
Getting it Right First Time (GIRFT)
The GIRFT programme has now been running for several years. The Pathology GIRFT report was published in 2021 and looked at variation across England in the way pathology is delivered. We developed the concept of the “Clean Framework” to try to keep focus on things that matter to patients. Too often services define success by things that matter to them, and things that they can easily measure. This de facto purpose can override our true purpose – which most would agree is helping people, and people who look after them, make better decisions about how they lead their lives.
The GIRFT Report
A lot of the report was based on a questionnaire sent to laboratories. There was a heavy focus on blood sciences, mainly because labs could provide data that was easily comparable. For instance, we used the proportion of bloods from ED without a numeric potassium result as an estimate of haemolysis rate. This showed huge variation across the country – in some places 10% of bloods are haemolysed or old before being analysed.
Our data gathering was followed up by “deep dives” – essentially discussions with those doing the work about what the data can tell us about how services are organised. This was most powerful when we found strong “positive” outliers and could use these to tell stories about improvement to more “negative” outliers. For instance, when considering haemolysis, we could point to Surrey and Sussex labs who had worked with their ED and equipment suppliers to get their haemolysis rate down to a staggering 2%. The art of the possible. It was great fun talking to fellow professionals about their work. And every single lab in the country had some example of excellence that could be shared with others. I would reflect that this could be such valuable CPD for all of us.
Infection Services
It was harder to do this with infection services. Our data is much less clean and it was hard to come up with things that were easily measurable and that tell us something meaningful about differences in services. Nevertheless, we did see some large differences in how we provide services for patients across the country. For instance, we saw around 5 fold variation in the number of MSUs submitted from primary care to each lab. We could point to several labs on the left of this graphic who had replicated work in places like Bournemouth to reduce unnecessary urine culture. Other labs, on the right of this graph, could learn at pace from this success.
The report has some other metrics that may be of interest to infection specialists, but the impact of these has been limited. The GIRFT Academy sits within the GIRFT programme to produce guidance on reducing variation. This is intended to complement institutions such as NICE. Potential areas for intervention have been identified and the priority is now how we as an infection community implement the recommendations made within pathology and the wider programme.
For instance, I have been approached by the GIRFT urology team to advise on best practice for pre-procedure work up before urological procedures. The orthopaedic team have asked about best practice for antibiotic prophylaxis in joint arthroplasty.
How you can support GIRFT
The expertise amongst the BIA membership could play a significant role in supporting GIRFT in several ways. Sometimes this might be by identifying a few individuals with specialist expertise or interest. Alternatively, a Delphi-like process with a wider group of clinicians may help identify consensus when the evidence base is weak and practice is highly variable. Finally, the BIA may help with audit as all these discussions (from a GIRFT perspective) should be grounded in discussions about unwarranted variation. These professional conversations about what variation means, and what we can do about it, should sit at the heart of GIRFT going forward.