PiF member Philip Dobson, Director at Interlagos Ltd, has shared a case study about their work with Sheffield Teaching Hospitals NHS Foundation Trust to streamline processes for publishing and updating patient information.
Dealing with over a million patients each year, Sheffield Teaching Hospitals NHS Foundation Trust (STH) provides a full range of local hospital and community services for residents of Sheffield, as well as specialist care for patients from further afield. The Trust has a history of high quality care, clinical excellence and innovation in medical research.
The provision of patient information is a key part of this care. Some 1500 patient information leaflets are currently produced by the Trust, and are used every day by staff and patients, including details about hospital procedures, services, medications and conditions. Most of these leaflets are given out as part of routine clinic appointments or as part of a patient’s preparation for treatment or recovery.
Within the Trust, the development and provision of clearly presented patient information is recognised as an important part of effective clinical care and is considered particularly important as part of the consent process. Nationally it is accepted that the provision of information allows patients to engage as effective partners in their healthcare and forms a key part of the overall patient experience.
As with all healthcare providers, STH have a range of obligations placed upon them to provide good quality and accessible patient information. These include the Equality Act (2010) and Mental Capacity Act (2005) as well as rights and standards specific to the NHS set out in the NHS Constitution and by the Care Quality Commission.
Sheffield Teaching Hospitals’ patient information leaflets are managed locally by a network of 160 Patient Information Leads (mainly nursing staff with an interest in patient information), supported by a small Patient Information Team who oversee the development and review of information. They also have access to a Medical Illustration department, who provide support with any illustrations which are required.
The majority of leaflets are produced as A5 booklets, which may range from a simple 4-page instruction leaflet to a 40-page guide. There are also A4 factsheets and DL leaflets.
Historically the Trust’s leaflets were produced by the Medical Illustration team using professional design software. Once complete they were digitally printed externally and published as low-resolution PDFs on the Trust’s intranet. This system worked well for a number of years and had brought a certain amount of standardisation to the visual style, but could only be updated by Medical Illustration staff which meant that even simple date changes would have to wait several weeks to be processed.
With a continuous improvement in standards, there was a need to update leaflets on a more regular basis, which increased workload for the staff responsible for producing and maintaining the documents and caused growing delays in leaflets being updated. In addition to this, the Trust took on responsibility for a range of Community Services, which added hundreds of leaflets to the portfolio, many of which had been created using Microsoft Word or Publisher and lacked consistent formatting.
The Trust needed a system that would save them money, improve the consistency of their brand and would be capable of tracking the progress of all the leaflets in the system.
Identifying the true cost of producing leaflets was a major issue, as staff generated the leaflets and Patient Information Leads maintained the leaflets as part of their day to day jobs and therefore no direct costs were apportioned to the production of leaflets. The only cost which could be measured was that of the Medical Illustration Team and the time that they spent in physically producing the leaflets.
The Trust recognised that they needed to look afresh at their production of leaflets. They identified that they needed a system that would provide a range of high quality templates which staff could access directly without burdening their already overstretched Medical Illustration team. They also felt that that there was scope for reducing duplication of content (and clinician’s time) by using nationally approved information from reputable sources such as NHS Choices. If they could find a system which allowed them to do this they could achieve significant costs savings, speed up production and give more control to staff.
The Trust embarked on a tendering process for the work and chose PIPS (Patient Information Publishing System) from Interlagos that offered all these advantages as well as bringing uniformity to their branding.
Publishing process transformed
Official publishing of leaflets with PIPS began in May 2013 and has dramatically streamlined the process. The publication of leaflets is now under the full control of the Patient Information Team and has significantly reduced the demands on the Medical Illustration Team who are now able to focus on their core design work without being constantly distracted with requests for minor text changes and other updates.
The Trust’s Patient Information Manager, Jo Evans explains that “Simple changes can now be made at the click of a few buttons and leaflets republished in minutes“. Feedback from staff using the system has also been positive with many commenting on the benefits of being more in control of their leaflets and the ease and speed at which they can now update them.
In the space of a year the team have found that they have been able to publish on average 75 leaflets per month. This is almost three times more than they were able to manage before they adopted the new system.
Consistency across A4 factsheets, A5 booklets and folded DL leaflets is now ensured. This has made the biggest impact in Community Services, the part of the Trust which previously produced their own leaflets using Word and Publisher. Templates have been set up to meet best practice outlined by the Department of Health’s Identity Guidelines as well as accessibility advice from the RNIB and MENCAP. These guidelines were used in deciding on font choice, size, emphasis and other typographic and layout parameters which are now automatically defined and implemented.
PIPS can also optimise the PDF documents it produces for cost-effective printing by allowing the inside pages of documents to be set to black and white where appropriate, which reduces external printing charges.
The workflow reporting requirement is addressed by PIPS too explains the Trust’s Patient Information Manager, “The system shows where a document is in the development process, if it’s with the author for editing or review, ready for further work by our team, complete or published.” Jo goes on to say that “PIPS is now routinely used to produce over 90% of our patient information and has given us far more confidence in the consistency of our information. I would say that, in terms of quality and efficiency, the system has been the single biggest improvement to patient information we have made”.
Following the success of implementing the system the Trust are keen to look at further developments including Easy Read and improved digital access to information. Based on advice from leading learning disability charities, Interlagos has already started developing an Easy Read template to help standardise these specialist leaflets which are frequently produced in different ways.
The Trust are also keen to exploit the way Interlagos can export data from PIPS in different ways. Although they already have pdf documents on their website the Trust are keen to look into how the system can publish their leaflets so that they are optimised for mobile devices such as smart phones and tablets.
A significant step has been the link to the NHS Choices content database. This allows staff to search and download content from NHS Choices direct from within the PIPS system, thus speeding up the creation of new leaflets. To take this a step further, Interlagos are already in discussions with NICE and EMIS to add further to this content.
80 staff were surveyed in October 2014, 35 responded as having used the system so far with the following results.
100% said the system was user friendly; 11% found it extremely user friendly, 42% very friendly.
- 100% reported the system was successful for publishing leaflets; 15% extremely successful, 66% very successful.
- 94% reported satisfaction with the system; 35% replied extremely satisfied, 42% quite satisfied. None reported dissatisfaction.
- 75% said the system had reduced the time spent on a leaflet; 56% said much quicker, 19% said somewhat quicker. When asked what they particularly liked comments included:
o Independence to do the [leaflets] yourself rather than going back and forth to the very busy patient info team.
o Keeps all patient information in one place, allows me to easily check what needs updating. The preview function is really helpful too.
o Quick and easy to make simple changes to review and you don’t have to phone around to check stuff is done.
o Being able to write and amend leaflets in one go as you can see problems with formatting etc and make appropriate changes – removing a step of the process when using the previous system. Seeing at a glance on a page all the leaflets I am responsible for and their review dates.
o In general there has been large scale acceptance of the system and virtually all users have said that it is easy to use, saves them a lot of time and it is much quicker.
High quality information is defined as that which is accurate, evidence based and developed with users (PIF 2013). PIPS is able to consistently ensure the provision of high quality information as follows:
- Accurate: Automated review process ensures leaflets are systematically checked to ensure they are up to date and reliable
- Evidence based: The requirement on PIPS to record evidence of clinically approved content ensures information is trustworthy
- User testing: The quick production of professional drafts enables staff to user test leaflets before final printing. The recording of user testing on the system is also compulsory before a leaflet can be published.
- Accessible: Best practice formatting standards are built-in to ensure leaflets are as accessible as possible. Additional large print and Easy Read templates take this further by directly supporting patients with a visual impairment or learning disability.
- Trustworthy: The ability to download content from NHS Choices avoids duplication and provision of conflicting advice. This content also meets NHS England’s ‘Information Standard’ which is recognised as being trustworthy and evidence based.
- Relevant: To meet the specific needs of patients, national content can be localised and tailored with Trust specific details.
- Preference: The ability to have different output options from the same source (both print and digital) ensures patients’ needs are met regardless of their preference for receiving information.
Value for money
- Saves clinicians’ time: The speed of leaflet creation through PIPS has saved clinicians valuable time. The link to NHS Choices reduces duplication as content can easily be localised, saving considerable time in researching and writing content.
A recent BMJ (2013) article highlighted vast inefficiencies in leaflet production nationally, describing the ‘NHS’s multifarious’ patient information leaflets as ‘inaccurate, inconsistent and confusing’. Research showed significant duplication through trusts commissioning their own leaflets on the same subjects.
PIPS offers a simple solution, by allowing trusts to use nationally approved content which can be tailored to fit local needs. This has the potential to improve efficiency across the NHS if you consider that a single Trust can have in excess of 1000 locally developed leaflets.
- Improved efficiency: The PIPS system can help streamline the process of producing information for patients. It allows changes to be made in minutes rather than weeks and puts those involved in updating patient information in the driving seat by giving them the tools they require to do a professional standard job quickly and easily.
Large print and other format documents (including web pages) can be easily produced using the same content as that used in the original leaflet. Due to standard templates the content can be simply and quickly channelled through another template.
- Reduced design costs: PIPS automatically creates leaflets in a predefined format. An author can therefore enter content, review how the document looks and when happy publish that document without the need for any technical help. This not only saves the cost of design specialists, but also eliminates the numerous rounds of proofing cycles that occur with a manual system.
- Reduced cost of complaints and litigation: The PIPS system supports the governance of information in an organisation. It provides an audit trail of updates, evidence base and helps to keep leaflets up to date, both in the ease with which leaflets can be updated and also through its reporting of leaflets due for review. As a consequence it is less likely an organisation will face litigation due to poor quality information.