Measurements of ‘Patient Centred Care’ in Anaesthesia Dr. Sujesh Bansal Consultant Anaesthetist...
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Measurements of ‘Patient Centred Care’ in Anaesthesia Dr. Sujesh Bansal Consultant Anaesthetist 18 th May 2015
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Transcript of Measurements of ‘Patient Centred Care’ in Anaesthesia Dr. Sujesh Bansal Consultant Anaesthetist...
Measurements of ‘Patient Centred Care’ in Anaesthesia
Dr. Sujesh BansalConsultant Anaesthetist
18th May 2015
• Why?
• What do we mean by– Measure of patient experience (Patient Satisfaction, PREMs)– PROMs
• Questionnaire?
• How many patients?
• REC?
Why?
“Patients will be at the heart of everything we do. .”
“Success will be measured, not through bureaucratic process targets, but against results that really matter to patients..”
Prime Minister, July 2010
Measures of quality of care will include patients’ own views on the success of their treatment and the quality of their experiences.
For the first time, patients’ own assessments of the success of their treatment and the quality of their experiences will have a direct impact on the way hospitals are funded (CQUIN).
Professor the Lord Darziof Denham KBE
NHS Operating Framework 2015/16
Evidence: Experience and Safety & Effectiveness
• There is positive associations between patient experience and the other two domains of quality (clinical effectiveness & patient safety)
– focusing on improving patient experience will increase the likelihood of improvements in the other two domains
• Negative association was rare
Doyle C, Lennox L, Bell D. BMJ Open 2013;3
• Weak positive relationship between PREMs and PROMs– Providers in top quartile for PREMs (all admissions) had outcomes
(PROMs) 2-4% better than providers in the lowest quartile
– A higher experience score of 1 SD (about 1.5 on a 10-point scale) was associated with about 30% less likelihood of the patient reporting a complication
– Improving patient outcomes can increase patient experience ratings by 10%
– Improving patient experience ratings will cause a 3% improvement on outcome scores
Black N, et al. BMJ Qual Saf 2014;0:1–9
Evidence: PROMs and PREMs
• 607 adult day case patients
• Day 1, 7 and 14: QoR 27 & Swedish PSRS • Day 1 and Day 30: EuroQol
• Recovery on day 7 was associated with health-related quality of life 30 days after the day surgery
• Assessment of QoR can be used to identify patients with risk of postoperative impaired HRQoL
Berg et al, BMC Nursing 2012, 11:24
Evidence: Recovery and Quality of Life
QUALITY
Mortality
Anaesthesia related mortality
Morbidity
LOS, Readmission rateITU/HDU admissions
Nerve damagePOMS
Patient Reported Measures
Quality of Recovery (QoR)Pain, PONV, temp control
FatigueEmotional well-being
Work status
Quality indicators in anaesthesia
Process
Evidence of SDMOn the day cancellationService efficiency data
Patient Reports (PR)
PROMsPatient Reported
OUTCOME Measures
How are you?HRQoL
Functional AbilitySymptoms
PREMsPatient Reported
EXPERIENCE Measures
What do you think?
Patient SatisfactionPatient Experience
Patient Satisfaction
Patient Experience
Objective experience of care i.e. what actually happened?
Avoid value judgements and the effects of existing expectations and remove the subjectivity associated with measures of satisfaction
Whether or not certain processes or events occurred at a specific point in time
Focus on aspects of the humanity of care
Patient Experience
Responses to these types of questions are intended to be factual rather than evaluative.
How long you waited after your appointment time before you were seen in the Preop clinic?
Patient Experience
Can help to pinpoint problems more precisely instead of asking patients to rate their care
Knowing more precise details what went wrong and monitoring trends in these indicators over time can be much more useful.
Discriminatory service, episode, clinician, hospital etc.
Patient Experience
Patient Satisfaction• Congruence between expectation and achievement i.e.
how well a patient’s expectations are met
• Subjective and often non-specific
• Evaluation of their experience based on their values, expectations, perception and interaction in hospitals – 91% of patients expected moderate to severe pain and 76%
reported such pain, only 8% were dissatisfied (Svensson et al, EJP 2001)
• Influenced by many factors:– previous experiences, media, cultural norms, health status
Assessed by questionnaire that has established validity & reliability
How satisfied are you with the amount of information provided in the preoperative assessment clinic?
How do you rate your doctor’s caring and concern for you?
Patient Satisfaction
Issue…
• Satisfaction tends to get high ratings even if experience is poor
• Clinician/service perspective• Global ratings do not reflect complexity of
modern care• Adequate or good quality?• Not discriminatory
Way going forward
• Use combination of experience & satisfaction– Experience - facts– Satisfaction – rating
• Triangulate from different sources – Surveys– Proactive patient engagement & Stories– Focus groups– Social media– Complaints
PROMsPatient Reported Outcome Measures
PROMs
“Any report coming directly from patients, without interpretation by physicians or others, about how they function or feel in relation to a health condition or its therapy”
(Patrick et al., 2007)
Patient’s view of their symptoms, functional status and health-related quality of life
Measure patient’s health at different time
Series of structured questions
PROMS: Types
• PROMs designed to measure dimensions of health– Biological– Social– Psychological
• Generic– EuroQol 5D-5L– SF 36
• Condition specific– UCLA Prostate– Oxford hip or knee
PROMS
• Advocated by DOH since 2008• National PROMs Programme– Mandatory since April 2009– Hip replacement, Knee replacement, Varicose
vein, Hernia– Questions before & after surgery– Preoperative & Postoperative Scores• Condition specific (Oxford)• Generic (EuroQol)
PROMs
• Scores compared before & after treatment or over a period of time
• Used – Referral threshold– Effectiveness of the intervention & Monitor LTC– Linking payment to quality & outcome - PbR – Benchmarking services & Comparing Providers– Informing patient choice (CaB)– Revalidation
PROMS: Concerns
• Return rate and sample size• Avoiding league tables• Data analysis• Triangulation• Performance management• Practicalities & Economics• Resources, Technology
Which Questionnaire?
Validated Questionnaire
• A validated questionnaire is one which has undergone a validation procedure to show that it accurately measures what it aims to do, regardless of who responds, when they respond, and to whom they respond or when self administered.
Validating a Questionnaire
• Item Generation
• Testing of Pilot Questionnaire (Reliability, Validity, Ease)
Validity (Content, Face, Criterion, Construct )
Reliability (Cronbach Alpha)
Acceptability (Time, Response rate)
• Retest FINAL Questionnaire
• Retesting of Pilot Questionnaire (Bias addressed)
Patient-satisfaction measures -SR
• 3,211 studies (full text) – 71 articles systematically reviewed, 34 questionnaires
• ISAS (Dexter et al)• Quality of preanesthetic visit (Snyder-Ramos et al)• Perioperative questionnaire (Capuzzo et al)• Perioperative questionnaire (Bauer et al)• LPPSq (Jlala et al)• Heidelberg Perianesthetic questionnaire (Schiff et al)
Barnett et al, Anesthesiology , Aug 2013
QoR (Day case) - SR
• 7 articles systematically reviewed– Not included scales used after 7 days
• QoR 40• QoR 9• Surgical Recovery Index• Postanesthesia Short-Term QoL• Postdischarge surgical recovery scale)
Harrera et all, A & A July 2007
Recovery specific QoL - SR
• 621 studies checked– 18 studies and 12 instruments reviewed– Twice within first 6 weeks of surgery
• QoR-40 – Reaches baseline at 1 month
• Postdischarge Surgical Recovery Scale– Day 2
• QoR-9• Surgical Recovery Index• Postoperative Recovery Scale• Systemic Symptom Index Kluivers et all, Surgery Feb 2008
• 13 & 14 May 2014
• 2 day UK-wide evaluation of patient reported outcomes after anaesthesia– Patient satisfaction after anaesthesia (Bauer)– Patient-reported awareness (Modified Brice)
• 265 LLI and 1369 LI
• 15,000 patients recruited
• Preliminary results presented March 2015
How many patients?
UK Parliamentary Elections 2015
• Election 2015– Total eligible voter = >46 millions– Voter turnout = 66.1% (>30 millions)– Parliamentary Seats = 650
• Exit polls– 20,000 voters polled (0.06%)– Only 140 polling stations
Conservatives Labour SNP Lib Dem UKIP0
50
100
150
200
250
300
350
EXIT POLLACTUAL POLL
REC Approval?
• Service Evaluation & Quality Improvement projects concerned with producing internal recommendations for improvements that are not intended to be generalised beyond the setting in which the evaluation took place should not be managed within the Research Governance Framework, and other appropriate systems should be used (e.g. QI, Audit etc)
• However, where it is intended to publish the results of an evaluation in a form that aims to generalise the results to others situations, the evaluation should be managed within the Research Governance Framework
REC Approval
Always take advice from Local RECand low threshold for REC application
Improved Patient experience & satisfaction
PATIENT FACTORS
• Information & Communication
• Continuity of care/Visits
• QoR (Incisional pain, PONV)
• Comfort & Support
• Reduced morbidity/Clinical outcome
• Individualised care (Only person in the room)
PROCESS FACTORS
• Efficient processes (one stop shop)
• Physical environment (cleanliness…)
• Perceptions (media, published results)
• Staff interaction (emotions, passion)
Your most unhappy customers are your greatest source of learning
Bill Gates
