly decline
was present in male and female
patient groups, but was steeper for
in health care..:the patient’.
younger age groups. The authors
believe that the pattern of results Generally an excellent
was due to elicit emotionally
positive associations with the end
of the working week and elicit
article.
emotionally negative associations Professor Pat Williams
with the beginning of the
working week.
College Board Trustee &
second round judge
October 2013 5
and win over those who could
potentially oppose, I thought it
would be advantageous to trial
the theory of this strategy on a
small scale by selecting a modality
within the spectrum of radiology
that suffered the highest DNA
rate. In order to achieve this I
took the initiative of arranging
a meeting with the radiology
and data manager at the Trust
where I carry out my placements.
Communicating at this level with
my proposal was unfamiliar and
daunting, however I was able to
identify that the area where there
was the highest level of DNA was
ultrasound and I was able to gain
a clearer understanding of some
of the issues around my idea and
problem solve. The manager was
enthusiastic about my service
improvement concept and I would
now feel much more confident on
future occasions, in negotiating
and securing resources with
senior staff.
Plan of action
Armed with valid and reliable
research and having identified
that the area to trial my service
improvement idea should be
ultrasound, I was able to outline
a plan of action within my poster
which was simple and low in
cost: To modify the current
appointment allocation with the
preferential loading of younger
patients onto high attendance
days, ie later in the week and
bringing older patients in at the
beginning of the working week.
After six months of piloting, the
results would be assessed and the
primary objective of reducing
DNA rates in the ultrasound
department would hopefully
reduce. It could be argued that
other advantages to this strategy
would be a reduction in the
published associated health risks
with patients not attending for
booked appointments6 and also
an improvement in the patient
experience and better patient
centred care.
As part of this assignment it
was a requirement to identify,
examine and critically appraise
different theories, tools and
techniques which would be
used to carry forward a service
improvement project. As well as
being thoroughly prepared in
this field by a series of academic
lectures, we were privileged
to receive a presentation by a
National Improvement Lead
from NHS Improvement,
covering policy and guidance
6 October 2013
and highlighting the challenges
we face in our role in improving
services. ‘Hot topics’ including I really like this article;
NHS outcomes framework, patient
reported outcome measures, the it looks at taking a
quality, innovation, productivity
and prevention challenge (QIPP)
and lean thinking were explored.
relatively simple idea and
evidence-based practice to
The NHS Institute for Innovation
and Improvement also provides
a diverse collection of proven
quality and service improvement
resources, which were easily
implement a small change
accessed and some of which
were applicable and used within and it is the small changes
my project. This organisation for
supporting the transformation of that tend to have the
the NHS has subsequently been
replaced (1 April 2013), along
with other NHS improvement
biggest and most positive
organisations by ‘NHS Improving
Quality’ hosted by the NHS impacts.
Commissioning Board7.
Leadership and carrying
forward change are closely
Editorial Board
related in the field of service
improvement8 and the NHS
Member
Leadership Framework, launched
by Health Secretary Andrew
Lansley in 2011, featured centrally
in both my poster and my oral
defence. This shared single model
was created specifically for the
heath and care environment,
representing clear best practice
standards for leadership
development9. What is crucial in
this model is that leadership is
not just the reserve of traditional
roles such as senior staff and
management, but staff at every
level of their professional career,
including student radiographers
during their formal training.
Although adopting leadership
as a student, in order to recognise
and solve problems, should be
embraced, it is important to be
aware of possible limitations
in influence amongst the
established radiology workforce.
I chose to discuss Covey’s circle
of influence/circle of concern
theory10 within my presentation,
stating ways I could widen the
relatively small circle of influence
I possessed. These included
creating a clear vision and
employing good communication
and listening skills and creating
enthusiasm amongst colleagues,
in order to attract them to the
idea. Furthermore, identifying
and analysing key stakeholders
involved with the project using
the influence/interest grid11,
was a method used to identify
staff that could be affected either
positively or negatively by the
service improvement strategy. This
technique would potentially assist
in ensuring that each stakeholder
received the correct level of
resources, information and
communication at the right time,
throughout the project.
Conclusion
Overall, this academic obligation
has proved to be a positive
learning experience which has
initiated me to identify, analyse
and evaluate current practice
and research for potential
service improvement. As well as
developing personally, gaining
key transferable skills in written
presentation, communication
and development planning, I
believe that I am now also able
to effectively discuss and present
an argument in a professional
manner.
October 2013
Although this assignment
was only to propose a service
improvement idea, it has given
me the confidence, knowledge
and understanding of the theory
and underpinning tools and
techniques significant to service
improvement. I have developed
an enthusiastic approach to
improving quality and I feel more
capable and determined to initiate
change within my area of practice
as a newly qualified radiographer.
I believe that this academic
exercise has demonstrated that by
embracing service improvement
opportunities in radiology, a ‘win
win’10 situation can be achieved,
not just for staff, managers and
the NHS, but most importantly
the prime focus in our health care
delivery; the patient.
About the author
At the time of writing this
article Paul Calder was a
third year student on the
BSc (Hons) diagnostic
radiography programme at
Teesside University. He has
since qualified gaining a
first class honours degree
and is now working as a
radiographer at the Freeman
Hospital in Newcastle upon
Tyne.
References for this article can be found at
http://www.sor.org//learning/library-publications/itp
This article has been prepared following local guidance
relating to the use of patient data and medical images.
To comment on this article, please write to editorial@
itpmagazine.co.uk
This article is designed to provide students and qualified
practitioners with a broader understanding of some of the
underpinning tools, techniques and considerations needed
to undertake service improvement. Service improvement and
innovation are part of the NHS core value ‘Improving Lives’ as
outlined in section two of the NHS Constitution (DH 2013).
You may wish to reflect on all the values in the Constitution,
thinking about how you will incorporate them into your daily
practice.
Do you have a working system that may be of interest to
others? Have you set up a reporting scheme that other
departments could adopt? Send your idea to editorial@
itpmagazine.co.uk or for information on submitting an article,
download the Guide to Authors from http://www.sor.org//
learning/library-publications/itp
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