Lack of provision of information was the single most common cause of poor performance in the 2008/2009 NHS Patient Survey Programme of trusts in the UK. Information leaflets have been shown to improve patient satisfaction with consultations.
We introduced a new patient information leaflet about the scheduled consultation in a district hospital´s dermatology outpatient clinic. We then assessed in a small study its effect on the patients regarding helpfulness, preparation for and satisfaction with the out-patient consultation.
Via the hospital´s booking office, leaflets were sent to all patients (n=32) due to attend two outpatient clinics, accompanied by a letter about the survey. After the consultation, patients were given a short anonymous questionnaire to complete.
Of the 32 patients, 12 patients did not receive the leaflet, three did not attend their consultation, and two left before they were handed the questionnaire. We gave out 15 questionnaires, and received 15 responses (100%).
46.9% of patients (n=15) answered the questionnaire. Of these 33.3% were new patients (n=5). 86.7% (n=13) found the leaflet helpful and 33% excellent (n=5). 86.7% felt well prepared for the consultation, 40% excellently (n=6). 86.7% were satisfied with the consultation, 73% rated their satisfaction as excellent (n=11). 60% of patients brought a list with their medication (n=9), 80% of the new patients (n=4). 13.3% of patients (n=2) wrote down questions prior to the consultation. Comments suggested the leaflet would be more useful for new patients.
Patients scored highly for satisfaction with the consultation, whether or not they had received and information leaflet (we asked n=20 patients without leaflet). This short survey supports the idea that patients find it helpful to receive an information leaflet, and actively prepare by bringing a list of their medication, and thinking of questions.
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In the UK, an outpatient consultation in hospital is something of value to the patient. In contrast to other European countries, a patient needs to be referred, usually from primary care, and usually waits some time for the appointment. Patients often attend with high expectations, and may be anxious.
Clinicians, on the other hand, need to perform a thorough clinical assessment in a limited time. Our setting is a district hospital dermatology outpatient clinic. How can the outcome of consultations for both patients and clinicians be improved?
Research has shown that patient satisfaction with the consultation is closely related to better compliance with treatment and better healthcare outcomes.(1) The most important factor for patient satisfaction seems to be that patients feel they interacted well with the clinician. A review of trials has shown that effective communication is as important as high quality medical practice for good outcomes.(2)
Factors important in achieving good communication include the need to identify and discuss patients´ concerns, to provide appropriate information, and to involve patients in their choice of treatment.(1,2) Lack of provision of information was the single most common cause of poor performance in the 2008/2009 NHS Patient Survey Programme of trusts in the UK.(3) A national survey of outpatients showed that 27% of patients seen in outpatient clinics for the first time would have liked to have more information.(4)
A simple intervention to help patients prepare better for their consultation is to send information leaflets prior to the outpatient consultation.(4) Little et al. have shown that patient information leaflets can increase patient satisfaction and their perception of good communication.(5) Patients want to be informed and are willing to spend time and effort on information leaflets.(6) Information leaflets also improve attendance rates (non-attendance dropped from 15% to 7.3%).(7) Following the distribution of a leaflet, patients were more likely to initiate conversation about their concerns (8, an increase of 100%). Information leaflets have been shown to improve satisfaction even three months after the consultation.(9)
Patient information leaflets have many potential benefits. These days, a large number of information leaflets are available. A recent review identified that the information provided in different leaflets on the same topic differed widely and was sometimes inaccurate.(10) Apart from the obvious clinical concerns, this could potentially damage patient confidence. Another potential risk for leaflets is that patients are given too much or sometimes irrelevant information, thus increasing their anxiety. In a trial in primary care where patients had received leaflets to encourage them to participate more during consultations, doctors had afterwards ordered significantly more investigations, in categories where neither doctor nor patient had found a strong need for them. This suggests that if patients raise more concerns then doctors may have responded with investigations (5), all of which may raise unnecessary anxiety for patients and pressure on the health system.
There are two reasons why we wanted to introduce a leaflet:
We were aware that patients could be better prepared for the clinic appointment:
- Patients did not know how to cancel or change an appointment and did not attend
- Patients often felt uncomfortable and surprised when asked to allow us to examine their full skin. This is frequently done in dermatology, especially when looking for skin cancer. Patients commented that they would have liked to wear different clothes
- Patients thought they would be operated on their first visit and were unnecessarily anxious, since operations are usually done during a subsequent visit
- Thorough consultations were sometimes unnecessarily difficult because not enough information was available to clinicians when patients arrived unprepared, not knowing that clinicians find it helpful to know about medical history, current medication, and family history.
The aim of our project was to design and introduce a patient information leaflet to prepare patients better.
The second reason was that other departments in our trust had introduced leaflets successfully and had received positive feedback.(11)
As baseline measurement, we asked 20 patients (nine new patients) about their consultation. Four of 20 (20%) would have appreciated more information before attending the department, Three of 20 (15%) had felt anxious before they came. We asked them to rate how well they felt prepared and how satisfied they felt with the consultation on a scale from 0 (awful) to 4 (excellent). The score for the satisfaction with the consultation was 3.7 (75% rated their satisfaction as excellent). They also rated highly how they felt prepared with a score of 3.3 (30% scored the felt prepared excellently).
We designed a patient information leaflet which was specifically intended to prepare patients better for their consultation in dermatology. Our patient leaflet has two main aims:
We want to enable patients and prepare them better for their consultation. This is not done commonly in other leaflets.
- We offer information on how to change and cancel appointments and where to find the clinic. The hospital can be a confusing building that is full of busy people, so this might reduce anxiety about finding the department
- We explain in detail what to expect before, during, and after the consultation
- We ask patients to participate; to bring a list of their medication, to be prepared for questions regarding their skin problem and their medical history, and to prepare any questions of their own
- We inform them about things that are common in dermatology; that they might need to be examined (and might need to undress for this), about surgery, and that they might be referred to another department
On the other hand, we want to reduce anxiety for patients who attend an unfamiliar place after a long wait:
- We call the leaflet " welcome to dermatology"
- We explain who works in our department and mention the names of staff members
- We mention that there are chaperones available
- We explain that we are happy to answer questions and encourage these
- We let patients know that we will inform their GP of the consultation so patients understand that we work together.
The leaflet has a format to make it easy to read. When you take it off the envelope it is a folded like a booklet, with colourful photos on the front page. The structure then is clear: when patients unfold it each page shows a new topic (from “the team” to before - during - after the consultation) and a separate page about treatment options.
We used a questionnaire to find out what patients think of their consultation in dermatology and the leaflet itself. Similar questionnaires are broadly used in medicine to evaluate patient satisfaction, answers were on a 5-point-scale from 1 (awful) to 5 (excellent). We asked how helpful they found the leaflet, how well they had felt prepared, and how satisfied they were with the consultation overall. We also wanted to know if they brought a list of their medication or wrote down questions (answer yes / no).
In the first instance, we sent the leaflet and questionnaire out to patients due to attend four clinics (n=63), and asked them to return with the questionnaire to clinic.
PDSA cycle 1. The patient information leaflet and questionnaire were sent out to patients due to attend four clinics (n=63). In the patient letter, we asked them to bring the questionnaire to the clinic. Unfortunately, of these 63 patients only seven returned the questionnaire (11%). Due to the poor response rate we did not feel these answers could be taken as representative and they were disregarded.
PDSA cycle 2. On the second occasion the booking office sent out the leaflet to a further group of patients. The deputy manager of the outpatient department redesigned the leaflet so that it had a more official format. It was then sent to patients of two further clinics (n=32). We handed out the questionnaires immediately before the consultation and collected them afterwards from the rooms.
Of the 32 patients, 12 patients did not receive the leaflet, three did not attend their consultation, and two left before they were handed the questionnaire. We gave out 15 questionnaires, and received 15 responses (100%). 33% of patients (n=5) found the leaflet helpful, 53% (n=8) good. 40% of patients (n=6) felt the leaflet prepared them excellently for the consultation, 46.7% (n=7) felt well-prepared.
Overall satisfaction was outstanding, providing some great feedback: 73% of patients (n=11) rated their satisfaction with the consultation as excellent, and only n=2 (13.3%) as fair.
60% of patients brought a list with their medication (80% of new patients n=4). 13.3% (n=2) patients wrote down questions on the leaflet.
Comments on the questionnaire were very positive about the consultation ("satisfactory in all areas", "always helpful and supportive", "I have always found everyone kind, helpful and knowledgeable") but suggesting that the leaflet would be more useful for new patients ("put my mind at ease", "very professional", "valuable to newcomers", "more useful for new patients").
Patients found the leaflet helpful and felt better prepared. Patient satisfaction was excellent if patients received a leaflet.
PDSA cycle 3. After evaluation of the questionnaires, the results were presented at the local dermatology multi-disciplinary team meeting. Some changes were made to the leaflet. The team decided to officially introduce the leaflet, and to send it to all new patients together with their invitation from the booking office.
See supplementary file: ds3041.docx - “PDSA cycles 1-3, as explained in the box”
Patient's feedback about our leaflet was very good: 87% found the leaflet helpful (rating it as 3 (good) or 4 (excellent)), and 33% rated it as excellently helpful. 87% of patients rated they felt well prepared (numbers 3,4), and 40% felt excellently prepared. Overall satisfaction with the consultation was excellent in 73%. 60% of patients brought a list with their medication to the consultation. 13.3% of patients wrote down questions.
Comparing this to the baseline measurements, patients scored similar about their satisfaction and how they felt prepared whether they had received a leaflet or not; the score of how they felt prepared was 3.27 with leaflet and 3.3 without. Overall satisfaction was scored as 3.6 with the leaflet, and 3.7 without. However, we noticed that patients were better prepared after they had received a leaflet: 60'% brought a list with their medication when they had received the leaflet, 45% if not. The leaflet encouraged patients to think of questions: 12% had prepared questions compared to those who had not got a leaflet. In addition, patients who had not been sent a leaflet would have appreciated more information in 20%, and 15% had felt anxious before the consultation. Our leaflet is designed to address these areas of concern.
Although we could not measure an improvement in satisfaction, or how patients felt prepared with a leaflet, comments from patients were very positive about the consultation and the leaflet ("Always helpful and supportive", "Satisfactory in all areas","I have always found everyone in this department helpful, kind and knowledgeable. Good job"). They also suggested the leaflet might be more useful for new patients ("I think the leaflet would be more useful for new patients - as I knew already what to expect", "Very professional and complete, put my mind at ease, very thorough. Thank you" from a new patient, "Leaflet is valuable to newcomers, but less so for people who have attended before").
We discussed results and comments in the multidisciplinary team meeting and decided to introduce the patient information leaflet for new patients only.
Lessons and limitations
During this project, I have been able to learn several lessons:
Teamwork is very important and necessary to work effectively. I had sent the leaflet and questionnaire to patients on my own in the first instance, but as this is a very lengthy job to do alone and could be done more effectively, I asked the booking office for help. They offered not only help with sending out leaflets, but the manager sat down with me to redesign the leaflet in the same design as other leaflets the hospital sends out.
It might be useful to involve patients earlier. Although we have collected responses and suggestions from patients during the consultations, it might have been interesting to ask patients what they would like to find in a leaflet in the first place. We could then have designed the leaflet, and improved it further in several rounds based on the patients' feedback
A limitation of this project is the small number of patients who took part:
- Why did from 32 patients who should have received the leaflet 15 did not receive it?
- Although 100% of patients who we asked to fill in the questionnaire handed it back to us we cannot be sure that this group is representative because it is very small
- A larger study involving more patients might be useful, and it might also be interesting to find out why more than 40% of patients did not receive the leaflet in the first place.
We did not find a difference in patient satisfaction. Our results show similar scores for patient satisfaction between patients who had received a leaflet and those who had not. It is good to know that our consultations are already highly satisfactory. To see a difference between a satisfaction score which is already excellent (3.7 was the satisfaction score for overall satisfaction) a measurement with later numbers of patients would be necessary.
Is the leaflet only useful for new patients? We have not formally compared changes in patient satisfaction between new patients and patients who had attended the department before. Our decision to send the leaflet only to new patients is based on patients comments. A formal evaluation might have been interesting here.
The design of a patient information leaflet and collection of patients feedback - this is how I would summarise the project. Feedback was positive, and the multidisciplinary team decided to introduce the leaflet for new patients as suggested by the patients.
In my opinion, the leaflet hopefully helps patients to get most from their consultation in dermatology. Pressures on dermatology clinics are high, and there is not enough time for appointments and not enough trained staff to offer these. Consultations are often short and patients need to wait a long time for an appointment. Our baseline measures show that patients would have appreciated more information before attending clinics, and that more than 10% feel anxious before their appointment. The leaflet means to address these concerns. Our questionnaire has shown that patients rate the leaflet highly; they feel well prepared and find the leaflet helpful. This is a good outcome for our project.
We also found that patients had become more active: 60% of patients and 80% of the new patients had brought a list with their medication along (as we had encouraged them via the leaflet), and a small number of patients have written down questions. Comments from patients said they were put at ease, and found the leaflet valuable. Patient information leaflets can improve patients participation in consultations and help prepare them better.
If I did the project again, I would change a few things:
- It might be interesting to find out patient opinions in a more structured way earlier on in the process. We might have asked them before designing the leaflet what they would like to find in a leaflet.
- When we collected feedback, 12 patients from 32 did not receive the leaflets. Two of these were very recent additions to the clinic list. Two were current inpatients. We have no explanation why the remaining 10 patients (>30%) did not receive the leaflet. It would be quite worrying if this happened to all information sent via the booking office, and we have informed the booking office and its deputy manager of this result, who might need to investigate further.
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Declaration of interests
Nothing to declare.
Dr Lyn Williamson (Rheumatology Consultant, GWH),
David Moss (Deputy Manager Outpatient Department, GWH)
Supplementary Material for A new patient information leaflet for Dermatology outpatients
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