Human centred design to improve healthcare NHS Expo
8 September 2016
Mobile Data-driven Unparalleled access
Design is problem solving
Image: 23andMe
Image: Wikipedia, public domain
Image: 23andMe
Image: 23andMe
DesirabilityHuman
FeasibilityTechnological
ViabilityEconomic
INDUSTRIAL DESIGN
VISUAL DESIGN
SERVICE DESIGN
DESIGN FORBEHAVIOUR CHANGE
INTERACTION
DESIGN
GRAPHICDESIGN
SYSTEMS/TECHNOLOGYDESIGN
ENVIRONMENTDESIGN
UX
DESIGN
Design is problem solving
9 / 10 of the lowest-rated cancer patient experiences are at large London NHS Trusts.2011/12 National Cancer Patient Experience Survey
Initial assessment may be done over the phone
About 1 in 20 women will be called back for further assessment.
(technical recall, area of concern, Normal but symptoms warrant clinical
+ Lump in the breast or axilla+ Ulceration+ Skin nodule+ Skin distortion+ Eczematous-like changes to the nipple, not just the areola+ Recent nipple retraction or distortion (less than 3 months)+ Unilateral nipple discharge which stains clothes Patient Asked about:
+ Age (risk increases with age)+ Lumps Other breast symptoms, such as:Ulceration, Skin nodules, Skin distortion, Nipple changes, Nipple discharge, pain, personal history of breast cancer
Refer to breast clinic for triple assessment (urgently)
Rout
ine
Scre
enin
g
20%
of b
reas
t can
cer p
atie
nts i
dent
ified
thro
ugh
rout
ine
scre
enin
g pr
ogra
ms.
Letter with appointment details
No
Review Medical History
General advice - Breast Aware Discharge to primary care
Is any additional information asked - when compared to visit to GP?????
ClinicalExamination
Patient should be seen within 2 weeks
PATIENT PROFILES
Women identified as being at higher risk, should be offered the opportunity to have their risk formally assessed and, where appropriate, to discuss their risk management options.
The National Health Service Breast Screening Programme offers three-yearly mammogra-phy.
Screening happens between 47-73 years of age
Around 1/ 3 of breast cancers are diagnosed through screening.
Patie
nt h
as C
onc
ern
80%
of b
reas
t can
cer p
atie
nts i
dent
ified
afte
r visi
t to
GP w
ith
Patient arrives at reception
Gen
eral Practitioner
Family History Review
+ Names and ages of all your family members who have had breast cancer (including men)
+ Any cancers your relatives have had
+ The age they were diagnosed
Yes
+ Unknown family history (adopted) may seek testing for genetic mutation
Gen
etic Counsellor
+ Breast cancer diagnosed before age 50 years+ Cancer in both breasts+ Both breast and ovarian cancers+ Multiple breast cancersTwo or more primary types of BRCA1- or BRCA2-related cancers in a single family member+ Cases of male breast cancer+ Ashkenazi Jewish ethnicity
FAMILY HISTORY CLINICGENETICS TEST (Tertiary Care)
SECOND STAGE SCREENING Triple assessment - Clinical Examination + Imaging + Cytology Each examination given offered a different perspective Hospital or breast clinic (All scans + tests are normally done in one day)
Undresses in changing room
A paper gown may be offered to the patient
Patient arrives for consultation
ASSESSMENT (ROUTINE)Routine screening for women (usually) with no signs or symptoms of breast cancer.Screening may take as little 5 minuets, visit will last for 30 minuets or longer
Patient arrives at reception. Patient is given a questionnaire to fill out
Patient undresses in changing room
A paper gown may be offered to the patient
A female nurse feels for any enlarged lymph nodes under arms and base of neck and around the breasts
Physical Examination in examination room
During the mammogram each breast is placed in turn on the x-ray machine and gently but firmly compressed with a clear plate. The compression only lasts a few seconds and doesn't cause any harm. It's needed to keep the breast still and to get the clearest picture with the lowest amount of radiation possible.
Mammography (x-ray) in examination room.
Breast care nurse explained reason for recall and the tests (that may be required (patients expected pathway).
Occasionally, the need for more tests is due to technical reasons; for example, if the mammogram picture was not clear enough. Around 2 women in every 100 (2%) are called back for technical reasons.
Breast care nurse explains the need for test
Patient book appointmentPatient receives referral letter
Screening Leaflet
Letter outlines what the patient can expect - Length of wait, result
Be Breast Aware leaflet
http://www.cancerscreen-ing.nhs.uk/breastscreen/publications/-breastaware.pdf
Touch Look Check by breakthrough
breakthrough.org.uk/tlc
After your breast screening appointment - what happens nextInfo for patients relatives and carers
Feedback form
QuestionnairePersonal information, Past medical history, Current medical history, Ethnic Origin
Touch Look Check breakthrough.org.uk/tlc
by breakthrough
Be Breast Aware leaflet
http://www.cancerscreen-ing.nhs.uk/breastscreen/publica-tions/breastaware.pdf
CLINICAL BREAST EXAMINATION (PRIMARY CARE)Assessment by primary care to - Check for - lumps & physical changes Goal - Early detection
Patient - Male
???????
Refer to family history clinic (Genetics)Yes
No
No
No
Could the abnormality have been caused by by the menstrual period
Yes
Notes added to patients record / file
Scans reviewed by two radiologists.Radiologists Radiologists
Brea
st Care Nurse
Patent finds a sign of breast cancer
Patient arrives / enters assessment room
Personal details + Past + current medical history.
Brea
st Care Nurse
Other literature - Breast implants and breast screening leaflet
Patient gets dressed / leaves clinic
Scans
1
Patient follows signs to ward/ checks in with reception
Patient fills out questionnaire Personal details + Past + current medical history
Patient may be approached bya research nurse and asked ifshe would like to take part in a study?
Patient will be asked to prepare some information for appointment / to discuss their family history with relatives
General advice - Breast Awareness
Wait in waiting room
Patent has concern based on family history, age or medication
Estimating carrier probability and offering genetic testing
Patient follows signs to ward/ checks in with reception
Results Letter
Referral to triple assess-ment clinic
Further investigation required
DischargeResults clear
Outcome communicated to Patient and GP
2 - 4 weeks Wait for results letter
Patients get confused about where screening room is / who to approach on entering the clinic
(Charing cross - Mammogra-phy)
Re
sults letter
Discharge
Return for re-examination in 2 weeks
Same day / Same week
Patient is asked if there is a personal / Family history of breast cancer?
No longer than three weeks between the mammogram and
the breast clinic appointment.
Examination - Are symptoms suggestive of breast cancer?
Patient book appointment with GP / Goes to a dropin clinic.
Patie
nt - Personal history
Scheduled for screening ever 6 months - 1 - 3 years
Patient finds symptom of possible breast cancer
Patient - Over 70
Entitled to routine screening (every 3 years) on request.
Scedualed for screening ever 3 years
Patient (47+)
Patient finds symptom of possible breast cancerPa
tient
- Found Early Sign
Family History
Patient finds out that a member of their family has or had breast cancer.
Women - 1 in 8
Men - 1 in every 1000
Patients follow lines painted on floor to guide them to appointment room. Lines are only 1 cm wide and hard to see
Letter sent to patient “Thank you for attending your breast screening appointment,. our screening images have been looked at and require further assessment as part of routine (or second stage) screening. the majority of women recalled for assessment are found to have normal breasts”
Direction leaflet
Cancer Research letter
leaflet “Your appointment at the breast assessment clinic”
The waiting area can cause frustrating , Patients from different wards can appear to jump the queue - DC (A plasma screen is being considered to show patient's position in the queue)
Patients must have a moderate or strong family history of breast cancer to be referred - (High risk group)
In some situations the GP may ask you to go back again in a couple of weeks time. This is because some non cancerous breast tissue changes naturally disappear after a menstrual period.
Yes
Changes to look out for - + Appearance. + Feelings. + Lumps. + Nipple change.
Lifestyle advice+ Alcohol+ Smoking, + Weight, + Hormone Replacement + Therapy+ Breastfeeding+ Hormonal Contraceptives
Info delivered in verbal & written form
NHS Genetics Testing Networkhttp://ukgtn.nhs.uk (not confirmed as supplied to patients)
GPs don't always follow referral guidelines, causes unnecessary anxiety
Scre
ening letter
Breast Cancer Patient Pathways
Imaging and
assessment
Diagnosis MDT
Therapy
KEY
Clinic
If further surgery needed
MDT
Multi-disciplinary
team meeting
(patients do not attend)
Results /
treatment
plan
Holistic
needs
assessment
Clinical reviewNeo adjuvant
therapy
Chemotherapy
Radiotherapy
Hormone therapy
Pre-surgery
assessmentSurgery /
reconstruction
MDT
Post-op
results
Adjuvant therapy
Chemotherapy
Radiotherapy
Hormone therapy
Reconstruction
if not done in
original surgery
Hospital follow-up Imaging /
clinical check-up
Six months after
surgery, then yearly
for five years
PATHWAY PLANNERA VISUAL GUIDE TO YOUR CARE
BREAST
PATHWAY PLANNERA VISUAL GUIDE TO YOUR CARE
BOWEL
PATHWAY PLANNERA VISUAL GUIDE TO YOUR CARE
BRAIN
PATHWAY PLANNERA VISUAL GUIDE TO YOUR CARE
PROSTATE
5.5m Asthma sufferers in
the UK
75% Asthma hospital admissions are
avoidable
90% Deaths due to
asthma are avoidable
£1bn Cost to NHS for
asthma treatment
MILD
MODERATE
SEVERE
CONTROLLED PARTLY CONTROLLED
POORLY CONTROLLED
2/3 people do not fill in their Asthma
Action Plan
32
Floot
Problem Solution
Design research ≠ focus group
Extreme “Normal” Extreme
JANE! VIDUR & SABITA! RICK!
ROBIN! ALISON!
Participates religiously
Never heard of bowel cancer
JANE! VIDUR & SABITA! RICK!
ROBIN! ALISON!
Physically difficult to do the task
alone
Extreme use cases fuel creative
thinking
1. Problem
2. Hunt statement
3. Super users
Referral to treatment times need improvement
We are going to research patient involvement in pre-assessment so that we can better engage them before a procedure
– Carer turned patient – Heavy drinker – Flight attendant
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