Mid Cheshire Hospitals Endoscopy Team - Withdrawal of Consent

Mid Cheshire Hospitals NHS FT

Organisation

Mid Cheshire Hospitals NHS Foundation Trust (MCHFT) provides good quality, safe and effective healthcare to the people of Cheshire and beyond. The Trust, which manages Leighton Hospital in Crewe, Victoria Infirmary in Northwich, and Elmhurst Intermediate Care Centre in Winsford, was established as an NHS Trust in April 1991 and became a Foundation Trust in April 2008.

It employs more than 4,500 members of staff, has around 540 hospital beds, and provides a range of services including A&E, maternity, outpatients, therapies, and children’s health. The Trust is also part of Central Cheshire Integrated Care Partnership (CCICP), a new and unique local health partnership that provides a range of community health services for people across South Cheshire and Vale Royal. Significant investment in recent years has meant a great deal of clinical expansion has taken place at the Trust  and it can now boast about having some of the very best clinical facilities.

General Summary

The Endoscopy department received a complaint from a patient who had undergone an endoscopy procedure and were concerned and distressed that they felt that they were unable to withdraw consent during the procedure. This complaint went through the formal complaint procedure process and staff met with the patient and patient’s relatives to address the issues and concerns raised. In response to and following the resolution of this complaint, a team led by Maureen Brown have implemented numerous local and national interventions to ensure patients fully understand the process around withdrawal of consent during an endoscopy procedure and to ensure high levels of patient satisfaction and safety going forward. Learning from this incident has been shared both nationally and locally. There has been a real focus on education and spreading awareness, both through patient consultation and patient information.

By educating patients on how to withdraw consent, and making this information as accessible as possible via national information leaflets, locally displayed information and discussions with healthcare professionals whilst taking consent prior to the endoscopy procedure, similar circumstances should be avoided going forward. There is an ethos, in Endoscopy, of taking proactive steps to continually improve the service provided to users of the service and their relatives and carers.

The nurses in the Unit are passionate about the quality of care delivered, and the senior nurses endeavour to create an environment in which this is encouraged. The patient is always at the centre of the service, and although receiving complaints can be unpleasant, the Unit strives to turn any negativity into a positive outcome going forward.

Rationale

The overarching aim was to educate and empower patients, improve their patient experience and allow them to feel in control. Through this initiative the endoscopy team aimed to educate both patients and staff working in the endoscopy unit about processes and procedures around consent, with the aim of disseminating learning as widely as possible (both internally and externally).

Also to avoid any further incidents in relation to withdrawal of consent going forward and ensure high levels of patient satisfaction around consent and withdrawal of consent. This is a compelling example of how patient feedback can be used to inform change and improve experience for future patients.

Planning

The Endoscopy Clinical Manager, Maureen Brown led on this initiative supported by Tracy Falkland (Endoscopy Unit Nurse Manager). Below are details of the interventions implemented, aimed at educating both staff and patients around the consent procedure and specifically how to withdraw consent during an endoscopy procedure. Interventions – EIDO are a national private organisation that  provide professionals with resources and support around informed consent.

The Endoscopy team have used the EIDO information leaflets, which were distributed to patients prior to the endoscopy procedure. It was noted following receipt of the complaint that the document contained no information about how to withdraw consent during the procedure. The team then worked with the Patient Experience Manager to look into the option of including the process into the national patient information leaflets (EIDO) and this was actioned. EIDO were contacted to establish if information
about withdrawal of consent could be added and the leaflet was updated for use.

Changes to the EIDO information sheet for endoscopy procedures, to include the text “If at any point you want the procedure to stop, raise your hand. The Endoscopist will end the procedure as soon as it is safe to do so”. This amendment to the leaflet was publicised via a leaflet update and mail shot, informing all users nationally of the change.

This complaint resulted in the creation of a formal process within the Unit. A flow chart is now displayed in all procedure rooms for patients to see. Additionally a Standard Operating Policy was created giving guidance to staff regarding the procedure around the consent process. Following the meeting the team reviewed and amended all patient information to ensure instructions and information around withdrawal of consent was included. Numerous training sessions about consent and withdrawal of consent were held for staff in the treatment centre. These sessions were very well attended with the majority of the endoscopy team attending the training over a 6-month time frame. The patient experience team hosted some of these training sessions and used a patient story film to emphasise the importance of the consent process to the patients.

The Endoscopy service runs an annual patient satisfaction survey to obtain feedback from patients around the service they are receiving. Following this complaint an additional question was added to this survey ‘has how to withdraw consent been explained to you?’ and ongoing monitoring via a patient satisfaction survey will be carried out on an annual basis.

Question added in response to patient complaint regarding withdrawal of consent (Q1.10)1.10. Was it clearly explained to you how to withdraw your consent during the procedure?

As a result: Flow chart in all procedure rooms; SOP created; EIDO leaflet change; Q to remain in annual patient survey for ongoing monitoring.All of the above issue and interventions were discussed with all relevant nursing teams at staff meetings. The endoscopy team have also presented learning around this issue at the Executive Patient Experience Group, Action Group for Patient Experience and Patient Register Group.

Impact

The EIDO leaflet is used by trusts throughout the UK, thus sharing learning outside of the organisation. There have been no further local complaints received relating to this issue since interventions have been implemented. Additionally the most recent patient survey (2017) indicated that 100% of patients were either completely satisfied or satisfied to some extent with the consent process for this procedure. The team have also introduced ongoing monitoring of patient awareness of how to withdraw consent through annual patient survey.

Patient Satisfaction Survey Results

On average around 100 patients are surveyed per year, about their experiences at the endoscopy unit. Patient comments:
“The leaflet explained the procedure in a manner which was easy to understand” – Annual Survey 2017.

“I found I understood all of the information given out. Very satisfied with everything given”
Annual Survey 2017.

“Full information provided by Consultant and information leaflet about the procedure” Annual Survey 2017.

“It wasn’t explained to me, but the leaflet said you could put you hand up to stop the procedure”
Annual Survey 2017

“Withdrawal of consent was discussed prior to procedure in the treatment centre – private room”
Annual Survey 2016

“The information was in the leaflet, I cannot remember being told verbally, but I’m not quite sure”
Annual Survey 2016

Relevance to Others

This initiative is relevant to all other endoscopy units across the UK and all endoscopy units should be encouraged to review their practices around consent and withdrawal of consent to ensure that patients and staff are educated around relevant processes. Changes to the national EIDO information leaflet have been shared Sharing the patient concerns and interventions with the endoscopy external accreditation body – JAG, which will be made available to all Units undertaking endoscopy via an online knowledge sharing system – Knowledge Management System (KMS) where users can access examples of best practice in endoscopy services across the UK.

Standing Out

The key standout feature of this initiative is that the learning has been shared externally. The issue around withdrawal of consent would have been brought to the attention of all trusts which use the EIDO leaflet. This is a compelling example of how we have made real and tangible changes in direct response to the concerns raised by a patient. The team has listened to feedback and responded making a difference to future patient experience based upon feedback from users of the service.
Success of this project has been down to the leadership within the team and their desire to make sustainable improvements in response to feedback from service users.

Key Learning Points

 The importance of listening to your patients
 Being proactive in managing patient concerns and seeking feedback
 Confidence in sharing negative feedback, and using it to make real improvements
 Involving staff and other agencies (external and internal) in creating solutions