Improving shared decision-making in pharmacist-led haematology clinics: a ‘Plan Do Study Act’ approach

Abstract

Introduction

The concept of person-centred care is regarded as an essential approach to healthcare. A core component of person-centred care is the shared decision-making process. There is evidence that effective shared decision-making can improve people's satisfaction with their care. This quality improvement project used the ‘Plan Do Study Act’ (PDSA) cycles to test the small changes made and to assess their impact on shared decision-making in clinic consultations.

Objective

To enhance patient satisfaction in pharmacist-led haematology clinics by improving shared decision-making.

Methods

Patients from a haematology clinic participated in a survey based on the validated ‘Benefit, Risk, Alternatives, do Nothing’ (BRAN) questions, which encourage patients’ involvement in shared decision-making conversations with clinicians. Data were collected from 142 consultations over 3 months, using three PDSA cycles, which provided the structure to implement changes, evaluate their impact, and build on the learning from previous cycles. The first cycle analysed the shared decision-making in the clinic. The second cycle involved shared decision-making training for pharmacists. On the third cycle, decision-making aid leaflets were implemented.

Results

First cycle results showed patients were mostly satisfied with the ‘Benefit’ statement. The second cycle revealed satisfaction improvements on ‘Risk’. On the third cycle, satisfaction increased on the ‘do Nothing’ statement. The baseline mean of the patient satisfaction score increased from 3.25/5 at the start to 3.75/5 by the end of the study.

Conclusions

The results show that each cycle had a positive effect, suggesting that training specialist pharmacists in person-centred care and shared decision-making led to an improvement in patient satisfaction. Encouraging patients to be involved in shared decision-making enabled them to ask questions in consultations and led to improved satisfaction. The project highlighted the importance of developing the skills and knowledge of the pharmacy workforce to support the needs of an expanding and ageing cancer population.

Introduction

There is a universal consensus on the benefits of integrating person-centred care into healthcare systems, which brings not only social benefits to the patients but also financial revenue by improving self-management and preventive care.^{1 2} The National Health Service (NHS) recognised its value in the ‘Long Term Plan’ and incorporated the ‘Universal Personalised Care’ into policies to encourage healthcare services to deliver care that responds to the needs of the individual.^{3 4}

The NHS is pursuing cultural change switching from a paternalist relationship to an equitable partnership that empowers patients to engage in choices about their health and wellbeing.^{5 6} Shared decision-making is a collaborative process that ensures the clinician assists patients with evidence-based knowledge and expertise to reach a decision about their health condition based on patients' preferences and personal circumstances.^7–9

As the cancer-surviving population continues to grow, the demand for cancer services across the NHS is increasing.¹⁰ This is creating a significant burden for healthcare providers as they attempt to meet patients’ needs as well as patients’ expectations.¹¹ Person-centred care and its essential component, shared decision-making, can improve the efficiency of healthcare services and their limited resources by tailoring them to the needs and expectations of their patients.^{1 7 9} There is evidence that this approach not only has a positive impact on the quality of care but also on patients’ satisfaction levels with the service provided.^{7 9 11}

Despite the clear motivation to promote person-centred care, the Care Quality Commission (CQC) reported in 2016 that improvements must be made.¹² There is a real challenge implementing changes to integrate mechanisms in real practice that support person-centred care.^{1 4 13} At a large UK-based teaching hospital, a survey in 2018 found that some patients attending the pharmacist-led outpatient haematology clinics reported poor patient satisfaction.¹⁴ The present study was designed to further explore shared decision-making in these clinics to identify issues and implement interventions that improve the level of patients’ satisfaction in the interest of providing a better quality service. Using the ‘Model for Improvement’ framework, the ‘Plan Do Study Act’ (PDSA) cycles were designed for rapid testing and evaluation of small changes in practice.¹⁵

Methods

There is no universally agreed approach to measuring person-centred care.^{1 16} Surveys completed by patients are one of the most common methods used to evaluate person-centred care and its specific components such as shared decision-making.¹⁶ Hence, a survey was designed to gather patient satisfaction data on shared decision-making as an outcome measure of patient experience.

The survey was based on ‘Benefits, Risks, Alternatives, do Nothing’ (BRAN) questions as a validated tool to encourage patients’ involvement in shared decision-making during conversations with their clinicians.¹⁷ The questions were modified into statements to tailor the study setting (table 1).

Table 1.

‘Benefits, Risks, Alternative, do Nothing’ (BRAN) shared decision-making validated questions¹⁷

Question	BRAN questions	Study survey statements
1	What are the benefits?	“I was explained the benefits of taking my medicines.”
2	What are the risks?	“I was explained the risks of taking my medicines.”
3	What are the alternatives?	“I was explained the alternative treatments.”
4	What if I do nothing?	“I was explained what I should expect if I do nothing about my treatment.”

Participants were asked to rate how much they felt the pharmacist helped them to understand the benefits of taking their medicines (statement 1), the risks of taking their medicines (statement 2), the possible alternative treatments (statement 3) and what to expect if they do nothing with regard to their treatment (question 4). Responses were recorded using a five-point scale with responses ranging from ‘strongly disagree’ to ‘strongly agree’.

Three haematology pharmacists gave the participants a printed version of the one-sided survey at the end of the consultation. Consenting participants were asked to complete the survey in the waiting room and submit it by means of a designated box at the reception desk. Participants who required support to complete the survey were signposted to seek assistance from the healthcare assistants managing the workflow in the clinic waiting room. These professionals had received previous training in offering help with survery completion prior to the launch of the project to ensure that there were no breaches of confidentiality in the responses provided.

The data were collected over a 9-day period between 28 October 2019 and 13 January 2020 from adult patients or their carers who attended the pharmacist-led haematology outpatient clinic at a large UK-based teaching hospital. The collected data from the five-point scale surveys were codified into a Microsoft Excel spreadsheet for analysis (1 = ‘strongly disagree’, 2 = ‘disagree’, 3 = ‘neutral’, 4 = ‘agree’, 5 = ‘strongly agree’). Demographic data were collected from all participants; however, the data collection tool used did not include any patient-identifiable information and all responses remained anonymous.

A multidisciplinary Quality Improvement Committee (QIC) was established to oversee this quality improvement project (figure 1). The haematology pharmacists attending the clinics identified the key stakeholders that would have influence and power over the success or failure of this project.¹⁵ These professionals were invited to join the QIC to help with understanding the different perspectives of interest and concerns between the respective professions and to support ownership of changes. The project lead shared the patient group feedback, which contributed to survey improvement, both to simplify the survey (online supplemental appendices 1 and 2) and to make it more comprehensive, targeting as many patients as possible.¹⁸

Figure 1.

Quality Improvement Committee (QIC) and their role in this project. BRAN, Benefits, Risks, Alternative, do Nothing; HCA, healthcare assistant; SDM, shared decision-making.

Using the ‘Model for Improvement’ framework, the PDSA cycles provided the structure to implement and evaluate the proposed interventions¹⁸ (figure 2). Three PDSA cycles provided the structure to implement changes, evaluate their impact, and build on the learning from previous cycles. The first cycle analysed the shared decision-making in the clinic. The second cycle involved shared decision-making training for pharmacists. On the third cycle, decision-making aid leaflets (online supplemental appendix 3) were implemented to help patients to ask questions and make informed decisions during their consultations. The effectiveness of the interventions was tested and adapted from the results from the previous PDSA cycle using feedback from patients and healthcare professionals.

Figure 2.

Plan Do Study Act (PDSA) project development. BRAN, Benefits, Risks, Alternative, do Nothing; PCC, person-centred care; QIC, Quality Improvement Committee; SDM, shared decision-making.

Ethics

The interventions implemented as part of this series of service evaluations were chosen to align practice with Standard 1 of the General Pharmaceutical Council (GPhC) Standards for Pharmacy Professionals to provide person-centred care. In the UK, ethics approval is not required for work that evaluates or improves services linked to nationally accepted standards.

Results

Over the study period, 142 surveys were issued and a total of 79 (55.6%) were returned, from which 24 were returned on cycle 1, 28 on cycle 2 and 27 on cycle 3. There were six submitted surveys that were incomplete and four submitted surveys that were partially complete. These 10 surveys were excluded and the remaining 69 completed survey responses were reviewed, where all shared decision-making-related questions had been completed. In order to use as much of the collected data as possible, the study did not exclude those participants that had failed to fully complete the demographic data section of the survey.

This study was not powered to allow statistical analysis. Review of the scores showed that the mean patient experience score increased from 3.25/5 at baseline to 3.75/5 at the end of the study. Each PDSA cycle that was implemented had some positive effect on the patient experience score. Responses to question 2 (risks of treatment) and question 4 (what to expect if do nothing) also showed improvements in scores (table 2).

Table 2.

Mean scores improvement through ‘Plan Do Study Act’ (PDSA) cycles

BRAN questions	Mean scores (out of 5) (n=69)
	PDSA 1	PDSA 2	PDSA 3
Benefits	4	4	4
Risks	3	4	4
Alternatives	3	3	3
Do Nothing	3	3	4
Total mean	3.25	3.5	3.75

The demographic data collected allowed study of the results in age category groups. All participant groups gave the same mean satisfaction score at the beginning of the study. However, the prompts implemented for the third PDSA cycle had a wider positive effect in the younger population in comparison to the elderly population (table 3).

Table 3.

Mean score improvement per participants’ age distribution on ’Plan Do Study Act’ (PDSA) cycle 3

BRAN questions	PDSA 3 mean scores (out of 5) (n=26)
	Age 41–59 years	Age 60 to >85 years
Benefits	4	4
Risks	4	4
Alternatives	4	3
Do Nothing	4	3
Total mean	3.25	3.5

The overall participation rate was 52.1%. The study participants aged over 60 years accounted for 72.5% of the responses (n=50). The ages of the survey respondents are shown in table 4.

Table 4.

Participants’ age distribution from which 46.4% were female evenly distributed across the age ranges through all three ’Plan Do Study Act’ (PDSA) cycles

Participation response
Age (years)	n	PDSA 1	PDSA 2	PDSA 3
18–25	1	1	0	0
26–40	5	1	4	0
41–59	13	4	4	5
60–74	22	5	9	8
75–84	22	9	3	10
>85	6	1	2	3
Total	69	21	22	26

Discussion

The NHS recognises the value of person-centred care and is progressively incorporating it into its policies to encourage healthcare services to upgrade their care.^{3 19} While the timescale and scope of this work precluded a full review of the literature, there is evidence that patients more engaged in their health leads to better health outcomes and, as a result, financial savings.^{4 13 20} More work is needed to investigate the positive economic impact of the development of person-centred care.²¹ An essential component is the shared decision-making process that ensures individuals are supported to make decisions that are right for them.^{4 7}

The results of this study show that comprehensive shared decision-making training increased patient satisfaction scores and the positive impact this could have on patient experience. The workforce that leads specialist consultations should continue developing person-centred care skills until these are fully embedded into multidisciplinary practice. Robust data are more likely to be generated when different tools are combined to measure person-centred care.^{7 16} A process measure such as the OPTION scale¹⁶ could be used to evaluate the person-centred approach taken by healthcare professionals during consultations in order to be able to relate improvements in the outcome measure to shared decision-making training.

This study explored how ‘Benefits, Risks, Alternatives, do Nothing’ (BRAN)-based questions can be used in a hospital clinic setting to help patients and carers in the shared decision-making process during pharmacist-led consultations. Pharmacists' mean score on discussing with the patients the ‘benefits’ of taking their medicines at baseline was high (score 4/5). The mean score for the remainder of the statements in the survey (‘risks’, ‘alternatives’ and ‘what to expect if I do nothing’) was lower at baseline (score 3/5). The mean scores of the ‘risks’ and ‘what to expect if I do nothing’ improved during the study. However, pharmacists did not fully meet patients’ expectations regarding ‘alternatives’. This might indicate that pharmacists struggle to explain alternative treatments, especially if they are non-prescribers, because the treatment decision is usually made prior to the pharmacist consultation. Alternatively, perhaps pharmacists' concept of alternative treatments differ from patients' understanding of alternatives.

A new PDSA cycle could look at how to improve the documentation from a person-centred care and shared decision-making perspective during consultations. This new cycle could also explore the reasons why the decision aid prompts implemented in this project were more effective in the younger population. The results may indicate that elderly patients are not be able to appreciate as much as the younger generation visual interventions such as posters. Understanding the patient experience is vital to fully integrating person-centred care into our services.^{1 22}

Planning the time to implement the interventions was essential as well as managing the participants’ expectations. The participants were explained the relevance of taking part in the surveys even if they had completed the survey before during previous appointments so as to be able to appreciate improvements in the service. Despite this, participation levels decreased towards the end of the project. There is scope for exploring the use of electronic devices to facilitate completion of surveys in the hope of gathering data more efficiently.

Overall, the project was successful in improving patient satisfaction scores. The collaborative efforts of all the stakeholders involved resulted in a rewarding contribution towards improving delivery of the shared decision-making process by cancer services. It was essential to include both staff and patients in the experience-based co-design of the project to ensure their engagement as well as making sustainable improvements at a local level.^{18 22} To ensure the sustainability and effectiveness of these changes, feedback from patients and clinic staff must be obtained regularly.²⁰

Limitations

The study only included 69 participants. This limited number of participants precludes statistical analysis of the results obtained; however, the focus of this project was to explore the potential to improve patient satisfaction and test the feasibility and efficacy of the implemented interventions.

The main challenge was the number of staff that ideally needed to be trained in respect of the delivery of person-centred care during consultations. Person-centred care training was specially designed for pharmacists and was provided to the three pharmacists who manage the haematology clinics at the hospital. Difficulty in reaching all members of the multidisciplinary team and time limitations precluded widespread training, which limits the study's generalisability across professions and comparison with the wider literature.

Future work

Due to the promising results of these interventions, the person-centred training was incorporated into the specialist pharmacists’ induction pack for all new starters. The posters were left up in the waiting room and prompt leaflets are available at the clinic. We currently are studying the feasibility of introducing similar tools in other outpatient clinics in specialties such as rheumatology, gastroenterology and dermatology, with the future plan of launching similar projects in analogous scenarios.

It is recommended that a trial be conducted to determine whether staff training or providing patient information has more impact. The best way of achieving improvements is to observe the population for whom the project is designed and evaluate which interventions will better target this population before making any assumptions. Listening carefully to those individuals who are initially more critical about the project and addressing their concerns before the launch will help to achieve a steady transition when implementing the changes.

Conclusions

The number of people living in the UK with cancer is increasing and it is imperative that the NHS focuses not only on helping people to survive after their diagnosis, but also on providing resources to achieve improved quality of life by targeting what matters most to individual patients.²³ This study suggests that there is potential use for ‘Benefits, Risks, Alternatives, do Nothing’ (BRAN)-based questions for measuring shared decision-making in pharmacy consultations. The study also provides evidence of the positive impact that these questions could have on patients prior to their consultations by supporting the needs of an expanding and ageing cancer population.

What this paper adds.

What is already known on this subject?

• Effective shared decision-making can improve patients' satisfaction with their care.

• A 2018 study showed that patients attending pharmacist-led outpatient haematology clinics reported poor patient satisfaction.

What does this study add?

• Staff and patients can be supported to embed shared decision-making and person-centred care in practice.

• Training specialist pharmacists in person-centred care and shared decision-making improves patient satisfaction.

• Encouraging haematology clinic patients to ask ‘Benefit, Risk, Alternatives, do Nothing’ (BRAN) questions about their treatment improves patient satisfaction.

Data availability statement

Data are available on reasonable request from LFL.

Ethics statements

Patient consent for publication

Not required.