School of Health StudiesUniversity of Bradford

Hysteroscopy Audit Reviewing percentage of women provided with patient information and asked for written consent.

Module Title: Nurse Led outpatient Hysteroscopy and Therapeutic Practices

Module code: HMPP701E

Disclaimer: I Elizabeth Cherfan confirm that by submitting this work it is all my own work (that I have not used a third party organisation), and that I have not plagiarised the work of others from printed and or published literature, or the work of other students.

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Executive Summary

Guidance on Consent and sharing information with patients has been published by the DOH: Department of Health (2003), and NICE: National Institute of Clinical Excellence (2012). The process of gaining consent links closely with providing the patient with information regarding their proposed care or treatment. Recommendations from the Bristol Royal Infirmary report (2002) and the Mid Staffordshire enquiry (2010) is that the NHS should put the patient first, and engaging and sharing information is a necessity for patients to make to an informed decision, but can also beneficial for service providers. The consent process is a continuous one. To enable the HCP: Health Care Professional to provide the best care, they need to be aware of how to access, and provide information to all patients in the most effective way.

Objective: To review whether Hillingdon Hospital Hysteroscopy Service is adhering to Local Trust Standards of gaining consent, and ensuring all patients will receive information, primarily prior to treatment.

Design: Anonymous Patient Satisfaction Survey conducted, asking questions on consent and patient information.

Results: N=111(100%), patients completed satisfaction survey. All clinicians performing Outpatient Hysteroscopy stated that consent is taken with all patients (written and oral). Audit identified written consent was taken in 69/111(62%), of patients, however 31/111(28%), stated no consent was taken. The type of information received was mainly written 30/111(27%). Audit identified a minimum of 26/111(23.3%) patients referred were of ethnic minority, yet information is currently provided in English format only. The Majority of patients received information at some point in their journey 91/111(82%), however audit identified that 20/111(18%), did not appear to have received any. Reasons identified for patients not receiving any information was mainly due to their referral pathway. Nearly fifty percent of patients found the information provided was helpful 54/111(49%), although, 42/111(38%) confirmed that they not had received written information prior to their procedure. Overall there was good patient satisfaction with 95/111(85.6%) recommending the procedure to a friend.

Keywords: Consent, Informed consent, Patient Information

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1 Aim and introduction

1.1 The focus of this report is to look at whether Hillingdon Hospital Hysteroscopy Service complies with Department of Health (2003) and (2010), and Local Trust standards, with regards to taking consent and providing all our patients with information.

1.1.1 It was also of interest to see if the type of referral pathway used, identified a difference in the information a patient received, and to review patient satisfaction with information currently offered, and identify areas for improvement through audit and patient feedback.

1.2 Currently Hillingdon Hospital provides an equivalent of 3.25 sessions per week with each session staffed with a HCA: Heath care assistant and Staff Nurse. Referral pathways identified are via the Gynecological clinics, RAC: (Rapid Access Clinic), Colposcopy Clinic, and direct from General Practitioner. Clinics have a mixture of general Gynecological slots; however the Tuesday AM and Thursday AM clinics have designated RAC slots which run concurrently with our RAC one stop service. This provides a cost effective but also an efficient service, enabling us to provide diagnostic / treatment to be performed on the same day, reducing delay in care and also providing reassurance for some patients and assisting with a speedy discharge.

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Standard

Consent must be obtained before starting any treatment or physical investigation or before providing personal care for a patient, and in conjunction with the consent process all patients should be given information relevant to their procedure and where possible printed information should be offered (Local Trust, 2013), Patient Information Policy, (Local Trust, 2011) Policy on obtaining valid consent to examination and treatment, in line with (DOH, 2003) Reference guide to consent for examination, Treatment or care and (DOH,2010) Equity and excellence: Liberating the NHS.

2 PROCESS

Prospective Patient Satisfaction Audit, devised to include certain questions pertaining to consent, patient information and satisfaction. Patients were offered an anonymous patient satisfaction survey on their arrival to the Hysteroscopy Clinic and were informed to answer questions once procedure and consultation was completed. A section was added at the end of survey for patients to add any further comments or recommendations. Completed form was placed in designated box. Data was collected over a three month period from November 2012 to February 2013.

2.1 Consent is to agree/ permit, give permission for something to happen: (Oxford English Dictionary). Within the field of health care, consent is when the clinician has obtained the full agreement of the patient to provide treatment or care. Obtaining consent can be seen as an informed agreement between the clinician and patient.

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2.2 Recommendation is to gain consent prior to any treatment or care offered (DOH, 2003). Patients have an ethical and legal right to understand what will be happening to their bodies (EHRC: Equality Human Rights.Com, NMC: Nursing and Midwifery Council 2008), and good practice is this should be sought by the clinician providing treatment or care (NMC: Nursing and Midwifery Council 2008, GMC: General Medical Council 2008). Case Law Chester v Afshar (2004) identified that if a HCP without valid consent touches a patient this can be seen as civil or criminal offence of battery, and so taking consent can be in the best interest of both the patient and Clinician (DOH 2003).

2.3 Written or verbal consent are both valid (GMC, 2008). It is not a legal requirement for consent to be in writing (Nicholas and El – Sayed 2006, DOH 2003), and a patients signature does not verify consent, but it can demonstrate that discussion and decision regarding proposed treatment or care had occurred (GOV.UK 2013). Written consent is seen as best practice especially if treatment involves considerable risks (DOH, 2003, and Local Trust Guidance, 2013) and can be advantageous for the patient, as the information can be reviewed at a later stage. However, some feel that too much importance is placed on written consent, and as long as the HCP is confident the patient is of complete understanding, then oral or implied consent is enough (GMC, 2008).

2.4 Consent however, is not a single step process but should be considered as continuous. For consent to be valid the patient needs to be informed sufficiently, so an informed decision can be made. Discussion should include reason for treatment or care advocated, risks, complications, and benefits, so consent can be given voluntarily (DOH 2003, GMC 2008). Even if the risk is found to be minor, recommendations following the Chester v Afsher Case Law, state, all risks should be clearly outlined, bearing in mind, all patients have an overriding right to fully understand what will be happening to their bodies (Nicholas and El-sayed 2006). The HCP is required to share and provide the patient with information regarding the intended treatment as this is a fundamental part of the consent process (Learning from Bristol report and Nice: National Institute of Clinical Excellence 2012).

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2.5 To make an informed decision, good information is key. (NHS: National Health Service, Quality and Service Improvement tools) research and systematic reviews, cite information increases patient satisfaction and (NHS 2010, and Gruman J et, al. 2010) suggest it can also improve health outcomes. PIF: Patient information Studies, found information can help in reducing service costs, as engaging patients in their health can increase adherence to treatment or care prescribed, however for information to have the desired effect it is essential that it is of a good standard and is evidence based.

2.6 NHS Audit Commission (1993),” What seems to be the matter: on Communication between hospitals and patients” suggest that a lack of information is a common patient complaint and the information available, can be of poor quality. Learning from the Bristol report (2002), identified, barriers with non English speaking patients not receiving adequate information in their first language, however over the last decade there has been great emphasis and efforts made on improving and sharing information (The Health Foundation, 2012)

2.7 Information is usually given verbally or in written format, but where possible, it is advisable to provide written (Martin et, al. 2005, and Local trust Guidelines 2011), as this can also be taken away and digested at a later date. Tang and Newcombe (1998) study suggest patients recall only 50% of information discussed after 5 minutes, therefore written information could help aid recall, and improve understanding of care prescribed. Not all patients will benefit from written information but if combined with other educational methods, this has been shown to be more effective, The Health Foundation, (2012).

2.8 Guidance on writing patient information, suggest information needs to be clear, easily understood, and accessible. The condition or treatment advocated, risks and benefits should be included and must be evidence based (NHS, QASIT: Quality and Service Improvement Tools). HCP’s have a duty to be aware of available current information, and need to know how to access this to enable patients to make an informed decision.

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2.9 Finally, gaining consent prior to providing treatment is not just a recommendation but a DOH (2003) and Local Trust (2011) and (2013) requirement. Providing information is not a separate process but is intrinsic in gaining consent. Patients today, have high expectations of healthcare. They expect up to date information on benefits and risks involved, and want to engage with the HCP to help them make an informed decision. With research and systematic reviews identifying the benefits gained by both the patient and Service providers, all HCP needs to be aware of types of information available, how to access this, and where to direct their patients.

3. Results /findingsPlease note, N/A = Not applicable and N/D = Not documented.

1. The Pie chart below shows age of patients referred into the Hysteroscopy clinic.

4; 4% 10; 9%

15; 14%

43; 39%

39; 35%ND25-3435-4445-54>55

82/111(74%) of women referred into the Hysteroscopy clinic were of >45 years

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N=111

2. Graph below shows the ethnicity of women referred.

Middle eastern

Asian Black Other ND English0

10

20

30

40

50

60

70

4,3.6% 9,8.1%5,4.5% 8,7.3%

23,20.7%

62,55.8%

62/111(55.8%) were of English Nationality and 26/111(23.5%) documented were of ethnic minority.

3. Pie chart below identifies the referral pathway.

3; 3%

28; 25%

18; 16%

15; 14%

47; 42% ColposcopyGOPDRACNDGP

47/111(42%) were direct General Practitioner referrals.49/111(44%) were in house referrals.

4. Graph below shows those patients who received information

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Referrals n=111

NO YES0

102030405060708090

100

20,18%

91,82% Series1

91/111(82%) received information

Trust Standard is that all patients should receive information on proposed treatment or care .100%

5. Pie chart shows the referral pathway of the 20/111(18%), who did not receive any information identified in graph above.

9; 45%

5; 25%

3; 15%

3; 15%

GPGOPDRACND

The majority of patients 9/111(45%) who did not receive any information were referred directly from the GP. A combined 8/111(40%), of referrals were made from GOPD and RAC.

6. Graph below shows type of information received

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n=111

n=20

Mostly, patients appeared to have received written information 30/111(27%), with some 4/111(3.6%) receiving both written and verbal. 47(42.4%) did not document anything.

Trust Standard is to provide written information were possible 100%.

7. If written did you receive this prior to your examination?

Only 42/111(38%) stated they received written information prior to their exam

8. Did you find the information helpful?

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N=111

17; 15%

35; 32%

5; 5%

54; 49% N/ANDNOYES

54/111(49%), found the information helpful and only 5/111(4%) stated it was of no help.

9. Patients who signed consent

Unsure NO YES ND0

10

20

30

40

50

60

70

1(0.9%)

31(28%)

69(62.1%)

10(9%)

Series1

69/111(62%) signed a consent form, however 41/111(37%) who did not document or stated No, audit cannot identify if verbal consent was taken.

10. Was the procedure what you expected?

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n=111

n=111

95; 86%

14; 13%

2; 2%

YESNOND

95/111(85%) stated YES, however of the 14/111(13%), who stated NO, it was found that 7/14(50%) had not received any information prior to their procedure.

Interestingly of the 91/111(%) (Graph 3) patients who had received information, only 4/91(4.3%) stated the procedure was not what they had expected.

11. Would you recommend this to a friend?

YES NO ND0

102030405060708090

10095,85.6%

12,10.8%4,3.6%

Series1

95/111(85.6%) would recommend this to a friend.

13. Patient feedback.

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n=111

More information required

Procedure and equipment

Excellent service Improve waiting time

0

2

4

6

8

10

12

14

16

18

20

4,11.4%5,14.3%

20,,57.1%

6,17.4%

Overall, 20/35(57%) shows we provide an excellent service; however, patients have requested more information and improvement on waiting time.

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N=35/11111

4 Discussion

4.1 Local Trust Standard states that taking consent is compulsory for all patients requiring treatment or care (100%). Audit results have shown that only 69/111(62%) of patients were offered written consent however there were limitations to the question as I was unable to identify if those who had answered No, had verbal consent taken, 1/111(0.9%) stated they were unsure and 10(9%) did not document this information. Improvements are needed with ensuring the patient is clear that they are giving their consent. Best practice is to provide written consent as this shows evidentially that discussion has taken place and this can be used to lead into discussion about risks and benefits and what the patient is likely to expect post treatment

4.2 Information was received by 91/111(82%) of patients, although I am aware that verbal information is given in most clinic settings. Trust standards are that all patients should be offered information, and best practice is to offer written where possible (100%). This audit also identified that some patients due to their referral pathway did not receive any information; this could be improved by changing the format of the invitation letter to include a section on what hysteroscopy involves and links for further information.

4.3 It was noted that only 42/111(38%) had received information prior to their hysteroscopy, this also could be improved if all departments (GOPD and RAC) ensure the hysteroscopy information leaflet is sent to all patients advising that this procedure may be required, thus informing the patient of what to do prior and what to expect during and post procedure.

4.4 Audit also identified that 26/111(23.5%) referred were of ethnic minority. Currently the hysteroscopy information is available in English only. There are immediate plans in place to update and provide information in other languages for Non English patients.

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4.5 Patient feedback is positive; however comments on improvement on waiting times and providing more information were noted. Waiting times could be improved if all Hysteroscopy slots were streamlined. Clinic diagnostic slots have been increased from 20 minutes to 25 minutes. This may help reduce waiting times for some patients and alleviate anxiety. A future review and audit of this would be advantageous. Further information was also requested and therefore it would be beneficial if additional information including the Service, the team and contact details were made available on the Trust website.

5 Conclusion

5.1 Overall patient satisfaction was high for those who attended the hysteroscopy clinic; however there were limitations to the audit. On reflection, questions could be reworded to obtain a more detailed overview of the service and to improve percentage of questions being answered.

5.2 We need to adhere to Local Trust standards in taking consent and providing information for all. Recommendations are for HCP’s to take consent, with written being best practice. Evidence shows benefits in providing information for Service Providers but primarily the patient. HCP’s are to be aware they are duty bound to provide this information as part of the consent process.

6 Recommendations

6.1 Take written consent were possible.

6.2 Provide all patients Including Non English patients with written information prior to consultation and investigation.

6.3 Change format of Hysteroscopy invitation letter to include explanation of procedure and link sites for further information.

6.4 All referral pathways to include patient information leaflet in their invitation letter.

6.5 Update Hysteroscopy information on Trust website.

Confirmed by Malini Sharma Trainer WORD Count 2500

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References

1. Department of Health, Social Services and Public Safety. (2003) Reference Guide to Consent for Examination Treatment or Care .Available from www.dhsspsni.gov.uk/ consent - [accessed on 24th September 2013].

2. Department of Health 2010 Equity and excellence: Liberating the NHS. Available from:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213823/dh_117794.pdf [accessed on 2ndOctober 2013].

3. EHRC Written Information Available from: http://www. equalityhumanrights .com/advice-and/guidance/service- providers-guidance [accessed on 14th October 2013].

4. General Medical Council. (2008) Consent: patients and doctors making decisions together Available from http://wwwgmc-uk-org. [accessed on 7th October 2013].

5. GOV.UK Public Health England (2013), Consent the Green Book, chapter 2.Available from: https://www.gov.uk/gov/[accessed on 24th September 2013].

6. Gruman, J. Royner, M H. French, M E. Jeffress, D. Sofaer, S. Shaller, D. Prager, D J. (2010) From patient education to patient engagement: Implications for the field of patient education. Patient Education and Counseling, 78(3), pp. 350-356.

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7. Hillingdon Hospital NHS Foundation TRUST. (2013) Policy for Obtaining Valid Consent to Examination and Treatment, 30(7.2)

8. Hillingdon Hospitals NHS Foundation Trust Patient information Policy . (2011)156(3.1).

9. Learning from Bristol. (2002) The Department of Health response to the report of the public enquiry into children’s heart surgery at the Bristol Royal Infirmary 1984 -1995.available from: http://www.official-documents.gov/ [accessed on 10th October 2013)].

10.Martin, R M. Williams, S L. Haskard, K B. DiMatteo, M R. (2005). The challenge of patient adherence. Therapeutics and Clinical Risk Management, 1(3), pp. 189-199.

11.Mid Staffordshire public enquiry care quality commission (2010) Available from: http://www.cqc.org.uk/public/mid-staffordshire-public-inquiry. [accessed on 11th

November 2013].

12.National Health Service Report No.12. (1993) What seems to be the matter: Communication between Hospitals and Patients. A-U-D-I-T Commission. Available from: http:// archive. audit - commission .gov.uk/ auditcommission /subwebs/

[accessed on 24/09/2013].

13. NHS Institute for Innovation and Improvement Quality and Service Improvement Tools. Patient Information. Availablefrom:http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/quality_and_service_improvement_tools_for_the_nhs. [accessed on 24th September 2013]

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14.Nicholas, N. El Sayed, M. (2006) Risk Management The changing face of consent: past and present. 8. pp. 39-44. Available from: www.rcog.org.uk/togonline [accessed on 10th October 2013]

15.Nursing and Midwifery Council. (2013) Consent Available from http://www.nmc-uk.org/Nurses-and-midwives/Advice-by-topic/A/Advice/Consent/ [accessed on 07th October 2013].

16.Oxford English Dictionary. Available from: http://www.oed.com/[accessed on 07 0ctober 2013}

17.Patient Information Forum. Making the case for information: The evidence for investing in high quality health information for patients and the public. Available from: www.pifonline.org.uk[accessed 11 October 2013].

18.Tang, P C. Newcomb, C. (1998) Informing Patients: A Guide for Providing Patient Health Information. Journal of the American Medical Informatics Association, 5(6), pp. 563-570.

19.The Health Foundation (2012) Evidence: Helping people share decision making, What is shared decision making. A review of evidence considering whether shared decision making is worthwhile. Available from: http://www.health.org.uk/publications/helping-people-share-decision-making [accessed on 7th November 2013].

20.Chester v Afshar  (2004) House of Lords Available from: http://www.e-lawresources.co.uk/Chester-v-Afshar.php[accessed on 10 November 2013].

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