Human centred design to improve healthcare NHS Expo

8 September 2016

Mobile Data-driven Unparalleled access

Design is problem solving

Image: 23andMe

Image: Wikipedia, public domain

Image: 23andMe

Image: 23andMe

DesirabilityHuman

FeasibilityTechnological

ViabilityEconomic

INDUSTRIAL DESIGN

VISUAL DESIGN

SERVICE DESIGN

DESIGN FORBEHAVIOUR CHANGE

INTERACTION

DESIGN

GRAPHICDESIGN

SYSTEMS/TECHNOLOGYDESIGN

ENVIRONMENTDESIGN

UX

DESIGN

Design is problem solving

9 / 10 of the lowest-rated cancer patient experiences are at large London NHS Trusts.2011/12 National Cancer Patient Experience Survey

Initial assessment may be done over the phone

About 1 in 20 women will be called back for further assessment.

(technical recall, area of concern, Normal but symptoms warrant clinical

+ Lump in the breast or axilla+ Ulceration+ Skin nodule+ Skin distortion+ Eczematous-like changes to the nipple, not just the areola+ Recent nipple retraction or distortion (less than 3 months)+ Unilateral nipple discharge which stains clothes Patient Asked about:

+ Age (risk increases with age)+ Lumps Other breast symptoms, such as:Ulceration, Skin nodules, Skin distortion, Nipple changes, Nipple discharge, pain, personal history of breast cancer

Refer to breast clinic for triple assessment (urgently)

Rout

ine

Scre

enin

g

20%

of b

reas

t can

cer p

atie

nts i

dent

ified

thro

ugh

rout

ine

scre

enin

g pr

ogra

ms.

Letter with appointment details

No

Review Medical History

General advice - Breast Aware Discharge to primary care

Is any additional information asked - when compared to visit to GP?????

ClinicalExamination

Patient should be seen within 2 weeks

PATIENT PROFILES

Women identified as being at higher risk, should be offered the opportunity to have their risk formally assessed and, where appropriate, to discuss their risk management options.

The National Health Service Breast Screening Programme offers three-yearly mammogra-phy.

Screening happens between 47-73 years of age

Around 1/ 3 of breast cancers are diagnosed through screening.

Patie

nt h

as C

onc

ern

80%

of b

reas

t can

cer p

atie

nts i

dent

ified

afte

r visi

t to

GP w

ith

Patient arrives at reception

Gen

eral Practitioner

Family History Review

+ Names and ages of all your family members who have had breast cancer (including men)

+ Any cancers your relatives have had

+ The age they were diagnosed

Yes

+ Unknown family history (adopted) may seek testing for genetic mutation

Gen

etic Counsellor

+ Breast cancer diagnosed before age 50 years+ Cancer in both breasts+ Both breast and ovarian cancers+ Multiple breast cancersTwo or more primary types of BRCA1- or BRCA2-related cancers in a single family member+ Cases of male breast cancer+ Ashkenazi Jewish ethnicity

FAMILY HISTORY CLINICGENETICS TEST (Tertiary Care)

SECOND STAGE SCREENING Triple assessment - Clinical Examination + Imaging + Cytology Each examination given offered a different perspective Hospital or breast clinic (All scans + tests are normally done in one day)

Undresses in changing room

A paper gown may be offered to the patient

Patient arrives for consultation

ASSESSMENT (ROUTINE)Routine screening for women (usually) with no signs or symptoms of breast cancer.Screening may take as little 5 minuets, visit will last for 30 minuets or longer

Patient arrives at reception. Patient is given a questionnaire to fill out

Patient undresses in changing room

A paper gown may be offered to the patient

A female nurse feels for any enlarged lymph nodes under arms and base of neck and around the breasts

Physical Examination in examination room

During the mammogram each breast is placed in turn on the x-ray machine and gently but firmly compressed with a clear plate. The compression only lasts a few seconds and doesn't cause any harm. It's needed to keep the breast still and to get the clearest picture with the lowest amount of radiation possible.

Mammography (x-ray) in examination room.

Breast care nurse explained reason for recall and the tests (that may be required (patients expected pathway).

Occasionally, the need for more tests is due to technical reasons; for example, if the mammogram picture was not clear enough. Around 2 women in every 100 (2%) are called back for technical reasons.

Breast care nurse explains the need for test

Patient book appointmentPatient receives referral letter

Screening Leaflet

Letter outlines what the patient can expect - Length of wait, result

Be Breast Aware leaflet

http://www.cancerscreen-ing.nhs.uk/breastscreen/publications/-breastaware.pdf

Touch Look Check by breakthrough

breakthrough.org.uk/tlc

After your breast screening appointment - what happens nextInfo for patients relatives and carers

Feedback form

QuestionnairePersonal information, Past medical history, Current medical history, Ethnic Origin

Touch Look Check breakthrough.org.uk/tlc

by breakthrough

Be Breast Aware leaflet

http://www.cancerscreen-ing.nhs.uk/breastscreen/publica-tions/breastaware.pdf

CLINICAL BREAST EXAMINATION (PRIMARY CARE)Assessment by primary care to - Check for - lumps & physical changes Goal - Early detection

Patient - Male

???????

Refer to family history clinic (Genetics)Yes

No

No

No

Could the abnormality have been caused by by the menstrual period

Yes

Notes added to patients record / file

Scans reviewed by two radiologists.Radiologists Radiologists

Brea

st Care Nurse

Patent finds a sign of breast cancer

Patient arrives / enters assessment room

Personal details + Past + current medical history.

Brea

st Care Nurse

Other literature - Breast implants and breast screening leaflet

Patient gets dressed / leaves clinic

Scans

1

Patient follows signs to ward/ checks in with reception

Patient fills out questionnaire Personal details + Past + current medical history

Patient may be approached bya research nurse and asked ifshe would like to take part in a study?

Patient will be asked to prepare some information for appointment / to discuss their family history with relatives

General advice - Breast Awareness

Wait in waiting room

Patent has concern based on family history, age or medication

Estimating carrier probability and offering genetic testing

Patient follows signs to ward/ checks in with reception

Results Letter

Referral to triple assess-ment clinic

Further investigation required

DischargeResults clear

Outcome communicated to Patient and GP

2 - 4 weeks Wait for results letter

Patients get confused about where screening room is / who to approach on entering the clinic

(Charing cross - Mammogra-phy)

Re

sults letter

Discharge

Return for re-examination in 2 weeks

Same day / Same week

Patient is asked if there is a personal / Family history of breast cancer?

No longer than three weeks between the mammogram and

the breast clinic appointment.

Examination - Are symptoms suggestive of breast cancer?

Patient book appointment with GP / Goes to a dropin clinic.

Patie

nt - Personal history

Scheduled for screening ever 6 months - 1 - 3 years

Patient finds symptom of possible breast cancer

Patient - Over 70

Entitled to routine screening (every 3 years) on request.

Scedualed for screening ever 3 years

Patient (47+)

Patient finds symptom of possible breast cancerPa

tient

- Found Early Sign

Family History

Patient finds out that a member of their family has or had breast cancer.

Women - 1 in 8

Men - 1 in every 1000

Patients follow lines painted on floor to guide them to appointment room. Lines are only 1 cm wide and hard to see

Letter sent to patient “Thank you for attending your breast screening appointment,. our screening images have been looked at and require further assessment as part of routine (or second stage) screening. the majority of women recalled for assessment are found to have normal breasts”

Direction leaflet

Cancer Research letter

leaflet “Your appointment at the breast assessment clinic”

The waiting area can cause frustrating , Patients from different wards can appear to jump the queue - DC (A plasma screen is being considered to show patient's position in the queue)

Patients must have a moderate or strong family history of breast cancer to be referred - (High risk group)

In some situations the GP may ask you to go back again in a couple of weeks time. This is because some non cancerous breast tissue changes naturally disappear after a menstrual period.

Yes

Changes to look out for - + Appearance. + Feelings. + Lumps. + Nipple change.

Lifestyle advice+ Alcohol+ Smoking, + Weight, + Hormone Replacement + Therapy+ Breastfeeding+ Hormonal Contraceptives

Info delivered in verbal & written form

NHS Genetics Testing Networkhttp://ukgtn.nhs.uk (not confirmed as supplied to patients)

GPs don't always follow referral guidelines, causes unnecessary anxiety

Scre

ening letter

Breast Cancer Patient Pathways

Imaging and

assessment

Diagnosis MDT

Therapy

KEY

Clinic

If further surgery needed

MDT

Multi-disciplinary

team meeting

(patients do not attend)

Results /

treatment

plan

Holistic

needs

assessment

Clinical reviewNeo adjuvant

therapy

Chemotherapy

Radiotherapy

Hormone therapy

Pre-surgery

assessmentSurgery /

reconstruction

MDT

Post-op

results

Adjuvant therapy

Chemotherapy

Radiotherapy

Hormone therapy

Reconstruction

if not done in

original surgery

Hospital follow-up Imaging /

clinical check-up

Six months after

surgery, then yearly

for five years

PATHWAY PLANNERA VISUAL GUIDE TO YOUR CARE

BREAST

PATHWAY PLANNERA VISUAL GUIDE TO YOUR CARE

BOWEL

PATHWAY PLANNERA VISUAL GUIDE TO YOUR CARE

BRAIN

PATHWAY PLANNERA VISUAL GUIDE TO YOUR CARE

PROSTATE

5.5m Asthma sufferers in

the UK

75% Asthma hospital admissions are

avoidable

90% Deaths due to

asthma are avoidable

£1bn Cost to NHS for

asthma treatment

MILD

MODERATE

SEVERE

CONTROLLED PARTLY CONTROLLED

POORLY CONTROLLED

2/3 people do not fill in their Asthma

Action Plan

32

Floot

Problem Solution

Design research ≠ focus group

Extreme “Normal” Extreme

JANE! VIDUR & SABITA! RICK!

ROBIN! ALISON!

Participates religiously

Never heard of bowel cancer

JANE! VIDUR & SABITA! RICK!

ROBIN! ALISON!

Physically difficult to do the task

alone

Extreme use cases fuel creative

thinking

1. Problem

2. Hunt statement

3. Super users

Referral to treatment times need improvement

We are going to research patient involvement in pre-assessment so that we can better engage them before a procedure

– Carer turned patient – Heavy drinker – Flight attendant