Acting on feedback

The colposcopy clinic at Cambridge University Hospitals sees women referred for abnormal cervical cytology test (‘smear test’) results and if a GP makes a referral for any other reason.

The clinic staff aim to provide safe, kind and effective care to all their patients. Patient satisfaction is a major indicator of quality care, and so it is important that the experiences of patients are taken into consideration and improvements made where necessary.

Colposcopy is an essential part of the NHS cervical screening programme and plays a central role in the management of disease. The purpose of the survey was to obtain feedback from patients regarding their overall experience as new attendees at the colposcopy clinic, so that the staff know how satisfied they are with the service and can identify areas for improvement.

A questionnaire was given to patients which asked about information giving, time management, the experience of the colposcopy procedure and staff, communication from the service before, during and after their contact with the service, and the overall experience.

What did the patients think about the service?

Overall, 100% of respondents rated the colposcopy service as ‘good’ or excellent’! In addition, 96% said they were seen within 30 minutes of arrival and 100% of patients felt welcome on arrival. 98% said that the colposcopist introduced themselves, 100% of patients said that the reason for their appointment was explained to them and over 98% of patients thought that there was good communication during their consultation and the procedure.

What can be improved?

Of the patients who were referred to the clinic because they had an abnormal smear result, only 77% of this group said they received the information about coming to the clinic. For those patient who did receive the information, 85% found it ‘very helpful’ and the rest thought it was ‘somewhat helpful’.

Only 67% of patients said that they were given contact information when they left their appointment. This may be because their examination was normal and did not require follow up in colposcopy. These patients are discharged back to their GP and a summary letter containing colposcopy service contact information is sent to all patients.

Sharing the learning and making improvements

The results of the survey were shared with the whole colposcopy team.

The staff have looked closely at how they are delivering the information about ‘coming to colposcopy’ to their patients, and information has been added to the end of appointment letters.

It was thought that patients who use the MyChart App may not have scrolled down far enough to see the information, so changes have been made to how the information is presented. In addition, the team now send an information letter to every patient by post.

The difference these changes make will be assessed in a repeat survey in a year’s time.

Systemic Anti-Cancer Therapy (SACT) includes chemotherapy, immunotherapy and hormone therapy. The SACT Patient Experience Survey was designed by patients and staff, with the aim of collecting patient views on how to improve information for patients receiving SACT treatment at CUH. The survey gave patients a chance to express what they found most useful or wish they had been told before and during treatment.

The survey results are being used to improve written information, contributing to patient films and information leaflets, and to improve the cancer pages on the CUH website and information available to patients on MyChart.

How do patients receive information?

All of the survey responses were from patients receiving treatment in the Oncology and Haematology Day Units.

60% of surveyed patients said they had received the ‘blue folder’ pack at the beginning of their treatment, and the rest said they didn’t receive or couldn’t remember it.

82% of patients said they were told about local cancer information and support services, but 18% said they didn’t or couldn’t recall receiving information about them.

36% of patients wanted written information (handed or sent to them) and 18% said that they would prefer to receive the information on MyChart about SACT before starting their treatment.

Only 10% of patients said they looked for information about SACT on the CUH website and 18% said they looked for SACT information on other websites. Patients expressed that the most useful information to include on the CUH website would be where to get further information if needed, who to contact at the hospital if they were feeling unwell, where to attend and how to prepare for treatment sessions.

Is the information useful?

73% of patients found receiving written information in the Day Units very helpful and 22% found it somewhat helpful, with only 6% of patients saying that the information was difficult to take in.

Overall, the SACT information given to patients is seen as excellent and satisfactory, with 64% saying that it helped them with their treatment and 32% agreeing that the information met their needs.

The key issue for improvement appears to be communicating patient information, as some patients were unsure where to look for the information or were not aware the SACT information was available online. Written comments gave the staff useful insight into what information could potentially be added or improved to ensure better patient experience.

Next steps

The results were shared with the Cancer Patient Partnership Group and other CUH staff. Some actions to improve information shared about SACT with patients before and during treatment have already been taken, and the plan is to include information within MyChart, which will enable patients to access necessary information before and during their cancer treatment.

The results will also be used to help with a project to improve the cancer information on the CUH website.

The survey results have also allowed for the focus group to be created with the aim of reviewing, creating and updating the information available to patients within the patient ‘blue folder’ pack and to focus on production of patient information films for the CUH website. The information films will provide general clinical information for new patients at the beginning of their treatment and when attending for subsequent treatment.

Staff in the children’s cardiology (heart problems) team wanted to understand how their patients experience their service, and if there are things to improve about the clinics. The staff asked patients and their families to answer survey questions on paper or online.

Most of the surveys were filled in by parents and carers, with a smaller number (8%) filled in by the patients themselves.

Overall, the survey results provided positive feedback to the service and to specific members of staff: 91% of people felt the overall care within the children’s cardiology team was excellent!

Over nine out of ten families were happy with the waiting times, felt that the consultant was reassuring, that they had an opportunity to ask questions at the appointment and that they had enough privacy.

Two thirds of families knew who to contact after their appointment, so staff have improved the information on our website and the clinic letters.

Here are some of the comments made by patients and their families – the bigger the word, the more often it was mentioned in the survey:

16% of survey respondents said their children had additional needs, and a suggestion was made that the information the service provided before and during the clinic could be improved. In response to this, the service developed a Playmobil animation to send out to families before appointments, telling them in a child friendly way about what happens in the clinic.

The animation is on the Clinic 6 web page.

The service has also begun to offer the use of the hospital passport (describing a person's needs, preferences and how they communicate) to more families, as well as involving the play team and the specialist learning disability nurse.

An outpatient survey is conducted every year to measure patient experience and gain feedback from patients on their experience of using outpatient services. The detailed questions allow staff to gain insight and identify areas for improvement. Because the survey runs each year, staff are able to measure changes in patient experience over time by comparing results with previous surveys.

Since the Covid-19 pandemic, many patients have been offered ‘virtual’ (telephone or video) appointments instead of face to face appointments at the hospital site. An appropriate survey is sent to each group, as the staff are interested to know about the different experiences of patients attending virtual or face to face appointments.

Results

Overall the survey results present a positive picture of the outpatient experience in 2021. The majority of the survey questions scored over 90% positive for patients attending both types of appointments (face to face and virtual).

The scores for the overall rating of the appointment remained approximately the same as 2020: patients are asked to give a rating from one to ten (ten being the most positive) and the combined scores of 8-10 were 85% in 2020 and 2021.

Is the experience of a face to face appointment different to an appointment over the telephone or video?

When comparing the patient experience of a face to face appointment to a virtual appointment, the overall rating indicates a better experience with in-person appointments: 91% of patients gave an overall rating of 8 – 10 if they had a face to face appointment compared with 77% for patients who had a virtual appointment.

For those patients attending a face to face appointment, scores for 2021 are comparable to pre-pandemic scores, and to 2020. While the 8-10 combined scores of overall rating of clinic experience is slightly lower than 2019, the 91% score remained exactly the same as 2020. The responses to detailed questions indicated that an area for improvement is communication – including informing the patient about medication side effects and danger signals, and what happens after the appointment. Patients indicated that they are satisfied with privacy during their appointment, and are treated with dignity.

The survey of patients attending a virtual appointment was introduced in 2020. Where patients had a virtual consultation (telephone/video appointment), the combined scores of 8-10 for overall rating of appointment experience was 77% - exactly the same as 2020. As for face to face appointments, communication was the area identified for improvement, including making the patient aware that they would need to have their appointment in a place that allowed confidential information to be discussed, discussing medication and danger signals, and who to contact if patient was worried about their condition. Some of the highest ratings related to the opportunity to ask questions as well as being comfortable to ask questions, understanding information. Patients felt they could talk about the same things during the virtual consultation as they would during a face to face appointment.

Future appointments

Patients were asked whether they would prefer a face to face appointment or a telephone/video appointment in future. There is evidence that the type of appointment a patient experienced has an impact on their preference for type of future appointments.

Of the 955 patients that had a telephone/video appointment, 44% said they would prefer their future appointments to be face to face, 27% said they would prefer a telephone appointment and 14% said they would prefer a video appointment.

Of the 1,022 patients that had a face to face appointment, 70% said they prefer their future appointments to be face to face, 12% said they would prefer a telephone appointment and 6% said they would prefer a video appointment.

Comparing the combined virtual consultation data with the face to face appointment results from 2020 to 2021, there is a 4% increase in patients preferring a face to face hospital appointment.

Sharing learning

The survey results have been discussed by the Outpatient Experience Group (which includes patients as members), with staff at outpatient departmental meetings and also with wider hospital staff. Separate survey reports for each specialty have also been shared (a ‘specialty’ is a defined group of patients or diseases – like dermatology).

Much of the feedback needs to be acted on by staff in the different specialties. The specific improvements that the centralised outpatient team is able to take forward are:

• Use feedback from patients attending virtual appointments to inform the design of a permanent virtual clinic call centre.
• Identify virtual clinics where patients would particularly benefit from the clinic being conducted in dedicated room (ie not in the virtual clinic call centre or a shared clinical office).
• Reassure staff that while lack of familiarity with virtual appointments can make patients fearful of them, experience of virtual appointments tends to make them more popular as an appointment choice.
• Communicate to staff that some appointments are more suited to face to face but others work well for video and telephone.
• Continue to make improvements to the technical aspects of video appointments for patients.

Staff in the children's recovery team were keen to understand more about how children and their families find the care given to children after they have had a general anaesthetic. A questionnaire which asked about what was good and what could be improved was given to parents, carers and children.

The staff were particularly interested to find out if different staffing levels and skills of the staff affected care. By looking at the experience of service users who are familiar with the children's recovery areas (those who have attended twice or more), staff hoped to identify any staff learning needs or other improvements. The staff aim to provide consistently high quality care across different recovery areas.

Staff asked for the questionnaire to be completed while families were in the hospital. No patient or parent / carer names were asked for.

Survey results:

- Overall, parents / carers and children really appreciate the care given in the recovery areas, and there was lots of praise for staff members’ positivity and kindness;

- Overall, parents/ carers and children really appreciate the care given in the recovery areas, and there was lots of praise for staff members’ positivity and kindness;it a long time outside recovery) or when the child is actually ready to be seen in recovery;

- Staff will also make sure that they remind parents / carers that there are limited food and drink options in recovery and that they can bring their child’s favourite snack with them to the recovery areas.

The main learning points have been displayed on the children's recovery notice board. A presentation has also been given to the relevant teams and managers.

Staff will continue to ask for feedback to make sure that children and families are satisfied and consistently receiving high quality care.

You said: that you didn’t know the name or role of the member of staff speaking to or caring for you and names on badges on lanyards are often hidden.

We did: we introduced new pin on name badges for our staff. Staff names are written in black on a yellow background making them easier for all patients to see, including those with impaired vision.

The distinctive #hellomynameis badges are designed to be clearly visible and to remind staff of the importance of introducing themselves.

The Cancer Patient Partnership Group (CPPG) raised the importance of staff asking patients ‘what name do you prefer to be called by?’ In the last National Cancer Patient Experience Survey, only 63% of CUH patients said staff had asked this, compared with 71% nationally. 

The CPPG discussed ways to improve this score with patients and staff.  Staff suggested making a patient’s preferred name more easily accessible in Epic, the electronic patient system.  We also learned from another NHS Trust about adding the patient’s preferred name to the inpatient wristband. This patient-led initiative was then raised and actioned at the CUH Patient Experience and CUH Patient Communication Groups.  As a result, the Epic 2020 upgrade in November has a new ‘Known as’ field which will be shown next to a patient’s legal name and on inpatient wristbands. 

We know that hospital can be a busy noisy place and patient feedback tells us that noise from staff and patients can make getting good restorative sleep difficult. The Sleep Sound Sleep Safe working group introduced sleep well packs on all wards.

It has also carried out a number of other improvements:

• Identified noisy equipment (eg telephones) which can be adjusted to reduce noise levels
• Quieter door closures were fitted by estates
• Foam pads were added to bin lids to reduce banging on closure
• Adjustable call bell volumes (when old systems are replaced)
• Staff asked to wear quiet shoes
• Staff asked to prevent keys etc jangling on lanyards
• Staff reminded to speak as quietly as possible at night
• Sleep promotion posters were displayed in wards
• Staff encouraged to close blinds and dim lights in corridors and patients bays at night
• Presentations were delivered to increase awareness of the impact of noise at night
• Noise warning systems in intensive care
• Key pads on doors silenced
• Hospedia TVs now turn on at 7am instead of 5am

Complaints can be a valuable tool to help us identify and act on issues: they are an opportunity for us to learn and improve.

As well as sharing the learning from complaints within the hospital, we would like to share some case studies on our website to help give confidence to patients - and their families and carers - to speak up.

Communicating with patients’ families

A patient was treated in Addenbrooke’s Hospital for symptoms of Covid-19. They improved on the ward and discharge home was planned. The patient was discharged home with support from carers, but sadly deteriorated and subsequently died. A close family member – the patient’s next of kin - complained that they had not been fully informed about the patient’s state of health when they were discharged.

The complaint was investigated and it was found that although there had been communication with the patient’s next of kin when the patient was being treated on the ward, no conversations had taken place on the day of discharge. On that day, another family member had been contacted - but not the next of kin.

A full explanation was provided to the patient’s next of kin regarding the arrangements for the patient’s discharge (which were complex), and an apology was offered for the failure to update the patient’s next of kin on the day of discharge. All nursing staff on the ward were reminded about the importance of clear communication with the person a patient has identified as most important to them, and received education about the steps they need to take when a patient is being discharged.

Improving the appointment booking system

A patient was in the early stages of pregnancy and was under the care of the Rosie Hospital. Sadly, the patient miscarried. Over the following weeks, the patient continued to receive notifications about upcoming appointments and pregnancy scans which caused distress.

The complaint was investigated and it was found that an error had been made on the patient’s electronic medical records: two orders for booking pregnancy appointments for the patient had been placed on the system. This meant that the ‘duplicate’ order was not cancelled when the patient miscarried – leading to staff continuing to book pregnancy appointments and scans for the patient when they should all have been cancelled.

Apologies and an explanation were provided to the patient. Staff members in the booking department were reminded of the importance of checking for duplicate orders before making arrangements to book appointments.

In addition, the electronic patient record system is being reviewed to determine whether a ‘failsafe’ mechanism can be put in place on the system to prevent further appointments and scans being booked inappropriately when a patient suffers a miscarriage.

Changes to how medicines are given

A patient was admitted to Addenbrooke’s Hospital because they needed to have their medicines delivered to their bloodstream through a needle in a vein – they needed to have an ‘infusion’.

The patient complained that the infusion was started in the early hours of the morning, when there were no nurses experienced in the procedure present on the ward. In addition, the patient was not shown how to weigh their infusion pump and therefore did not know whether the infusion was working correctly.

As a result of the complaint investigation, the ward staff now do not start infusions during the night time, and always wait until a staff member with the right training and experience is available. The ward now holds a register of all patients receiving infusions so that a fully trained and experienced nurse has oversight of all the patients’ treatments and ensures that proper checks are carried out. Scales and instructions are now available on the ward so that patients can be shown how to take measurements in order to monitor their infusions.

Improving care for diabetic patients on wards

A patient was admitted for a planned operation, which was carried out successfully and the patient then stayed on a ward to recover. After they had been discharged from hospital, the patient contacted the hospital to complain about the care they had received on the ward.

In their complaint, they described how their reports of pain were not believed whilst they were staying on the ward after their operation. They felt that a staff member did not listen to them or examine them thoroughly.

The patient had diabetes and they were used to carefully controlling what they ate in order to keep their diabetes under control. Whilst they were on the ward, they experienced difficulties because the food available to them was not sufficient and wasn’t always available. In addition, they received some out of date information in a leaflet.

The care that the patient received was investigated by the medical staff and the dietitians. It was found that there were shortfalls in the communication with the patient and a staff member reflected on their communication skills with their educational supervisor in order to make improvements.

The dietitians provided education for the ward housekeepers about the type of food and portion sizes for patients with diabetes, and they also made changes to one of the patient information leaflets.

Managing a patient's pain in the Emergency Department

A patient went to the Emergency Department because they were experiencing severe pain. The cause of the problem was diagnosed and treated, but the patient subsequently complained about the management of the pain. The patient described being left in pain and distress without sufficient medication, and also being given too much of one type of painkiller.

The treatment of the patient was investigated and it was agreed that there had been a shortfall in the care provided. As a result, a specialist team of staff have worked with the department to increase their knowledge of giving painkilling medicine and identify any individual staff in need of further training. The care provided for the patient was also discussed at a team meeting so that all staff could be aware of the events and reflect on how to make improvements to systems for giving painkillers.

In addition, the Emergency Department reviewed staffing levels in order to determine whether additional staff were needed in order to be more responsive to patients. A request was made for new equipment to assist in the delivery of medicine straight into patients’ veins.

Communicating with patient’s families when visiting patients in hospital is restricted

A patient was admitted to hospital after a serious stroke, and stayed on a ward for several weeks. The patient’s family were rarely able to see the patient in hospital because of the restrictions on visiting put in place to reduce the spread of Covid-19.

In their complaint, the patient’s family described how they found it difficult to contact staff at the hospital to discuss what was happening with their relative’s treatment. Updates from staff were didn’t happen very often and sometimes staff promised to telephone and then the call didn’t happen. The family felt worried and confused as they did not receive enough information about how their relative was progressing, and the treatment and medication they were receiving. Sometimes the staff who did call the family didn’t have the right information to hand.

When the patient was ready to leave hospital, the discharge was not discussed fully with the family, and they felt that arrangements were rushed and they did not have enough time to prepare.

The issues raised by the family were investigated and an apology was given for the shortfalls in communication. Some of the difficulties were caused by staff having to work in different ways and in different areas of the hospital due to Covid. This meant that it was not possible to provide updates to families as often as normal, and the fact that families could not visit also made communication more difficult.

Despite the problems caused by Covid, the staff responding to the complaint agreed that some things could have been done differently by the staff which would have improved the communication with the patient’s family.

As a result of the complaint, all the teams involved with the patient’s care discussed the steps they could take to improve communication with families in future. One team decided to try involving family members in the patient’s therapy sessions by video link. Another team gave their staff education about record keeping.

Improving the care of patients with learning disabilities

A patient with a learning disability was admitted to a ward after a fall. The patient needed support with communication and understanding information about their health and treatment, but they did not have their ‘hospital passport’ with them when they arrived on the ward.

A ‘hospital passport’ gives information about a person’s needs, preferences and how they communicate. Patients are often admitted with their passport, but if they are not, a passport can be started on the ward. Patients’ families and carers can help with providing information for the passport.

Some staff on the ward did not know how best to work with someone with a learning disability. A hospital passport was not started. This meant that communication between the patient and staff was difficult, and the patient was anxious and sometimes distressed.

After the patient was discharged, a relative complained about the lack of support for the patient - they considered that the patient’s needs had not been properly assessed. The relative also felt that hospital staff had not provided enough information to the staff looking after the patient after they were discharged from hospital.

The complaint investigation found that some of the staff needed education about working with people who have a learning disability. An apology was provided to the complainant, and the staff received additional education.

A member of staff took on the role of ‘learning disability champion’ in order to improve links between ward staff and the hospital’s Learning Disability Specialist Nurse. Staff also received teaching about communicating effectively with other care providers.

Improving patient communication before treatment

Before any procedure, operation or treatment is carried out, patients must be given information which they understand and they must be asked whether they are happy to go ahead. This is called ‘taking consent’.

A patient made a complaint after they had had a medical procedure because they felt that the information they had received beforehand was not clear, particularly about which member of staff would be carrying out the procedure.

For the particular procedure the patient had, explaining the process and gaining consent is undertaken by the nursing team and the procedure is carried out by other staff members. The patient had a conversation with the nursing team and gave their consent for the treatment, but when the treatment began they realised that the person performing the procedure was not who they expected.

Because the patient had not fully understood which staff member was going to be treating them, they were very distressed.

The complaint was investigated and an explanation and apology were provided to the patient. It was agreed that the discussion between the nursing staff and patients about the staff members carrying out the procedures needed to be clearer, and so staff received additional training. The nursing staff have also been provided with a written list of points to cover in the discussion with patients about consent. These changes have been introduced in order to emphasise the importance of explaining the roles of different staff members and making sure that patients understand.

The complaint, and the improvements made as a result, were also discussed at a meeting of the whole department to raise the importance of clear communication between staff and patients.