Don t just listen, Co-produce! November 18 th 2013 Swales stadium
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1 No decision about me without me Implementing Shared Decision Making into clinical practice Ann Jones Continuous Service Improvement Team, Cardiff and Vale UHB Don t just listen, Co-produce! November 18 th 2013 Swales stadium
2 Overview Shared decision making - What is it? Why do we need it? What is the evidence base? The MAGIC programme- implementation of SDM - Challenges - Successes How does SDM fit into Co-production?
3 What is shared decision making? A process whereby a patient (expert in their own life) and a clinician (expert in evidence- based care) communicate together to make a decision eg, -When undergoing a screening, a diagnostic test or a medical/surgical procedure -When choosing between different types of medication -When attempting a lifestyle change
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6 Models of clinical decision making Paternalistic Shared decision making Informed Choice
7 What can be shared? Clinicians Diagnosis Cause of disease Prognosis Treatment options Outcome probabilities Patients Experience of illness Social circumstances Attitude to risk Values Preferences
8 How are we doing? Wanted more involvement in treatment decisions Source: NHS inpatient surveys (England)
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10 How are we doing? Patient Complaints Lack of information about choices Lack of information about risks and benefits Expert Patients Lacks understanding of my preferences Don t acknowledge my experience and knowledge
11 Why do it? Ethically the right thing to do- supports patient autonomy SDM provides a model through which we can better: -Listen to patients and respond to their concerns and preferences -Give patients the information they want or need in a way they can understand -Respect patients rights to reach decisions with clinicians about their treatment and care
12 Does it benefit patients? In 86 trials evaluating tools that cover 35 different screening or treatment decisions, use has led to: Greater participation in decision-making Greater knowledge More accurate risk perceptions Greater comfort with decisions Fewer people remaining undecided Fewer patients choosing major surgery Stacey et al. Cochrane Database of Systematic Reviews, 2012 Improves adherence to medication (Joosten, 2008)
13 Shared decision making in clinical practice Has tended to be used in episodic decision making such as in comparing clear cut surgical options Is becoming more popular in long term condition management particularly in self management support (SMS) but the principles can be applied in almost all situations where decisions are made. SDM and SMS have similar philosophies: Clinicians recognise and respect the patient s role in managing their own health. Clinicians require advanced communication skills and the use of a number of tools and techniques to support informationsharing, risk communication and deliberation about options.
14 The MAGIC programme
15 Key enablers for SDM Organisational Culture Clinicians' Behaviour, Skills and Tools Patient/Public Expectations
16 MAGIC-What did we offer to participating teams? Facilitation and support from an expert team (researchers, QI, patient experience) SDM skills training (basic and train the trainer) Support to develop measures and collect data Support to develop and implement decision support tools Opportunities to share and develop practice with others
17 Challenges Barriers to implementation Resistance from some staff We are doing it already It takes too long Competing priorities Getting staff released to undertake skills training Whole team sign up Clinical pathways Measurement
18 Successes Ask 3 questions campaign Leaflets, posters, animations, postcards A prompt for patients to ask three basic, but important, questions about what options are available to them Useful prompts for clinicians too.
19 Successes Breast team Women with early breast cancer face difficult decisions when choosing between mastectomy or wide local excision with radiotherapy. The team undertook skills training and introduced a SDM tool to support the discussion around these options both in the consultation and at a later home visit
20 Successes Option Grid for breast cancer surgery Short decision tools don t replace skills only supports them!!
21 Outcomes The team developed a measure called a decision quality measure and collected data to show the influence of changes in practice (Option Grid/SDMskills) on; - patient knowledge -readiness to decide -choice of treatment After introducing the changes in practice patients knowledge scores, readiness to decide and confidence in choice of treatment dramatically improved
22 Outcomes Patients reported high levels of satisfaction in being more involved in treatment decisions I was really chuffed to have choices and options discussed. It felt like I had made the right decision I was unsure about SDM at first but now my consultations are less process driven and more patient centred. I enjoy them more SDM has become routine practice in the breast unit and is part of the culture and norm
23 Summary SDM aims to place the patient on an equal footing with clinician and is a strong pillar in the Co-production agenda. Shared decision making provides us with the skills to: Even if teams think that they are doing SDM already, there are skills, tools and measures that can help them do it better.
24 Thank you! Diolch yn Fawr! Maureen Fallon Mike Spencer Amy Lloyd Natalie Joseph-Williams Andrew Rix Kate Brain Glyn Elwyn The Health Foundation Resource centre:-
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