Time to be more efficient: Reducing wasted transthoracic echocardiography (TTE) diagnostic appointment slots at Guy’s and St Thomas’ NHS Trust

Dario Freitas, Sam Alner, Camelia Demetrescu, Grazia Antonacci, Nathan Proudlove

Research output: Contribution to journalArticlepeer-review


Transthoracic echocardiography (TTE) is one of the most requested non-invasive cardiac imaging diagnostic modalities available in the National Health Service (NHS). There is persistently high demand, but nationally, activity has lagged, producing increasing numbers of breaches of the 6-week waiting time target. This delays patients' diagnosis and treatment. Patients attend hospital for TTE either as a clinic-linked or a standalone appointment. In this quality improvement project, we identified that the clinic-linked slots were a major source of wasted capacity due to both unbooked slots and a high rate of patients not attending their appointments (DNA). DNA is a complex issue, aggravated in our trust by many IT systems, complex clinic-booking pathways and restricted patient communication channels. We parked changing these processes, pending an imminent, unifying IT development programme. We focused instead on unused clinic-linked appointments, with the goal of reducing these from 18% (∼31 of ∼175 allocated each week) to 5% by the end of the 14 week project period. In close collaboration with service stakeholders, we identified that the primary root causes were related to the clinic-linked TTE booking pathway. The change idea was a 7-day rule: after reminders at 9 and 8 days prior to the clinic date, any appointment slots still unbooked by cardiology sub-specialities for patients attending clinic-linked appointments at 7 days, would be used for booking standalone TTE patients. We refined this process over two plan-do-study-act (PDSA) cycles, reducing unused (wasted) appointment slots, allocated initially to clinic-linked patients, to a sustained level of 5.1%, meaning we could now perform approximately 21 additional TTE tests weekly; we have materially increased activity without increasing capacity. This contributed to a significant reduction in 6-week TTE waiting-time breaches. Over the project, this went from 378 (30%, February 2022) to 71 (8%, September 2022) and latest data show 28 (4%, February 2023).

Original languageEnglish
Article numbere002317
JournalBMJ Open Quality
Issue number3
Publication statusPublished - 17 Jul 2023


  • Coronary Disease
  • Diagnostic Services
  • Efficiency, Organizational
  • Process mapping
  • Statistical process control


Dive into the research topics of 'Time to be more efficient: Reducing wasted transthoracic echocardiography (TTE) diagnostic appointment slots at Guy’s and St Thomas’ NHS Trust'. Together they form a unique fingerprint.

Cite this