Outpatients – the enigma

1. Outpatients – the enigma Enhancing the Outpatient/Client Experience – through Staff Development, Service Improvement & User Engagement/ Involvement Barbara McDowell Anderson South Eastern HSC Trust

2. 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

3. 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

4. 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’

5. Dermatology – nursing Staff Training • Commissioned courses - academic base • Study Days • Workshops • ‘In-house’/ ‘on the job’ training • Service • Improvement • 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 • User • Involvement • Patient • Questionnaires • Patient Stories • User Involvement • Staff • Team Meetings • Supervision • Sharing Successes

6. 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

7. Nurse-led Cryotherapy Clinics • Dermatology Consultants refer patients to Nurse Led Cryotherapy Clinics • Appointments arranged • Treatment process explained • Patient attend weekly/ fortnightly

8. 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

9. 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

10. 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

11. 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

12. 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

13. Patient Centred – Safety • Staff Training • Policies, Procedures & Protocols • Incidents/ Accidents • Near Misses • Complaints

14. Patient Centred – Quality • Evidence Based • Audit - practice • Patient Attendance • Staff Absence/ Turnover • Communication/ Professional Forum

15. Patient Centred – Experience • Patient Experience • Questionnaires • Patient Stories • User Involvement • Staff Experience • Team Meetings • Sharing Success • Staff Involvement in professional forums

16. Patient Experience • Patient Experience • Patient Care Survey • Dermatology Outpatient Questionnaires • Online Patient Satisfaction Questionnaires • Staff as Patients • Patient Stories/ Themes • User Engagement/ Involvement

17. Patient Care Survey Questionnaires(Dermatology)

18. 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%

19. 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

21. Positive comments 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 Getting the all clear Efficient & professional way at which the procedure was carried out Local access, fairly prompt appointments / information given The relaxed manner and friendliness of the doctor & nurse in attendance

22. Areas of improvement Difficulty with directions once inside the hospital Shorter waiting time for the appointment and in the department Had to park in a public car park and walk across main road, in the pouring rain Clearer contact details should they be needed Need better facilities in the waiting area More punctual attendance at the clinic may – may help prevent long waits at the clinic

23. Online Patient Questionnaires(Staff as Patients – n=34)November 2012 – February 2013

24. HOSPITAL ATTENDED

25. CLINIC ATTENDED

26. DID STAFF INTRODUCE THEMSELVES TO YOU WHEN YOU FIRST MET?

27. RESPECT

28. ATTITUDE

29. BEHAVIOUR

30. COMMUNICATION

31. PRIVACY & DIGNITY

32. OVERALL SATISFACTION

33. Patient Stories - themes

34. Staff The way staff put me at ease, they saw I was worried and were so kind and reassuring 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. It felt as if I was on a conveyor belt, just another person to be seen on a particular day Receptionist very helpful and courteous

35. Person centred processes I 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 have been useful if the information leaflet given to me at the clinic had been posted to me prior to my appointment 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

36. 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

37. Processes There was a ½ hour delay but at least we were informed of that The time between referral and appointment was good Booking in was confusing for a 90 year old The speed and efficiency with which my appointment was conducted

38. Environment The open environment, clean and professional with a friendly atmosphere Better catering facilities at the clinic The impossibility of car parking

39. 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

40. User Engagement/ Involvement

41. Questionnaire feedback • 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. I 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.

42. Complaint - learning A 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 .

43. Incident review A 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

44. 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 waits Yet 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

45. 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

46. 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 Cardillo A Daybook for Beginning Nurses

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