Tag Archives: Patient experience design

Triggering better health outcomes

The first piece of data we collect in healthcare is: date of birth. Could it be used to trigger better habits?

50th birthday bashes have overtaken 21st celebrations as 50 now considered the “peak” age to throw a party, sales figures for cards and party paraphernalia show.

Sales of 50th birthday cards have for the first time eclipsed the number of 21st birthday cards sold, according to data from Clintons, the UK’s biggest cards retailer.

With 50th birthdays now leading on the birthday league table and accounting for 16 per cent of all card sales, 21st birthday cards now make up 14.1 per cent of all cards sold. Katie Morley. The Telegraph Oct 2017

I explore the possibilities.

Picture by synx508

Improve patient experience to deliver better results

Joe and Brenda are now in their 60s they have a number of chronic healthcare problems some of which will put them at risk of life limiting pathology (hypertension) and others detract from their quality of life (low back pain). Everyone involved in providing healthcare to this couple wants the best for them. Best case scenario Joe and Brenda are satisfied every time they consult their doctor and improve from whatever ails them.  It is also better if their use of the healthcare resources is minimised. But what predicts that outcome?

In 2001 the BMJ considered the issues. Paul Little and his colleagues approached three local practices that served 24 100 patients. They invited consecutive patients attending the surgery to participate. All patients able to complete the questionnaire were eligible. 661 participants completed a questionnaire before their consultation in which they were asked to agree or disagree with statements about what they wanted the doctor to do. A questionnaire after the consultation asked patients about their perception of the doctor’s approach. Both questionnaires were based on the five main domains of the patient centred model: exploring the disease and illness experience, understanding the whole person, finding common ground, health promotion, and enhancing the doctor-patient relationship

The post-consultation questionnaire included items about the reason for consultation and a positive and definite approach of the doctor to diagnosis and prognosis as well as sociodemographic details, the short state anxiety questionnaire, number of medical problems, and current treatment. The team also included questions relating to important patient related outcomes from the consultation: enablement (six questions about being enabled to cope with the problem and with life), satisfaction (medical interview satisfaction scale), and symptom burden (measure yourself medical outcome profile, which measures the severity of symptoms, feeling unwell, and daily restriction of activity). Patients were followed up after one month with the measure yourself medical outcome profile, and the team reviewed the medical records after two months for reattendance, investigation, and referral.The outcome measures of interest were patients’ enablement, satisfaction, and burden of symptoms. Factor analysis identified five components:

  1. Communication and partnership (a sympathetic doctor interested in patients’ worries and expectations and who discusses and agrees the problem and treatment);
  2. Personal relationship (a doctor who knows the patient and their emotional needs);
  3. Health promotion;
  4. Positive approach (being definite about the problem and when it would settle); and
  5. Interest in effect on patient’s life.
  • Satisfaction was related to communication and partnership and a positive approach.atisfaction was reduced if expectations were not met for communication and partnership, a positive approach, and an examination but were not affected by expectations of a prescription.
  • Enablement was greater with interest in the effect on life, health promotion, and a positive approach. Enablement was also less if expectations were not met for an examination, health promotion, and a positive approach.
  • A positive approach was also associated with reduced symptom burden at one month. Symptom burden at one month was worse if expectations of a positive approach were not met.
  • Referrals were fewer if patients felt they had a personal relationship with their doctor.If expectations of a personal relationship were not met, referrals were more likely.

From these data and similar results published before and since we can conclude that Joe and Brenda expect the following:

  1. To have their perspective considered by someone who clearly cares
  2. To be examined
  3. To have the impact of the illness on their lives taken into consideration
  4. To be advised when they are likely to feel better and
  5. To receive advice on how to avoid problems in the future

In return they will use healthcare resources less and their symptom burden will reduce. All this might be achieved without major policy reform and can be implemented locally to improve the patient experience and by corollary reduce the strain on healthcare resources.

Picture by Jenny Mealing

Why don’t people take medical advice?

Significant proportions of people walk out of doctors’ clinics and disregard or fail to act on the opinion offered. The data reported in the literature does not make for encouraging reading. This behaviour has been observed in almost every clinical scenario and every speciality:

Paediatrics

Medication compliance in pediatric patients ranges from 11% to 93%. At least one third of all patients fail to complete relatively short-term treatment regimens.

Psychiatry

Of the 137 patients included in the study, 32% did not show up for their first appointment.

Hypertension

Similarly, although men receiving health education learned a lot about hypertension, they were not more likely to take their medicine.

Diabetes

We conclude that compliance with the once-daily regimen was best, but that compliance with a twice-daily regimen was very similar, and both were superior to dosing three times a day.

Primary care

Seven hundred and two patients (14.5%) did not redeem 1072 (5.2%) prescriptions during the study period, amounting to 11.5% of men and 16.3% of women.

Sexual health

Eighty percent of 223 patients enrolled completed the study by returning their bottles. The rate of strict compliance with prescription instruction was 25%. The rate of noncompliance was 24%. Fifty-one percent used some intermediate amount of medication. There was no statistical difference in compliance by gender, presence or absence of symptoms, or site of enrollment.

Physiotherapy

Ultimately, this study suggests that health professionals need to understand reasons for non-compliance if they are to provide supportive care and trialists should include qualitative research within trials whenever levels of compliance may have an impact on the effectiveness of the intervention.

The fact that this happens is important because it is a costly waste of resources. There are many explanations for this phenomenon but they are all summarised in the findings of one study:

Studies have shown, however, that between one third and one half of all patients are non-compliant, but different authors cite different reasons for this high level of non-compliance. In this paper, the concept of compliance is questioned. It is shown to be largely irrelevant to patients who carry out a ‘cost-benefit’ analysis of each treatment, weighing up the cost/risks of each treatment against the benefits as they perceive them. Their perceptions and the personal and social circumstances within which they live are shown to be crucial to their decision-making. Thus an apparently irrational act of non-compliance (from the doctor’s point of view) may be a very rational action when seen from the patient’s point of view. The solution to the waste of resources inherent in non-compliance lies not in attempting to increase patient compliance per se, but in the development of more open, co-operative doctor-patient relationships. Donovan and Blake

What practitioners can do without waiting for policy change is to review their communication style. As Bungay Stanier has suggested it can’t be assumed that the first thing the person mentions is what is uppermost in their mind. Bungay Stanier’s suggested questions will reduce the rush to action. A rush that fails to identify the issue that the patient may feel is a greater priority than hypertension or diabetes.

Picture by Sergio Patino

First I’ll ask what’s on your mind then I’ll shut up


Every doctor in general practice/family medicine learns about the ‘models‘ of the consultation. My favourite is the Pendleton model. The thinking behind a map of the medical consultation is summarised by  Pawlikowska and colleagues

A fundamental change in medical culture in this area has been the recognition and acceptance of the fact that the way in which health professionals communicate, on all levels, can be enhanced, irrespective of the innate and learned abilities they already possess.

In 2016  Michael Bungay Stanier published The Coaching Habit: Say Less, Ask More  & Change the Way you Lead Forever. This comes at a time when the relationship between doctors and the people who seek their help is changing. With each passing generation, people expect to be actively involved in making choices in healthcare.

Women, more educated, and healthier people were more likely to prefer an active role in decision making…..Preferences for an active role increased with age up to 45 years, but then declined. Livenson

Doctors and the people who consult them will frame themselves as a team. At the same time, the major challenges relate to non-communicable chronic disease. Specifically to encourage people to stop smoking, eat and drink less, exercise more, and to be screened for early detection of malignancies. And for those who succumb to actively manage their chronic illness.

Therefore the interaction between the person seeking advice and the ‘expert’ is more likely to be akin to coaching. Given that people present to primary care with undifferentiated conditions the agenda for the meeting is set by the person who made the appointment. That’s why Bungay Stanier’s practical approach is a significant contribution. If we accept that the doctor is to be the ‘coach’ the author sets the scene in the very first chapter:

Only 23% of people being coached thought that the coach had a significant impact on their performance or job satisfaction. Ten percent even suggested that the coaching they were getting was having a negative effect. ( Can you imagine what it would be like going into those business meetings? ” I look forward to being more confused and less motivated after my coaching sessions with you.”)

The book emphasises that ‘coaching’ is a habit. Something that needs to be valued for three reasons:

  1. To avoid the team members becoming overdependent on the coach.

Building a coaching habit will help your team be more self-sufficient by increasing their autonomy and sense of mastery by reducing your need to jump in, take over and become the bottleneck.

There is already such a concern about over-dependence in medicine. Read Naomi Hartree’s summary ( Helping Patients Avoid Doctor Dependency)

2. To avoid getting overwhelmed.

Building a coaching habit will help you regain focus so you and your team can do the work that has real impact and so you can direct your time, energy and resources to solving the challenges that make a difference.

Being overwhelmed is a recognised problem in medicine.  Read locumstory(Physician Workload)

3. To help people do more work that has impact and meaning.

Coaching can fuel courage to step out beyond the comfortable and familiar , can help people learn from their experiences and can literally and metaphorically increase and help fulfil a person’s potential.

Again this has strong resonance in healthcare specifically because of the limited predictive value of tests or the large number needed to treat. In addition, there is mounting concern about the variation in these outcomes across geographical areas. See John Newton.

The Coaching Habit emphasises seven questions in a specific order. The first question is arguably the most important. Bungay Stanier calls it the kickstart question: ” What’s on your mind?” He justifies it as follows:

Because it’s open, it invites people to get to to the heart of the matter and share what’s important to them. You’re not telling them or guiding them. You’re showing them trust and granting them autonomy to make choices for themselves. And yet the question is focused, too. It’s not an invitation to tell you anything or everything. It’s encouragement to go right away to what’s exciting, what’s provoking anxiety, what’s all-consuming, what’s waking them at 4 a.m., what’s got their hearts beating fast.

This question followed by the space to answer is one that creates the opportunity to find what is really bothering someone. It is not universally common in healthcare. There’s an eloquent summary of the data from Juliet Mavromatis

Why do physicians interrupt? In practical terms, throughout the course of a given day a physician may be tasked with listening to twenty to thirty patient derived histories and with solving difficult problems for each of these patients in a matter of ten to fifteen minutes. This is a tough, if not impossible job. Consequently, once a physician believes that the meat of the story is out there, he or she may respond and interrupt before hearing details that the patient (or colleague) feels are important. In more abstract terms interruption is a communication strategy that reinforces physician dominance in the hierarchy of the patient-physician relationship.

Picture by Allie Hill

The infographic bandwagon rolling in to your clinic

In the wake of her book launch I had the honour to interview Dr. Halee Fischer-Wright President and CEO of MGMA. In her book: ‘Back to  balance:The art, science and business of medicine’ the author asserts:

We have lost our focus on strengthening the one thing that has always produced healthier patients, happier doctors, and better results: namely, strong relationships between patients and physicians, informed by smart science and enabled by good business.

In a separate blog post Larry Alton, business consultant addressing the business community says:

In 2017, you’ll find it difficult – if not impossible – to be successful without strategizing around customer communications. Customers have become conditioned to expect interaction and service. Provide both and you’ll be delighted with the results.

Most people will interact only with primary care when they need healthcare. The average consultation in primary care is less than 15 minutes. Therefore efficient communication is a priority. Larry Alton goes on to advise:

Communication is at the heart of engaging and delighting customers. The problem is that, even with all of the new advancements in communication technology, very few businesses are taking this all-important responsibility seriously. This results in poor relationships and a bad brand image.

His four key action points are:

  1. Hire empathetic employees
  2. Leverage the right communication mediums
  3. Use analogies to explain technical concepts
  4. Become a good listener

One area that seems to receive scant attention in medical practice is explaining technical concepts. And yet technical concepts are integral to medical practice:

  1. What pathology brought me here today?
  2. Why has my physiology responded in this way?
  3. What is the prognosis?
  4. Why do need this therapy?
  5. What are the risks?

Ours is a technologically proficient but emotionally deficient and inconsistent medical system that is best at treating acute, not chronic, problems: for every instance of expert treatment, skilled surgery, or innovative problem-solving, there are countless cases of substandard care, overlooked diagnoses, bureaucratic bungling, and even outright antagonism between doctor and patient. For a system that invokes “patient-centered care” as a mantra, modern medicine is startlingly inattentive—at times actively indifferent—to patients’ needs. Meghan O’Rourke

When explaining complex ideas there is a checklist:

  1. Does the patient want all the information?
  2. What are the implications of the prognosis?
  3. How can you explain with reference to something they are already know?
  4. What details can you leave out that would only serve to distract from an understanding?
  5. How can the patient assimilate this information actively?

Adapted from a post by Thorin Klosowski

Perhaps the neatest medium to communicate some aspects of a complex idea is the infographic. According to experts:

In the past 5 years, the term “infographic” has seen an impeccable rise in trend.In fact, the popularity of infographics is expected to see an increase of almost 5% by next year, meaning that anyone who isn’t yet riding the infographic bandwagon is bound to fall behind. The Daily Egg

Here are the data:

The Journal of Health Design has recently introduced the Infographic as a submission type. Communicating using this medium could reduce the time required to assimilate the information needed to make a decision.

Picture attribution

Designers will rescue the health sector

Much of what we do in healthcare is communicate ideas. That is far more common than ‘doing’. Executive control over decisions are the purview of the patient. It is a basic tenant of medicine that the patient has autonomy.

Often armed with little more than a stethoscope doctors must communicate to the patient that:

When communication about the evidence base is effective the patient, the practitioner and ultimately the economy benefit. How we communicate such ideas is where innovation has the brightest future. It gives us hope that we can improve outcomes in health without recourse to major policy change or curbing freedom of choice.

We communicate in words, pictures, video, audio and using models. Yet so much of how that is done in the doctor’s office hasn’t changed over the decades. ‘It’s just a virus’ doesn’t cut it any more.

We experience the power of effective communication everyday and in every other area of our lives. Look at your credit card statement this month- does it all make sense? What pressed your ‘purchase‘ button?

What if this extraordinary power deployed so effectively in commerce was unleashed in the clinic?

Picture by Dan Moyle

Be careful when you break eye contact

 

The duration of consults in medicine has been a bone of contention for years. Nowhere has the issue received more attention than in the UK where the issue of access to general practice has been the subject of debate and discussion since at least since the late nineties. The following graph depicts the duration of consults in one data set:

The accompanying commentary summaries the position well:

The shape of the curve highlights the extent of variation, though the mean is just under 12 minutes … In the GP contract 2014 the requirement for a 10 minute consultation has sensibly been dropped.  Some clamour for 15 minutes – and they are right, but for only a small minority of patients.  Many more need under 10 minutes, also right. What is inefficient is allocating the wrong time – too short, and rework results.  Too long, throughput falls and waits rise.

Therefore the issue is not merely the ‘duration’ of consults but what actually transpires in those meetings. Decades of research have identified the tasks for both parties in the consult (the paper below may not have been written by someone whose first language was English but they make their point):

For example: patients face the issues of how to put their concerns on the floor (Robinson and Heritage 2005); how to show themselves to be properly oriented to their bodies (Halkowski 2006, Heritage and Robinson 2006, Heath 2002); how to direct the doctor’s attention toward and away from certain diagnostic possibilities (Gill and Maynard 2006, Gill et al. forthcoming, Stivers 2002b); and how to deal with diagnoses and treatment recommendations that may or may not correspond to their own views and preferences (Heath 1992, Stivers 2002a, 2006, Peräkylä 2002).
From the point of view of doctors, issues include eliciting all of a patient’s concerns (Heritage et al. 2007, Robinson 2001) and designing solicitations that are fitted to the concerns that patients are likely to have (Heath 1981, Robinson 2006); preparing patients for no-problem diagnoses (Heritage and Stivers 1999) as well as difficult diagnostic news (Maynard 2003, Maynard and Frankel 2006); and securing patient agreement in regard to diagnoses (Peräkylä 2006) and treatment recommendations (Stivers 2006, Roberts 1999). Pilnick et al

We know that the doctor will be taking notes or referring to the patients records during the consultation.

Conversation analytic studies have shown that participants of a conversation constantly monitor each other
and the unfolding speech in order to be able to perform the relevant next action when the present speaker has finished his turn of talk (Sacks, Schegloff & Jefferson, 1974). The direction of gaze is of utmost importance here, as gazing at the speaker constitutes a display of attention by the recipient (Goodwin, 1980, 1981; Heath, 1986; Robinson, 1998).

In addition to direction of gaze, the engagement framework may be created and maintained by shifting one’s posture (Kendon, 1990; Schegloff, 1991; Robinson, 1998), or gesturing in the visible field of the intended recipient (Goodwin, 1986; Heath, 1986). Shifts in posture that may be treated as displays of attention or disattention can be analyzed as shifts of ‘home position’ of the body (Schegloff, 1991)

As in everyday conversation, in doctor– patient interaction the participants constantly monitor each other’s movements and direction of gaze (Heath, 1986; Robinson, 1998)

Johanna Ruusuvuor’s research, quoted above also suggests that there are four circumstances in which the consultation becomes dysfunctional insofar as the patient’s narrative is inhibited.

  1. Disengagement with home position away from the patient:

The doctor is seated facing the a desk away from the patient and does not make eye contact with the patient as they start to disclose the reason for the consultation.

2.  Disengagement with manifest shift in orientation:

The home position of the doctor is towards the desk with his head in torque towards the patient. He releases his torque simultaneously as he withdraws his gaze from the patient.

3. Disengagement at critical point of description:

Turning away at a moment when maintaining mutual involvement in a common focus of interest has been made specifically relevant, and when the utterance is still incomplete with only the very core of the complaint pending, seems to be interpreted by the speaker as a disengagement from the role of the recipient.

In the last two examples the postural orientation of the doctors, and the way in which the doctors turned away from the patient to the records within the patients’ turns were enough to convey a disengagement from interaction with the patient

4. Disengagement at critical point of story-telling:

 The doctor’s home position is towards the patient. From time to time he turns his upper body to torque towards the desk, making notes. The doctor disengages when the patient is about to reach the completion of her/his turn.

There are specific moments in which disengaging from interaction with the patients hampers a good outcome because it interrupts the narrative and the conversation becomes disjointed. Therefore it may pay great dividends to note where you are looking and how you are positioned during the consultation.

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