Making the Experience of Elective Surgery Better
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Open Access Quality improvement report BMJ Open Qual: first published as 10.1136/bmjoq-2017-000079 on 9 August 2017. Downloaded from Making the experience of elective surgery better Tajinere Fregene,1 Sarah Wintle,2 Vishal Venkat Raman,1 Holly Edmond,3 Shoaib Rizvi1 To cite: Fregene T, Wintle S, ABSTRACT five domains in the National Health Service Venkat Raman V, et al. Making Objective Patient experience is one of the three pillars (NHS) Outcomes Framework, which is a set the experience of elective of quality in healthcare; improving it must be a key aim surgery better. of indicators that measure performance and BMJ Open Quality if we are to make the overall quality of the healthcare we 2017;6:e000079. doi:10.1136/ is the primary mechanism of accountability 6 bmjoq-2017-000079 provide better. in the NHS. It therefore follows that efforts Methods We devised a quality improvement project made to provide a good patient experience ► Additional material is to improve the patient experience of elective surgery. are to the benefit of both the patient and the published online only. To view We conducted surveys of patients and assessed their please visit the journal online experience by using semistructured interviews and patient organisation. (http:// dx. doi. org/ 10. 1136/ questionnaires. We gathered data about their overall Coming to hospital for elective surgery is bmjoq- 2017- 000079). satisfaction, fasting times and their communication with undoubtedly a stressful time for many people. staff. We used this information to inform strategies aimed There is some evidence to show that patients Received 10 April 2017 at improving patient experience. with less anxiety before their surgery feel less Accepted 22 June 2017 Results Our initial results showed that patients who pain postoperatively and their wounds may had their operations later in the day were significantly heal more quickly.7 8 When a poor service is less likely to report a positive experience. We found the provided, it costs more money and is linked to main reasons for this were long waiting times, poor decreased staff satisfaction.9 One could argue communication and prolonged fasting. We implemented that, as healthcare providers, it is our duty to changes over ‘Plan, Do, Study, Act’ cycles, including strive to give our patients a good experience copyright. (1) staggering patient arrival times, (2) introducing the concept of the 'Golden Patient', (3) having a single point of as part of our delivery of high quality care. In contact on the day surgery unit to communicate between the paper, ‘High Quality Care for All,’ Lord theatre staff and patients, (4) using the WHO checklist Darzi states “Quality of care includes quality of to finalise list order, and (5) altering patient information caring. This means how personal care is—the letters to include the possibility of a wait on the day of compassion, dignity and respect with which surgery. patients are treated. It can only be improved http://bmjopenquality.bmj.com/ Conclusion This project increased the percentage of patients by analysing and understanding patient satis- reporting an ‘Excellent’ or ‘Good’ experience from 65% faction with their own experiences.” 10 to 96%. In addition to improving our patients' experience, If we are to improve the overall quality of our project has also delivered shorter waiting times, better the healthcare we provide, improving our dissemination of information and fewer patients reporting patients’ experience must be one of our key hunger or thirst. aims; however, if we are to improve patient experience, we must first measure it. Previ- PROBLEM ously, measurements of patient experience Patient experience is one of the three pillars have not been considered as important as of quality in healthcare.1 2 If healthcare some other outcome indicators10 but, in a on September 28, 2021 by guest. Protected organisations are to improve the quality of review of the subject, Manary et al state “the 1Royal Free Perioperative medicine and Anaesthesia care they provide; then efforts to improve available evidence suggests that measures Quality Group (RoFPAQ), Royal their patients’ experience must be integral to of patient experience are robust, distinctive 11 Free London NHS Foundation any quality improvement plan. indicators of health quality.” Trust, London, UK Improved patient experience is not only 2 Anaesthesia, University linked to increased satisfaction; there is College London Hospitals NHS BACKGROUND Foundation Trust, London, UK evidence that organisations which emphasise 3Anaesthesia, Christchurch this have better outcomes in terms of patient The Royal Free London NHS Trust is a large, Hospital, Christchurch, New safety and clinical effectiveness, the other acute trust in North London. It comprises Zealand two pillars of quality.3 Good patient expe- three hospitals: the Royal Free Hospital rience is associated with a shorter length of (RFH), a large teaching hospital which Correspondence to Dr Tajinere Fregene, Royal Free stay, lower readmission rates and a lower cost performs approximately 11 500 elective oper- 4 5 London NHS Foundation Trust, per patient. ‘Ensuring that people have a ations per year (personal communication UK; taj. fregene@ nhs. net positive experience of care’ is one of the from Mr S. Smith, 2016), and two district Fregene T, et al. BMJ Open Quality 2017;6:e000079. doi:10.1136/bmjoq-2017-000079 1 Open Access BMJ Open Qual: first published as 10.1136/bmjoq-2017-000079 on 9 August 2017. Downloaded from generals, Barnet Hospital and Chase Farm Hospital (CFH). One of the Trust’s governing objectives is ‘to provide excellent experience for our patients and staff’ and one of its annual objectives is ‘to be in the top 10% of all providers for patient satisfaction and experience.’12 13 Our project focused on the RFH and the CFH sites because this is where the majority of elective surgery is performed. While there was anecdotal evidence of good patient satisfaction with our service, there had not been any in-depth fact-finding about what our patients really thought about their care. The process on the day of elective surgery had been tailored primarily for the convenience of the staff. At the RFH, patients were typically asked to arrive at the hospital at 07:30, irrespective of the time of their operation and it was common for them to have fasted longer than neces- sary,14 as is common in many hospitals.15 We developed a quality improvement (QI) project that would take an in-depth look at the experience of our patients and produce both quantitative and qualita- tive results. We then used QI methodology to institute changes designed to improve the experience of elective surgery for patients at the Royal Free Hospital. BASELINE MEASUREMENT In July 2015, we conducted a one-day survey of patients copyright. on the Day Surgery Unit (DSU) at the RFH.16 The Figure 1 Satisfaction scores in 2015 by time of day. patients surveyed were those scheduled to have general anaesthesia on an all-day theatre list which had at least and qualitative information about their experience of the two patients on it. We assessed the experience of those elective surgical process. patients by using semistructured interviews and a patient We also conducted audio or video interviews with those http://bmjopenquality.bmj.com/ questionnaire. Patients were asked questions about their patients who consented to this. overall satisfaction, fasting times and their communica- This information gave us insight into the reasons behind tions with staff. our patients’ experiences and we used this to devise and This baseline measurement found that 65% of our develop potential ways to improve the service. We fed patients rated their experience as ‘Excellent’ or ‘Good.’ back the information about our patients’ experience, When results were analysed by time of day, we found that including the video interviews, to relevant stakeholders 71% of patients who had their surgery before 12:00 rated such as the Theatres Strategy Group, the Anaesthetic their experience as ‘Excellent.’ However, of those who Department and the DSU nurses. We collaborated with had their surgery after 1500, 80% rated their experience these stakeholders to make changes. as ‘Average’ or ‘Poor.’ People having their operations We used a series of PDSA (Plan, Do, Study, Act) cycles on September 28, 2021 by guest. Protected after 15:00 were significantly more likely to report an to improve patient experience in a strategy that included ‘Average’ or ‘Poor’ experience (p=0.01) (see figure 1). all team members in a multidisciplinary approach. PDSA cycles were implemented over a matter of weeks or months. DESIGN The baseline data collection showed that the processes on DSU worked well for some patients, but poorly for others. STRATEGY Those who had their surgery very soon after arriving in PDSA cycle 1: engaging the multidisciplinary team the hospital had a more positive experience. We spoke to all the nurses on the DSU at the RFH site. We We went to the DSUs at the RFH and CFH and spoke used a combination of written surveys and unstructured to the patients about their experiences. As with the interviews, then analysed their comments and suggestions baseline surveys, we spoke to those who were scheduled about how to improve the patients’ experience on their to have general anaesthesia on an all-day theatre list day of surgery. We then presented the findings of both the which had at least two patients on it. We asked them to patient and staff surveys to the Theatre Strategy Group, complete a questionnaire that would elicit quantitative the Head of Nursing and the Anaesthetic Department. 2 Fregene T, et al. BMJ Open Quality 2017;6:e000079. doi:10.1136/bmjoq-2017-000079 Open Access BMJ Open Qual: first published as 10.1136/bmjoq-2017-000079 on 9 August 2017.