Santos Carlos, Ajayi-Obe Abiola, Aurelio Marco
Quality Improvement Department, East London NHS Foundation Trust, London, UK
Governance and Risk Team, East London NHS Foundation Trust, London, UK.
BMJ Open Qual. 2025 Jul 16;14(3):e003234. doi: 10.1136/bmjoq-2024-003234.
Timely completion of serious incident reports is crucial for patient safety and regulatory compliance. Delays hinder organisational learning and compromise patient outcomes. Between May 2021 and April 2022, East London NHS Foundation Trust (ELFT), a provider of mental health, community health and primary care services to approximately 1.8 million people across London and Bedfordshire, faced a significant backlog of serious incident reports. Completion times averaged 208 days-well beyond the 60-day target set by NHS England at the time.
A quality improvement (QI) initiative employing structured methodologies, including the ELFT Sequence of Improvement, statistical process control, Ishikawa analysis, a driver diagram and plan-do-study-act cycles to diagnose and address process inefficiencies.
Three main change ideas were tested and implemented: concise reporting templates to streamline documentation, a caseload tracker for real-time monitoring and team escalation meetings to improve communication and accountability.
These interventions led to a 65% reduction in average completion time, decreasing from 208 days to 74 days. Additionally, staff collaboration and workflow efficiency improved, fostering a culture of continuous improvement, continuous learning and accountability.
This project demonstrates the effectiveness of structured QI methodologies in improving serious incident reporting. The implemented changes are sustainable and provide a scalable model for other healthcare organisations aiming to enhance patient safety and compliance. Future work will focus on embedding these improvements into routine practice and exploring their impact on broader organisational learning.
及时完成严重事件报告对于患者安全和法规合规至关重要。延迟会阻碍组织学习并危及患者治疗结果。在2021年5月至2022年4月期间，东伦敦国民保健服务基金会信托基金（ELFT），一家为伦敦和贝德福德郡约180万人提供心理健康、社区健康和初级保健服务的机构，面临着严重事件报告的大量积压。完成时间平均为208天，远远超过了当时英国国民保健服务体系设定的60天目标。
一项采用结构化方法的质量改进（QI）计划，包括ELFT改进序列、统计过程控制、石川分析、驱动图和计划-执行-研究-行动循环，以诊断和解决流程效率低下问题。
测试并实施了三个主要的变革理念：简化文档的简洁报告模板、用于实时监控的工作量跟踪器以及改善沟通和问责制的团队升级会议。
这些干预措施使平均完成时间减少了65%，从208天降至74天。此外，员工协作和工作流程效率得到提高，营造了持续改进、持续学习和问责的文化。
该项目证明了结构化QI方法在改善严重事件报告方面的有效性。实施的变革具有可持续性，并为其他旨在提高患者安全和合规性的医疗组织提供了可扩展的模型。未来的工作将集中于将这些改进融入日常实践，并探索它们对更广泛的组织学习的影响。
