QI Project – Improving the timeliness & quality of 72-hr reports in Luton and Bedford

 18th July 2025

Fiona and Johnson take us through their story on how they reduced the time taken to complete 72-hour reports.

Around a year ago, our trust initiated a quality improvement project to enhance the timeliness and quality of 72-hour reports in Luton and Bedfordshire. These reports, requested from clinical teams following serious incidents, provide a preliminary review within 72 hours to understand the facts and immediate learnings.

A deep dive into report completion times revealed outliers, with some reports taking up to 30 days. We identified patterns such as multiple team involvement and excessive information in inpatient reports. Engaging clinical directors and assistant directors helped emphasize the importance of timely report completion.

Initially, the completion of these reports varied significantly, often exceeding the 72-hour timeframe. To address this, we formed a project team including community and inpatient mental health teams, crisis pathway teams, a service user, and a clinical director. We identified key challenges such as lack of clarity on the 72-hour process, varied understanding of acronyms, and insufficient training.

Our driver diagram (Figure 1) highlighted primary drivers like education, collaboration, resources, and clarity. Secondary drivers included improving language and terminology, providing peer support, and enhancing stakeholder engagement. We also focused on feedback mechanisms to encourage robust reporting.

 

Figure 1 – Driver Diagram

Change ideas included guidance sessions from the risk team, annotated templates with clear instructions, and adjusting report request timings to avoid weekends. We provided one-to-one support for staff, streamlined the report template, and improved communication about report deadlines and responsible parties.

Our efforts have led to a significant improvement in report timeliness (Figure 2), with data showing a clear shift towards faster completion.

 

Figure 2

Moving forward, we aim to sustain these improvements, spread best practices across the organisation, and explore alternative response tools like MDT/Swarm Huddles, After-Action Reviews (AARs) and Care Review Tools (CRT).

Fiona Whittell (Deputy Head of Incident Management) and Johnson Oredein (Assistant Director – Bedford Community Mental Health Services)