Introduction to Outpatient Communication Kirsty Vickerstaff, GP NHS Highland Neil Houston, National Clinical Lead SPSP-PC

Aims of session Introduce the outpatient communication measures Discuss measures, operational definitions and rationale. Discuss data collection process and frequency Discuss ways to involve patients Share resources, challenges and learning

Outpatient Communication Measures - Which patients Any patient seen at any medical clinic Letter needed to suggest a new or a changed management plan 70% of outpatient letters are FIO

Outpatient Communication Measures Has the outpatient letter been reviewed by the appropriate clinician within 2 working days? ‘Appropriate clinician’ is defined as a GP/Pharmacist/Duty Doctor, for example however the practice process is set up for reviewing outpatient department letters. Has the change in management plan been clearly implemented? ‘management plan’ is defined as a course of treatment/medication advised by the consultant. This could involve the prescription of new medicines, changes to existing medicines (such as changes to dose or frequency) and the stopping of medicines that the patient has been taking prior to the clinic appointment. Is there documented evidence that the patient has been notified of the change in management plan? Have all measures been met? Was a forth measure around patient understanding but this was removed as not reliable and too difficult to test. Tine consuming

Outpatient Communication Measures Has the outpatient letter been reviewed by the appropriate clinician within 2 working days? ‘Appropriate clinician’ is defined as a GP/Pharmacist/Duty Doctor for example or however your practice process is set up for reviewing outpatient department letters. If practices encounter problems when GPs are out of the practice unexpectedly, for example on sick leave, it may be necessary to implement systems to overcome this, such as a ‘buddy system’ where each GP has a depute or buddy identified, so that the administrative team know who to pass the outpatient letter to when the named GP is off. Answer “Yes” if the record shows that the letter has been reviewed by the appropriate clinician (or their depute/buddy) within 2 working days of receipt. Answer “No” if the record shows that the letter has been reviewed by the appropriate clinician (or their depute/buddy) out with the 2 working days of receipt.

Communication Measures Outpatient Communication Measures M2 Has the change in management plan been clearly implemented? ‘management plan’ is defined as a course of treatment/medication advised by the consultant. This could involve the prescription of new medicines, changes to existing medicines (such as changes to dose or frequency) and the stopping of medicines that the patient has been taking prior to the clinic appointment. Answer “Yes” if the record shows that the patient is getting the treatment recommended by the consultant. Answer “No” if there is no record that the patient is getting the treatment recommended by the consultant. Answer “No” if the record shows that the patient’s treatment has not been changed following receipt of the letter. .

Communication Measures Outpatient Communication Measures M3 Is there documented evidence that the patient has been notified of the change in management plan? Answer “Yes” where there is evidence that the changes have been discussed with the patient and/or their representatives. Answer “No” where there is no evidence that the changes have been discussed with the patient and/or their representatives in the patient’s record. Tick n/a for all discharges where there are no changes to the medications.

Out Patient Communications Care Bundle Have all the above measures been met?   Answer “Yes” for all letters with all three “Yes” answers Answer “No” for all letters with any “No” answers.

Have all the bundle measures been met?

Data Collection Process and Frequency Data collection frequency – collect data on a random sample of 10 patients. This could be 10 per month or 5 every 2 weeks. We have different mechanisms for data collection and health boards will have the options of: Using a national web-based data collection tool developed by Healthcare Improvement Scotland Inputting data into spreadsheets developed for the bundle Adapt local systems to support data collection Further information on the data collection process is available from the SPSP-PC team.

The Model for Improvement ‘This model is not magic, but it is probably the most useful single framework I have encountered in twenty years of my own work on quality improvement’ Dr Donald M. Berwick Former Administrator of the Centres for Medicare & Medicaid Services Professor of Paediatrics and Health Care Policy at the Harvard Medical School The rationale for PDSA comes from systems theory and the concept that systems are made up of interdependent interacting elements and are therefore unpredictable and non-linear: small changes can have large consequences. Short-cycle, small-scale tests, linked to reflection, are seen as helpful because they enable health care teams to learn on the basis of action and its observed effects. The rapid cycle change model calls for sufficient (just enough) data to be collected to know if the change has resulted in an improvement. Changes are tested on a small scale, permitting experimentation and discarding unsuccessful tests. Numerous small cycles of change can successfully accumulate into large effects; for example, an intensive care unit could improve quality by working on a series of cumulative and linked PDSAs in different aspects of care at the same time e.g. respiratory care, medication use, and patient flow (Berwick 1998). In contrast to large-scale approaches, PDSA changes are small (therefore controlling risk and disruption), take minimal time, and require little financial investment with the majority of staff needing little formal training to proceed

Why Test Changes? To increase the belief that the change will result in improvements in your setting To learn how to adapt the change to conditions in your setting To evaluate the costs and “side-effects” of changes Overall it helps to minimise the resistance when spreading the change throughout the practice.

Outpatient Communication Measures – Data Collection Data collected is for local use, to allow practice teams to gain a better understanding of their systems and make the necessary changes. Data is displayed in a run chart and allows you to see improvements over a period of time. This is a vital piece of information sharing

SIPC Evaluation Impact More systematic approaches to processes, e.g patient monitoring/repeat prescriptions Better documentation Better communication of results Less Variation Proactive Educated patients Less stress Increased confidence in roles

Patient Involvement Encourage and support your practice teams to involve patients in their improvement journey. This can include: - Small tests of change – develop patient educational leaflets in conjunction with patients. - Process mapping and value stream mapping – understanding systems from patient perspective. - Patient Feedback – focus groups, questionnaires, make changes using small tests of change and ‘you said, we did’. NHSG did involve patients from the very start and together worked on wording of data collection forms an then a follow up questionnaire for the GP’s to initially use to see if the patient understood the changes in treatment plans etc. Was useful but too labour intensive for the GP’s to use as they were dragged into other conversations and it was felt to be inappropriate for the admin team to use so it was not really a good measure for us.

Feedback from a practice team involved in SIPCs 1 Responsive enthusiastic patients appreciate being involved “The main learning was that they appreciate being involved in their own care” “Barriers have just been ourselves”

How will you support your practices to involve patients? At your tables take 5 minutes to discuss how you could involve patients in the programme?

Sharing Successes, Challenges and Resources Some of our Challenges: Time Competing priorities Negative attitudes Understanding of tools and methods Struggling practices need support Sharing the information within practices – assumptions made that this was actually happening Time – to collect data can be challenging to engage all practice team members – need to collect data to hightlight value in investing time. Negative attitudes of lagards – just ignore and work with the willing!

SIPC Evaluation “Bundle” Challenges Can be disheartening when small numbers skew results & graphs don’t show gradual improvements “we all had bother with the composite bit of it understanding what we were actually to be putting in there” “the main strength is negative as well cause doing them every two or four weeks, that is quite a time commitment”

SIPC Evaluation Successes “they are straight forward, it is not too complicated” “it is a simple tool that highlights if there is a drop (in care) and why, it is visual because you can print it off” “the main strength is when you see them improving, it encourages you and motivates you”

“The care bundle was useful because it identified gaps” SIPC Evaluation “The care bundle was useful because it identified gaps” “You can see week by week, month by month, whether or not you are showing any improvement, we seem to be improving and that’s good” 24

Resources www.healthcareimprovementscotland.org/pspc/aspx 25

Resources www.knowledge.scot.nhs.uk/spsp-pc.aspx 26