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Quality improvement in health care: a sonographer’s experience exploring ‘scanxiety’ and the fetal anomaly scan

11 October, 2019

Author: Helen Ong, Lead Sonographer for the Anomaly scan and Gynaecological Ultrasound, Ulster Hospital, South Eastern Health and Social Care Trust, Belfast


Albert Einstein believed that you cannot use the same thought processes to solve your problems as you used when you created them. I have to admit that prior to engaging with a quality improvement (QI) programme there have been numerous occasions when I have done exactly this. 

Batalden1 states “…everyone in healthcare really has two jobs when they come to work every day: to do their job and to improve on it.” I now understand that quality improvement in healthcare is reliant on not just the efforts of the individual, but also the efforts of everyone both within the organisation (those using and staffing the service) and those outside such as researchers and relatives. Co-production in healthcare is essential for service improvement.

The trust where I am employed has a strong commitment to QI. A year ago I began the trust’s Leading in Safety, Quality and Experience Programme. My area of focus was to try and explore the concept of ‘scanxiety’ (scans + anxiety) and the fetal anomaly scan. A colleague had come across the term scanxiety on line. It was evident that anxiety existed for some women attending for the anomaly scan.

It was also apparent that because of changes to departmental practices, anxiety was a problem for some staff carrying out the scan. Together with a team of volunteer colleagues representing the three hospitals within our trust, we decided to find out if we could help to reduce it.

QI needs to be performed in a tested way in order to understand the complexity of what you are trying to improve. Deming’s2 system of profound knowledge highlights the importance of not oversimplifying a problem, but looking at the system as a whole, considering the interrelated processes and individuals involved.

Initially, we needed to find out if anxiety existed and what our pregnant women felt were the causes. What did they understand about the scan? What (if anything) made them anxious? Were our staff anxious and, if so, why?

We gained important baseline data using patient and staff questionnaires and informal conversations. This gave us direction as to what areas we could potentially improve and how we could set measurable aims. To help understand the extent of the problem, we were introduced to process mapping, Fishbone/Ishikawa diagrams, Pareto charts, histograms, and scatterplots, all of which are useful tools for analysing where problems lie.

Once the data was analysed, we formulated our project charter, which defined what we were trying to improve, why, and by when. Our driver diagram-pictorial helped us translate our improvement goal and uncovered the variables and processes that had to be considered to achieve our overall desired aim.

The most tried and tested model for healthcare is the Model for Improvement3. This was developed in the USA at the Institute for Healthcare Improvement. It has three main components: aim, measures, and changes. 

We needed to consider outcome measures: the results of our changes, process measures (relating to the actions taken), and balancing measures (what other parts of the system your changes will affect).

One of our balancing measures considered was: were we going to increase anxiety by the process measures we introduced? Plan-Do-Study-ACT (PDSA) cycles became a regular important exercise. When analysing PDSAs we could be clear about what we had learnt, what worked and what didn’t.

Our ‘scanxiety’ project is nearing completion. So far we have gathered what we feel is important data. We have proved that ‘scanxiety’ certainly does exist and we have found that by using a patient information video prior to the scan we can reduce anxiety. We are proud that we made the patient video in our lunch break!

This work wouldn’t have occurred if I hadn’t had the opportunity to engage with QI. Once complete, we will look at spread and sustainability of this project and perhaps disseminate our knowledge to a wider healthcare audience. We have had compliments regarding the outcomes thus far and the interim results achieved. Patients and staff have reassured us that this is all very worthwhile, and that we have made positive improvements. We have reduced anxiety as we had hoped. The full results of our project will be published at BMUS 2019.

If you asked me during the eight month period of trying to complete this programme if I was enjoying my introduction to QI, I would not have given the same response as I do today. I am convinced improving systems is crucial to improving care.

Finding the time to do QI is not easy. We all have busy lives in healthcare. The online modules were difficult to understand at times. Co-production demands time. However, I know that today I think differently about my work.

The exposure that I have had to quality improvement has made me more thoughtful of the importance of not just improving patient experience, but also improving the staff experience. I have become more inquisitive and more understanding of both intrinsic and extrinsic factors affecting my working environment.  I have met many lovely people within the trust that I would never have met if I hadn’t experienced QI. I have had to listen and learn from staff outside of my radiology environment which has been beneficial.

The absolute thing I love most about QI is its inclusivity. It is actively encouraged that any member of staff can and should undertake this. It is clearly not just for a chosen few.


  1. Batalden P, Quality and Safety in Healthcare, BMJ 2007 16(1) : 2-3
  2. The W. Edwards Deming Institute [internet]. 2019 [cited 8 October 2019]. Available from:
  3. (2019). site. [online] Available at: [Accessed 28 Aug 2019]

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