Davinder Kaur, Clarissa Sørlie and Will Diaz explain how Quality Improvement methodology is helping to reducing waiting lists for community therapies.
Community therapy teams across Bedfordshire, Newham and Tower Hamlets have used Quality Improvement (QI) methodology to reduce waiting lists.
These community therapy teams provide comprehensive occupational therapy and physiotherapy assessment, treatment and care within a person’s home to improve their ability to do everyday tasks.
While people wait for therapies input, they may be at risk of falls, further functional deterioration, unnecessary dependence on social care, social isolation, reduced motivation and delay in follow-up rehabilitation.
Community health services in these three areas had all built up backlogs in their waiting lists for a combination of reasons. When therapy services were suspended for all but urgent cases during the COVID-19 pandemic, this led to reduced clinical capacity.
Teams were also affected by staff sickness absence, vacancies and an increase in referral numbers and complexity after the pandemic.
Waiting times varied across boroughs, with patients in Bedfordshire waiting up to 34 weeks, while those in Tower Hamlets waited an average of 18 weeks. In Newham, the average wait time was only five weeks, but an average of 31 people a month waited longer than the six-week target.
In Newham and Tower Hamlets, where therapies provision was divided into localities, patients experienced inequity in waiting times based on postcode, which was further exacerbated by a lack of cross-cover during times of staff absence.
Recognising how complex and multi-faceted the problem was, the teams used a tool called a driver diagram to visually represent what they could do to address waiting times (Bennett and Provost 2015).
They generated numerous change ideas and systematically tested them using Plan Do Study Act (PDSA) cycles (Langley et al 2009). PDSA cycles involve testing out changes before implementing them, to learn if the change is effective while minimising the risk of unwanted effects on the system.
Change ideas
Teams across the three boroughs got together to identify the change ideas that had the biggest impact on their waiting lists. They grouped these change ideas into the following categories:
Improving the referral process: recognising that valuable time was spent on rejecting inappropriate referrals, the teams tested a range of ideas including updating the questions on referral forms, updating referral criteria on the trust website and updating leaflets for patients and referrers.
Triage and screening: the teams evaluated their triage process and made changes locally. In Newham and Tower Hamlets, triage had traditionally been completed by nurses, with therapists only becoming involved if there were any queries.
Both teams now involve therapists in triaging all therapy referrals. In addition to this, Tower Hamlets has introduced a daily integrated triage meeting with social care/reablement and admission avoidance colleagues to reduce duplication and ensure that patients are on the correct pathway.
Administrative support: the teams leveraged administrative resource to free up therapist capacity for clinical work. This included contacting patients and booking visits. In Bedfordshire, administrative staff members received Millbrook training to support urgent equipment ordering on behalf of clinicians.
Increasing capacity: the Newham and Tower Hamlets teams trained their therapy assistant practitioners as trusted assessors and recruited occupational therapy apprentices able to conduct basic occupational therapy assessments.
Using existing resources in this way has freed up occupational therapists to focus on more complex assessments.
Integrating teams: to reduce inequity in waiting times between localities, both Newham and Tower Hamlets integrated their teams to create one waiting list per borough. This had the added benefit of improving cover for annual leave/ sickness absence, reducing isolated working, and standardising processes, thereby reducing variation in care.
Outcomes
Through their efforts, the Bedfordshire team was able to see almost all patients on time, reducing its 18-week breaches from 4.11% to 0.5% per month – an 88% decrease (Gillett et al 2024).
The Newham team has successfully reduced the number of people waiting longer than six weeks from 31 to three per month – a 90% decrease – and continues to test change ideas so that all patients are seen on time.
Zahra Famurewa, Lead Community Therapy Therapist in Newham says: ‘We are proud that Newham residents are now prioritised by need rather than by postcode, and all referrals are screened on time.’
The team in Tower Hamlets reduced the number of people waiting longer than six weeks by 89%, from an average of 111 to 12 people per month. The team has noticed an improvement in staff satisfaction, as well as improved recruitment and retention.
Staff have fed back that they feel there is better clinical oversight, that senior occupational therapists and physiotherapists now have more clinical time, and that communication with the admin team has improved.
Key learning
Using a Quality Improvement approach supported teams to review their processes and identify areas for improvement.
Eleanor Gillett, Therapies Clinical Service Manager in Bedfordshire, reflects: ‘Involving the team in the quality improvement process empowered staff to identify and solve problems, fostering a sense of ownership and collaboration.
‘The successful implementations were highly motivating, as staff could see their contributions leading to tangible improvements.’
Introducing successful changes required constant ‘tweaking’ of ideas as they were tested in different environments. With variation in how each locality worked, teams responded differently to proposed changes.
Project leads played a vital role in supporting this change by keeping staff informed and working with them to understand the need for changes.
Regularly reviewing their waiting list data to learn where to prioritise their efforts and determine the impact of their change ideas.
Above: Tower Hamlets Community Therapy Team
Tower Hamlets Therapies Pathway Manager Davinder Kaur explains: ‘Before the project, we were receiving data from our performance team, but we weren’t consciously utilising it. Now we review our data about longest waiters and breaches weekly and prioritise those patients when booking appointments.
‘This gives us the bigger picture of where things are not going so well, so we can make improvements. That has really helped me to manage our service better.’
Bennett B and Provost L (2015) ‘What’s Your Theory?’, Quality Progress. Available at https://tinyurl.com/yzhdyw64 [accessed 25 November 2024].
Gillett E, Hughes L and Collins M (2024) ‘Reduction in 18+ weeks breaches for community occupational therapy and community physiotherapy in Bedfordshire Community Health Services’. Available at https://tinyurl.com/2p8d4w5d [accessed 25 November 2024].
Langley GJ, Moen RD, Nolan KM, Noland TW, Norman CL and Provost LP (2009) The Improvement Guide (2nd ed). San Francisco: Jossey-Bass
Words DAVINDER KAUR, OT and Therapy Pathways Manager, Community Therapy Team, Tower Hamlets, East London Foundation Trust, and QI coach; CLARISSA SØRLIE, OT and Improvement Adviser, East London Foundation Trust; and WILL DIAZ, Nurse and Improvement Adviser, East London Foundation Trust. With thanks to Christopher Harvey, Eleanor Gillett, Louise Hughes, Megan Colins, Nizamul Hoque, Prabhakar Subramani and Zahra Famurewa for their contributions