Abstract
Background
General practice (GP) is at the heart of the care provided by the NHS. NHS England has recognised the pressures faced within primary care services and formulated a plan for improvements through the General Practice Forward View (Mathers, 2016). This was heralded as one of the most important events for primary care since the GP Charter of 1996 and outlined goals with a 10-point plan for improvements across GP. Specific goals included improved investment in primary care, more preventive care, promoting self-care and driving efficiency (Mathers, 2016).
Through the ‘Securing Excellence in Primary Care Digital Services’ initiative, Information and Communication Technologies (ICT) have become vital tools within healthcare practice (Gagnon et al., 2009). A common task within primary care is the sourcing of important contact information for referrals, pathways, and patient signposting. This may be identified via telephone numbers, email address, online portals/links and names of important outside organisations and services. ICT permits the introduction of collaborative electronic directories aiming to improve efficiency and performance within the primary care multi-disciplinary team (MDT). Driving efficiency is at the heart of primary care audit projects and is a key focus of the GP Forward View.
It is important not to overlook the impact that small improvements in common, regular tasks can have. Potential benefits from the introduction of an electronic and physical directory include less staff time spent on tasks, less opportunity for errors, improved care for patients, and the possibility of a more positive MDT culture. Patient satisfaction is likely to improve with faster access to the right services. It is important to audit aspects of primary care leading to meaningful change for patients and all members of the MDT.
The current methods of sourcing contact information were audited within a local practice. Using the data from this audit the authors then designed, developed and implemented a collaborative electronic directory. This directory was designed to be readily and easily accessible within the primary care ICT services by the whole GP MDT. The practice use of this new directory was then re-audited to assess change.
Standard
A literature review was conducted to identify an evidence base for best practice in this area. Guidelines and/or protocols do not exist for the development and evaluation of directory tools in primary care. Thus, the audit standards set were agreed within the local practice. To ensure the standards represented the strongest evidence of best practice they were developed using stakeholder consultation through focus groups in the local practice. The focus was on acceptability and efficiency (as outlined in the GP forward view). The standard set was a 100% improvement in the scores obtained from the questionnaires following introduction of the electronic directory.
Design
This audit took place over 3 months within one GP. An online questionnaire was developed to gain quantitative and qualitative data. Consideration was then given to the need for an intervention. This questionnaire was repeated after a significant period following the implementation of the intervention, to measure change following the intervention. A particular focus was on acceptability and efficiency. The questionnaire was delivered to all members of the MDT and aimed to reach all relevant stakeholders using a collaborative approach to the design and implementation of the directory tool.
Data was gathered using a five-point Likert scale. The average score based on each question within the questionnaire was collected. The change in score pre and post intervention was then recorded. Statistical significance was analysed using a two-tailed t-test and was carried out using IBM SPSS Statistics software.
The pre-intervention questionnaire also collected qualitative data, analysed through thematic analysis (Maguire & Delahunt, 2017). This aided the design of the directory tool, allowing the directory to incorporate relevant knowledge and experience of important staff members in the design. The identified themes were then analysed and interpreted, making sense of the data and applying this to the design and improvement of the directory tool.
Audit results
The pre-tool questionnaire yielded important data on the current working practices. Table 1 shows questions included within the questionnaire and the Likert scale scores for the pre-tool questionnaire. This showed that the MDT felt that current working practice was not efficient with large amounts of time spent sourcing information independently or by asking other MDT members. The MDT felt strongly that a tool was needed to improve efficiency.
Audit results demonstrating average Likert score
(1 = Strongly disagree, 2 = Disagree, 3 = Neither agree nor disagree, 4 = Agree, 5 = Strongly agree).
The pre-intervention questionnaire also gathered qualitative data on the design of the directory tool. Important themes gathered from the qualitative data and incorporated in the design included:
A directory with different forms of contact information, i.e. telephone numbers, email addresses, departmental addresses The ability to regularly review and update the directory Structure and organisation of the directory using a classification rather than a simple alphabetical list A broad range of services and organisations
Intervention
The best interventions should be assessed using evidence and standards set by feedback from the relevant stakeholders. The initial audit demonstrated a need for the MDT to co-produce an appropriate and effective directory tool for use in the practice. The credibility of the information within the directory had to incorporate stakeholder experience and knowledge (practice doctors, nursing staff, managerial staff, and administrative staff), trustworthiness and message attributes (Wathen & Burkell, 2002). The design of the intervention incorporated the quantitative data (scores from initial audit) and qualitative data on the acceptability, design, delivery and feasibility of the proposed directory.
A directory tool was developed based on the initial audit results. An important consideration was the effective delivery of the directory tool within GP ICT services. The aim was to incorporate a directory tool that was readily accessible, aesthetically pleasing and easy to navigate. It also needed to be updated easily. The tool was developed as an electronic co-editable word document and placed on the GP ICT shared drives. A hard copy poster version was placed in a convenient, accessible location within each administrative and medical professional office space. Co-editing allowed the document to be regularly updated by all relevant users, consistent with information gathered from the initial qualitative phase of the audit. A leader was appointed to oversee regular updates of the tool.
Re-audit results
An audit was repeated 3 months after introduction of the directory tool. The results are displayed in Table 2. The change in average Likert score for each question was not statistically significant (p-value less than 0.05).
Results of the differences in score between the pre and post tool questionnaire.
(1 = Strongly disagree, 2 = Disagree, 3 = Neither agree nor disagree, 4 = Agree, 5 = Strongly agree).
Qualitative data was gathered to feedback on the advantages and disadvantages of the tool, improvements that could be made, and information on the accessibility and feasibility of the tool. The thematic analysis suggested that the electronic directory:
Helped reduce time spent on sourcing contact information Was an excellent resource for new trainee staff and locum staff Could be further improved with greater input in the design by administrative staff
Discussion
Referrals, secondary care contact, and patient signposting are some of the most commonly performed tasks in GP. These tasks can be time-consuming, tedious, and frustrating. Medical and administrative professionals are often left to seek and/or create personal directories. This approach risks omission of services and providers in the directory by not including relevant stakeholders and wider members of the MDT. Inclusion of MDT members and relevant stakeholders is likely to achieve better acceptability, feasibility, and utility of the tool. Introduction of a usable, effective directory tool without relevant consultation and audit is less likely to be successful.
This audit incorporated a careful, evidence-based approach to the introduction of an electronic directory in a practice. The results show that users felt the directory resulted in stakeholders having to contact colleagues less for important phone numbers, improved accessibility to relevant contact information and reduced time spent sourcing telephone numbers. The results did not reach statistical significance due to the small numbers of participants and poor adherence to the post-tool questionnaire.
The directory received excellent qualitative feedback suggesting improvement in acceptability, feasibility, and efficiency within the practice. Integral to the design of the directory was the co-production element involving MDT members and appropriate ICT services.
