Mr. Edward A. DeGregorio * Dr. Raymond A. Janssen ** Dr. Lee W. Wagenhals ***
BPS SIGOPAC Bristol October 2016 - Dr Sue Smith & Dr Anna Janssen
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Transcript of BPS SIGOPAC Bristol October 2016 - Dr Sue Smith & Dr Anna Janssen
showing we make a difference: quality, value and outcomes
Dr Sue SmithConsultant clinical psychologist
Dr Anna Janssen clinical Psychologist
POST (psychology support in cancer), Dimbleby Cancer Care
Guy’s and St Thomas’ NHS foundation trust
OVERVIEW
•Setting the Scene: using psychological resource within a
cancer context
•Quality and outcomes: creating a meaningful focus
•Using outcomes to inform service development
PART ONE: SETTING THE SCENE
A CANCER DIAGNOSIS IS DISTRESSING•A threat to self and others (real or imagined)•Connects with loss, death and dying•Experience brutal and toxic treatment regimes•Live with treatment affects, e.g. pain, fatigue, change in appearance•Many decisions, many appointments
A CHANGING LANDSCAPE: THINGS WILL NOT BE THE SAME AGAINLoss, feelings and re-evaluation •Physical health •Self and identity•Beliefs, values, behaviour •Relationships
MANY VIEWS,MANY RESPONSES •Our individual experiences of illness/ health•Past and present experiences we have with friends and family•Social, cultural, politics and faith•Some gain dominance, others hidden
YOU ARE NOT THINKING WHEN SOMETHING HITS YOU
And so…Need to make sense all over time
Integrate and story the experiences for self and with others
How we make sense differs…as will what helps
No size fits all…Harness the wisdom of our systems: Patients, colleagues, one another.
What might be helpful/useful right now and over time?
Telling that which might not get told
A SERVICE RESPONSE: DIMBLEBY CANCER CARE
We work across the cancer pathway: with patients, friends, family and staff
Relapse
Meaningful outcomes for staff and patients
-Improved experience -Enhanced and meaningful engagement with care-Increase confidence and competence of dealing with distress-Making sense of loss-Informs service development
Therapy:-Patient and significantly involved others-Group therapy-Specialist therapy e.g. psycho-sexual
Psychological knowledge and
resource
Package of suggested support for staff:-Nurses-Doctors-Allied Health Professionals (AHPs)-other
Key target groups:-Senior staff-Junior staff
Level 2 CNS
Tailored training
De-brief and consultation Ad-hoc
Supervision
Psychological knowledge a resource for patients and staff
A range of Psychological
therapies6.4 WTE
Clinical psychologyCBT, ACT, complex concerns, systemic approaches2.0 WTE
Psychosexual
therapy0.6 WTE
Counselling & psychotherapy0.6 WTE
Fear of recurrence therapy group
Family interventions
Area to broaden beyond prostate cancer to Gynae
Triage, Audit, outcomes
Existential psychotherapyEOL, death/dying1.4 WTE
Bereavement Therapy
Men’s therapy group
Psychiatry0.1 WTE
Assistant psychologist0.8 WTE
Supervision of psych colleaguesSupervision of medical and AHP staffTraining-Level 2 and tailored (to be developed)
PART TWO: CREATING AND SHOWING QUALITY AND OUTCOMES
Co creating a focus: the process of creating outcomes
Agreeing outcomes:
Getting it done, using it meaningfully
CREATING A FOCUS, CREATING CHANGECollaborating as a team-the team is our resource
Assistant Psychologist, Lead and Clinical Psychologist (research and outcome lead) guided the process
Use a systemic approach to guide the process
OUR POSITION
Honour multi-therapy approach, honour those using our service, honour those commissioning our service
Meaningful, useful, and know our limitations
Inform service development and showcase what we do, i.e. visibility, telling our service users’ stories
Understanding our various audiencese.g. patients/friends family, Trust, commissioners
Learning from what has not worked
SHOW AND TELL: WHAT WE DO EffectivenessGHQ and SRS and qualitative feedback Safety and equitableChange our MDT structure, include monthly outcome meetings Timely and responsiveness: Focus on demand and DNA’s: 8 sessions, introduce triage Patient centered: Triage, patient survey, flexibility of approach/appointment Efficient, using our resource wisely: organisational levelStaff supervision, Level 2 training, de-briefs
Organised using BPS, DMQ in psycho-oncology, 2015
PART 3: WHAT WE SHOW Monthly outcome meetings:
SRS, GHQ Referrals (Outpatient, inpatient, Carer/patient; individual or
couple Staff training and supervision outcomes Meeting informs next steps, future focus
Blogs Case studies
SESSION RATING SCALE: 2014-PRESENTSignificant differences: •start - mid-therapy•mid - end of therapy
SRS MEAN SCORES: 2014-PRESENT
SRS Mean Scores
9.27
8.91
9.11
9.92
9.27
9.19
9.3 9.32
9.439.38
9.469.43
8.4
8.6
8.8
9
9.2
9.4
9.6
9.8
10
Relationship Goals/Topics Approach/Method Overall
Mea
n StartMidEnd
Significantdifference: mid - end all start – end all
mid – end
GHQ12 Mean Total Scores over the Course of Therapy
18.29
6.02
3.07
0
2
4
6
8
10
12
14
16
18
20
Start Mid End
Time
Mea
n
GHQ-12 MEAN SCORES ACROSS DOMAINS: 2014-PRESENT
QUALITATIVE FEEDBACK, BLOGS AND CASE STUDIES
“These psychotherapies sessions has helped me immensely to cope with CANCER, all my fears about cancer and been able to accept it a bit more and move on. Thank you all from Dimbleby Cancer Care”
“I think these therapy sessions are helping in dealing with my chemo and wider issues to do with coping with the whole idea of cancer = death”
“I have reached a point where I feel I have been listened to and understood. I have been able to explore all the feelings and issues that crowded in on me when I lost my husband. I can move forward confidently and positively and can face the issues that are affecting other members of the family”
SHOWINGVALUE
Clinical Area Frequency and duration
1. Direct Patient Activity (N= ) Hours spent
TRIAGE
Referrals received
Contacted
Declined
Not able to contact, letter sent
Allocated
Triaging calls
OUTPATIENT THERAPY
1st apps offered
1st app seen
1st app Canx
1st app DNA
Follow-up seen
Follow-up Canx
Follow-up DNA
INPATIENT PSYCHOLOGICAL INPUT
Referrals received
1st Seen
Follow-up
Declined
Staff liaison/support relating to inpatient
OTHER PATIENT ACTIVITY
Support Groups
Health and Well being events
2. Indirect psychology activity
Staff training
Staff supervision
CNS
Psychologist/therapist
Other
Staff de-brief/consultation
Response to crisis
Pre-planned regarding complex patient
MDT attendance (other than POST)
Outcomes showing we make a difference in a variety ways additional to 1:1 outpatient and inpatients therapy
•Teaching / training•staff support (debriefs etc)•Staff supervision •consultation re. patients•Support groups•therapy groups•Health and Wellbeing Events
Routinely collected on a monthly basis
SHOWING QUALITY OF SERVICE DELIVERY Survey: patient/carer satisfaction 2016
(n= 100 outpatients)
Patient Age
55-7434%
75+1%
Unanswered9%
Under 181% 18-34
12%
35-5443%
Showing quality of Service DeliverySurvey: patient/carer satisfaction 2016(n= 100 outpatients)
Patient Sex
Male27%
Female64%
Unanswered9%
Showing quality of Service DeliverySurvey: patient/carer satisfaction 2016(n= 100 outpatients)
Was the Waiting Environment Comfortable?
Definitely70%
To Some Extent29%
Unanswered1%
Showing quality of Service DeliverySurvey: patient/carer satisfaction 2016(n= 100 outpatients)
Was There Enough Privacy During Consultation?
Always98%
Unanswered2%
Showing quality of Service DeliverySurvey: patient/carer satisfaction 2016(n= 100 outpatients)
Would You Recommend This Service to Family/Friends?
Definitely91%
Probably8%
Unanswered1%
Showing quality of Service DeliverySurvey: patient/carer satisfaction 2016(n= 100 outpatients)
Patient Appointments
97.1
9.8
92.2
2.9
86.3
23.9
5.9
0
10
20
30
40
50
60
70
80
90
100
Offered Choice of Appointment Time Appointment Altered by Service Seen on Time
Perc
enta
ge YesNoUnanswered
Showing quality of Service DeliverySurvey: patient/carer satisfaction 2016(n= 100 outpatients)
Therapeutic Relationship
97.1 97.1
2.9 2.9
0
10
20
30
40
50
60
70
80
90
100
Confidence and Trust in Therapist Dignity and Respect from Therapist
Perc
enta
ge
YesUnanswered
Showing quality of Service DeliverySurvey: patient/carer satisfaction 2016(n= 100 outpatients)
Service Information
82.4
86.3
1
6.97.8 8.86.9
0
10
20
30
40
50
60
70
80
90
100
Queries about Psychological Therapies Appropriately Dealt With Provided with Contact Information
Perc
enta
ge YesNoTo Some ExtentUnanswered
Showing quality of Service DeliverySurvey: patient/carer satisfaction 2016(n= 100 outpatients)
Significant relationships of potential interest:
Privacy - Trust in TherapistPrivacy - Dignity MaintainedDignity Maintained - Trust in Therapist Dignity Maintained - whether patient would recommend service Trust in Therapist - whether patient would recommend serviceEnvironment - whether patient would recommend serviceQueries appropriately dealt with - whether patient would recommend service
Current concern: Demand and DNA
NUMBER OF REFERRALS 2006-2016Increased
No. of Referrals 2006 - 2016
431557
722859
926 904
1082 1063
1297
1695
886
0
200
400
600
800
1000
1200
1400
1600
1800
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
No.
of R
efer
rals
Number of referrals : 2010-2016Number of Referrals
862 889
1030
1135
1253
1545
1191
1588
0
200
400
600
800
1000
1200
1400
1600
1800
2010 2011 2012 2013 2014 2015 2016 (until endSept)
Year
ActualExpected
OUTCOMES: AUG 2015 AND AUG 2016
August 2016 August 2015
Inpatient referrals 9 6
Outpatient referrals 116 118
New Appointments Attended 90 71
New Appointments DNA 19
(17.4% DNA rate)
6
(7.8% DNA rate)
Follow-Up Appointments Attended 174 219
Follow-Up Appointments DNA 21
(10.8% DNA rate)
21
(8.8% DNA rate)
Total Appointments Attended 238 290
DNAS
DNA % Rates 1st Appointment
6.7
10.411.5
15.814.8
13.2
5.8
13.1
9.6
2.8
9.48
12.6
19.418.3
17.3 18.1
23.4
11.76
14.313.13
11.96
14.1 14.8
0
5
10
15
20
25
2011 2012 2013 2014 2015 2016
Year
%
CounsellorPsychologistsPsychotherapistAverage
Stable over the last 5 years, ranging from 11 – 14%.
DNAS: 1ST APPOINTMENT & FOLLOW-UPJan – Sept 2016 DNA Rates 2016
20.9
13.33
9.09
18.6
20.2921.13
22.95
20.88
23.68
10.33
9.38
11.76
14.42
8.659.47
7.18
11.23
10.27
0
5
10
15
20
25
Jan Feb Mar Apr May Jun Jul Aug Sep
Month
DN
A R
ate
(%)
NewF/U
IMPACT OF DEMANDAverage Number of Days Between Referral and Assessment
0
21.64
44.82
0
14.35
51.24
18.48
11.61
0
10
20
30
40
50
60
Referral First Contact Attempt Phone Triage Assessment
Num
ber o
f Day
s
20152016
RESPONSE TO DEMAND AND DNAS•Introduce triage - no impact on DNA rates
•Introduce text reminders, which has had no impact on DNA rates
•DNA Audit - no conclusive information regarding the variables influencing the likelihood of a DNA
•Increased assessment slots
•Psychiatry introduced telephone follow-up
Next steps Audit referrer behaviour
Who is referring and for what reason? Use to inform a meaningful response
Focus on routine patientsPilot an Opt in for routine referrals
Identify specific measures for specialist therapies
OPT-IN PROPOSALDNA Referral demand Patient experienceReduce DNA rates, which reached a high of 21.1% for new appointments in the month of May 2016.
Assess 20 more people a month if our first assessment DNA’s were reduced to below 5% (based on the DNA figures for may)
Increase interventions that could be delivered by a band 5 and / or trainee that patients could attend instead / before / after 1:1 therapy
Reduce Follow up DNA Rates Approx 45% of those referred are not being seen (Due to failed contact / Declined / DNA)
Patient experience would be improved if a strategy shortened the wait for assessment slots (Informal patient complaints have risen)
Increase in clinical time from Band 5 Assistant Psychologist. Therefore increasing through put of routine patients
An Opt in could be more convenient for patients who cannot answer telephone calls immediately. Each day, at least 1 hour a day is spent by triage leaving voicemails etc
Approx 1/3 of all patients referred decline / failed contact at triage. Each failed contact / declined referral takes minimum of 10 minutes to process.
National Cancer Survey 2016 – Points to patients requesting more input for anxiety, worry and depression management earlier on. Similar informal feedback has also been given at health and well being events attended by POST. We could address this if current DNA and demand managed differently
The MacNamara Fallacy -Yankelovich
“The first step is to measure whatever can be easily measured.
This is OK as far as it goes.
The second step is to disregard that which can’t be easily measured or to give it an arbitrary quantitative value.
This is artificial and misleading.
The third step is to presume that what can’t be measured easily really isn’t important.
This is blindness.
The fourth step is to say that what can’t be easily measured really doesn’t exist.
This is suicide.”
SUMMARY AND CONCLUSION We need to ‘show and tell’ the
stories that get lost Capture the richness of our various
approaches and collaborations: with staff, patients, friends and family
Show what is special/unique about our interventions
Know when we get it wrong and show curiosity in our responses
SUMMARY AND CONCLUSION Distress is a normal human
response to a significant life event such as a cancer diagnosis
We have a responsibility to those we support, and professionally, to not pathologise or medicalise the distress and behaviours which may be experienced and shown