Improving the handling of repeat prescribing
Using CQI methodology to improve repeat prescribing in a general practice in Bournemouth
- Why was the initiative launched?
- What was done?
- Is it working?
- Tips for success
- For more information about the initiative at Talbot Medical Centre contact
- For more information about the application of CQI methodology contact
Why was the initiative launched?
Questions about repeat prescribing arose at Talbot Medical Centre when the practice was exploring ways to improve how it ran. A survey of receptionists had shown that handling repeat prescribing was their most stressful and frustrating activity. They felt that their work was becoming increasingly unmanageable. They seemed to spend large parts of their time waiting in corridors to ask GPs to sign prescriptions. Although it was felt that a good service was being provided to patients, this was at a high cost to themselves.
The practice was already talking about adopting continuous quality improvement (CQI) methodology as a means of improving systems within the practice. A review of the handling of repeat prescribing would provide a valuable way of checking its usefulness.
What was done?
A small team undertook the detailed work, led by a GP partner and including the practice manager, three receptionists and a facilitator from Bournemouth University. In picking the team, care was taken to ensure that all levels of the process were represented by those involved. The facilitator brought experience of CQI methodology, for example the Plan-Do-Study-Act (PDSA) cycle. The team met four times over three months, usually at lunchtime.
The first question in the PDSA cycle is ' What are we trying to achieve?' The team agreed this should be ' To improve the repeat prescribing system so that all patients' repeat prescriptions are processed within 48 hours and are ready for collection at the specified time' . Initial discussion helped them be clear about what they needed to know. They used various methods to help them build up a complete picture of what was happening currently, including a short audit to assess how many repeat prescriptions were ready within 48 hours.
The team used brainstorming techniques in their meetings so that all the members could contribute their ideas. Two early products of the team's work were flow-charts which:
- Identified the main steps in the process and listed the individual tasks which were required to make the process work.
- Illustrated how a prescription request travelled through the system and the links between the individual steps.
These charts enabled the team to think through their task and focus on activities that offered scope for improvement, such as where it was unclear what happened, or where delays occurred.
The second question in the PDSA cycle is 'How will we know that a change is an improvement?' The team chose four areas, to
- Increase the percentage of prescriptions available for collection within 48 hours.
- Reduce the number of prescriptions requiring checking of medical records.
- Create an overall system which works better - with receptionists wasting less time.
- Reduce patients' complaints.
There came a time when the talking had to stop and action taken. The team had to answer the critical third question in the PDSA cycle 'What changes can we make that will result in an improvement?' They focused on four changes to the way that the practice had previously handled repeat prescribing. The team led discussions across the practice to ensure that the changes were understood by all and acted on. The four changes were:
- Prescribing protocols were drawn up and endorsed by all partners as a standard approach to prescribing in the practice, and drugs prescribed during visits would also be recorded in medical records.
- Signing of prescriptions would be given higher priority; for example, they would be passed to GPs at breaks, midway through surgery, so that they could be signed with the computer to hand rather than signed in a central area where there were many interruptions.
- The computer used for printing prescriptions was moved closer to the reception desk so that queries could be dealt with by a designated member of staff.
- The detailed flow chart of the process for handling repeat prescription to be used by everybody in the practice is on the wall next to the computer as a constant reminder and useful for training new staff.
Is it working?
A series of audits and surveys was planned to check progress in the four key areas: the results are encouraging. The work has shown that the use of CQI methodology offers a productive way to learn about and improve practice. Specific improvements are:
- The percentage of prescriptions available for collection within 48 hours has shown improvement. The Table shows the progress made in the first two years. The hiccough in the 24-month figure was due to one partner accidentally taking prescriptions home over the weekend and not bringing them back!
- The percentage of prescriptions available for collection within 24 hours has shown a steady improvement indicating that the system is running smoothly.
- The number of prescriptions needing records has also shown a gradual decline. The level of reduction could be equated to about one working day each month.
- The overall system of working has been well received by staff throughout the practice. A survey has shown staff to be very positive about the new process. In particular receptionists have said that the system is much less stressful and they now spend much less time waiting in corridors.
- Staff have noticed a reduction in the level of complaints from patients. Indeed no complaints from patients have been recorded in a new complaints book that was opened when the new system was introduced.
| Repeat prescribing process at Talbot Medical Centre | ||||
| Months | ||||
| Baseline | 6 | 12 | 24 | |
| Prescriptions in audit | 1444 | 986 | 1624 | 1445 |
| Prescriptions done in 48 hours or less (%) | 95 | 98 | 99 | 97 |
| Prescriptions done in 24 hours or less (%) | 71 | 83 | 86 | 88 |
| Needing medical records (%) | 18 | 11 | 11 | 9 |
Tips for success
- Make sure that the individuals in the team undertaking the work have good current knowledge about the system for review.
- A locally respected leader for the team is important: the Talbot Medical Centre was able to build on the respect for a local GP.
- Use a tried and tested approach like CQI methodology to provide a structure. It helps teams to be systematic and learn about the costs of achieving change.
- Make sure that arrangements for managing to work include regular reports to all staff about progress. Most will have an interest in its success.
- Involving an external facilitator who can offer advice on methodology can speed progress, but has costs that may be difficult to cover.
For more information about the initiative at Talbot Medical Centre contact
Dr Sue Cox, Talbot Medical Centre
63 Kinson Road, Bournemeouth BH10 4BX
Telephone 01202 523055
Fax 01202 533239
For more information about the application of CQI methodology contact
Peter Wilcock
Institute of Health and Community Studies
Bournemouth University
Christchurch Road, Bournemouth BH1 3LT
Telephone 01202 504114
Fax 01202 404131
Email pwilcock@bournemouth.ac.uk
The following material is available
- Paper from Quality in Health Care providing a more detailed description of CQI and of the work in the practice.
- Some key references and sources of advice about CQI and PDSA.
- download additional charts as pdf file
ImpAct bottom line
- Investment in time may be worthwhile if it produces a uniform and efficient way of doing things - rather than major change