How Satisfied are the Patients Attending the Outpatient Hysteroscopy Clinic at a London Teaching Hospital?

Introduction

The National Health Service (NHS) has been making great strides towards empowering patients and including them in decisions surrounding the provision of their care. This includes aims set out by the Department of Health as well as guidance laid out by the General Medical Council (GMC), where doctors are not only encouraged to maintain good relationships with patients but also to work in partnerships and enable patients to care for themselves [1]. This has become central to the way medicine is practiced, patient response is not only a powerful tool to assess particular treatments or procedures but is now crucial to developing NHS services. Doctors have been shown to be poor at assessing the effect of diseases and management decisions on patients’ daily lives, which can lead to poor outcomes for patients and reduced levels of satisfaction with the services they receive [2]. This raises the question of the role of the patient’s views in their own care and how they can be used to assess particular treatments or procedures.

Patient experience is a concept that has increasingly gained interest and become more prominent over the years. Alongside clinical effectiveness and patient’s safety, it is recognised as one of the three pillars of healthcare quality [3]. Patient reported outcome measures (PROMs) capturing experience measures focus on various aspects of the humanity of care such as patient privacy, receiving all relevant information or being kept waiting [4]. PROMs which focus on patient experience provide insight into the quality of care during the intervention. It is important that service providers are assessed on various aspects of care such as treating patients with dignity, respect and compassion and involving patients in their own decisions in addition to gathering data on harm avoidance or success rates for treatments [4]. Providing clear information, being empathetic, maintaining an open two- way communication and respect for beliefs and concerns of patients from different cultural backgrounds will lead to well informed patients with ownership of their own clinical decisions.

There is a drive towards improving provision of healthcare using patient feedback as crucial information for developing services in medicine and in the NHS; one of the ways this is manifested is the use of PROMs. PROMs are currently used within the NHS as patients having one of four operations are asked to complete a questionnaire about their health and quality of life before and after treatment to assess the benefits from the patient perspective [5, 6]. The results are used to inform decisions on changes to service delivery and on healthcare providers. PROMs, when put into practice, have been shown to lead to improved communication between healthcare professionals and patients, with better outcomes reported by patients [7, 8]. In particular, benefits have been shown with pain management, chronic conditions and depression [5].

A questionnaire addressing patient satisfaction in the setting of an Outpatient Hysteroscopy Unit was used in this study to gain the patients’ perspective of the service and understand what information and support they most value. The findings from this questionnaire enable us to have a greater insight into the patient journey, leading to greater satisfaction with services and better outcomes for patients. In the NHS, measurement of patient experience data is now mandatory to identify strengths and weaknesses of health care delivery, drive quality improvement and promote patient choice. Patient choice remains a crucial aspect of NHS care, however, many patients struggle to decide whether to choose an outpatient hysteroscopy or undergo the procedure under a general anaesthetic. Using information obtained through PROMs capturing experiences such as this, patients are empowered to make an informed choice.

Outpatient hysteroscopy is used to examine the uterine cavity and is a way of visualising intrauterine abnormalities and pathologies, particularly in the context of abnormal uterine bleeding. A dedicated service should be provided by all gynaecology units, with evidence for the clinical and economic benefits from its diagnostic as well as therapeutic intervention [6, 7, 8]. It is a procedure which is well tolerated by patients but can be associated with concern, particularly due to pain, anxiety and embarrassment [9]. Whilst there is a relevant and necessary focus on minimising pain and complications with the procedure itself, PROMs are vital to further developing partnerships with patients and improving all aspect of their care.

This approach has the potential to improve engagement with the service and improve outcomes for patients. Our survey was aimed at improving the services at a teaching hospital by utilising patient feedback and assessing the performance of the unit.

Methods

This perspective study was aimed at women attending the outpatient hysteroscopy clinic in a London based university teaching hospital. A questionnaire was devised and validated to assess patients’ satisfaction of multiple aspects of the outpatient hysteroscopy clinic and their overall experience, with a scale used to rate satisfaction. Questionnaires were produced in the English language and distributed to patients as they entered the unit on the day of their procedure. The questionnaire was given to consecutive women attending our hysteroscopy clinic between January and March 2014 and was repeated two years later between January and March 2016 to ensure concerns had been addressed and the level of care maintained. Items on the questionnaire covered areas of patient satisfaction with: information given prior to outpatient hysteroscopy appointment, efficiency of the service provided, the procedure, information given post procedure and overall satisfaction.

The hysteroscopy procedures are performed by Consultant Gynaecologists, Nurse Specialists and Senior Registrars under Consultant supervision. The unit uses a mini hysteroscopy alphascope with a 1.9mm diameter, via vaginoscopic approach that avoids the use of vaginal speculum. Local anaesthetic is not routinely used; it is used for para-cervical block in cases where cervical dilatation is required.

Results

A total of 40 women participated in the survey in 2014 with 71 women completing the questionnaire in 2016. We assessed patients’ satisfaction soon after their hysteroscopy procedure (see Appendix). Over 95% of patients received an information letter or leaflet prior to attending their appointment in both 2014 and 2016, although in 2014 7.5% patients felt that they were given insufficient information by what was provided whereas only 7% of patients in 2016 felt that not enough information was provided. Access to a phone number was confirmed by 87.5% in 2014 which improved to 93% of patients in 2016. Almost all patients found staff to be friendly and courteous through all their encounters.

Waiting times were minimal with 30% and 38% of patients being seen on time in 2014 and 2016 respectively. A total of 95% and 97% of patients were seen by the clinician within 30 minutes of arrival 2014 and 2016 respectively.

Discussion

Gynecology is transforming into an ambulatory service with procedures traditionally performed in theatres under a general anaesthetic being performed in an outpatient setting with awake patients. It is therefore more important than ever to collect feedback from patients undergoing awake ambulatory procedures to constantly improve an evolving service.

The majority of patients report an excellent standard of care in the outpatient hysteroscopy clinic and all patients were satisfied with the service.

However, reduced satisfaction appeared to be related to lack of information prior to the patients’ appointment and staff communication, either before their procedure or during it.

We compared our results to a National Survey of the Outpatients department in 2011 across England, where only 45% of patients reported that they ‘definitely’ knew what would happen during their appointment. Similarly, in both survey years, 95% of our patients were seen within 30 minutes of their appointment, compared to the National Survey which reported only 24% of patients seen on time for their appointment and 38% waiting more than 15 minutes to be seen.

One challenge noted during the distribution of questionnaires was the diverse population served by the dedicated Gynaecology unit and the range of languages present. The information provided was all in English and at times this information was not conveyed adequately, with improvements needed in the quality of information distributed as well as access to language services for this particular unit. This could have contributed to increased anxiety and negative outcomes for patients, resulting in disengagement with a vital service. Despite many positive comments, others highlighted the anxiety that patients felt. As a result of this survey, the unit will provide more information to patients through leaflets and specialists passing on information in the patient have preferred language prior to their appointment. Another avenue of information provision that could be explored is a video explaining the procedure in different languages. The video would provide the necessary information with regards to the actual procedure and manage patient expectation.

The number of patients who were not aware of who was performing the procedure halved between 2014 and 2016. This may be reflected by a change of badges worn by the health professionals with clear identifying roles introduced in 2015.

Outpatient hysteroscopy is becoming a popular first line choice for investigation of abnormal uterine bleeding however the experience of pain can be a deterrent for patients offered outpatient diagnostic hysteroscopy [10]. This survey showed most patients tolerated the vaginoscopic procedure well and commented that it was either less or not as painful as they expected. One study has shown that a vaginoscopic approach to hysterscopy was found to be significantly less painful than the traditional hysteroscopy with speculum and cervical block with local anaesthetic in keeping with the satisfaction seen by our patients [11].

Local anaesthetic has been found to reduce pain experienced by women undergoing outpatient hysteroscopy. The most favourable administration of local anaesthetic was shown to be paracervical or intracervical [12]. Currently this outpatient hysteroscopy service does use local anaesthetic unless cervical dilatation is required, however it is something to note on any patient who does not initially tolerate the procedure to improve patient satisfaction.

Limitations

We did not collect demographic information with the questionnaires. It is therefore not possible to assess which group of patients found the procedure more uncomfortable. If this could be done in future research, improvements could be further tailored according to patients’ needs.

Future Work

Further work needs to be addressed at how PROMs can be introduced into Gynaecology Units to improve services. Future research should involve longer follow up of patients using PROMs and to correlate negative experiences in the unit against post-operative recovery and complications. This work could be used to highlight areas which need most improvement and the changes that patients would most benefit from. In our comparisons against national studies, our unit performed above expectations which our patients would recommend to others. It is crucial for further work to try to understand all the reasons behind this and ensure that successful procedural outcomes correlate with this satisfaction. We feel this is crucial to the patient journey and improving satisfaction.

Conclusion

This study demonstrates that patient reported outcome measures can help to transform the quality of care given to the patients. We performed this quality improvement project by surveying patient satisfaction and introducing changes based on the results and recommendations from the initial audit and the re-audit demonstrated significant improvement in the patients. The majority of patients report an excellent standard of care in the outpatient hysteroscopy clinic and all patients were satisfied with the service in the re-audit. After the initial audit and survey further improvements were made by giving adequate information to patients prior to their outpatient hysteroscopy appointment that allowed patients’ to be better informed of what to expect when they attended the clinic. Information leaflets should be distributed to all patients ahead of their appointment and these should be reviewed to ensure women have enough relevant information prior to attending. Informing patients about the procedure in their own language using language line or interpreter service during consultation and giving out leaflets also in their language if they do not speak English helps with better communication with the patient.

Acknowledgement

We would like to thank all the patients, administrative and nursing staff in the outpatient hysteroscopy department at Whipps Cross Hospital for making this study possible.