Sharon Sykes Trainee Nurse Hysteroscopist Patient satisfaction survey April 2014 OPH Service Pinderfields Hospital Gate 22

Introduction Aim of clinical audit is quality improvement Clinical audit is a team endeavour It is a mainstream accountability and not solely clinician owned It is a quality management and governance activity alongside being a professional development activity (HQIP- Health Quality Improvement Partnership 2010)

Introduction Service was last audited 2012 for patient satisfaction and recommendations made were: More OPH can be done (capacity not addressed in this audit) Need to update patient information leaflets BSGE green top guidelines (March 2011) outlines Best Practice in Out Patient Hysteroscopy. A suggested audit topic area is Patient satisfaction – to review key elements of the service. The Best Practice areas we have reviewed in relation to this audit are as follows: Written patient information should be provided before the appointment and consent for the procedure should be taken. Women without contraindications should be advised to consider taking standard doses of non-steroidal anti-inflammatory agents (NSAIDs) around 1 hour before their scheduled outpatient hysteroscopy appointment with the aim of reducing pain in the immediate postoperative period.

The MYH Trust has its own agenda for ensuring standards of care: In line with our Vision and values we will strive to treat all patients, carers, visitors and staff with ‘Respect’ and dignity at all times, to put ‘Caring’ at the heart of everything we do, to ensure that ‘High Standards’ of patient services and experience are provided at all times and ‘Improving’ what we do is our constant ambition. The core values that were determined from this work are: Caring– ensuring quality of care is at the heart of everything we do High standards– taking responsibility for providing the best services and patient experience Improving– we always look for ways to improve what we do. We encourage involvement, value contributions and listen to and positively act on feedback Respect– showing value and respect for everyone and treating others as we would wish to be treated.

MYH Trust Quality account Priority 5: Improve outpatient scheduling, bookings and communications with patients Lead: Chair of the Integrated Care Division Sponsor: Chief Operating Officer / Deputy CEO

Aim The purpose of this audit is to review and improve the quality of OPH services through patient involvement

Objectives To review current standards of care as perceived by patients To compare the audit findings with previous audit undertaken in 2012 To reflect on audit findings and improve / make adjustments where necessary to offer high standards of patient focussed quality care

Method An audit period of April 2014 was chosen as all Hysteroscopists were available for clinical practice within this month - offering good representation of practice Potential of 147 appointment slots 10 patients Did Not Attend At least 10 patients excluded (time constraints, language barriers, clinical diagnosis) Final number not known Circulated the final draft questionnaire to all Hysteroscopists prior to the audit period for comment and amendments. We had a start date of 1st April for one calendar month Unit Manager was asked to make all nursing staff aware that were rostered into the clinic to encourage dissemination of the audit questionnaire to patients as the clinician may forget. We feel that this may not have happened in some clinics, lowering the overall response rate No exclusions in terms of procedures undertaken

Method Patients were asked by clinician or clinic nurse to anonymously complete the questionnaire immediately after their procedure, prior to leaving clinic and place them in a sealed envelope then in a sealed box in Gate 22 waiting area. They were assured that regardless of participation or response, their care would not be affected Response rate was 83 returned questionnaires The audit covered all aspects of hysteroscopy, including polypectomy (multiple and single), directed biopsies, pipelle samples, Essure sterilisation and fitting of Mirena IUS. NO Patients were recorded as having Essure sterilisation and completed a questionnaire

Results Results have been calculated on the number of responses completed for each question and as such the number of responses (N) vary as some patients did not respond to some questions but responded to others. A total of 83 women completed the questionnaire either fully or partially The figures in blue are results for same questions in 2012 audit- for comparison / information purposes

Before the appt When you received your appointment letter- did you receive OPH leaflet? Y= 70/76 (92%) N = 6/76 (8%) 67/71 (96%) 4/71 (4%) Did the OPH leaflet help you to understand what would happen at the appt? Y = 71/ 74 (96%) N= 3/74 (4%) 65/68 (91%) 3/68 (5%)

At your appointment If no please tell us why 71/71 100% Were staff polite and helpful during your visit? (yes / no / no contact) Reception Y= 81/82 (99%) N = 1/81(1%) NC= 0 Nursing Y= 81/81 (100%) N = 0 NC= 0 Doctors Y= 50/52 (96%) N = 2/52 (4%) NC= 28/81 NC- 28 attended nurse led clinics 70/71 (99%) 1/71 (1%) If no please tell us why Receptionist kept us waiting then snatched letter from me Was the procedure explained so you could understand what was going to happen? Y 81/83 ( 96%) N (0%) NR (4%) 71/71 100%

Were you given the opportunity to ask questions? Y 81/83 (96 %) N (0%) NR (4%) 70/71 (99%) 1/71 (1%) Were your questions answered in a way that was clear and understandable to you? Y = 73/73 (100%) N = 0 71/71 (100%) Did the staff respect your privacy and dignity? Y = 62/83 (74%*) N = 0 70/71 (99%) * All 62 respondents who answered the question said YES (100%) NO negative comments

The procedure you had today Did you take any pain relief prior to attending (as suggested in the OPH leaflet)? If yes- what did you take? How many hours prior to the procedure did you take the pain relief? Which procedure did you have today? Was the procedure more or less uncomfortable than you expected? Please indicate on the visual analogue scale what level of pain / discomfort you felt during the procedure (0- no pain- 10 worst pain ever)

Hysteroscopy and pain relief did you take any pain relief prior to attending (as suggested in OPH leaflet)? if yes: what did you take? how many hours (mins) before the appt did you take the pain relief? which procedure did you have done today? was the procedure more uncomfortable than you expected? VAS pain Y PARACETAMOL 60 HYSTEROSCOPY 9 120 7 IBUPROFEN N 2 NR 5 ZAPAIN 180 8 6 30 4 10 COCODAMOL 3 ANADIN EXTRA HYSTERSOCOPY 45 PARACETAMOL IBUPROFEN TRAMADOL 240

Hysteroscopy and No pain relief did you take any pain relief prior to attending (as suggested in OPH leaflet)? if yes: what did you take? how many hours (mins)before the appt did you take the pain relief? which procedure did you have done today? was the procedure more uncomfortable than you expected? VAS pain N NA HYSTEROSCOPY 3 5 NR 10 4 HYSTEROECOPY 1 Y 2 8 NO EXPECTATIONS 7 6

HYSTEROSCOPY POLYPECTOMY MIRENA Y 2 did you take any pain relief prior to attending (as suggested in OPH leaflet)? which procedure did you have done today? was the procedure more uncomfortable than you expected? VAS pain Y HYSTEROSCOPY DBX N 3 5 NR 4 did you take any pain relief prior to attending (as suggested in OPH leaflet)? which procedure did you have done today? was the procedure more uncomfortable than you expected? VAS pain Y HYSTEROSCOPY MIRENA N 4 NR 6 7 did you take any pain relief prior to attending (as suggested in OPH leaflet)? which procedure did you have done today? was the procedure more uncomfortable than you expected? VAS pain N HYSTEROSCOPY POLYPECTOMY MIRENA Y 2 6 did you take any pain relief prior to attending (as suggested in OPH leaflet)? which procedure did you have done today? was the procedure more uncomfortable than you expected? VAS pain Y HYSTEROSCOPY DBX POLYPECTOMY N 4

HYSTEROSCOPY POLYPECTOMY 3 6 did you take any pain relief prior to attending (as suggested in OPH leaflet)? which procedure did you have done today? was the procedure more uncomfortable than you expected? VAS pain Y HYSTEROSCOPY PIPELLE NR 1 N 3 did you take any pain relief prior to attending (as suggested in OPH leaflet)? which procedure did you have done today? was the procedure more uncomfortable than you expected? VAS pain N HYSTEROSCOPY POLYPECTOMY 3 6 Y 4 5 7 did you take any pain relief prior to attending (as suggested in OPH leaflet)? which procedure did you have done today? was the procedure more uncomfortable than you expected? VAS pain Y HYSTEROSCOPY POLYPECTOMY PIPELLE N 5

Hysteroscopy +/- procedure NO analgesia 37 pts in this group 25 women had hysteroscopy alone 12 women had hysteroscopy + procedure Hyst & dbx 3 Hyst & pipelle 1 Hyst & IUS 2 Hyst, Polyp, dbx 0 Hyst & polyp 4 Hyst, polyp, pipelle 0 Hyst, polyp, IUS 2 Average pain score 4.2 with a range of 0-10 common score was 5 Hysteroscopy +/- procedure taken analgesia 40 pts in this group 27 women had hysteroscopy alone 13 women had hysteroscopy + procedure Hyst & dbx 2 Hyst & pipelle 1 Hyst & IUS 1 Hyst, Polyp, dbx 1 Hyst & polyp 7 Hyst, polyp, pipelle 1 Hyst, polyp, IUS 1 Average pain score 7.1 with range of 0-10 common score was 5

Average time pre procedure for women who took pain relief (mins) Types of analgesia taken & average pain scores (irrespective of procedure) Paracetamol 23 (4.7) Ibuprofen 7 (3.4) Paracetamol + Ibuprofen 0 (0) Cocodamol 3 (6) Anadin Extra 1 (6) Zapain 1 (8) Paracetamol/ Ibuprofen/ Tramadol 1 (7) <<hysteroscopy >> Paracetamol / Tramadol 1 (5) Paracetamol 23 (70 mins) Ibuprofen 7 (62.5mins) Paracetamol + Ibuprofen 0 ** (0) Cocodamol 3 (150 mins) (1 non-responder) Anadin Extra 1 (60 mins) Zapain 1 (180 mins) Paracetamol/ Ibuprofen/ Tramadol 1 <hysteroscopy > (120 mins) Paracetamol / Tramadol 1 (30 /240 mins)

Was it more uncomfortable than you expected? 78/83 responses (64%) 22 yes 55 no 1 “no expectations” 5 non- responses

General information you had about the procedure in OP clinic today Have you ever had the procedure before? Y= 15/82 (18%) N=67 (72%) If you had the procedure again, would you prefer to be awake or asleep? Awake pref asleep= 2 Asleep pref awake =1 Spinal pref awake = 1 11= either no pref or awake

Who carried out your procedure today? Nurse or Doctor Don’t know 3 (3.6%) (slightly concerning!) No response 2 (2.4%)

Conclusions Caution should be given to VAS pain scores as pain is subjective- monitoring this in isolation lacks validity as there are external / back ground influences (prev experiences, lack of understanding, cultural, anxiety, pain thresholds, analgesia - type amount, timings). Score may not truly represent pain experienced at time of actual hysteroscopy but overall perceived pain experienced at the visit as questionnaire completed retrospectively Patients who took analgesia pre procedure did not have comparatively better pains cores on VAS than those women who didn’t take analgesia. Those women who did take analgesia- length of time between taking analgesia and procedure did not affect pain score positively. Suggesting that pain is both subjective and personal

The greatest difference between pain scores for the same procedure is as follows: Hysteroscopy + Mirena 2.5 Hysteroscopy + Pipelle 2 Hysteroscopy + DBX 1.5 2 negative comments in free text section: I had an hours wait- it may be worth revising the time required for procedures A very long wait 1hour 20 mins and the procedure took a good 30 mins. No-one is at fault for these delays- it was just a long time! 37 patients responded with praise and very positive comments about the care they had received Number of women receiving booklets pre procedure should be 100% and we have failed with 6/76 women who answered not receiving one

The staff who work in OPH services offer women a welcoming, supportive, informative service that allows women to feel at ease during an intimate and uncomfortable examination Reception staff are part of the team that patients meet on a daily basis and must also take responsibility for ensuring they are polite, professional and helpful at all times to women attending clinic. Patients will form their expectations based on first impressions and negative first impressions leave the clinician in a vulnerable and difficult position before they have undertaken the procedure 81 out of 83 women said they had had good clinical explanations about their visit and the procedure and that the information was given at a level they understood. There was no difference between nurse or medical clinician in counselling.

Keep the wonderful staff you have- they are brilliant Very quick, staff lovely and explained everything in layman's terms Keep the wonderful staff you have- they are brilliant Absolutely wonderful team- never felt so comfortable & at ease- keep up what you are doing Yes- it was excellent, the department nursing staff were extremely professional The staff and doctor was very helpful- happy to meet all of them, thanks Fantastic service- speedy, polite, kind, helpful, humorous, dignified and informative- THANK YOU Staff very helpful- explained everything. Procedure much better than expected I was absolutely terrified but all the staff were so friendly and caring, they really put me at ease

Recommendations The layout of the patient questionnaire when asking about privacy and dignity was poor- the question was at the top of the second page and separated from the rest of the section. This, I feel led to a poor response rate on this question and needs addressing if the questionnaire is to be used for repeat audit To ensure as many questionnaires are given out as possible to capture ALL clinicians for future audits To have robust guidelines in place to ensure all women receive a OHP pre procedure regardless of route of referral To amend the patient information booklet to suggest Ibuprofen is the recommended (evidence based) analgesia as opposed to Paracetamol but any analgesia is better than nothing if unable to take NSAID’s

Recommendations Time was mentioned negatively in two patients comments – as a team we must keep patients informed of any delays in clinic to ensure complaints do not ensue and to communicate positively with women and their families - delays are both inevitable and unavoidable at times and patients are more likely to be compliant and less angry if kept informed Development of a separate booklet may be useful for women attending for Essure sterilisation as the pre and post procedure advice / expectations are different To ensure OP Hysteroscopy leaflets are on MY Services web page

References RCOG / BSGE (March 2011) Green Top Guideline No 59 Best Practice in Outpatient Hysteroscopy www.midyorks.nhs.uk (search performed for patient information leaflets, Patients / Visitors and MY Services) HQIP- Health Quality Improvement Partnership (2010) www.hqip.org.uk Oppenheim A. N. (1992) Questionnaire design, interviewing and attitude measurement

Any questions?