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

2. Why? What do we mean by – Measure of patient experience (Patient Satisfaction, PREMs) – PROMs Questionnaire? How many patients? REC?

3. Why?

6. “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

7. 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 Darzi of Denham KBE

8. NHS Operating Framework 2015/16

9. 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

10. 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

11. 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

12. QUALITY Mortality Anaesthesia related mortality Morbidity LOS, Readmission rate ITU/HDU admissions Nerve damage POMS Patient Reported Measures Quality of Recovery (QoR) Pain, PONV, temp control Fatigue Emotional well-being Work status Quality indicators in anaesthesia Process Evidence of SDM On the day cancellation Service efficiency data

13. Patient Reports (PR) PROMs Patient Reported OUTCOME Measures How are you? HRQoL Functional Ability Symptoms PREMs Patient Reported EXPERIENCE Measures What do you think? Patient Satisfaction Patient Experience

14. Patient Satisfaction Patient Experience

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. PROMs Patient Reported Outcome Measures

24. 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

25. 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

26. 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)

28. 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

29. PROMS: Concerns Return rate and sample size Avoiding league tables Data analysis Triangulation Performance management Practicalities & Economics Resources, Technology

30. Which Questionnaire?

31. 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.

32. Validating a Questionnaire Item GenerationTesting 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 )

33. 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

34. 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

35. 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

36. 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

37. How many patients?

38. 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

40. REC Approval?

41. 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

42. Always take advice from Local REC and low threshold for REC application

43. 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)

44. Your most unhappy customers are your greatest source of learning Bill Gates