The importance of qualitative methods for generating patient reported outcome measures and patient reported experience measures for pre-hospital and emergency care of stroke and heart attack

Context: The Patient Reported Outcomes for Vascular Emergencies: Interview Study (IS-PROVE) of patients and practitioners was conducted in a large regional ambulance service in the East Midlands region of the UK from 2010-2011. The aim of the study was to explore the experiences of patients and practitioners for emergency care of stroke or heart attack in the pre-hospital setting. Problem: Current health policy emphasises patient experience, together with effectiveness and safety, as key components of quality of care. As a consequence, patient reported outcome measures (PROMs) and patient reported experience measures (PREMs) are increasingly being seen as important, whether by providers, commissioners, regulators or service users themselves for assessing quality of care, by researchers for evaluating the outcomes of specific interventions and also clinicians for assessment and decision support. Despite the introduction of PROMs into the NHS in 2009 there are few validated PROMs in use or under development in the field of urgent (or emergency) care. Assessment of problem and analysis of its causes: We identified an important need to develop PROMs/PREMs for pre-hospital stroke and heart attack care and undertook the initial steps to develop appropriate item content for inclusion in such instruments. Patients that had suffered from these conditions and Practitioners that treated these conditions in the pre-hospital setting participated in qualitative interviews in order to obtain rich, in depth data. Intervention: Data were analysed with the support of Nvivo software and coded before final items for inclusion in the PROM/PREM were agreed by the research team. The PROMs and PREMs have been refined following elaboration of individual items and the next stage will involve formal testing and modification of the (construct) validity, reliability and responsiveness of the instruments. Study design: We used a qualitative design; individual interviews were conducted with patients or practitioners. Participants were also given the opportunity to take part in a focus group if they preferred. The benefits of focus groups are that they enable a range of experiences, beliefs, views and feelings to be explored in a setting of mutual understanding Strategy for change: The PROM and PREM tools for stroke and heart attack that we have developed will be piloted by ambulance clinicians that routinely treat these conditions to assess their validity and feasibility in the setting. We envisage that the tool will enable us to quantify patient reported outcome measure scores and examine the effects of organisational changes on patient outcomes. Measurement of improvement: The initial themes that emerged from the qualitative interviews and focus groups have included aspects such as reassurance, confidence in paramedic abilities, professional persona of clinicians and timeliness of service. These have allowed us to obtain a more informed understanding of the issues that patients attach greatest importance to in the pre-hospital setting. Effects of changes: We will use the PROM and PREM tools to assess the quality of care for patients with stroke and heart attack presenting to ambulance services. This will enable the regular monitoring of care standards and identify areas for improvement. Lessons learnt: We acquired new first hand knowledge from patients about their experiences of using the ambulance service for stroke and heart attack as well as learning about the issues that pre-hospital clinicians felt were important for improving care. Message for others: Development of PROMs and PREMs will be important for evaluating health care services and improving the quality of care. The methods used in this study may be useful for the development of PROMs in other settings

Development of a Patient Reported Experience Measure (PREM) for use in the ambulance service

Background NHS health policy emphasises the crucial role of patient experience as a core component of high quality care, alongside effectiveness and safety. Patient Reported Experience Measures (PREMs) measure patients’ experiences with their healthcare. They are increasingly being seen as valuable for assessing patient outcomes and differences in quality between health care providers. Previous patient surveys to assess ambulance service care have not been implemented routinely or in a standardised way. This research forms part of a doctoral study to develop a PREM for use in UK ambulance services. Methods The study comprised three subsections: 1. A secondary analysis of interview data exploring patients’ experiences of their prehospital care. 2. Development of questionnaire items based on those themes emerging from the secondary analysis. 3. Semi-structured interviews with service users that explore their opinions of the questionnaire items and whether the PREM includes all aspects of the ambulance service experience that should be encompassed. Results The secondary data analysis revealed specific ‘processes of importance’ to service users accessing ambulance care i.e. ‘timeliness’ and parallel ‘experiential components of care’ i.e. ‘reassurance’ that either enhanced or reduced the perception that the ‘processes of care’ were undertaken to a high standard. The key themes formed the foundation for generating the 53 item questionnaire. The interview stage is on-going and the data obtained are being used to amend the questionnaire items. Conclusions The construction of the PREM has incorporated the views of patients that the measure is ultimately designed for, and conforms to the concept of patient-centred care—the theoretical foundation of the research. Once completed, the PREM will enable ambulance trusts to measure differences in patient experiences, between and within organisations. This can result in positive changes to patient experience through the introduction of feedback, training and education to prehospital clinicians

Interpersonal communication skills in the traumatic brain injury population : an analysis across situations

ABSTRACT This thesis investigates a range of everyday interactions of traumatic brain injury (TBI) subjects when compared with control subjects to examine whether there are differences in the overall structure of interactions, in the way information is exchanged and in the wording which is used. Analyses from systemic functional linguistics including generic structure potential analysis, exchange structure analysis and analysis of politeness markers were used to examine the interactional impairments reported to follow TBI. Results indicated that TBI subjects differed from controls in their use of interpersonal language resources. These differences were exaggerated when subjects were interacting with someone in authority. When placed in a more powerful role, TBI subjects were able to utilise language resources to a similar extent to controls across the three levels of analysis. This thesis has important implications for the assessment and management of interactional communication impairments which may follow TBI, including suggestions for therapy with the person with TBI and for communication partners of people with TBI including therapists, family members and the community

Interpersonal communication skills in the traumatic brain injury population: An analysis across situations

ABSTRACT This thesis investigates a range of everyday interactions of traumatic brain injury (TBI) subjects when compared with control subjects to examine whether there are differences in the overall structure of interactions, in the way information is exchanged and in the wording which is used. Analyses from systemic functional linguistics including generic structure potential analysis, exchange structure analysis and analysis of politeness markers were used to examine the interactional impairments reported to follow TBI. Results indicated that TBI subjects differed from controls in their use of interpersonal language resources. These differences were exaggerated when subjects were interacting with someone in authority. When placed in a more powerful role, TBI subjects were able to utilise language resources to a similar extent to controls across the three levels of analysis. This thesis has important implications for the assessment and management of interactional communication impairments which may follow TBI, including suggestions for therapy with the person with TBI and for communication partners of people with TBI including therapists, family members and the community

New South Wales Vegetation Classification and Assessment : part 1, plant communities of the NSW Western Plains

For the Western Plains of New South Wales, 213 plant communities are classified and described and their protected area and threat status assessed. The communities are listed on the NSW Vegetation Classification and Assessment database (NSWVCA). The full description of the communities is placed on an accompanying CD together with a read-only version of the NSWVCA database. The NSW Western Plains is 45.5 million hectares in size and covers 57% of NSW. The vegetation descriptions are based on over 250 published and unpublished vegetation surveys and maps produced over the last 50 years (listed in a bibliography), rapid field checks and the expert knowledge on the vegetation. The 213 communities occur over eight Australian bioregions and eight NSW Catchment Management Authority areas. As of December 2005, 3.7% of the Western Plains was protected in 83 protected areas comprising 62 public conservation reserves and 21 secure property agreements. Only one of the eight bioregions has greater than 10% of its area represented in protected areas. 31 or 15% of the communities are not recorded from protected areas. 136 or 64% have less than 5% of their pre-European extent in protected areas. Only 52 or 24% of the communities have greater than 10% of their original extent protected, thus meeting international guidelines for representation in protected areas. 71 or 33% of the plant communities are threatened, that is, judged as being ‘critically endangered’, ‘endangered’ or ‘vulnerable’. While 80 communities are recorded as being of ‘least concern’ most of these are degraded by lack of regeneration of key species due to grazing pressure and loss of top soil and some may be reassessed as being threatened in the future. Threatening processes include vegetation clearing on higher nutrient soils in wetter regions, altered hydrological regimes due to draw-off of water from river systems and aquifers, high continuous grazing pressure by domestic stock, feral goats and rabbits, and in some places native herbivores — preventing regeneration of key plant species, exotic weed invasion along rivers and in fragmented vegetation, increased salinity, and over the long term, climate change. To address these threats, more public reserves and secure property agreements are required, vegetation clearing should cease, re-vegetation is required to increase habitat corridors and improve the condition of native vegetation, environmental flows to regulated river systems are required to protect inland wetlands, over-grazing by domestic stock should be avoided and goat and rabbit numbers should be controlled and reduced. Conservation action should concentrate on protecting plant communities that are threatened or are poorly represented in protected areas

Participants’ perspectives of feasibility of a novel group treatment for people with cognitive communication difficulties following acquired brain injury

Purpose: To determine whether treatment was acceptable to participants and perceived as beneficial by exploring the experiences of people with cognitive communication difficulties following acquired brain injury who participated in a novel, group, communication, project-based treatment. The purpose of the treatment was to improve participants’ communication skills and quality of life, by focusing group activity towards the production of a project and by incorporating individualised communication goals into group sessions. Methods: Twenty-one people with acquired brain injury recruited from community settings participated in project-based treatment, which comprised one individual and nine group sessions (of 2-3 people) over six weeks. Structured interviews were conducted post-treatment as part of a broader assessment battery. Interviews were transcribed verbatim and analysed using content analysis to identify codes, categories and themes. Results: Themes identified from the analysis centred around the treatment experience (general experience; group experience; project experience; working on goals) and benefit of treatment (communicative benefit; other benefits; emotional effects; meeting others; something to do). These themes were consistent with the treatment being perceived as acceptable and having initial efficacy for the participant group. Conclusion: The qualitative data presented here provide positive feasibility findings (acceptability and initial efficacy) of project-based treatment for people with acquired brain injury. The results highlight the value of incorporating participants’ views in assessing feasibility in developing novel interventions

Reducing inappropriate hypnotic prescribing using a quality improvement initiative in a rural practice

Context This improvement project was set in a single general practice in rural Lincolnshire, East Midlands, UK. All doctors and practice staff were actively engaged in reducing inappropriate long term prescribing of hypnotic drugs in the practice population as part of a Quality Improvement Collaborative (QIC). Problem Hypnotic drugs are only licensed for short term use but inappropriate long-term prescribing of hypnotics is common. Evidence from previous studies shows that hypnotics have limited therapeutic value and potential for significant adverse cognitive and psychiatric effects. Although there is evidence for hypnotic drug withdrawal programmes there have been few improvement projects showing whether and how this might work in practice. Assessment of problem and analysis of its causes Baseline rates of hypnotic prescribing were analysed and charted using statistical process control (SPC) methods. Patients on repeat prescriptions of hypnotic drugs were identified from the practice database. Causes, solutions and barriers were determined using surveys and focus groups of patients and staff. A withdrawal programme was implemented for all patients on long term hypnotics by writing to patients, arranging a consultation, making a detailed assessment and using techniques such as tapering doses of drugs and using cognitive behavioural therapy for insomnia (CBTi) during general practice consultations. The improvement was supported by a QIC called REST (Resources for Effective Sleep Treatment) which supported the practice team to implement sleep assessment and management tools using plan-do-study-act cycles, process mapping and new protocols. Strategy for change The change was coordinated in the practice over six months, with each practitioner maintaining an agreed and consistent approach for managing sleep problems. All staff including doctors, nurses, administrative staff and practice manager took part. Patients were informed of the planned alteration to their treatment for their sleeping problem via a letter detailing exactly how the new regime would be implemented alongside the reasons for this. Patients were offered an appointment to discuss the proposed changes with their GP and all did so. Measurement of improvement We measured improvement by analysing prescribing rates using statistical process control charts. We also surveyed patients and conducted a focus group to explore the patients’ personal experiences of the new service the support they received during the withdrawal programme and how they manage their sleep now. Effects of changes There was a significant reduction in hypnotic prescribing of benzodiazepines (664.9 to 62.0 ADQ per 1000-STAR-PU) and Z drugs (2156.7 to 120.1A ADQ per STAR-PU) in the practice over the six months of the project and this improvement has been sustained since the initiative. Some patients were initially unhappy about being taken off sleeping tablets but with the approach described were successfully withdrawn. No patients are now prescribed long term benzodiazepines or Z drugs for sleep difficulties in the practice. Psychological treatments for the management of sleep problems are used first-line instead of hypnotics. The transition from hypnotics to psychological treatments is evidence of improvement in patient care. Lessons learnt It is possible to implement a hypnotic withdrawal programme over a relatively short period of time in general practice using a carefully constructed programme applied consistently by staff comprising a letter to patients, tapering of drugs and CBTi supported through education of practitioners in sleep management and quality improvement methods. Message for others Key factors for success in this improvement project were a motivated practice team, a range of solutions which could be adapted locally, expert support on sleep management and quality improvement methods and feedback of results. We will present further data on the experience of patients in this improvement project

Using mixed methods for evaluating the effect of a quality improvement collaborative for management of sleep problems presenting to primary care

Context This improvement project was set in Lincolnshire, a large rural county in the East Midlands with high prescribing rates of hypnotic drugs compared with the rest of England. Eight general practices volunteered to participate in a Quality Improvement Collaborative (QIC) designed to improve management of sleep problems in patients presenting to primary care. Problem Sleep problems are common affecting around 40% of adults in the UK. Insomnia has considerable resource implications in terms of disability, impaired quality of life and health service utilisation. Up to half of individuals with Insomnia seek help from primary care and hypnotic drugs are often inappropriately prescribed for long term use. Non-pharmacological treatment measures are rarely implemented in practice despite guidance supporting their use. A lack of training as well as limited availability of resources for effective sleep assessment and treatment in primary care are possible explanations for this. It is clear that there is considerable scope for improving management of sleep problems in general practice Assessment of problem and analysis of its causes We used a Quality Improvement Collaborative to introduce practitioners to sleep assessment tools including the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI) and Sleep Diaries and non-pharmacological interventions such as Cognitive Behavioural Therapy for Insomnia (CBTi). Practitioners from participating practices were asked to begin using these where appropriate within their day to day practice. Strategy for change The project team met bi-monthly with practice teams to share learning. We used adult learning techniques to promote rapid experimentation (Plan, Do, Study, Act) cycles, process redesign and monthly feedback of prescribing rates and costs of hypnotic drugs using statistical control charts. Data were collected from the collaborative meetings to understand the facilitators, barriers and changes that practices were making as a result of the Quality Improvement Collaborative (QIC). Measure of improvement Qualitative data were collected via audio recordings of practice and collaborative meetings with practitioners and practice staff. This data was then transcribed verbatim. Thematic analysis was carried out supported by computer software MaxQDA using a framework method. Nine themes emerged which were then reviewed by five members of the evaluation steering group to assess inter-rater reliability of the themes. We used statistical process control charts and an interrupted time series design to analyse prescribing data for the two year period preceding the establishment of the collaborative and for the six months of its operation. Effects of changes There was a significant reduction in hypnotic prescribing of benzodiazepines and Z drugs in the practices over the six months of the project and this improvement has been sustained since the initiative. Nine themes emerged from the qualitative data: - Engagement of staff: Most practitioners showed enthusiasm to incorporate changes in their practice and encouraged other members of the practice to become involved by demonstrating use of the tools and reminders during meetings “It’s brought up at every practice meeting and so it’s always fresh in people minds. It’s not something that’s then forgotten.” Practitioner views of the tools: Practitioners tried the tools and techniques and overall seemed to favour the Sleep diary and Insomnia Severity Index (ISI) over the Pittsburgh Sleep Quality Index (PSQI) “Generally we found that the ISI was easy to complete, score and interpret and can be used in general practice” Practitioner preconceptions: Practitioners came with preconceptions about the feasibility of sleep tools and techniques. Patients’ age and intellect were factors that practitioners thought might affect whether tools were completed correctly or at all. Needs & educational needs of patients & staff: Before this project hypnotics had been seen as the solution to most sleep problems by both patients and practitioners. “When people come in it was so easy to give them a prescription” "As GPs we’re overly limited and actually to have a slightly more sophisticated response would actually be better for us but also for the patient”. Barriers to implementing tools & techniques: This related to systems (of care) practitioners and patients Systems: “Once the psychiatrist says you should have this, it is really hard as a GP to go against it because you know they say the psychiatrist has asked me to take this.” Practitioner: “We come down to the cognitive behaviour therapy approach; it’s a bit thin on my part, we’ve not got great skills in that”. Patient: “I think the key is also definitely how to communicate it…the minute you start even trying to approach the subject that the tablets are not really very good and what about thinking about alternative ways, they will kind of glare very rudely and be like I have been there before doc[tor]. So you have got to kind of approach it in a kind of a fresh way to make them thing they are trying something new. You have got to be a salesman’. Changes initiated by practices: Some practices had taken other measures to try and reduce hypnotic prescribing including implementing withdrawal programmes and limiting repeat prescriptions which let to improvement is patient and practitioner experience GP-Patient treatment & expectations: Practitioners revealed what they thought patients expected and made suggestions of how consultations could be improved to meet patients’ needs and increase successful outcomes from a sleep consultation. Importance of tailored approach: Each patient with Insomnia would need to have their treatment tailored to their individual requirements therefore every consultation could potentially have very different solutions Lack of feedback from patients: Receiving feedback from patients was difficult for some practitioners when patients didn’t return for their follow-up consultation or didn’t complete and return their sleep assessment tools. This lead practitioners to feel unsure as to whether patients had read and absorbed the information provided to them Lessons learnt Qualitative methods for collecting and analysing data were invaluable in understanding the factors which helped bring about change, how change happened and the effect of the change on process of care and patient and practitioner experience Message for others Quality improvement collaboratives benefit from careful analysis using qualitative as well as quantitative methods. Further information www.restproject.org.uk Project manager: [email protected] Project lead: [email protected]

Effect of a quality improvement programme on leadership, innovation and use of quality improvement methods in general practice

Introduction Market mechanisms and pay-for-performance have failed to deliver continuing improvements in UK clinical care. Leadership and innovation are currently seen as essential to maintain and improve clinical quality but little is known about the relationship between these and the extent to which quality improvement (QI) methods are used in general practice. This study aimed to investigate the effect of quality improvement training on leadership behaviour, culture of innovation and adoption of QI methods in general practice. Method Self-administered postal questionnaires were sent to general practitioner quality leads in one UK county at the beginning (2007) and the end (2010) of a QI programme. The questionnaire consisted of background demographic information, a 12-item scale to assess leadership behaviour, a seven-dimension self-rating scale for innovation culture and questions on current use of quality improvement techniques and the effect of this on practice. We analysed change between the two surveys and the effect of participation in QI training. Results Sixty-three completed questionnaires (62%) were returned in 2007 and 47 (46%) in 2010; 32 practices completed both surveys. Although leadership behaviours were not commonly expressed, many practices reported a positive culture of innovation with significant positive correlation between leadership and innovation (r = 0.57; P < 0.001); apart from clinical audit and significant event analysis, QI methods were not reported as having been adopted by most participating practices. Percentage leadership score changed little over three years (increase 4.0 points, 95%CI -8.9 to 16.9) with little difference between participating and non-participating practices (7.6, -6.4 to 21.6) and no evidence of differential change (-1.5, -17.0 to 14.0). Percentage innovation culture scores showed a similar pattern (time -4.1 points, -15.1 to 6.9, group -1.6, -12.7 to 9.4, differential change 5.3, -7.8 to 18.5). Conclusions Leadership behaviours were infrequently reported, and despite describing a culture of innovation there was low uptake of QI methods beyond clinical and significant event audit even after practices participated in a QI programme. There is evidence that practices may need greater support to enhance leadership competences and develop quality improvement skills to stimulate innovation if improvements in health care are to accelerate

What do users value about the emergency ambulance service?

Introduction: Response times have been used as a key quality indicator for emergency ambulance services in the United Kingdom, but criticised for their narrow focus. Consequently, there is a need to consider wider measures of quality. The patient perspective is becoming an increasingly important dimension in pre-hospital outcomes research. To that end, we aimed to investigate patients’ experiences of the 999 ambulance service to understand the processes and outcomes important to them. Methods: We employed a qualitative design, using semi-structured interviews with a purposive sample of people who had recently used a 999 ambulance in the East Midlands. We recruited patients of different age, sex, geographical location, and ambulance service response including ‘hear and treat’, ‘see and treat’ and ‘see and convey’. Results: We interviewed 20 service users. Eleven men and nine women participated and 12 were aged 65 years and over. Users valued a quick response when they perceived the call to be an emergency. This was of less value to those who did not perceive their situation as an emergency and irrelevant to ‘hear and treat’ users. All users valued the professional approach and information and advice given by call handlers, crew and first responders, which provided them with reassurance in a worrying situation. ‘See and convey’ users valued a seamless handover to secondary care. Limitations: We found it challenging to engage participants to consider quality indicators beyond response times because these were considered to be abstract in comparison with their concrete experiences. Conclusions and recommendations: Aspects other than response times were important to patients, particularly in situations perceived by patients to be non-emergency. The results will be combined with issues identified from systematic reviews and used in a Delphi study to identify candidates for new outcome measures for emergency ambulance services