Outpatients – the enigma Enhancing the Outpatient/Client Experience – through Staff Development,...

Outpatients – the enigma

Enhancing the Outpatient/Client Experience – through Staff Development, Service Improvement & User

Engagement/ Involvement Barbara McDowell Anderson

South Eastern HSC Trust

Leading Care, Leading Teams – Shaping the FutureWard Sister/Charge Nurse and Team Leader Conference, 17th April 2013

Outpatient Nursing… it is more than:• Directing ‘lost’ patients and visitors• Forwarding phone calls to relevant departments• Handling patient records• Chasing up missing notes/ results/ doctors• Setting up before clinics• Chaperoning doctors during consultations• Clearing up after clinics• Handing out leaflets• Making review appointments


Outpatient Nursing… in SET includes: • Routine clinic ‘work up’ – ECG’s/ spirometry/ bloods• Ophthalmology – pre and post op assessment/ review

clinics• Urology – flow clinics• DVT/ VTE - risk assessment/ prophylaxsis treatment• Anticoagulant (Warfarin ) clinics• ENT – micro-suction clinics• Gynae – Pessary assessment clinics• ED – injection clinics• Diabetic clinics• Dermatology clinics


Dermatology Service in SET• Integrated team– Hospital Clinicians – Consultant/ Associate

Specialist Registrar/ Staff Grade Doctors– Hospital Specialist Nurses– ICATS – GPwSI– ICATS – Specialist Nurses– GP’s– Outpatient Nurses • a ‘general specialist’ or a ‘special generalist’


Dermatology – nursing

Staff Training• Commissioned

courses - academic base

• Study Days• Workshops• ‘In-house’/ ‘on

the job’ training

ServiceImprovement• Establishment of a

variety of nurse led clinics• Patch Test Clinics• Cryotherapy Clinics• Roaccutane Clinics• Biologics Clinics• PUVA/ UVB Clinics• PDT Clinics• Botox Clinics• ICATS Clinics

UserInvolvement• Patient • Questionnaires• Patient Stories• User Involvement

• Staff • Team Meetings • Supervision• Sharing Successes


Nurse-led Patch Testing ‘allergy’ Clinics• Dermatology Consultants refer

patients to Nurse Led Patch Testing Clinics

• Appointments arranged• Nurses prepare allergy tests in

advance• Treatment explained & test

strips applied• Patient attend 48 hours later

for ‘reading of patch tests’• Review with Doctor or Nurse

and further treatment plan

http://www.google.co.uk/url?sa=i&rct=j&q=allergy+patch+testing&source=images&cd=&cad=rja&docid=U9jcT4Q3rE-m7M&tbnid=Iz8g44na89l43M:&ved=0CAUQjRw&url=http://www.allergytestinglaboratory.com.au/patchtest.html&ei=GyJhUdfBG4am0AW42oHIBQ&bvm=bv.44770516,d.d2k&psig=AFQjCNF1cUtNlNAVbvcYOcTWNXtH8L1-vQ&ust=1365406571660602

http://www.google.co.uk/url?sa=i&rct=j&q=allergy+patch+testing&source=images&cd=&cad=rja&docid=eSJRVB4xH00oCM&tbnid=MyMbNMxCYhqHTM:&ved=0CAUQjRw&url=http://www.morgandermatology.com/?page_id=84&ei=AyNhUeHUD7Sn0wWT_4CgBw&bvm=bv.44770516,d.d2k&psig=AFQjCNGFoEAx6juOSJnYyTFhK6jN9mz2Tg&ust=1365406750371559


Nurse-led Cryotherapy Clinics• Dermatology

Consultants refer patients to Nurse Led Cryotherapy Clinics

• Appointments arranged

• Treatment process explained

• Patient attend weekly/ fortnightly

http://www.google.co.uk/url?sa=i&rct=j&q=before+and+after+images+cryotherapy+treatment+&source=images&cd=&cad=rja&docid=iCnTtBNhAolLdM&tbnid=RGbmQ9cl2sWuxM:&ved=0CAUQjRw&url=http://skin212.com/eyelid.php&ei=gyxfUdS2IInT0QXzsoGwBg&psig=AFQjCNEA2ymC7KYoW710B6Yn135EanDBGg&ust=1365278117771135

http://www.google.co.uk/url?sa=i&rct=j&q=cryotherapy+for+warts&source=images&cd=&docid=Q9G80V4Oo7YDuM&tbnid=48oDHaRW_9S6VM:&ved=0CAUQjRw&url=http://www.videojug.com/film/how-to-remove-warts&ei=kiRhUbyUFMix0QWWroHABg&bvm=bv.44770516,d.d2k&psig=AFQjCNHS9vHv7Fvi67tCYXpUEVv-F44Law&ust=1365407089128073

http://www.google.co.uk/url?sa=i&rct=j&q=cryotherapy+for+warts&source=images&cd=&cad=rja&docid=ohYcMoH_Bj445M&tbnid=II8I0NeVodRfHM:&ved=0CAUQjRw&url=http://www.clinicaladvisor.com/warts/slideshow/122/&ei=TSVhUYnPLMmS0QWn6YGoBg&bvm=bv.44770516,d.ZWU&psig=AFQjCNFQM1F-vVk799y0p37Z22sz7l4nbQ&ust=1365407396247160


Nurse-led Roaccutane Clinics• Dermatology

Consultants refer patients to Nurse Led Roaccutane Clinics

• Systemic drug therapy for treating acne

• Consultant only initiated treatment for 4 months

• 4 weekly review for ladies (pregnancy testing )

• 4 & 16 week review for males

http://www.google.co.uk/url?sa=i&rct=j&q=before+and+after+images+roaccutane+treatment+&source=images&cd=&cad=rja&docid=vDfdcguErS7G7M&tbnid=fdB-isPj6oQrPM:&ved=0CAUQjRw&url=http://westderm.com.au/before-and-after/120/acne-treatments-roaccutane&ei=cC1fUdtx6NTRBZiIgZAH&psig=AFQjCNHMOu77zIcQtJgqZRYE1RFiMjVk4Q&ust=1365278275062215


Nurse-led Biologics Clinics• Dermatology Consultants refer patients with Psoriasis to

Nurse Led Biologics Clinics• Appointments arranged/ treatment/ process explained • Information added to the Badbir Database• Ongoing IV or SC drug therapy monitoring – 3 monthly

http://www.google.co.uk/url?sa=i&rct=j&q=before+and+after+images+biologic+drug+therapy+for+psoriasis&source=images&cd=&docid=JHHI9qksVwgToM&tbnid=3xgLCrFXX-I7pM:&ved=0CAUQjRw&url=http://jama.jamanetwork.com/article.aspx?articleid=196673&ei=bi5fUZf_BKbP0QWSqIDABg&psig=AFQjCNGX4APsJ1VkpofbbzRvbTu797jYZw&ust=1365278664738990


Nurse-led PUVA/UVB Light Therapy Clinics• Dermatology Consultants

refer patients with eczema /psoriasis to Nurse Led PUVA clinics

• Appointments arranged • Treatment/ process

explained • Patient attend 3 times a

week for 15 treatments • Initial treatments are only

seconds/ minutes long

http://www.google.co.uk/url?sa=i&rct=j&q=PUVA/%20PUVB%20psoriasis%20treatment&source=images&cd=&docid=7r2NuEFH_pfd1M&tbnid=hA6nlBH9xqv1zM:&ved=0CAUQjRw&url=http://www.sciencedirect.com/science/article/pii/S0190962299703610&ei=qDBfUdubK8qJ0AW45oGQBg&bvm=bv.44770516,d.d2k&psig=AFQjCNHCRH9jmqTmYO9i4-O70DO0pb7p0Q&ust=1365279261397084


Nurse-led PDT clinics• Dermatology Consultants refer

patients with oncological/ non-oncological conditions, including non-melanoma skin cancers and acne to Photodynamic therapy (PDT) Nurse Led Clinics.

• Particularly lesions in difficult, cosmetically sensitive and poor healing sites.

• Straightforward treatment: • Procedure can be undertaken by

a skilled nurse practitioner

Bowens disease before and after

http://www.google.co.uk/url?sa=i&rct=j&q=pdt+treatment+before+and+after&source=images&cd=&cad=rja&docid=wRExGSFif-6vhM&tbnid=rhpS03RXsQg4lM:&ved=0CAUQjRw&url=http://www.omnilux.co.uk/nonmelanoma.aspx&ei=YDJfUb_AC4Gf0QXa6YDgBg&bvm=bv.44770516,d.d2k&psig=AFQjCNGR7UZfXA7yhsuZWFDUIre2K37Bfw&ust=1365279340377345


Nurse-led Botox clinics• Dermatology Consultants refer

patients with hyperhidrosis (excessive sweating) problems to Nurse Led Clinics.

• The Botox injections can be undertaken by a skilled nurse practitioner


Patient Centred – Safety

• Staff Training• Policies, Procedures

& Protocols• Incidents/ Accidents• Near Misses• Complaints


Patient Centred – Quality

• Evidence Based• Audit - practice• Patient Attendance• Staff Absence/

Turnover• Communication/

Professional Forum


Patient Centred – Experience • Patient

Experience– Questionnaires– Patient Stories– User Involvement

• Staff Experience– Team Meetings– Sharing Success– Staff Involvement

in professional forums


Patient Experience

• Patient Experience–Patient Care Survey • Dermatology Outpatient Questionnaires

–Online Patient Satisfaction Questionnaires• Staff as Patients

–Patient Stories/ Themes–User Engagement/ Involvement


Patient Care Survey Questionnaires(Dermatology)


Survey – January 2013

• Response:– 53:150 = 35.3%

• Male: – 46%

• Female:– 54%

• <59 years:– 42%

• >60 years:– 58%

• Ethnicity– White: 98%– Other: 2%

• First Language– English: 95.5%

• Questionnaire easy to complete:– Very Easy: 64%– Easy: 36%


14 KPI’s

• On arrival• Respect• Attitude• Behaviour• Communication• Information Leaflets• Privacy & Dignity

• Infection Control• Consultation • Waiting times• Medical Records• Treatment & Care• Environmental Factors• Overall Satisfaction


Positive comments

The relaxed manner and friendliness of the doctor

& nurse in attendance

Efficient & professional way at which the

procedure was carried out

Getting the all clear

The doctor and nurse spoke directly to my

daughter, they didn’t talk over her

That I was seen and treated by people who

cared for my health and who did their best

for me

Local access, fairly prompt appointments /

information given


Areas of improvement

More punctual attendance at the clinic may – may help prevent long waits at the clinic

Clearer contact details should they be needed

Had to park in a public car park and walk

across main road, in the pouring rain

Difficulty with directions once inside the hospital Shorter waiting time

for the appointment and in the department

Need better facilities in the waiting area


Online Patient Questionnaires(Staff as Patients – n=34)

November 2012 – February 2013


HOSPITAL ATTENDED


CLINIC ATTENDED


DID STAFF INTRODUCE THEMSELVES TO YOU WHEN YOU FIRST MET?


RESPECT


ATTITUDE


BEHAVIOUR


COMMUNICATION


PRIVACY & DIGNITY


OVERALL SATISFACTION


Patient Stories - themes


Staff

It felt as if I was on a conveyor belt, just

another person to be seen on a particular

day

Staff put me at easy and explained everything in a very warm and friendly manner. I felt that I was being treated by a friend

who just happened to be a professional.

The way staff put me at ease, they saw I was

worried and were so kind and reassuring

Receptionist very helpful and

courteous


Person centred processesI am profoundly deaf. At the beginning of the appointment, the doctor finger spelled his name to me. It had never

happened to me before. It was a lovely and thoughtful gesture, which

made me feel at ease. The doctor was also willing to write everything down

which was very helpful.

If it was possible to be told who you could contact

should you have a query as to your treatment or

next appointment

I am very pleased by the way I was spoken to and

not spoken down to, everyone came to my

level

I think it would have been useful if the information leaflet given to me at the clinic had been posted to

me prior to my appointment


Involvement in care

Staff were really nice. Very respectful in promoting my privacy and dignity. Explaining everything really well to me and due to the nature of my appointment I was

anxious. Staff were very reassuring. My daughter being so

upset throughout the procedure however that was no-one’s fault. We did however enjoy the

fact that she left the clinic being able to hear

properly

The information provided allowed me to make an informed choice


Processes

The time between referral and appointment was

good

The speed and efficiency with which my

appointment was conducted

There was a ½ hour delay but at least we were informed of that

Booking in was confusing for a 90 year

old


Environment

The impossibility of car parking

The open environment, clean and professional with

a friendly atmosphere

Better catering facilities at the clinic


ACTION PLAN• Feedback and results shared with staff with

specific reminders: – Confidentiality– Signage – Person Centred Practice

• Ongoing collection of patient satisfaction surveys and patient stories

• Transforming Your Care projects– OP Reform workstream working in tandem with the

Long Term Conditions workstream to promote greater User Involvement


User Engagement/ Involvement


Questionnaire feedbackI am profoundly deaf. At the

beginning of the appointment, the doctor finger spelled his

name to me. It had never happened to me before. It was a

lovely and thoughtful gesture, which made me feel at ease. The doctor was also willing to write everything down which

was very helpful.

•I think it would be an excellent idea to provide ‘Deaf Awareness Training’ to medical staff. •The standard Deaf Awareness training is 1 full day. •The training enables the participants to become more informed on how to deal with a range of deaf people including those who use Sign Language and also Hard of hearing people. •The Deaf Community will benefit hugely form this innovation, as that will ensure that the next generation of doctors are more aware how to deal with deaf patients with compassion.


Complaint - learningA child attending the

Fracture Clinic had a plaster cast removed. The parent

complained that the procedure was not explained

to the child, nor was he shown the plaster saw or

made aware of how noisy it was.

Following investigation/ discussions the following actions were implemented:

•Patient information leaflet was reviewed•Further training/ awareness for staff dealing with paediatric fractures•Ear protectors made available•Provision of Entonox gas as required for pain relief

A patient attending the Fracture Clinic

complained that they had not been offered

(adequate) analgesia prior to fracture manipulation/ application of a plaster

cast .


Incident reviewA patient should have had a 6 week review following a wider

excision of melanoma.Regrettably this did not happen due to human error - in that the current administrative processes

were found not to have been followed completely and the

systems and processes were not robust enough to prevent or

detect a failure

•Clarity of roles and responsibility of secretarial staff for clinic attendances•Discussed at induction of new staff & reviewed at annual appraisal•Clinical staff urged to provide clearer information/ instructions to patients•Information reports utilised to validate and follow up patients with outstanding reviews•Explore technology solutions for follow-up surveillance


What of the future…Outpatient Nursing is unlikely to be seen as:• Life saving – ICU / Theatre• Cute / lovely – Maternity & Paediatrics• Emotive – Cancer Services• Headline hitting – ED trolley waitsYet Outpatient Departments are uniquely placed at the

Primary and Secondary Care interface & currently have ¼ - ½ million opportunities per year to provide Transformational Outpatient Care to all patients


Outpatient Nursing needs

• To exploit the natural conduit between Primary & Secondary Care

• To influence Trust/ Board/ Department for further opportunities and resources to provide more Outpatient Nurse Led Clinics

• To gain recognition for the work currently undertaken – Monetary/ Non Monetary

• To ask for a regional professional forum for Outpatient Department Sisters/ Managers

• To raise the professional profile of Outpatient Nursing


• When I think about all the patients and their loved ones that I have worked with over the years, I know most of them don't remember me nor I them. But I do know that I gave a little piece of myself to each of them and they to me and those threads make up the beautiful tapestry in my mind that is my career in nursing.

Donna Wilk CardilloA Daybook for Beginning Nurses

http://www.google.co.uk/url?sa=i&rct=j&q=kitten+looking+in+the+mirror+and+sees+a+lion&source=images&cd=&cad=rja&docid=ML9xaDdJAxt0hM&tbnid=_Rp85ptyyV_S0M:&ved=0CAUQjRw&url=http://personalorbitchange.blogspot.com/2010/09/see-lion-in-mirror.html&ei=jDlfUaTIHcrQ0QWYi4CABg&bvm=bv.44770516,d.d2k&psig=AFQjCNEF0Sj5OQFWcjV57w8YMMOHNufIoQ&ust=1365281435900422

http://www.google.co.uk/url?sa=i&rct=j&q=kitten+looking+in+the+mirror+and+sees+a+lion&source=images&cd=&cad=rja&docid=ML9xaDdJAxt0hM&tbnid=_Rp85ptyyV_S0M:&ved=0CAUQjRw&url=http://personalorbitchange.blogspot.com/2010/09/see-lion-in-mirror.html&ei=jDlfUaTIHcrQ0QWYi4CABg&bvm=bv.44770516,d.d2k&psig=AFQjCNEF0Sj5OQFWcjV57w8YMMOHNufIoQ&ust=1365281435900422


“They may forget your name, but they will never forget how you made them feel”– Maya Angelou

Thank you& Questions

http://www.google.co.uk/url?sa=i&rct=j&q=changing+role+of+nurses&source=images&cd=&cad=rja&docid=R0wZYiriAeJ0LM&tbnid=RXEX0WjT-FXDJM:&ved=0CAUQjRw&url=http://www.sgh.com.sg/clinical-departments-centers/nursing/internationalorthopaedicnursingcongress/pages/inaugural-international-orthopaedic-nursing-congress.aspx&ei=uTNhUacWp8TRBb6MgZAG&bvm=bv.44770516,d.d2k&psig=AFQjCNFO_FNrpqJr-mZr1fvmYqcmFWWwZg&ust=1365411051355970

Outpatients – the enigma Enhancing the Outpatient/Client Experience – through Staff Development,...

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