Tools and resources

Quality improvement tools and resources you can use locally to help improve waiting times for elective care.

We have grouped the resources below based on the different stages of the improvement journey as outlined in the QI Zone.

We are continually developing and sharing new resources. We welcome any suggestions you have for new resources and feedback to improve existing resources.  If you have quality improvement tools or resources that have helped you improve access or you want to provide feedback, please get in touch by emailing us at his.accessqi@nhs.scot

Build will and conditions for change

Building will and conditions for change is necessary to consider at the start of your improvement journey and will require continual attention and effort throughout your access improvement project.

• Overview: You can find information on building the will and conditions for change on the QI Zone.  This focuses on Creating the Conditions, Facilitating Improvement Teams and Engaging and empowering the whole organisation.
• Programme driver diagram: The programme driver diagram outlines the key components required within an organisation to use quality improvement to improve access.
• Remobilisation: Toolkit outlining a process and key considerations for NHS boards to safely remobilise elective care for COVID-19.  This working draft was developed for use in NHS Tayside and will be refined and updated over time.  An editable word document is available on request by emailing his.accessqi@nhs.scot
• Big Room: A case study developed with the support of NHS Forth Valley of the Big Room methodology for improvement teams who work across an elective care pathway on improvement projects. A further case study has also been developed with the support of NHS Dumfries and Galloway. 
• SIGN resources: COVID-19 specific evidence to support teams across NHS Scotland as they remobilise their elective care services. These guidelines can help teams build the will to support improvement whilst confident that their services are following the most accurate and clinically informed guidance.
• COVID-19 Outpatients physical distancing: A quality improvement change package containing the key resources and guidance required to run an improvement project to maximise the number of outpatient appointments while physical distancing during COVID-19.  This was created as part of the Access Learning System.

Understanding your system

Waiting times increase when demand is greater than the service's capacity to respond. Understanding local systems to identify the constraints in the system helps identify the right improvements that will address the biggest issues in reducing waiting times.

• Pathway diagnostic guidance: Guidance outlining a process and range of tools for pathway diagnosis.
• System flow overview: Guidance to understanding people’s experience of moving through a series of services, or the movement of work through a series of processes.  This includes introductions on the concepts of demand, capacity, activity and queue (DCAQ).
• Last 10 patients: Mapping the last 10 patients can help understand patient flow within a pathway and identify the longest waits. The last 10 patients tool was used by NHS Lothian, who shared their experience in a case study.
• Scheduling diagnostic tool: A tool to assess how the current approach to managing appointments may cause constraints that increase waiting times. 
• Involving patients: Community Engagement (formally known as Scottish Health Council) provides a range of tools that support services to engage with people and communities. NHS Grampian have shared their learning from using NHS Near Me to engage virtually with patients in this guide.
• Measurement:  The Access QI measurement plan and data collection template are used to review changes in access data over time that can help improve the understanding of the system.
• COVID-19 unknowns:  Key factors related to COVID-19 that have an impact on demand and capacity of elective care services.  This was developed by NHS Tayside to help understand how COVID-19 may impact on elective care activity.

Developing aim and change theory

Teams undertaking improvement projects need to be able to articulate what they want to improve, including what ‘better’ looks like (aim) and how they think they will do that. 

• Access aim statements: Guidance on creating aim statements.
• Access driver diagrams: Guidance on creating driver diagrams that visually present a team's theory of how an improvement goal will be achieved.  A template of a driver diagram for access as a starting point for your local project. 
• Online learning modules: Turas contains an elearning modules focused on developing aims and driver diagrams. NHS Scotland staff will need to use their Turas log-in to access these modules.

Identify specific change ideas, test and refine using PDSA

To get different, improved outcomes we need to identify and develop specific ways to change the system. These ideas should then be tested to find out what works.

• Overview: Guidance on creating change ideas and using Plan-Do-Study-Act cycles to test and refine changes. 
• Measurement plan: The Access QI measurement plan outlines process, outcome and balance measures for projects focused on improving access. 
• Measurement guidance: A general guidance on measurement for QI projects is also available, as well as reflections from a Data Measurement Advisor on measuring access.
• COVID-19 change ideas: The Access learning system has specific examples from across Scotland and beyond of elective care services adapting their system to safely and effectively deliver care during COVID-19. The examples are grouped into:
  • Maximising service capacity and capability,
  • Managing the physical environment,
  • Enabling digital access, and
  • Maintaining staff safety and wellbeing.
• COVID-19 elective surgery change ideas: SIGN rapid evidence review of reducing the risk of postoperative mortality due to COVID-19 in patients undergoing elective surgery that contains evidence-based recommendations that can inform the creation of local change ideas.
• Scottish Access Collaborative-led change ideas: The Scottish Access Collaborative are a national programme that provides resources that NHS boards can use to implement changes to their elective care pathways.  The Endorsed Challenges are potential change ideas for improving elective care.  These include Active Clinical Referral Triage (ACRT), Team Service Planning and Remote Consulting. Created by the Scottish Access Collaborative, the ACRT toolkit helps staff enhance their vetting to triage patients more efficiently. This case study illustrates how the University Hospital Hairmyres Gastroenterology team were able to use ACRT to reduce clinic demand by ~50% and still service the same volume of new patient referrals as before.

Implement and sustain where tested

Implementation uses PDSA cycles to support making the change a routine and integral part of the system before spreading to other parts of the organisation.

• Overview: Guidance on making changes normal practice across the service. 
• Case studies: Examples from across the accelerator sites will be developed and shared by March 2021.

Share learning and spread where relevant

Sharing learning with others can help accelerate change across the system.  Spread normally takes place once a change idea has been successfully tested, implemented and sustained under a variety of conditions.

• COVID-19 learning for elective care: You can share local changes to elective care pathways by completing this template and emailing it to us at his.accessqi@nhs.scot You can access learning from other NHS boards via the learning system.
• Support sharing your learning: If you have undertaken a local quality improvement project to improve access to elective care and would like to share your learning, please contact us at his.accessqi@nhs.scot