Accentuate the positive, eliminate the negative

The Royal College of General Practitioners (RCGP) has a very interesting series on its website. It’s called Bright Ideas and shares a better way of doing things, tried and tested by frontline healthcare professionals. Healthcare professionals delivering care on the frontline often see better ways of doing things, ways to improve patient outcomes, release time, improve the patient journey or reduce costs. Here’s a case study of one such idea

This is an edited version of an item on RCGP Bright Ideas webpage.

The RCGP recently awarded a patient with a High Impact Bright Ideas Award for innovation in primary care. Shirley Bull, the first patient ever to win the award, was recognised for her new approach which uses behavioural psychology to reduce missed appointments at her practice – Ley Hill Surgery – in Sutton Coldfield, Birmingham.

The problem

In our GP surgery, like many others, staff and patients were frustrated when people did not attend their booked appointments, or cancel in time to free the appointment up for another patient. Although there are many reasons why patients miss appointments, surveys indicate that often they simply forget.

Solutions to address this issue are difficult to come by. Notices in the waiting room often point out the number of missed appointments – and the consequences of this – to try to make people take the issue more seriously, but psychology research suggests that other strategies are likely to work better.

The context

Our GP partners and practice managers explained the difficulties the practice was having with missed appointments to meeting of our patient participation group (PPG) and asked for help. A PPG member, who is also a psychologist, suggested that two aspects of behavioural psychology i) social norms and ii) active commitments, could be helpful; these have been tested in previous short-term research in primary care.

• Social norms: people tend to follow what they think most people do, so notices showing that most people in the surgery keep their appointments or cancel in good time highlight the social norm of people doing the right thing are likely to be more effective than those lamenting the waste of professional time when people don’t.
• Active commitments: the more actively involved we are in making a commitment, the more likely we are to keep it. Active commitments involve staff inviting patients to write down or repeat back their appointment when they book it.

The Bright Idea 

Our PPG and practice staff were excited to try these low-cost strategies out over a 12-month period in the practice to see if they could impact on missed appointments and cancellations.

The psychologist worked closely with the practice manager and receptionist staff to change notices in the practice using each month’s figures; for example, ‘95% of our patients came on time to their appointments last month in January. Thank you!’

The psychologist trained reception staff to invite patients when booking appointments to actively commit to cancel their appointment if needed and to write down their own appointment details.

A health psychologist from the University of Manchester advised the team on the running of the study and data analysis, and helped make a short animated video to share the project findings.

This bright idea offered a very low-cost solution, with no equipment or specific funding needed. The project did need time for planning but, once the training was completed, the practice manager estimated time commitment to be around just two hours a month.

The impact

• Patients: we improved access to GP appointments using a patient-originating innovation. Members of our PPG group supported all stages of development. This is a meaningful example of patient participation as a joint venture between a PPG member and the staff at the practice.
• Staff: members of staff were almost unanimously positive about their own commitment, understanding and confidence in using the bright idea. Staff felt well-supported by their fellow receptionists and team leaders and felt empowered to be able to make a difference to DNA levels.
• Practice:  missed appointments were reduced by an average of 20% (up to 33% some months) while early cancellations were increased by an average of 21%. We had an average of 37 fewer missed appointments per month, or approximately one working day saved every month.

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