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What is the challenge your project is going to address and how does it connect to your chosen theme?

Currently the Trust carries out on average 440 primary joint replacements in a year, that are delivered by four surgeons (soon to be five). All patients are currently seen at 6 weeks, 1 year, 5 years and 10 years in a face-to-face clinic by a member of the multidisciplinary team – consultant, registrar or senior physiotherapist (ESP). This level of activity will generate 1740 follow up appointments each year for the next 10 years. This is going to increase because of a growing and ageing population. This is unsustainable and wasteful.

The current system has resulted in patients having to wait longer for clinic appointments, sometimes inappropriately and dangerously. This results often in poor patient experience and unnecessary generation of clerical work and contact that add nothing to patient care.

Our new system and processes will stop this while we increase capacity and decrease cost of delivery without compromising patient safety or quality of care for new and follow up patients.

What does your project aim to achieve?

Our project aims to

  • Improve patient experience/satisfaction and outcomes
  • Prevent waste through ensuring appropriate stream of follow up (face to face (F2F) with known consultant / team or non F2F (no clinical concerns) optimising added value of every patient contact / interaction
  • Improve staff satisfaction through using a more efficient scheme

Benefits to Patients include, decreased need to travel and costs associated, decreased carbon emissions and follow up and care more locally.

Benefits to the Trust include, decreased need for already scarce clinic space and time, decreased staffing costs, decreased need for parking on site, increased direct clinical care time for surgeons to do operations, and reduced carbon footprint related to follow up visits.

Measures will include: Patient & staff satisfaction, no. of non F2F and F2F follow up appointments, number of clinic appointments freed for new patients, emergency admissions for revision surgery or periprosthetic fractures.

How will the project be delivered?

Through a triad of:

  • Online patient outcome questionnaire
  • X-Ray
  • Trends associated with sequential outcomes from questionnaire and x-ray

We aim to deliver this through an interactive digital platform compatible and directly linked into current hospital platforms.

The team has experience in delivering successful improvement projects previously, we will use methods learned.

The project team comprises of a multidisciplinary team of:

– Patient involvement in co-designing the future of the service

– Orthopaedic surgeon (member of the British Hip Society Executive Committee)

– Physiotherapy Lead

– Improvement Advisor / Q Member / Data Specialist

– Orthopaedic Service Manager

– Orthopaedic Clinical Service Lead (previous successful Improvement project experience)


Omitting patients – suitable digital technology required to ensure all patients are tracked

Inconsistency – ensure standardized pathways, binary questionnaires and radiology assessment checklists for all patients

What and how is your project going to share learning throughout?

This project will use improvement methodology including PDSA cycles to test and learn. It will be shared internally via Improvement Grand Round presentations, Newsletters and by word of mouth and externally via Social Media, presentations at meetings, GIRFT reports and in journals. The model should be easy to replicate and therefore implement in other departments and trusts facing similar challenges.

We plan to do regular blogs with the progress of this work.

We intend to publish an article outlining our approach and results in the BMJ Open Quality Journal.

We will share our project at appropriate conferences and meetings nationally.

We will be active on social media throughout the project and encourage participation from outside of the current team from Q members and wider.

How you can contribute

  • Ideas from other Q community members about similar projects they have worked on or experiences they have had around this.
  • Advice on how other Trusts have used IT solutions for problems similar to this
  • Advice from other Trusts on companies that they have used for any IT solutions
  • Thoughts on other pathways that could benefit from this solution
  • We are keen to link in with other Trusts working on similar projects to share learning including examples we are aware of at Sheffield and Cornwall Hospitals.

Plan timeline

13 Nov 2019 Funding decision announced at Q conference
18 Nov 2019 Mapping of resources
18 Nov 2019 Open invitation to Q members to participate in the project
25 Nov 2019 Agree proposed pathway with clinicians
25 Nov 2019 Develop protocols for clinicians triaging
25 Nov 2019 Explore how Maxims can be utilised to support
25 Nov 2019 Identify Patient cohorts for each step of the pathway
25 Nov 2019 Mapping current service and proposed
2 Dec 2019 Communications to patients and stakeholders
2 Dec 2019 Priority setting
2 Dec 2019 Stakeholder Engagment
9 Dec 2019 PDSA Cycles / Tests of change
6 Apr 2020 Review, evaluate and spread


  1. Hi team,

    given you are in PENCLAHRC's catchment area, it strikes me that it might be helpful to discuss this exciting project with them as they have some excellent mathematical and simulation modelers and have great evaluation expertise in this kind of scheduling and logistic dynamics.

    good luck

    best wishes


  2. Hi Dimple

    It is agreed by our hip surgeons based on the Hip Society and BOA recommendations. The discussions were led by Mr Bolland who is responsible for developing and endorsing standardized national guidelines for long term follow up of patients whom have received THR / TKR’s. Involved as an expect opinion to critique Virtual Clinic follow up programme initiated in Midlands by past BHS and BOA President.

    The assumption is that 20% of this patients cohort will need to be seen by the Consultant face to face in clinic. They will be identified through the virtual clinic triage process. This assumption is based on experience of the patients in our demographic and the feedback from our clinicians.

    We are able to identify patients who are on this pathway using Maxims (electronic patient records) and retrospectively to 2016.

    We will measure the success of this project with the following:

    1. Reduction of face to face clinic attendances

    2. No increase in Emergency revision surgery (due to patients being missed on this pathway)

    3. Patient experience

    4. Care closer to home

    5. Less visits to acute setting for patients

    6. Integrated working (Primary & Community Care)

    There will be PDSA's running for all parts of the proposed process to test effectiveness and fine tune before any roll out.

    The first PDSA for example, will be with one patient (that had their procedure a year ago) having an x-ray and a virtual clinic appointment (with questionnaire).

    We plan to publish our findings following the project in a QI journal. We already have a successful publication on reducing length of stay in patients having spinal surgery.

    Thank you very much for your interest, if there is anything else you would like to know, please do let us know.

    Kind Regards

    Claire & The Team

  3. Hi Claire and team,

    Is there any clinical guidance on the follow up schedule and methods for this patient cohort? As a non clinician, I wondered whether some of these follow ups would be better in real life so the clinician can observe how the individuals are walking and moving around?

    I also wondered if your proposal could expand more on what technology you'd be using and how patients would be identified and how you might evaluate the success of the project? (not sure what cycles will be included in the PDSAs).

    Finally, in terms of sharing the results of your project, it might be worth writing up your QI report in bmj open quality (Q members can publish for free):

    Just a few things to think about as you develop the proposal, I hope that's helpful.

    Good luck!

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