Findings

DEMO DATA

Interpretation of current project data, areas of good practice, key gaps and safety implications.

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Results summary

Overall compliance across all criteria was 88% (156/177 applicable responses). Referral made within the locally expected timeframe was 57%, specialty review or advice within the locally expected timeframe was 29%, advice documented clearly was 100%, and action owner documented was 86%. 2 episode(s) recorded a specialty-referral-related safety concern. The most frequently recorded primary delay reason was “urgency / priority unclear”.

Overall performance is below the local target of 90%. The largest gaps are: criterion 1 (86%), criterion 3 (86%), criterion 4 (57%), criterion 6 (86%), criterion 7 (86%). Recorded length of stay impact equates to an estimated 14.5 bed day(s) across the sample. Findings should be interpreted alongside sample size, case mix and local referral capacity.

Key findings
  • •Overall compliance 88% against a local target of 90%.
  • •Specialty review or advice within the local timeframe: 29%.
  • •Action owner documented: 86%; recommendation actioned: 100%.
  • •2 specialty-referral-related safety concern(s) identified.
  • •Most common primary delay reason: urgency / priority unclear.
Areas of good practice
Criteria meeting the local target of 90%.
100%
Specialty referred to was documented clearly.
100%
Referral route used was appropriate to local policy and urgency.
100%
Senior specialty review was completed where required by local policy or clinical context.
100%
Advice or review outcome was documented clearly.
100%
Management recommendation was documented where advice was given.
100%
Investigation, procedure, transfer or treatment recommendation was documented where relevant.
100%
Interim clinical management plan was documented while awaiting specialty advice where relevant.
100%
Alternative specialty, pathway or escalation route was considered where appropriate.
Key gaps identified
Criteria below the local target, lowest first.
29%
Specialty advice or review was completed within the locally expected timeframe.
57%
Referral was made within the locally expected timeframe after it became clinically indicated.
71%
Specialty recommendation was actioned within local expected timeframe where required.
71%
Impact on discharge readiness, expected discharge date or length of stay was documented or inferable.
83%
Reason for delayed referral, delayed review or delayed action was documented where applicable.
83%
Referral delay was escalated according to local policy where escalation criteria were met.
86%
Clinical question or reason for specialty referral was documented.
86%
Referral urgency or priority was documented.
Impact and safety
Operational and safety implications of referral delay.

Estimated bed days attributable to referral delay across the sample: 14.5.

Specialty-referral-related safety concerns recorded: 2.

Most common primary delay reason: urgency / priority unclear.

Sample of 7 episode(s); retrospective documentation review cannot capture verbal advice that was not recorded. Not applicable and Unable to determine responses reduce the denominator for some criteria.

Governance implications
For departmental governance discussion and escalation where required.

Where referral delay contributed to a patient safety concern, confirm local incident reporting and escalation processes have been followed in line with the local incident reporting policy.

Findings should be reviewed with the specialty teams involved, the patient flow team and the clinical governance lead before agreeing improvement actions.