Copenhagen 2007

Dr Pat Straw, Head of Patient & Public PartnershipNHS Lothian University Hospitals Division, Edinburgh

E-mail pat.straw@luht.scot.nhs.uk

RE-DISCOVERING PATIENTS: Evidence-based Improvement

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Re-discovering patients?

•Engage with patients in different and better ways

•Systematic and robust methods to obtain information on clinical care to complement clinical conversations

•Place these daily exchanges in a broader and more powerful context

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Presentation

1. Introduction

2. Background – rigorous surveys

3. Summary of results

4. Dissemination and publicity

5. Patient Information

6. Pain Management

7. Questions

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Introduction

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Edinburgh, Scotland

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Edinburgh, Scotland

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NHS Lothian – University Hospitals Division

9 hospitals on 8 sites, including the Royal Infirmary of Edinburgh, the Western General Hospital, St John’s, and the Royal Hospital for Sick Children.

One of the largest teaching organisations in the UK, employing around 16,000 staff, and with almost a million patient episodes per year.

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Royal Infirmary

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Background

Patients, clients and parents are experts

A great deal of expert knowledge

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Feedback overview

Poor surveys - methodologically flawed, untrained staff, badly resourced, few (if any) improvements

Over reliance on unrepresentative information:

Complaints = 0.1%Patient groups – anecdote

and participants self-selected

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External PartnersPatient Perspective, Oxford

* recognised leaders in the field

* independent

* rapid turnaround time

* better value for money than in-house

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Survey and Change Management Programme - Essentials

•Using aggregated data from large representative samples of patients/clients/parents to make a difference to individual patients/parents in a ward or in a clinic

•Providing information to clinicians and managers about patient priorities that is immediately useful (so although methodologically rigorous, programme is not mainly an academic exercise)

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Methodology 1 - Components of the Study

All adult in-patients (9 broad groups)

Coronary Heart Disease (national priority area)

Medicine of the Elderly

Paediatric Services

Maternity Services

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Methodology 2 - Development of Questionnaires

Focus groups in local libraryIndependent, professional moderatorTape-recorded, transcribed, report

Draft questionnaireCognitive interviews to test questionnaire

Final questionnairePilot postal survey - analysis & report

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Patients tell us what’s important to them ...

8 Dimensions of Care

– Respect for values, preferences and expressed needs

– Access to care

– Co-ordination of care

– Information, communication and education

– Pain management

– Emotional support

– Involvement of family and friends

– Transition and continuity

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Picker Research 1980’s - Rating

(satisfaction)questions

0

10

20

30

40

50

60

%

Excellen t V. G ood G ood Fair Poor

USA

Canada

England

Overall, how would you rate your care?

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Reports not RatingFacts not Satisfaction

Questions that:

•elicit reports about specific care experiences that reflect quality of care, not amenities

•are less subjective and less influenced by patient characteristics and expectations (eliminate bias)

•are more interpretable and point to specific areas for improvement

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NO to Patient/Client/Parent Satisfaction!

Asking patients/clients/parents to report on what happened

NOT

Asking patients/clients/parents to rate their satisfaction

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Methodology 3 - The Surveys

Mailing of questionnaires, 3 weeks after stay/visit, to randomly samples

Mailing of 2 reminders to non-respondersFreepost envelope for patients to return questionnaires

Freephone telephone for queriesResponse rate of around 70% = margin of error 3%

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Methodology 3 - The Survey

New method 2006/07!

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Summary Results

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OP Programme Essentials

•Majority of patients do not stay overnight; outpatients outnumber inpatients by a ratio of 5:1.

•Contact time between patients and staff in OP setting more limited and circumscribed than IP context so quality of experience highly significant.

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How would you rate the care you received?

Adult outpatients:

What percentage of our patients were ‘very satisfied’?

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86% of our patients were ‘very satisfied’

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Did you feel involved enough in decisions about your care?

What percentage of the SAME patients did not feel involved in decisions about their care?

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Reporting Questions Orthopaedics, ENT, Dermatology

44% (Ortho.), 37% (ENT), 41% (Derm.) wanted to be more involved in decisions about their care

%Didn’t always see same doctor 70 63 49Didn’t know names of staff64 60 60Not told what would happen at appointment

46 65 54Not told who appointment was with51 55 32Not enough chance to discuss problem with dr.39 30 33How surgery/treatment went not explained well36 32 29Risks & benefits of operation not discussed35 28 29Not told what to do if symptoms got worse35 34 34

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Reporting Questions

%No understandable explanation of test results29 37 46Reason for appointment not dealt with26 31 27Dr. didn’t know enough about medical history24 23 22Not told side effects of medication 23 22 19Staff contradicted each other 22 11 13Didn’t get answers to questions from doctors

18 11 17Spent < 5 minutes with doctor 36 3 19No written information18 16 18Clinic not well organised 42 27 26

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Improving the Patient’s Journey: Outpatient Clinics

• Patient Information• Staff

communication within/between departments

• Appointments• Numbers of

patients• Junior doctors’

roles• Role of nurse

practitioners• Culture

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How would you rate the care you received?

Adult inpatients:

What percentage of our patients were ‘very satisfied’?

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90%, 89% , 92% of our patients were ‘very satisfied’

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Did you feel involved enough in decisions about your care?

What percentage of the SAME patients did not feel involved in decisions about their care?

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Findings - Reporting Questions

55%, 40%, 60% of patients wanted to be more involved in decisions about their care

2006 2002 1999Not told about danger signals N/A 56% 44%Not told when to resume normal activities 55% 55% 60%Side effects of drugs not explained 44% 36% 38%No explanation of surgery 20% 22% 29%Patients didn’t get opportunity to talk to doctorN/A 31% 31% Risks & benefits of operation not discussed 24% 23% 22%

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Strategic & Local Action Plans

Pain Management

Patient involvement in decision-making

Who’s in charge of care?

Discharge Planning

Informed consent and info. about surgery

No. of nurses on the ward/in clinic

Clinical Improvement Teams (directorates)

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Dissemination & publicity

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Managed Patient Information

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Individual Patients making informed decisions and choices about their treatment and care

Members of the public exerting informed influence on service planning and delivery.

Information is Power

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Genesis of Project

Patient feedback …

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No info about warning signals

56% (60%)

Doctors & nurses saying different things

23% (23%)

No explanation of surgery

22% (29%)

No opportunity to talk to doctor

31% (31%)

No discussion of worries with doctors/nurses

33%/32% (34%/33%)

No explanation of test results

33% (43%)

No explanation of

drug side-effects

36% (38%)

Family/friends not getting enough info

37% (39%)

Home situation not considered at discharge

43% (43%)

Inaccurate info about how they would feel

after treatment

48% (46%)

No info about resuming normal activities

55% (60%)

Lack of involvement in

decisions/communication

meaning

care not patient-centred

40% (60%)

KEY DRIVER TO IMPROVING COMMUNICATION WITH PATIENTS PERCENTAGE OF PATIENTS REPORTING PROBLEMS 2002 (1999)

Risk/benefits of surgery not explained

23% (22%)

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To make it easy for staff to ‘get it right’ - give the right sort of information, the right amount of information, at the right time, in the right place, in the right format

Genesis of Project

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Modules (text and graphics) of health information to make leaflets, folders or booklets, as well as everything related to system administration

Information for hospital staff and GPs to view or print, and share with patients, relatives and carers + direct access for people via home, school or library PCs, kiosks and bedside terminals.

Audit trails of creation, approval, updating and re-approval; what’s been updated and when (and what hasn’t); archive and date the content modules and leaflets at each update

Web-based System (but much more than a web-site)

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Northumbria Healthcare NHS Foundation Trust

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It enables staff to be educationally, socially, spiritually and culturally competent via:

Minimising Barriers Checklists (instant access to barriers service users themselves have identified)

Service Contact Lists (25 data bases, e.g. homelessness, learning disabilities, alcohol/drugs)

Helplines Contact List (phone based services, local and national)

Signposting Briefing Sheets (e.g. smoking, careers, benefits, adult learning, exercise)

Equality and Diversity (psychosocial-prescribing)

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Pain Management

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Internal BenchmarksSevere or moderate pain all, most, some of time

0 20 40 60 80 100

Unit 9

Unit 8

Unit 7

Unit 6

Unit 5

Unit 4

Unit 3

Unit 2

Unit 1

Un

it

Percentage

Internal Benchmarks

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Pain results

Hospital visited * F3. How much of the time were you in pain? Crosstabulation

% within Hospital visited

20.5% 48.7% 30.8% 100.0%

29.2% 51.3% 19.5% 100.0%

32.4% 51.5% 16.2% 100.0%

14.0% 46.3% 39.7% 100.0%

16.9% 48.3% 34.9% 100.0%

24.6% 49.2% 26.2% 100.0%

17.6% 49.5% 33.0% 100.0%

21.6% 52.9% 25.5% 100.0%

16.7% 50.0% 33.3% 100.0%

23.2% 49.7% 27.1% 100.0%

Royal Medical

Royal Surgical

Royal Orthopaedic

Royal Other

Western Medical

Western Surgical

Western Other

Royal Elderly

Western Elderly

Hospitalvisited

Total

All or mostof the time

Some ofthe time Occasionally

F3. How much of the time were you inpain?

Total

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Who experiences more severe pain ?

• Younger people• Emergency admissions• Patient’s feeling less involved in their care• Patients having tests• Patients who reported the doctors and nurses

working poorly together

NOT• Patients having surgery• Patients able to give themselves pain medicine

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Who experienced pain all or most of the time?

• Younger people• Patient’s feeling less involved in their care• Patients not able to give themselves pain medicine

NOT• Patients having surgery• Patients having tests• Emergency admissions• Patients who reported the doctors and nurses

working poorly together

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Pain Management - Issues

• Research and science sophisticated v. routine practice primitive

• Pain fundamental - vital sign - surely should be monitored like blood pressure, heart rate, etc.

• Related to morbidity and mortality

• Training

• Equipment

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•LOS reduced from 7 to 4 days = Shorter waiting times

•Severe pain on movement 68% down to 12%

•81.3 % use of prophylactic antiemetics now

•100% prescription of oral analgesia

•Pre-printed drug charts

Major Gynae. Surgery – Improvements in 9

months

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Where did system breakdown?

•In theatre - under-dosing

•In recovery - no staff trained to give intravenous drugs

•In ward - PCA discontinued too soon

•Oral analgesia not prescribed

•Antiemetics not prescribed

•PCA Bolus too small

•Prescribed oral analgesia not given

•Prophylactic antiemetics not used

•Prescribed antiemetics not given

Major Gynaecological Surgery

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•Fedback results

•Training in intravenous drug administration

•Production of guidelines

•Introduction & training in use of guideline

•Pre-printed drug charts

What did we do?

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•No severe pain

•100% use of prophylactic antiemetics

•100% prescription of oral analgesia & rescue antiemetics

•Better morphine - loading, bolusing, duration of use

•Crossover from morphine to oral analgesia

Standards set

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Overall, how much pain medicine did you get?

0

4

6

8

10

12

Pic

ker

20

01

Amount of pain medicine not enough (or too much)

Amount of pain medication given much improved compared to Picker.

Do you think that hospital staff did all they could to help control your pain?

3

12

24

20

01

Staff didn't do all could to control pain

Per

ce

nta

ge

Staff rated very much better compared to Picker results.

How many minutes after you requested pain medicine did you get it?

1

3

5

7

Pic

ker

20

01

Day

1

20

01

Day

2

Waited > 15 mins/got none

Per

ce

nta

ge

Improvements on Picker results for timely administration of pain medicine

on Day 1.

Pic

ker

Per

ce

nta

ge

2

Have we improved?

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•Increase use of oral opioids? Oxycodone?

•Increase use of regional techniques - epidurals

•Other co-treatments? Drugs used in chronic pain? Amitryptiline?

•Ensure 100% antiemetic prophylaxis - increase PCA bolus to 2mgs morphine, increase guideline compliance

•At least maintain improvements

•Pre-printed drug charts

What more can we do?

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Pain Management - Issues

• Staff expertise - many doctors and nurses have had little training on pain management (sometimes the pharmacists are the only experts)

• Co-ordination - who is in charge of pain management; at admission,on the ward(s),before surgery,during surgery,after surgery,back on the ward(s),at discharge

• The surgical patients see the acute pain team and have their pain well controlled post-operatively - what about after “post-operative” and what about non-surgical patients?

• Patients are often under dosed or dosed at the lower end of a suggested range

• Concerns over addiction still exist

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Improving the Patient’s Journey: Pain Management

• Division strategy - standards, time scales, responsibilities

• Expert team at strategic level• Best practice• Education• Equipment• Improved patient care &

savings

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Any Questions?