Measurements of ‘Patient Centred Care’ in Anaesthesia Dr. Sujesh Bansal Consultant Anaesthetist 18 th May 2015.

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