Improvement — Delayed Investigations Impact Audit

Governance reminder

Lazomis QI supports quality improvement planning and documentation. It does not replace clinical judgement, local policy, diagnostic pathways, professional responsibility or organisational governance processes. Ensure all improvement activity is agreed and implemented in accordance with local requirements.

1. Baseline findings summary

Generated from current dashboard data — editable.

2. Key problems identified

Lowest-performing criteria in the current dataset.

1) Investigation was performed or sample was taken within the locally expected timeframe. — Compliance 33.3% against a local standard of 90% (8 yes, 16 no, 0 excluded).
2) Outpatient, ambulatory, planned return or community diagnostic option was considered where the patient was otherwise discharge ready and this was safe. — Compliance 36.4% against a local standard of 90% (4 yes, 7 no, 13 excluded).
3) Investigation delay was escalated according to local policy where escalation criteria were met. — Compliance 65.2% against a local standard of 90% (15 yes, 8 no, 1 excluded).
4) Investigation was requested within the locally expected timeframe after it became clinically indicated. — Compliance 75% against a local standard of 90% (18 yes, 6 no, 0 excluded).
5) Result was reviewed by the clinical team within the locally expected timeframe. — Compliance 79.2% against a local standard of 90% (19 yes, 5 no, 0 excluded).
6) Alternative investigation or pathway was considered where appropriate. — Compliance 87.5% against a local standard of 90% (21 yes, 3 no, 0 excluded).

3. Possible causes / contributory factors

People · Process · Environment · Equipment / IT · Documentation · Communication · Training · Capacity

4. Improvement aim

Specific, measurable, achievable, relevant, time-bound.

5. Suggested local improvement actions

Potential improvement opportunities derived from the current findings. Editable — framed as local implementation ideas, not national guidance.

Issue or gap identified	Proposed action	Responsible person / team	Target date	Status
Results not reviewed within the expected timeframe	Introduce a daily ward review of pending and unacknowledged results with a named owner	Ward clinical lead	Add target date	Not started
Results not actioned within the expected timeframe	Agree an explicit result acknowledgement and action process, including out-of-hours cover	Clinical director	Add target date	Not started
Investigations not requested promptly once indicated	Add a prompt for required investigations to the post-take and board round process	Audit lead	Add target date	Not started
Outpatient or planned return options not considered	Agree which investigations can safely be completed as outpatient or planned return	Diagnostics lead	Add target date	Not started
Delayed-investigation safety concerns identified	Confirm each concern has been reported through local incident reporting and reviewed	Governance lead	Add target date	Not started
Most frequent delay reason: No reason documented	Run a focused improvement cycle targeting this delay reason with the relevant diagnostic service	Audit lead	Add target date	Not started

6. PDSA cycle 1

Plan · Do · Study · Act

7. Intervention log

Changes that do not fit neatly into a PDSA cycle.

8. Re-audit / next-cycle plan

9. Sustainability plan

10. Learning points

11. Governance summary

12. ARCP / portfolio evidence summary

Populates the ARCP evidence output in the Export centre.

Improvement themes

Common action areas for delayed investigation improvement work.

Early recognition of required investigations

Documentation of clinical indication

Investigation requesting quality

Prioritisation and urgency documentation

Radiology vetting / protocoling workflow

Pathology sample collection and rejection reduction

Imaging scheduling and completion

Endoscopy / specialist diagnostic triage

Patient transport / portering reliability

Weekend and out-of-hours diagnostic access

Result reporting turnaround

Result review and acknowledgement

Abnormal result escalation

Actioning of results

Diagnostic delay escalation process

Senior review of pending investigations

Outpatient / planned return investigation pathways

Discharge planning despite outstanding non-urgent investigations

Criteria-to-reside and diagnostic delay review

EPR prompts and investigation tracking

Ward review of pending investigations

Patient communication and safety-netting

Feedback to clinical and diagnostic teams

Incident learning and governance review

Re-audit and sustainability