BPS SIGOPAC Bristol October 2016 - Dr Sue Smith & Dr Anna Janssen

showing we make a difference: quality, value and outcomes

Dr Sue SmithConsultant clinical psychologist

Dr Anna Janssen clinical Psychologist

POST (psychology support in cancer), Dimbleby Cancer Care

Guy’s and St Thomas’ NHS foundation trust

OVERVIEW

•Setting the Scene: using psychological resource within a

cancer context

•Quality and outcomes: creating a meaningful focus

•Using outcomes to inform service development

PART ONE: SETTING THE SCENE

A CANCER DIAGNOSIS IS DISTRESSING•A threat to self and others (real or imagined)•Connects with loss, death and dying•Experience brutal and toxic treatment regimes•Live with treatment affects, e.g. pain, fatigue, change in appearance•Many decisions, many appointments

A CHANGING LANDSCAPE: THINGS WILL NOT BE THE SAME AGAINLoss, feelings and re-evaluation •Physical health •Self and identity•Beliefs, values, behaviour •Relationships

MANY VIEWS,MANY RESPONSES •Our individual experiences of illness/ health•Past and present experiences we have with friends and family•Social, cultural, politics and faith•Some gain dominance, others hidden

YOU ARE NOT THINKING WHEN SOMETHING HITS YOU

And so…Need to make sense all over time

Integrate and story the experiences for self and with others

How we make sense differs…as will what helps

No size fits all…Harness the wisdom of our systems: Patients, colleagues, one another.

What might be helpful/useful right now and over time?

Telling that which might not get told

A SERVICE RESPONSE: DIMBLEBY CANCER CARE

We work across the cancer pathway: with patients, friends, family and staff

Relapse

Meaningful outcomes for staff and patients

-Improved experience -Enhanced and meaningful engagement with care-Increase confidence and competence of dealing with distress-Making sense of loss-Informs service development

Therapy:-Patient and significantly involved others-Group therapy-Specialist therapy e.g. psycho-sexual

Psychological knowledge and

resource

Package of suggested support for staff:-Nurses-Doctors-Allied Health Professionals (AHPs)-other

Key target groups:-Senior staff-Junior staff

Level 2 CNS

Tailored training

De-brief and consultation Ad-hoc

Supervision

Psychological knowledge a resource for patients and staff

A range of Psychological

therapies6.4 WTE

Clinical psychologyCBT, ACT, complex concerns, systemic approaches2.0 WTE

Psychosexual

therapy0.6 WTE

Counselling & psychotherapy0.6 WTE

Fear of recurrence therapy group

Family interventions

Area to broaden beyond prostate cancer to Gynae

Triage, Audit, outcomes

Existential psychotherapyEOL, death/dying1.4 WTE

Bereavement Therapy

Men’s therapy group

Psychiatry0.1 WTE

Assistant psychologist0.8 WTE

Supervision of psych colleaguesSupervision of medical and AHP staffTraining-Level 2 and tailored (to be developed)

PART TWO: CREATING AND SHOWING QUALITY AND OUTCOMES

Co creating a focus: the process of creating outcomes

Agreeing outcomes:

Getting it done, using it meaningfully

CREATING A FOCUS, CREATING CHANGECollaborating as a team-the team is our resource

Assistant Psychologist, Lead and Clinical Psychologist (research and outcome lead) guided the process

Use a systemic approach to guide the process

OUR POSITION

Honour multi-therapy approach, honour those using our service, honour those commissioning our service

Meaningful, useful, and know our limitations

Inform service development and showcase what we do, i.e. visibility, telling our service users’ stories

Understanding our various audiencese.g. patients/friends family, Trust, commissioners

Learning from what has not worked

SHOW AND TELL: WHAT WE DO EffectivenessGHQ and SRS and qualitative feedback Safety and equitableChange our MDT structure, include monthly outcome meetings Timely and responsiveness: Focus on demand and DNA’s: 8 sessions, introduce triage Patient centered: Triage, patient survey, flexibility of approach/appointment Efficient, using our resource wisely: organisational levelStaff supervision, Level 2 training, de-briefs

Organised using BPS, DMQ in psycho-oncology, 2015

PART 3: WHAT WE SHOW Monthly outcome meetings:

SRS, GHQ Referrals (Outpatient, inpatient, Carer/patient; individual or

couple Staff training and supervision outcomes Meeting informs next steps, future focus

Blogs Case studies

SESSION RATING SCALE: 2014-PRESENTSignificant differences: •start - mid-therapy•mid - end of therapy

SRS MEAN SCORES: 2014-PRESENT

SRS Mean Scores

9.27

8.91

9.11

9.92

9.27

9.19

9.3 9.32

9.439.38

9.469.43

8.4

8.6

8.8

9

9.2

9.4

9.6

9.8

10

Relationship Goals/Topics Approach/Method Overall

Mea

n StartMidEnd

Significantdifference: mid - end all start – end all

mid – end

GHQ12 Mean Total Scores over the Course of Therapy

18.29

6.02

3.07

0

2

4

6

8

10

12

14

16

18

20

Start Mid End

Time

Mea

n

GHQ-12 MEAN SCORES ACROSS DOMAINS: 2014-PRESENT

QUALITATIVE FEEDBACK, BLOGS AND CASE STUDIES

“These psychotherapies sessions has helped me immensely to cope with CANCER, all my fears about cancer and been able to accept it a bit more and move on. Thank you all from Dimbleby Cancer Care”

“I think these therapy sessions are helping in dealing with my chemo and wider issues to do with coping with the whole idea of cancer = death”

“I have reached a point where I feel I have been listened to and understood. I have been able to explore all the feelings and issues that crowded in on me when I lost my husband. I can move forward confidently and positively and can face the issues that are affecting other members of the family”

SHOWINGVALUE

Clinical Area Frequency and duration

1. Direct Patient Activity (N= ) Hours spent

TRIAGE

Referrals received

Contacted

Declined

Not able to contact, letter sent

Allocated

Triaging calls

OUTPATIENT THERAPY

1st apps offered

1st app seen

1st app Canx

1st app DNA

Follow-up seen

Follow-up Canx

Follow-up DNA

INPATIENT PSYCHOLOGICAL INPUT

Referrals received

1st Seen

Follow-up

Declined

Staff liaison/support relating to inpatient

OTHER PATIENT ACTIVITY

Support Groups

Health and Well being events

2. Indirect psychology activity

Staff training

Staff supervision

CNS

Psychologist/therapist

Other

Staff de-brief/consultation

Response to crisis

Pre-planned regarding complex patient

MDT attendance (other than POST)

Outcomes showing we make a difference in a variety ways additional to 1:1 outpatient and inpatients therapy

•Teaching / training•staff support (debriefs etc)•Staff supervision •consultation re. patients•Support groups•therapy groups•Health and Wellbeing Events

Routinely collected on a monthly basis

SHOWING QUALITY OF SERVICE DELIVERY Survey: patient/carer satisfaction 2016

(n= 100 outpatients)

Patient Age

55-7434%

75+1%

Unanswered9%

Under 181% 18-34

12%

35-5443%

Showing quality of Service DeliverySurvey: patient/carer satisfaction 2016(n= 100 outpatients)

Patient Sex

Male27%

Female64%

Unanswered9%


Was the Waiting Environment Comfortable?

Definitely70%

To Some Extent29%

Unanswered1%


Was There Enough Privacy During Consultation?

Always98%

Unanswered2%


Would You Recommend This Service to Family/Friends?

Definitely91%

Probably8%

Unanswered1%


Patient Appointments

97.1

9.8

92.2

2.9

86.3

23.9

5.9

0

10

20

30

40

50

60

70

80

90

100

Offered Choice of Appointment Time Appointment Altered by Service Seen on Time

Perc

enta

ge YesNoUnanswered


Therapeutic Relationship

97.1 97.1

2.9 2.9

0

10

20

30

40

50

60

70

80

90

100

Confidence and Trust in Therapist Dignity and Respect from Therapist

Perc

enta

ge

YesUnanswered


Service Information

82.4

86.3

1

6.97.8 8.86.9

0

10

20

30

40

50

60

70

80

90

100

Queries about Psychological Therapies Appropriately Dealt With Provided with Contact Information

Perc

enta

ge YesNoTo Some ExtentUnanswered


Significant relationships of potential interest:

Privacy - Trust in TherapistPrivacy - Dignity MaintainedDignity Maintained - Trust in Therapist Dignity Maintained - whether patient would recommend service Trust in Therapist - whether patient would recommend serviceEnvironment - whether patient would recommend serviceQueries appropriately dealt with - whether patient would recommend service

Current concern: Demand and DNA

NUMBER OF REFERRALS 2006-2016Increased

No. of Referrals 2006 - 2016

431557

722859

926 904

1082 1063

1297

1695

886

0

200

400

600

800

1000

1200

1400

1600

1800

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Year

No.

of R

efer

rals

Number of referrals : 2010-2016Number of Referrals

862 889

1030

1135

1253

1545

1191

1588

0

200

400

600

800

1000

1200

1400

1600

1800

2010 2011 2012 2013 2014 2015 2016 (until endSept)

Year

ActualExpected

OUTCOMES: AUG 2015 AND AUG 2016

August 2016 August 2015

Inpatient referrals 9 6

Outpatient referrals 116 118

New Appointments Attended 90 71

New Appointments DNA 19

(17.4% DNA rate)

6

(7.8% DNA rate)

Follow-Up Appointments Attended 174 219

Follow-Up Appointments DNA 21

(10.8% DNA rate)

21

(8.8% DNA rate)

Total Appointments Attended 238 290

DNAS

DNA % Rates 1st Appointment

6.7

10.411.5

15.814.8

13.2

5.8

13.1

9.6

2.8

9.48

12.6

19.418.3

17.3 18.1

23.4

11.76

14.313.13

11.96

14.1 14.8

0

5

10

15

20

25

2011 2012 2013 2014 2015 2016

Year

%

CounsellorPsychologistsPsychotherapistAverage

Stable over the last 5 years, ranging from 11 – 14%.

DNAS: 1ST APPOINTMENT & FOLLOW-UPJan – Sept 2016 DNA Rates 2016

20.9

13.33

9.09

18.6

20.2921.13

22.95

20.88

23.68

10.33

9.38

11.76

14.42

8.659.47

7.18

11.23

10.27

0

5

10

15

20

25

Jan Feb Mar Apr May Jun Jul Aug Sep

Month

DN

A R

ate

(%)

NewF/U

IMPACT OF DEMANDAverage Number of Days Between Referral and Assessment

0

21.64

44.82

0

14.35

51.24

18.48

11.61

0

10

20

30

40

50

60

Referral First Contact Attempt Phone Triage Assessment

Num

ber o

f Day

s

20152016

RESPONSE TO DEMAND AND DNAS•Introduce triage - no impact on DNA rates

•Introduce text reminders, which has had no impact on DNA rates

•DNA Audit - no conclusive information regarding the variables influencing the likelihood of a DNA

•Increased assessment slots

•Psychiatry introduced telephone follow-up

Next steps Audit referrer behaviour

Who is referring and for what reason? Use to inform a meaningful response

Focus on routine patientsPilot an Opt in for routine referrals

Identify specific measures for specialist therapies

OPT-IN PROPOSALDNA Referral demand Patient experienceReduce DNA rates, which reached a high of 21.1% for new appointments in the month of May 2016.

Assess 20 more people a month if our first assessment DNA’s were reduced to below 5% (based on the DNA figures for may)

Increase interventions that could be delivered by a band 5 and / or trainee that patients could attend instead / before / after 1:1 therapy

Reduce Follow up DNA Rates Approx 45% of those referred are not being seen (Due to failed contact / Declined / DNA)

Patient experience would be improved if a strategy shortened the wait for assessment slots (Informal patient complaints have risen)

Increase in clinical time from Band 5 Assistant Psychologist. Therefore increasing through put of routine patients

An Opt in could be more convenient for patients who cannot answer telephone calls immediately. Each day, at least 1 hour a day is spent by triage leaving voicemails etc

Approx 1/3 of all patients referred decline / failed contact at triage. Each failed contact / declined referral takes minimum of 10 minutes to process.

National Cancer Survey 2016 – Points to patients requesting more input for anxiety, worry and depression management earlier on. Similar informal feedback has also been given at health and well being events attended by POST. We could address this if current DNA and demand managed differently

The MacNamara Fallacy -Yankelovich

“The first step is to measure whatever can be easily measured.

This is OK as far as it goes.

The second step is to disregard that which can’t be easily measured or to give it an arbitrary quantitative value.

This is artificial and misleading.

The third step is to presume that what can’t be measured easily really isn’t important.

This is blindness.

The fourth step is to say that what can’t be easily measured really doesn’t exist.

This is suicide.”

SUMMARY AND CONCLUSION We need to ‘show and tell’ the

stories that get lost Capture the richness of our various

approaches and collaborations: with staff, patients, friends and family

Show what is special/unique about our interventions

Know when we get it wrong and show curiosity in our responses

SUMMARY AND CONCLUSION Distress is a normal human

response to a significant life event such as a cancer diagnosis

We have a responsibility to those we support, and professionally, to not pathologise or medicalise the distress and behaviours which may be experienced and shown

BPS SIGOPAC Bristol October 2016 - Dr Sue Smith & Dr Anna Janssen

Healthcare

Transcript of BPS SIGOPAC Bristol October 2016 - Dr Sue Smith & Dr Anna Janssen