I arrive at a hospital I haven’t been to before.
I have been told in my appointment letter to go directly to the outpatients desk to let them know I’m here.
I look around – there are three reception areas – but which one is for outpatients?
I logically choose the one nearest the front entrance, wait in a queue for five minutes but am then told that this is the reception area, and that I need to go to the one near the coffee shop. Looking at my watch (as I’m now afraid I’ll be late) I head over to the queue that has over ten other people waiting also to sign in. Eventually, ten minutes later, I give my details to the administrator and am now given new directions as to how to get to the clinic. I try to absorb everything she is saying and nod that I understand. I try my best not to forget.
But I do.
I stop and ask a nurse along the corridor for directions. She kindly helps me, but I can tell by her expression that she is trying to get somewhere in a hurry – probably to tend to a patient – I hate having to ask.
I eventually arrive at the waiting room (15 minutes late through no fault of my own) but am unsure if I should just sit there with my file, as a note on the clinic says not to knock on the door. I ask another patient. They tell me that a nurse will come out to me to collect it. I sit back waiting, noticing that Jeremy Kyle is showing on the TV. Not interested, and slightly concerned about the content being shown as young children are in the room, I go for my phone to keep me from boredom.
Only to find there is no Wi-Fi available in the hospital.
There are no magazines or newspapers – only books for children. I would love a cup of tea, or even a glass of water, but I can’t see any machines nearby. I know I am in for a long wait.
Ten minutes later a nurse comes out and takes all the files from various patients. I wonder will we be seen in order of the files being received, or by the times our appointments were at. Either way, I’m here now and I prepare myself for the long waiting period I have now become accustomed to through using public health services.
I see an elderly lady get wheeled into our waiting room – she has obviously just been in A&E or been up on a ward. The porter takes her file, knocks on the door, explains to the nurse her situation and then leaves her there to tend to other patients. I feel embarrassed for this lady, being left in a bed in front of everyone.
Thankfully she is seen within the next half an hour, and the porter comes back to collect her.
An hour later, I now really need to go to the bathroom – but am afraid to leave my seat in case I am called. I ask another patient could they listen out for my name and could they explain to the nurse my situation. I have learned that patients often help each other out.
I see a mother with a disabled child come in, there are no seats left. I offer my seat up.
Ninety minutes after my appointment time, I am now called in. Frustrated and now exhausted from boredom [and standing], I still put a smile on my face, as I know it is not the nurses or doctors fault.
I have a few questions written down to ask the doctor but I am now acutely aware that there are many more patients to be seen.
I meet the doctor, and it is not the consultant I thought it might be – it is his registrar. I am disappointed, but don’t say anything. Upon shaking hands with him I notice that the doctor seems rushed. He doesn’t make eye contact or introduce himself.
At this point, I make a decision to not to take out my questions but instead try to remember what I had wanted to ask. I feel like I am adding to the chaos of this doctors day. I feel guilty.
He asks me questions about previous appointments – I panic as I thought he would have them in his file. I am told that hospitals have different files and the information doesn’t transfer over. I try my best to remember dates; tests I had done and which consultants I had met previously. A nurse is sent off to retrieve previous information from my GP – it is not in my file. She comes back with a Fax document.
The doctor takes all of my information down, not looking at me as he does so. He asks me questions about my own and my family history – I try my best not to leave anything out. I suddenly can’t remember what the name of one of my medications are. I feel embarrassed.
The doctor moves on and proceeds to examine me quickly.
He tells me I look good and once I remember my medications he says that he will increase one of them. He gives me a new prescription. At this point, I don’t feel strong enough to tell him that, that medication makes me feel ill, meaning I often don’t take them. I proceed to tell him I regularly have pain in my knees. He tells me to keep a pain diary, but does not give me a diary of any sort. I just take his advice and walk out of the room – ten minutes later.
I go the reception area for my follow up appointment. I am given a date for six months later.
Before I leave the hospital I can’t find the parking ticket machine. I again ask the receptionist. I pay €7.50 for my two hours time in the hospital.
When I get home I go to fill in my new appointment time in my calendar. I notice we have a wedding on the same day. I ring the hospital back only to find all dates have been taken by now for that month and they can only give me a new appointment for two months after that time. At 8 in the morning. I have to travel from Mayo to Dublin. It will be an early start. I go about getting sheets of paper to design a pain diary of sorts.
Later that day, I pick up my new prescription from my pharmacist. I am told that I cannot take that dose, as it’s too strong for me. The pharmacist rings the hospital to clarify the situation.
I ring my husband in work and tell him the doctor said I’m fine. My husband is happy about this. But I am not. I just don’t feel reassured.
The next week, I again end up back in my GP’s office asking him what I should do. I am now referred to see someone else. He adds an anti nausea drug to help counteract the sickness I get.
I somewhat now feel reassured that I have been listened to.
But why did it take for my GP to help me feel this? Was all the time, stress and worry necessary? Could these issues ever be resolved?
And here are a few thoughts of my own on how I think it could be done with minimal cost, time and efforts.
Problem 1:“I look around – there are three reception areas – but which one is for outpatients?”
Solution 1: Signposting or even lines and markings on the floor would help here. A map on the appointment letter could also help.
ROI*: Save time for receptionist; ensures patients are on time for appointments, reduces stress for patients and carers.
Problem 2:“I give my details to the administrator and am now given new directions as to how to get to the clinic. I try to absorb everything she is saying and nod that I understand.”
Solution 2: Again markings on the floor would help (i.e. follow the blue line until you get to Clinic 1, 2, 3…) or again even a little map would help. If the receptionist could ask the patient for a read back this would be helpful to ensure the patient does understand.
ROI: Save time for health professionals being asked along the way; reduce stress for patients and carers.
Problem 3:“I am unsure if I should just sit there with my file, as a note on the clinic says not to knock on the door.”
Solution 3: The note on the door could say that a nurse will come out to you.
ROI: Reduce unnecessary communication issues – especially required for those with limited communication abilities. Informed patients = better outcomes for all.
Problem 4:“I sit back waiting, noticing that Jeremy Kyle is showing on the TV…there are no magazines or newspapers”
Solution 4: A health and well-being talk show or small snippets of appropriate, relevant information for the patients attending that clinic could be aired, such as local resources, services or treatments – or even ways to manage medications etc. Daily newspapers and magazines from the hospital coffee shop could be distributed. Even notepads for patients to write questions or notes prior to their appointments could be made available.
Cost: Minimal – Low
ROI: Informing patients of resources can empower them to seek these out instead of having to ask health professionals for same. Boredom can lead to tension, thus leading to angry outbursts at times so alleviating this will create a more relaxed environment.
Problem 5: “I would love a cup of tea, or even a glass of water, but I can’t see any machines nearby.”
Solution 5: Install a water or coffee/tea machine – this will create additional revenue for the hospital.
ROI: Ensure patients aren’t dehydrated (important for well-being/blood tests); creates a relaxed environment and reduces stess. Hospital can gain revenue on vending machines.
Problem 6:“There is no Wi-Fi available in the hospital.”
Solution 6: Install publicly accessible Wi-Fi! Opportunity here to promote hospital, local resources through an app.
Cost: Mid – High
ROI: Reduces boredom thus reduces tension and stress. Stress can also lead to false high blood pressure readings. Having appropriate information pushed through this system could educate patients and carers. Also may allow patients have access/input to medical apps.
Problem 7: “I wonder will we be seen in order of the files being received, or by the times our appointments were at…I see a mother with a disabled child come in, there are no seats left. I offer my seat up.”
Solution 7: A simple ticket system could help here, or again this could be written on the note of the clinic door. Nurses could inform patients to come back at a certain time and they could feel free to use the bathroom/get coffee/tea etc.
Cost: Low – Mid
ROI: Ticket systems work very well and everyone feels it is fair. It also frees up space in the waiting area.
Problem 8:“I feel embarrassed for this lady [in the trolley], being left in a bed in front of everyone.”
Solution 8: If it is just for a clinic review then anyone who is in a trolley should be seen where they are placed, or later/earlier clinic times given appropriately. It is a patient safety risk, for them, and the patients in the room, to have them in an exposed environment. It also takes away dignity and respect of the person in the trolley.
ROI: Reduces patient safety risks thus reducing unnecessary infections, medications etc. Saves time, money for hospital. Reduces need for porter. Increases dignity for patients.
Problem 9:“Ninety minutes after my appointment time, I am now called in. Frustrated and now exhausted from boredom [and standing], I still put a smile on my face, as I know it is not the nurses or doctors fault, I still smile. Upon shaking hands with him I notice that the doctor seems rushed.”
Solution 9: You don’t need stats to know that waiting time for patients in public systems is usually over one hour! Increasing clinics, appropriate management of times [and sticking to them]; chronic clinics separated from acute clinics or having weekend clinics can all help reduce this waiting time. Having no seats means patients are left standing which can increase blood pressure leading to possible false readings.
ROI: Doctors and nurses can spend more time with patients. Reduce stress and risks for them associated with being rushed. Show true blood pressure readings. Patients not being left feeling panicked can create a more relaxed, engaged environment – often leading to more honest and the transfer of accurate information. Better chances of appropriate diagnosis. Saves money, time and stress.
Problem 10: “I have a few questions written down to ask the doctor…at this point, I make a decision to not to take out my questions”.
Solution 10: In the waiting room notepads [as mentioned above] and recommendations by health professionals to write questions down prior to appointments can aide in this.
ROI: If patients have questions to hand when talking to health professionals, they can leave feeling more reassured. The number of questions can be limited at times of increased time pressures. Reassured patients = better self-management; less unnecessary appointments, miscommunication and stress. Health professionals can make the most of their time with patients.
Problem 11: “I meet the doctor, and it is not the consultant I thought it might be – it is his registrar. I am disappointed, but don’t say anything.”
Solution 11: Having a folder with the various health professionals and their bios/backgrounds available in the waiting room can help patients feel reassured about who they are seeing.
ROI: This can prevent concerns patients may have about the health professional looking after them – often patients feel the “top consultant” is the best and can be untrustworthy of “junior doctors”.
Problem 12: “He [the doctor] doesn’t make eye contact or introduce himself. I feel like I am adding to the chaos of this doctors day. I feel guilty.”
Solution 12: Basic training with health professionals on communication and time management can alleviate this issue. Providing self care therapies and services for health professionals can help them better manage stress. Doctors and nurses feel guilty too.
Cost: Low – Mid
ROI: Happy staff = better outcomes for patients. Better outcomes for patients = reduction in money, time, resources and stress.
Problem 13: “He [the doctor] asks me questions about previous appointments – I panic as I thought he would have them in his file. I am told that hospitals have different files and the information doesn’t transfer over. A nurse is sent off to retrieve previous information from my GP – it is not in my file. She comes back with a Fax document.”
Solution 13: Effective integrated IT solutions across the system would help with the efficiency of the flow of information. FAX systems replaced with e-communication tools.
ROI: Having accurate information to hand is essential part of the diagnosis and treatment process. Patients cannot be expected to remember everything and they may not have test results to hand. Appropriate and timely diagnostic and treatment is the key to proactive care and can prevent unnecessary medications, use of resources and waste of time. Save time, money and resources. Better patient safety outcomes. Saves nurses having to leave their stations to retrieve FAX’s.
Problem 14: “I try my best to remember dates; tests I had done and which consultants I had met previously…he asks me questions about my own and my family history – I try my best not to leave anything out. I suddenly can’t remember what the name of one of my medications are. I feel embarrassed.”
Solution 14: There is always information patients will have that health professionals may not have – especially if it is related to self management and care in the home. A simple health organiser, app or diary can help patients capture information to have to hand for appointments. This should be recommended at the point of care by health professionals, and should be easily recognisable across the disciplines.
Cost: Low – Mid
ROI: When patients have accurate information to hand more informed and accurate decisions can be made by health professionals. It also aides in better self management and care in the home. Integrated care is about needs, not disease, age or gender. Simple health organisers or PHR’s can effectively reduce unnecessary readmissions, appointments, medication non adherence and so much more.
Problem 15: “Once I remember my medications he says that he will increase one of them. At this point, I don’t feel strong enough to tell him that I’m not feeling good and that, that medication makes me feel ill, so I often don’t take them. I also tell him I regularly have pain in my knees. He tells me to keep a pain diary, but does not give me a diary of any sort. I just take his advice and walk out of the room – ten minutes later…Later that day, I pick up my new prescription from my pharmacist. I am told that I cannot take that dose, as it’s too strong for me. The pharmacist rings the hospital to clarify the situation.
Solution 15: Health professionals could have triggers in their IT systems to help them remember to ask patients if they have issues with medications or are there any contraindications. Additionally, asking patients to note their concerns with medications prior to the appointment could be helpful. E-prescribing can be particularly effective here – ensuring medications are reconciled at every point of care. A trained pharmacist could be placed in outpatient clinics to discuss medications with patients. Ten minute appointments are often not appropriate to capture all the information required, and to then administer treatments or diagnosis. Proper time allocations should be considered in relation to the needs of the patient. Often patients are asked to keep diaries but are not given one, meaning they have to devise or resource one themselves – additionally meaning accurate information from them may not be captured upon return to clinics. Simple pain diaries (paper or electronic) devised by health professionals could be developed to ensure appropriate information is recorded, these could be given to patients at the point of care.
Cost: Minimal – High [depending on solutions]
ROI: If patients are concerned about their treatments, or adverse reactions, often they won’t take them. This contributes to medication non adherence**. Additionally, they may not disclose this to health professionals as they may be concerned that they will get in trouble. Open conversations and recommendations by health professionals can greatly reduce these issues. Effective medication reconciliation between hospitals and communities is key to ensuring patients are safe. IT solutions can greatly impact on the saving of money, time..and lives. Spending more time at a first consultation can reduce unnecessary follow up appointments or readmission, and this can save time in the long run.
Problem 16: “I go the reception area for my follow up appointment. I am given a date for six months later…When I get home I go to fill in my new appointment time in my calendar. I notice we have a wedding on the same day. I ring the hospital back only to find all dates have been taken by now for that month and they can only give me a new appointment for two months after that time. At 8 in the morning. I have to travel from Mayo to Dublin. It will be an early start.”
Solution 16: At the point of making the first appointment the receptionist could give patients time to look in their diary or phone to see if there are any clashes. Additionally, their IT system could trigger a few quick questions to ask patients or carers such as what is the best time in the day; is there appropriate travel services in place (i.e. buses, lift from friends/family) and where are they coming from (to give latest time possible for appointment if travelling from afar).
Cost: Low – Mid
ROI: Approximately €80 million a year is lost for the HSE for patients not attending clinics. Many reasons are cited for this but most of which I feel could be addressed through appropriate first point of contact when making appointments.
Problem 17: “I just don’t feel reassured…the next week, I again end up back in my GP’s office asking him what I should do. I am now referred to see someone else. He adds an anti nausea drug to help counteract the sickness I get.
I somewhat now feel reassured that I have been listened to.”
Solution 17: If all of the above solutions were put in place I feel I would not only feel reassured, but I would feel less stressed, more trustworthy…and all over safer. I also feel that health professionals would too.
Cost Overall: Priceless
ROI: Never Ending
If you have done any of the above in your health service or have ideas as a patient, carer or health professional on what else could be done, I would love to learn about them.
If you are a patient or carer and struggle with recording, storing or managing medications, symptoms or appointments then we have developed a simple to use health organiser called the MediStori, as funded by the HSE, and researched by NUIG. This may be a useful tool for you.
*ROI – Acronym: Return on Investment. Explanation: What the hospital/organisation/individual will gain/save in terms of money, time or resources by achieving the action.
**Nonadherence with medication is a complex and multidimensional health care problem. Adherence is defined as the extent to which patients are able to follow the recommendations for prescribed treatments. Taken from: www.ncbi.nlm.nih.gov/pmc/articles/PMC3711878/
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