Breaking bad news to patients
- Why was the initiative launched?
- What was done?
- Creating a Care Route
- Improving outpatient experiences
- Patient communication: breaking bad news
- Has it made a difference?
- Tips for success
- For more information contact
- The following material is available
Using patients' views to improve neurosciences at King's Healthcare NHS Trust in south London
Why was the initiative launched?
A new neuroscience service was created at King's Healthcare in 1995. Services previously based at the Brook and Maudsley Hospitals were brought together on the King's site. The management team wanted to link the creation of the new service with multi-disciplinary team working and improved service to patients. The team sought help from the Trust's Transforming Healthcare Delivery team.
What was done?
In the early 1990s King's Healthcare was one of two Trusts in England funded to explore the relevance of process re-engineering techniques to the NHS (see ImpAct January 2000, v 2 issue 1). A Transforming Healthcare Delivery team grew out of that work. A range of services has been tackled by the team, including cardiac disease and asthma. The teams' approach focuses on care routes to redesign health service delivery from the patients' perspective (Figure).
Creating a Care Route
The first task was to create an overview of the service from the patients' perspective. It was decided to concentrate on patients with brain tumours as a catalyst for change: they use all aspects of the neurosciences service. It is a regional service, and travel for staff to clinics at other sites, and patients, is inevitable. Patients are happy to travel to receive a high quality service. But that travel creates the challenge of ensuring that the service is organised and efficient. Staff drew up and validated a process map showing patients' journeys through the service. The chart covered 100 square feet and demonstrated the complexity of the system. The work was managed to ensure that all staff were aware of the project and how they could contribute.
The second task was to interview randomly selected patients who had recently used the service. Interviews were deliberately unstructured to allow the patients to speak freely about all aspects of their care. All the interviews were transcribed. Patients' comments could then be stuck on to the process map: a blue bubble for positive comments and red bubble for problem areas. After this analysis was completed it was obvious from the red bubbles that two areas needed attention: outpatients, and communications with patients, or how bad news was given.
Two multi-disciplinary teams were set up which included staff from St Thomas' where patients receive radiotherapy. Members of the Transforming Healthcare Delivery team facilitated the project teams: they met monthly for six months to analyse problems and develop solutions.
Improving outpatient experiences
Two problems needed attention. Patients expressed concern about delays and an apparent lack of organisation of clinics. Delays happened because patients were seen by a large number of clinicians, and consequently were often intimidated by the process. The team recommended a new process for allocating patients to the most appropriate clinician, the person best suited to the patients' needs on the day.
Scans were often unavailable because of the time taken to get them back to the Department from King's (requiring transfer across the hospital site) or other hospitals. Moreover they were stored in fourteen different places on site. Finding them at the right time was a real problem. A number of changes speeded up the process, with a computerised tracking system and a central store.
Patient communication: breaking bad news
Patient concerns ranged from the way that telephone messages were passed to the way that staff handled giving bad news about a patient's diagnosis, which could range from a couple of breezy sentences about death or disability to a gory account of every possible risk. The team looked at written material (there was none) and the way that verbal communication was handled. Some quick improvements were achieved by creating a new information package.
The main challenge was to find ways to improve the process for breaking bad news. The team's investigation identified a number of problems (Box).
Problems identified
Information was given:- By inexperienced staff
- In an insensitive manner
- Without the relatives being present
- By an inappropriate person
- By staff who could not then answer questions
- After an unnecessary delay
- In a poor environment
- Without the opportunity for discussion
A structured approach was needed which took account of:
- the time when news can be broken; when test results were available
- the availability of an appropriate person; suitably qualified to engage in a two way dialogue
- what sort of information was required
- when patients have the support their families.
Nurses hold the key to the new process: a nurse co-ordinates a meeting to pass on the results of the diagnosis. This enables appropriate staff to be available, allows the patient to ensure friends and relatives are present, and ensures that the discussion takes place in a separate room not in front of other patients. A training programme was devised to ensure that all staff understand and can contribute to the new approach. The programme includes a new session in their induction programme for junior doctors, workshops for nurses, therapists and radiographers, and for administrative and clerical staff as well.
Has it made a difference?
When detailed work had been completed the team arranged a launch day. The board room walls were covered with all the work undertaken and the team members were available throughout the day to talk staff through the solutions.
The team identified a number of indicators which could be monitored to gauge whether targets had been achieved. Some of these data were gathered when the initial analysis was being undertaken. A range of techniques was used, including the use of routine data to the use of questionnaires to patients. The majority of the targets set have been met or surpassed. The key indicators are set out in Table 1.
Table 1: Making a difference
| Indicator | Baseline | Target | March-00 |
| Maximum wait in clinics (minutes) | 145 | 30 | 15 |
| Median wait in clinics (minutes) | 33 | 20 | 5 |
| Availability of scans, Kings (% available) | 78 | 85 | 96 |
| Availability of scans, other hospitals (% available) | 57 | 75 | 75 |
| Written material for patients | 0 | 5 leaflets 1 poster 6 racks | 11 leaflets 1 poster 6 racks |
| Training programmes for nurses | 0 | 60% by 9/99 80% by 12/99 | 100% |
| Training workshops for A&C staff | 0 | 3 | 3 in 1999 |
| Patients' perceptions (%) of adequacy of: | |||
| privacy | 31 | 70 | 65 |
| time given by staff | 44 | 70 | 69 |
| clarity of explanation | 48 | 70 | 73 |
The programme has also enabled the King's Transforming HealthCare team to further develop its methodology. The focus is now much more on the task of implementation where resistance is more likely to be met and where the hard work of previous phases can fall down.
Tips for success
- Using patients' views prevents disagreement about whether there is a problem and about whether it is important.
- Working through teams helps to keep a focus on realistic solutions owned by those involved.
- Remember that teams can lose enthusiasm in the middle of projects when problems have been identified but solutions are proving difficult to implement. It's not unusual.
- Encourage radical thinking in seeking solutions because people may have a natural propensity towards conservative solutions and want to take the easy route.
- Senior commitment can help create more confident teams and allow them to pursue more radical solutions.
- Achieving changes requires stamina: it's hard work. Make sure that the right level of support is available when solutions are being implemented.
For more information contact
Kate Grimes
Programme Leader: Transforming Healthcare Delivery
King's Healthcare NHS Trust
King's College Hospital
Denmark Hill London SE5 9RS
Telephone 020 7346 3188
Fax 020 7346 3721
E-mail Kate.Grimes@mail.kingshc.nhs.uk
The following material is available
New consent form
Documentation for results discussion
Written information for patients
View of staff who took part in the project
ImpAct bottom line
Involving patients helps get commitment from staff and gives momentum for action