Improving patient satisfaction & training opportunities in a consultant-led outpatient clinic

An interview with Mr. Giles Toogood, Consultant Hepatobiliary and Transplantation Surgeon

Contributions from Mr. Samir Pathak, Mr. Andy Cockbain and Mr. Rajiv Dave, Specialist Registrars in General Surgery at Leeds Teaching Hospitals NHS Trust

By Thomas Shanahan, 2nd year medical student and University of Leeds Representative for the Faculty of Medical Leadership and Management

Background

The St James's University Hospital Hepatobiliary Unit is one of the busiest in Europe, performing liver transplantation, liver resection and laparoscopic surgery. As one of the consultants in the unit, Mr. Toogood performs both open and keyhole hepato-biliary surgery. The outpatient clinic sees a mixture of cancer and non-cancer patients.

A patient survey was recently performed at the clinic, as its structure and management are not normal practice. All patients are discussed with the consultant in charge, who in turn sees the majority of patients as well. Patients were highly satisfied with the service provided. Patients felt that the service provided was either ‘excellent’ or ‘very good’ in the following areas:

• The amount of time spent with doctor: 81%
• The knowledge and experience of the patient and condition: 78%
• Thoroughness of care received: 81%
• The information given about illness/condition: 82%
• The information given about condition: 82%
• The information given about investigations: 84%
• The information given about operation/treatment: 81%
• The willingness to listen to all of your concerns: 81%

I asked Mr. Toogood and his registrar colleagues what factors contributed to these results. 

What is the vision for the outpatient clinic?

“When patients arrive at a tertiary centre outpatient clinic they may have already seen several doctors and often have a good understanding of their condition, its management and follow-on care and therefore have high expectations. What would I want if I were a patient? I would like to be looked after by a team that is competent, listens to my concerns and communicates well. At some point during the initial consultation, I would also like to meet the consultant in charge of my care. As specialist services increasingly become more centralised they could become more remote from patients. We recently undertook a patient survey of the clinic. The results demonstrated the importance of the personal touch, where 73% compared to 50% of patients preferred being contacted initially by my secretary. Taking this concept further, each patient has the contact details of my secretary, the specialist nurse and myself and we tell them they can contact any of us at any time. In support of this, the survey found that 91% of patients felt they knew whom to contact if they had questions.”

What is the structure of the outpatient clinic?

“The clinic is structured around a central hub, where the registrars, clinical fellows, specialist nurses and myself discuss all patients after initial review. It is a ‘multi-disciplinary team type scenario’ for every patient. The patient is initially seen by a registrar who formulates an initial diagnosis and management plan. We then have a brief discussion regarding the history, any scans and test results and discuss the optimal plan going forward. I then meet with the patient, summarise the plan and answer any questions they have. This approach is resource intensive and patients can end up waiting. However, 72% of patients felt that it was ‘very important’ to see a consultant at their first outpatient appointment, and a majority (55%) were willing to wait 45 minutes or more if it meant they would definitely see a consultant. This approach also ensures the clinic is practising good clinical governance.”

How do you ensure doctors in training are provided opportunities to learn in your outpatient clinic?

“Before the clinic I review the patients to be seen and make sure the registrars and clinical fellows sees a range of different patients. This provides them with an opportunity to develop their knowledge and skills.”

One of the members of team, Mr. Samir Pathak, Specialist Registrar and Research Fellow said, “the central hub is an open and stimulating environment, as we are able to hear about all the cases in clinic. There is a culture of openness, where everyone is able to debate management in a respectful way and contribute to decision-making. This provides an excellent learning opportunity for us as doctors in training.”

A former member of the team, Mr. Rajiv Dave, Specialist Registrar said, “initially seeing patients with Mr. Toogood is a learning opportunity and reinforces a clear sense of direction in terms of how we should communicate with, support and empower the patients we see.” This is reflected by 97% of patients that felt they received information on follow-on investigations and referrals in a way they could understand and 86% felt they definitely were involved in decisions about their care and treatment.

In the HPB outpatient clinic, there is an even split between patients being seen primarily by the registrar and the consultant within the survey, and there was no difference in the overall satisfaction of the care they received from the clinician they met (‘excellent’ and ‘very good’: 83% registrar and 84% consultant).

Another former member of the team, Mr. Andy Cockbain, Specialist Registrar said “it is my firm belief the culture created in the clinic by Mr. Toogood is the reason patients have a high satisfaction of the care they receive by different members of the team.”

What is your management/leadership philosophy?

“I start from the premise that I would never ask someone to do something that I am not prepared to do myself. It is important to respect each member of the team and value the contribution they bring to the clinic. I try and create a culture of openness, where all members of the team feel comfortable and aren’t worried about being shot down or embarrassed when they offer opinions. Despite years of experience, I know I am not always right and it is good to be challenged. I have learnt something from every registrar that I have worked with. It is my hope that by creating an open and friendly environment, all members of the team feel able to raise concerns about patient safety and offer ideas of how to improve the service we provide to patients.”

Any final remarks

Mr. Toogood said, “As a team we think the HPB outpatient clinic at St. James University Hospital is a good example of how to provide consultant-lead services, with good clinical governance, whilst optimising training opportunities within the confines of the European Time Working Directive (EWTD).”