Case study – Frimley Health

Implementing the Outpatient Letter Standard - Frimley Health case study

Outpatient letters are the main method of contact and communication between hospital staff and GPs and are often the sole record of the consultation held by the outpatient department and hospital. 

Best practice for most outpatient letters is writing directly to people using services, so that they can better understand what’s been discussed with their healthcare professional, including their treatment and results.  

On this page

Background

The PRSB’s Outpatient Letter Standard allows relevant clinical information to be recorded, exchanged and accessed consistently across care settings, and shared with people who use services, in plain English. This results in improving the continuity of care and people’s overall experience of healthcare services.

This case study shows how Frimley Health NHS Foundation Trust worked with two system suppliers, Microsoft and Epic, to implement the standard and identifies the benefits that it will have on the efficiency of healthcare services and people’s experience of care. 

The Outpatient Letter Standard is one of the standards that could be soon mandated to be implemented by health and care organisations and system suppliers – the case study shows why it makes sense to start the implementation sooner rather than later.

Nurse using computer to record health information

The process

Nurse speaking into phone - voice recognition

Frimley Health NHS Foundation Trust uses Microsoft’s Dragon Medical Once solution, which captures voice-generated content directly into clinical systems. Dragon voice commands can also be used to navigate electronic health records and to insert customised templates, also known as auto-texts. 

When Frimley implemented their EPR system supplied by Epic, they decided it was a great opportunity to utilise the PRSB’s Outpatient Letter Standard, as it’s widely endorsed and would allow them to build the letters using a clear, standardised structure. 

Standardisation of information is important as it helps improve interoperability between different systems. 

All Frimley’s departments have been involved in the project. The organisation also worked closely with primary care providers, such as GPs, who were supportive of standardising letters and adhering to the PRSB standard. It was reasonably straightforward to build the letter templates to the standard, concentrating on implementing the mandatory fields first. 

Almost all letters are transcribed using Dragon Medical One, and Frimley encourages clinicians to use auto-texts and voice commands to make the letter creation more efficient while also making it easier to share standardised templates. 

Further work is planned to allow the solution to automate these processes even more.  

 

Lessons learnt

During the implementation process, Frimley identified that it can be challenging to include some of the fields marked ‘required’, and collection of structured data in the EPR is required, so that recorded data items are brought into the letter.

To make the adoption of Outpatient Letter Standard easier, Frimley is currently working with Epic, to ensure that the PRSB Outpatient Letter Standard becomes an integral part of their UK Foundation System and making the configuration more standardised for new NHS customers. 

In the near future, the Frimley team will begin to review the current build to increase the number of optional PRSB fields that might be present in the body of the letter.

Lessons learnt

The benefits

Improving communication with patients
Better communication with patients is one of the perceived benefits of the standard implementation – over time Frimley believes that it will enable people to receive letters about their appointments, treatment and results in a way that is easy to understand, helping them become more empowered and knowledgeable about their ongoing care.
Better quality information for GPs
It is also expected that the implementation of the standard will help improve the quality of the information received by GPs, supporting them in working more efficiently, and improve the ability to facilitate more shared decision-making conversations.

Feedback

Graham Smith, Consultant Orthopaedic Surgeon and Chief Clinical Information Officer at Frimley Health NHS Foundation Trust, has useful advice to organisations and system suppliers looking to implement the standard:

“Take the opportunity when you are making a change in your system or working on a new project. Our outpatient review process served as a great occasion to encompass the PRSB standards – we’re glad we did it, as it made the whole implementation process so much easier than doing it as an isolated project.”

Resources

The Outpatients Letter Standard
View the full standard and supporting documentation, examples and other resources.

Why use the standard?
In our short film, Dr Ian Logan from The Freeman Hospital, explains how the standard has benefited his patients receiving regular kidney dialysis.

Support services
Proactive support for our standards and ongoing maintenance and release management of published standards. 

Personalised care and support planning for people with severe mental illness

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides more detailed explanations about each element of the plan, including advice on how the planning process might be best conducted.
These questions might form a checklist for current plans to be compared with. 

1. Does the plan include an About Me section in which the service user, in their own words, can indicate the information they want to be available about their lives, their values, their interests, and priorities, available for all those who may care for them?
2. Is the approach to developing a care plan patient centred and engaging, allowing plans to be based on patient priorities goals, and aspirations, along with the actions they plan to take and the support that they will receive?
3. Is there space for a “formulation” to be recorded in which the person receiving care and the professionals who provide it, share and record the personal meaning and the origins of the person’s difficulties?
4. Are relevant procedures and therapies recorded?
5. Where relevant, are one or more contingency plans included for anticipatable disruptions, exacerbations, or deterioration, and do they include advice on what to do and points of contact for those called upon to respond?
6. Where relevant are additional supporting plans incorporated, (an example being an “educational and health plan” for someone with a neurodevelopment disorder)
7. Is a version of the plan available to a service user (if they wish to have it) in a form and format that they can understand and find to be of value?
8. How is a version of the plan available to the GP and other key parts of the health and care system?

Work conducted by PRSB and partners recently has looked specifically at the suitability of this approach to the development and documentation of care and support plans for people with Severe Mental Illness. This resulted in an updated version of the standard (v1.4), for use by any service and for any group of service users, but with some modifications to ensure that it meets the needs of this community. The approach to a patient centred process of identifying goals, hopes, and values, and the support needed to achieve them, is fully compatible with and can be conducted using, specific tools in use in mental health, such as DIALOG, DIALOG+, and ReQoL, for example. 

Where analysis indicates the need for improvement in the content and process of personalised care and support planning for patients with Severe Mental Illness, specific improvement projects should be instituted to co-design with service users and their representatives, and the relevant staff groups, new approaches, and documentation that would be of value in delivering improvement. The toolkit includes a range of existing resources that could be used to engage in this improvement work, including signposting to relevant existing approaches informed by patient experience-based design.

Moving to a single holistic plan

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides A key development, consistent with national policy on support for Personalised Care across all health and care sectors, is the move towards an individual with complex needs having a single, integrated, care plan, rather than a series of plans developed by different parts of the health and social care system in isolation of one another. For a patient with severe mental illness, the related concerns and challenges might form a very prominent part of such an integrated plan; many will also have concurrent health challenges and needs. The intention is that the relevant services work together to plan and wrap support around the patient and their family in an integrated way, rather than as a series of sequential or disconnected encounters in which the service user or their friends and family have to adopt the role of the integrator.

A starting point would be to agree priority groups of service users who may already have more than one care plan because they need care from more than one part of the system of health and social care. This could be initiated by looking at service users registered with some sentinel practices or PCNs. Alternatively, the approach might focus initially on people with defined co-morbidity or risk that entails collaborative care with agencies beyond specialist mental health services.

The focus here is on the process of care planning and agreement on what should be shared, rather than solely on the technology used;

1. What is the process to agree which professional will initiate care planning and act as the “lead point of contact” for the service user?
2. Will initial plans be agreed with the service user in joint consultations or sequentially? Where and how will they be conducted?
3. What will be the process to agree the elements of the plans which should be available to professionals and potential authorised users beyond the immediate care teams, (A&E services, Ambulance Services, Social services, etc.) with the service user’s consent?
4. How will elements of the plan be updated following consultations in a way which is proportionate, to allow contact and progress notes to be maintained by the service conducting the consultation, whilst avoiding unnecessary work for partners in care if there is no significant change to the personalised care and support plan?
5. What are the implications for workload, logistics, and administration arising out of these decisions?

The answers to these questions and others will best be elicited through focused joint working, grounded in real, or at least realistic examples. This will entail process mapping, and co-design with a range of professionals, service users, and families. Resources from the toolkit and outputs from the Simulation element of this project will be valuable. Some organisations would adopt an approach such as a Rapid Process Improvement Workshop, planned over several weeks and conducted over a number of sequential days, to develop prototype ways of working that could be tested in the field.