Changing the logic in A&E / ER


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With budget cuts and efficiency drives, hospitals are under pressure to save money in emergency services. This patient led investigation generated user insights and practical ideas that could make a difference

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Changing the logic in A&E / ER

  1. 1. “It’s not only doctors or the Chief Executive who have responsibility for this hospital. We all must look after our society. This is a public service and we are all part of the public” Afghani patient Understanding and changing patient behaviour at A&E Based on staff and patient research in North Middx Hospital
  2. 2. Report contents  Objectives  Methodology  Summary of research results (context, 2 patient types, key recommendations)  Detailed research results (GPs, profiles and needs of patient types)  Applying research results (healthy nudges and practical ideas)  Conclusion
  3. 3. Objectives  Understand patient attitudes and behaviour when choosing to use the Accident and Emergency service  Explore what it would take to change this behaviour
  4. 4. Methodology  30 patients interviewed between 10am and 5pm on 15.03.11 about their A&E story  Sample:  male and female  12-87 years old  range of cultures including Afghanistan, Afro-Caribbean, Eastern Europe, England, Ireland, India, Poland, Sri Lanka, Taiwan, Turkey  Ethnographic observations of waiting room behaviour  Staff discussions with admin staff, matron and security
  5. 5. 1.1 Context 1.2 Two patient types 1.3 Two sets of recommendations Part 1: Summary of the research results
  6. 6. Key conclusions 1.1 Context  Medical expertise rarely challenged.  Habits have shifted :“one stop solution”  There is a lack of alignment between NHS needs and patient needs.  Little room for patients to participate in the solution. First Class ECONOMY
  7. 7. Key conclusions 1.2 Patient types Note: Parents of children under 12 are a special case: over-reacting is seen as good parenting in absence of soothing support network (eg recent migrants). 100% of these parents were Health Victims Health victims passive, needy, under- confident  Use A&E often Health managers proactive, organised, busy  Use A&E “correctly”  Two main patient types emerge, according to attitudes and behaviour
  8. 8. Key conclusions 1.3 Recommendations 1. Practical changes to reduce patient anxiety (and therefore improve efficiency of dealing with them) 2. NUDGE* ideas that can help to increase a sense of co- responsibility and therefore shift behaviour Nudge... *Nudging is the application of subtle signage, messaging and environment details to encourage individuals to follow appropriate behaviour patterns. SEE Thaler & Sunstein, “Nudge”
  9. 9. 2.1 GP gap 2.2 Patient MindSet 2.3 Implications Part 2: Detailed research results
  10. 10. GP referral NHS call back Self - GP unavailable Self - GP no good Self - GP inconvenient Self - "too serious" Self - no local GP 2.1 GP gap A&E is bearing the brunt of GP shortfall Reasons patients give for being in A&E
  11. 11. 2.1 GP Gap Patient quotes relating to GPs I needed to see a doctor today and the first appointment he had was next week The GP is no good. He never finds a solution I don’t like hospitals but my GP said he couldn’t see me for 3 days The GP just wants you out of their office. They start writing a prescription before you’ve even finished explaining My GP was very thorough, then she said I needed to go to A&E
  12. 12. 2.2 Patient MindSet Patients feel like Victims or In control • The position an individual feels they hold in the world is always important • Language and Behaviour (LaB) profiling of this group shows 2 types • physical cause to be in A&E • emotional but not necessarily a medical need Health Victim (c70% of sample) More likely to have self-referred for convenience / reassurance / a belief in hospitals (vs. GPs). Health Manager (c30% of sample) Confident, informed, proactive, better educated, impatient, busy.
  13. 13. 2.2 Patient MindSet The A&E balance for the Health Manager Avoid A&E unless situation is dire Shame / sense of weakness 4 hours waiting time (should be at work) A&E likely to resolve the problem Benefits DOWNSIDEs “I can sort this out myself”
  14. 14. 2.2 Patient MindSet The A&E balance for the Health Victim 4 hours wait time (but I have plenty of time) A&E will solve the problem Feel relaxed / safe, “at home”, cared for, welcome Being a good parent / daughter Free service Go to A&E “Life is a struggle... Now look what happened to me...” Benefits DOWNSIDEs
  15. 15. Patient types comparison (caution: tendencies only, based on small sample) MindSet profile Proactive, solution focused, know what to do Passive, problem focused, want to be told what to do Attitude Self-responsible Self-righteous Support network Yes No, lonely, isolated Education Level 2 + Below Level 2 Citizenship Established More recent migrants Lifestyle Employed, retired Parents of young children, unemployed, Activity in A&E Reading / talking Staring Age 40+ 20s, 30s, some >70s It’s the process, we treat everyone the same (member of staff) Health Manager Health Victim
  16. 16. 3.1 Recommended approach 3.2 Nudge ideas 3.3 Practical ideas Part 3: Applying the research results
  17. 17. 3.1 Recommended approach AIM: Increase co-responsibility “This is a public service and we are all part of the public”. More co-creation / co-responsibility. Choose your queue Behaviour will only change if the Health Victim’s practical and emotional needs are met in new ways. This will require: 1. Practical changes to redress the imbalance that currently pushes them towards A&E 2. “Nudge” changes to increase their sense of ownership
  18. 18. “Conceptual models are critical to good design... Without feedback one is always wondering whether anything happened” Don Norman, The Design of Everyday Things (and Apple VP of Advanced Technology) EG1: when “WAIT” doesn’t light up we keep pressingEG2: it is much easier to choose the right knob to turn on the red hotplate on the right hand hob 3.1 Recommended approach AIM: Help the patient make good choices
  19. 19. “Structuring choice sometimes means helping people to learn they can make better choices on their own” Thale and Sunstein, Nudge Nudge Condition A&E idea 1. Incentives to change Increase salient costs 2. Understand mappings Think like a patient 3. Get defaults right Status quo bias 4. Structure choices 1st choice bias 5. Give feedback Beepers, queue number 3.1 Recommended approach AIM: Apply healthy nudging
  20. 20. 3.2 Nudge recommendations i. Increase salient costs Clarify consequences of their actions to patients by showing information in the waiting room. Last year our ambulances received 1,325 calls and attended 742 people. Not all of them really needed an ambulance. So for Bob it was too late. Sorry Bob. Jack and Jill both got injured. Jack went to the GP and got help which cost our country £75. Jill went to A&E and got the same help but it cost our country £265. Thanks Jack. Sample communication
  21. 21. 3.2 Nudge recommendations ii. Understand mappings, increase co-responsibility Use social norms to emphasise the “right” behaviour But only 3% needed to 10% came at least once DID YOU KNOW? 90% of the population did not come to A&E at all last year Ask our advice on using A&E well Sample communication
  22. 22. 3.2 Nudge recommendations iii. Understand mappings  Use status quo bias by expecting patients to see a GP in A&E  SUPPORT: Coaching session if visit was not necessary (good parent?)  SELF HELP: Touch screen app  FACE SAVING: Easy to leave without seeing somebody CAN YOU HELP? • Avoid unnecessary visit, save £145 • Avoid unnecessary ambulance, save £575 It’s your A&E. So save it for a rainy day. Sample communication
  23. 23. 3.2 Nudge recommendations iv. Use first choice bias Always offer options in NHS preferred order PICK THE CHAIR YOU NEED 1. Green chair if you feel a GP can probably help you 2. Amber chair if you are in too much pain 3. Red chair if you feel you need help urgently I can wait Severe pain Urgent & critical If they had one queue for emergencies and one for other things, most people would stand in the right queue. Sample communication
  24. 24. They couldn’t pronounce my name and I waited an extra 2 hours unnecessarily 3.3 Practical recommendations i. Give feedback I don’t hear so well and I worry I’ll miss my name Introduce LED display with next patient’s name and room rather than staff calling out name
  25. 25. Introduce deli style ticketing system  sense of how many people are before you I don’t mind the wait so much as the anxiety of not knowing how long or if I’ve been forgotten I’ve been dying for the loo for an hour now but I daren’t leave the room 3.3 Practical recommendations ii. Give feedback
  26. 26. 3.3 Practical recommendations Communications that change minds The MindSet profile of the Health Victims is important to bear in mind when creating communications for them. In particular they are:  More interested in problems than solutions  Feel safer with clear procedures than multiple options  Like to be directed, not proactive Do say things like... Don’t say...  There is always a right way to deal with any health situation. Ask us for guidance  First fill in this form then...  The problem is too many people come here when they don’t need to  Don’t get stuck in the wrong queue. Fill in the form correctly.  We have many ways we can help you here at the hospital or at your GP, online or on the phone  Our goal is for every patient to get the best treatment  Our aim is to have an excellent package of health options  Fill in the form correctly for quick service
  27. 27. Conclusions  There are two main patient types: Health Victim (about 2/3) and Health Manager (1/3).  Misuse of A&E by Health Victims is driven by  GP issues (unavailable, uncaring, unable)  Emotional need for reassurance / certainty  No penalty for choosing the “easy” option  There are nudge techniques that could tip the A&E balance and these can be trialled and impact measured