Improving the compliance of orthopaedic wrist and hand referrals against the musculoskeletal recommendations from the 2018 Evidence-based Interventions programme, along with local guidance in Greater Manchester: A quality improvement project.

Abstract

Background: The National Health Service Long-Term Workforce Plan calls for improving clinical pathways for surgery. Four wrist and hand surgeries, including carpal tunnel syndrome release, Dupuytren's contracture release, ganglion excision and trigger finger release, are described as procedures of limited clinical value and are included in the 2018 Evidence-based Interventions programme, as well as local guidance in Greater Manchester (GM).

Local problem: A pre-scoping exercise audit at a single musculoskeletal service in GM conducted from May 2021 to June 2023 highlighted that clinician compliance rates for these referrals were 15% below the service provider's internal national average and 25% below the service provider's internal national target, demonstrating the need for a quality improvement project.

Methods: The Model for Improvement was implemented using four Plan-Do-Study-Act (PDSA) cycles. These cycles were executed over 14 weeks and aimed to improve compliance through educational sessions, clinical resources, interactive learning and practical tools.

Intervention: The project comprised four PDSA cycles: PDSA 1 introduced educational sessions and case discussions, PDSA 2 implemented a clinical flowchart to guide decision-making, PDSA 3 included a knowledge retention quiz and PDSA 4 involved a repeat quiz and further discussions to consolidate learning. The target was to increase compliance rates from 70% to 85% or more.

Results: The project successfully improved compliance rates by 30%, with the final compliance rate reaching 100%, surpassing the service provider's internal national average and target, respectively. 100% compliance was achieved and sustained during PDSA 4 until the end of the project. Clinician confidence and quiz scores also increased during the intervention.

Conclusions: Educational initiatives, combined with practical tools like clinical flowcharts and quizzes, significantly improved compliance rates. The project provides a scalable model that can be adapted by other community healthcare services to enhance compliance with orthopaedic referrals.