International Journal of Health Care Quality Assurance Listening to patients: improving the outpatient service Cecilia Mercieca Sara Cassar Andrew A. Borg

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To cite this document: Cecilia Mercieca Sara Cassar Andrew A. Borg , (2014),"Listening to patients: improving the outpatient service", International Journal of Health Care Quality Assurance, Vol. 27 Iss 1 pp. 44 - 53 Permanent link to this document: http://dx.doi.org/10.1108/IJHCQA-03-2012-0033 Downloaded on: 30 January 2016, At: 05:56 (PT) References: this document contains references to 28 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 872 times since 2014*

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IJHCQA 27,1

Listening to patients: improving the outpatient service Cecilia Mercieca

44

Academic Rheumatology Unit, Bristol Royal Infirmary, Bristol, UK, and

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Sara Cassar and Andrew A. Borg Received 27 March 2012 Department Revised 6 August 2012 19 October 2012 Accepted 12 February 2013 Abstract

of Rheumatology, Mater Dei Hospital, Msida, Malta

Purpose – This paper assesses the patients’ healthcare information needs and expectations when they attend a rheumatology outpatient clinic. It proposes that obtaining the patients’ perspectives about the services they use is an essential service-development tool. The aim of this paper is to expand the current domains used to evaluate these perspectives. Design/methodology/approach – This paper is an exploratory study, looking at quality assessment and improvement based on Donabedian’s quality model in a rheumatology outpatient setting. A structured interview schedule addressing care pathways was used and 70 consecutive patients were recruited. Findings – The article provides insights about how relevant change can be brought about when service development is contemplated. It suggests that patients are important stakeholders in the ongoing service development process. Research limitations/implications – Because rheumatological conditions tend to be chronic and require long-term follow-up, the results may lack generalisability. Therefore, researchers are encouraged to test propositions in different clinical settings. Practical implications – The article highlights healthcare delivery areas that are not meeting patient expectations. Some recommendations (such as informing waiting patients regularly about any delays) require minimal additional resources for successful implementation. Service providers need to obtain the patients’ healthcare perspectives to ensure that services are built around their needs. Originality/value – This article fulfils an identified need to study how patients perceive service quality. Keywords Organisational development, Patient perception, Quality improvement, Patient centredness, Patient expectation Paper type Literature review

International Journal of Health Care Quality Assurance Vol. 27 No. 1, 2014 pp. 44-53 q Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-03-2012-0033

Introduction Over the past few years, patient participation in illness management has been increasingly encouraged (Guadagnoli and Ward, 1998; Ward, 2004a). Several studies show that involving patients in their medical care results in a better outcome and greater satisfaction (Wressle et al., 2002; Brekke et al., 2001). Rheumatological conditions tend to be chronic and patients often suffer from fatigue, pain, impaired function and psychosocial problems. Disease management requires a multidisciplinary approach (Kjeken et al., 2006). Obtaining the patient’s rheumatology outpatient service perspective is essential to provide high-quality services (Joint Working Party, Royal College of Physicians, 2004). The patient experience starts from the appointment letter, then consultation and follow-up. An efficient and effective service depends on the whole team The authors thank Dr Mario Vassallo, MD, FRCP for his helpful comments.

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(Petersson, 2005; MacKay et al., 2005) including doctors, nurses, pharmacists, therapists, receptionists, secretaries, service facilities and clinical pathways. The relatively few publications on patient needs, satisfaction and health service preferences are striking and are reflected across different clinical specialities. Most professional guidelines focus on pharmacological treatments rather than health service delivery. In 2004, a publication suggested making medical outpatients more user-friendly and providing a better service. Four domains covered: outpatient clinic; communication; before and during the consultation; and results and follows up ( Joint Working Party, Royal College of Physicians, 2004). Our aim, therefore, was to survey the patients’ healthcare information needs and expectations when attending rheumatology clinics at the main secondary care hospital for the whole Maltese islands. We applied Donabedian’s (1986) model to assess service quality: structure, process and outcome. Structure includes the human resources and expertise, facilities and equipment. Process refers to actual service delivery and patient pathways. Outcome denotes service efficacy on the patients’ health status. The results then form the basis for improving the service to match patients’ needs and expectations. To the best of our knowledge, this is the first study that attempts to assess outpatient service provision using a structure-process-outcome approach in rheumatology. Methods This was a structured interview schedule based on 38 questions developed following discussion among the authors and their patients. The questions were designed to address rheumatology out-patient consultation structure, process and outcome. We specifically tried to address conceivable aspects related to the service including appointment letter, clinic structure, waiting times, consultation, follow up, compliance with medication and overall satisfaction. Responses were measured either on a Likert scale or a yes/no response. A total of 70 consecutive patients attending the rheumatology clinic on Wednesdays, over a three-month period, were recruited. Patients were interviewed by an independent assessor (SJC) in a separate location immediately after their scheduled clinic appointment. The average time taken for the interview schedule was eight minutes. Results Patient characteristics are shown in Table I. The main findings from the 38-point questionnaire showing outpatient structure, process and outcome perspectives are summarised in Table II. Structure The waiting area was found to be unsatisfactory by 34.7 per cent; 5.7 per cent were indifferent while the rest were satisfied. Common comments included inappropriate chairs for patients with arthritis and disabilities, and the small waiting area (25.7 per cent). Disorganised queuing and patients accompanied by more than one relative reduced space and made it particularly difficult for patients manoeuvring wheelchairs or using walking aids. Process An appointment letter confirming the date, time and location was received by 16.7 per cent; the rest had been given the details on their appointment card from the previous visit. When asked whether the letter contained a contact number to telephone in case

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Table I. Patient demographics

Characteristic

Value

Gender Males Females

25 45

Mean age/years

59.0

Rheumatology condition Inflammatory arthritis Metabolic bone disorders Soft tissue conditions Osteoarthritis

36 10 15 9

Cases New Follow up

10 60

Strongly Moderately agree agree (%) (%) Structure Suitability of waiting area

Table II. The main findings from the 38 point questionnaire showing outpatients’ perspective on service structure, process and outcome

Process Staff efficiency at reception Privacy of consultation Adequate consultation time Clear explanation about investigations Clear follow up plan Clear instructions about medication Information about illness Outcome Satisfaction with helpline advice Overall satisfaction

SD

15.1

Neither agree nor disagree (%)

Moderately Completely disagree disagree (%) (%)

35.7

32.9

5.7

14.3

11.4

87 100 91.4 90.8 84.1 92.6 75.7

8.7 0 7.1 7.7 11.6 7.4 8.6

1.4 0 0 0 4.3 0 5.7

2.9 0 1.4 0 0 0 1.4

0 0 0 1.5 0 0 8.6

72.7 94.3

18.2 4.3

0 1.4

0 0

9.1 0

they were unable to attend, 33.3 per cent answered positively; 23.8 per cent said there was no number while 42.9 per cent were unsure. Most patients (71.4 per cent) correctly noted that the appointment letter did not remind them to bring medication details and investigation results (carried out at other hospitals). Most patients (81 per cent) felt adequate advance notice for the appointment was given. Satisfaction with reception desk efficiency and service was high (87.1 per cent). Only 8.6 per cent were unable to recall the consulting doctor’s name; but 91.2 per cent recalled seeing staff wearing identification tags. Delays more than 30 minutes past the appointment time were reported by 55.7 per cent and 97.8 per cent were not informed about the reasons. All patients felt that their privacy and dignity were maintained and 98.5 per cent agreed that they had adequate time to discuss their condition. One third were disappointed that the consultation was interrupted by telephone calls or other

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staff entering to speak to the doctor. Nearly all patients received clear instructions about further tests (98.5 per cent) and follow-up instructions (84.1 per cent). Most patients (75.7 per cent) strongly believed that receiving written information helped them to understand their illness. Only 24.3 per cent felt they received sufficient information by the medical team and needed no further written information. Educational meetings and discussions with healthcare professionals rather than written leaflets were preferred by 10 per cent. The majority (80 per cent) believed that a typed letter sent promptly to the patient and their primary care physician facilitates clinical care and information transmission. Outcomes – medication Regarding compliance with medication; 43.4 per cent reported they never missed taking their medications, 32.1 per cent missed occasionally, 9.4 per cent rarely and 15.1 per cent very rarely. The main reason reported was forgetfulness, especially those on weekly medication. When questioned about serious side effects, 80 per cent could not recall any side effects they might experience during treatment. Overall satisfaction Most (94 per cent) were highly satisfied with the overall service. When asked an open question about what could be improved, 34.3 per cent volunteered comments. Areas needing improvement were: appointments kept to time; avoiding rescheduling; more accessible car parking spaces for disabled patients; and information in languages other than English. Other important issues were access to rapid or emergency appointments, more flexibility in the appointment system to allow patients being seen when needed and regular appointments. Patients commented that the phlebotomy service appointments could be scheduled in the late afternoon to make it more accessible for working people. When asked to rank (0-10) service delivery according to importance, being seen on time was ranked first by most followed (in decreasing order): emergency appointment availability (when needed); being informed beforehand, specifically about who will be performing the consultation; less interruptions during the consultation; and more time with doctors. Better organisation and structure and receiving written information about medication and illness were ranked less important. Finding the clinic, a better helpline service or more time with the nurse-specialist were ranked the lowest. Discussion Hospital out-patient staff struggled to cope with their workload, given that need and demand are always greater than supply – the main factor creating waiting times. Staff try to cope with the demand by separating new patient and follow-up clinics, to ensure that new patients can access the system. Where clinics are mixed, attempts are made to have a new to-follow-up patient ratio that is appropriate for the specialty. Providers should be continually asking two questions when assessing service provision: (1) Are we following-up patients who specifically need specialist care, or can they be treated by other practitioners? (2) Are we reviewing patients that need following-up at appropriate intervals? In the UK, for example, the National Institute of Clinical Excellence Rheumatoid Arthritis clinical guideline (National Institute of Clinical Excellence Guideline 79, 2009),

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recommends that newly diagnosed patients commence treatment within 12 weeks of symptom onset. Additionally, the guideline indicates intensive monitoring and tailoring treatment in the first months. This has caused a major challenge for service providers to identify extra clinic slots to accommodate this requirement. Patient satisfaction is an important quality indicator and an invaluable tool for tailoring services to user needs. Dissatisfaction may influence adherence to treatment, confidence in the health system and ultimately outcomes. The main reasons influencing patient satisfaction are whether their expectations are met; whether their symptoms improved; and whether they are provided with adequate information and good communication with the healthcare professionals (Sixma et al., 1998; Jackson et al., 2001). Most patients in our survey were satisfied with their overall care – in keeping with other published studies (Brekke et al., 2001; Kjeken et al., 2006). However, several points were raised that also need addressing. The appointment letter The appointment letter is the first contact with the patient. It should contain clear, relevant information to prepare patients for their visit and inform them what to expect. A contact number or email address in case they cannot attend their appointment may help reduce the total patients who do not turn up. More than half did not receive an official appointment letter. Even if they are follow-up consultations, a reminder (letter, text message, phone call or email) about their appointment and about what to expect on the day should be standard. Also reminding the patient to bring medicine details, pending or current referrals, investigations or treatments they have/had at other hospitals may help to improve efficiency without incurring extra resources. Some patients were not sure what the letter contained. It could be that the information was not clear or easy to find. All the patients interviewed in the study had English or Maltese as their primary language, so it is unlikely that the letter could not be understood by those speaking English or Maltese. However, we cannot exclude the possibility that appointment letters are more challenging for less-educated people. Arrival at the clinic Few patients reported having problems finding the clinic probably because most cases were follow-up consultations. Finding a way through hospitals can be difficult. Sometimes patients have to go to different departments, which may be located at more than one site. Clear sign-posting, a hospital map, the nearest drop-off or pick-up point and details about car parking for the disabled attached to the appointment letter may go a long way to reduce anxiety. On arrival to the clinic, patients first call at the reception desk, which is usually a busy area. Staff are required to answer phone calls, book appointments, input data, explain to and direct patients. This may be daunting to some patients. Although most were highly satisfied with the reception staff, they still remarked that there needs to be better organisation. To ensure patients are greeted properly, it may help to separate the tasks and the areas used for welcoming patients. Volunteers may be a great asset in welcoming and directing patients to the appropriate registration and waiting areas. Waiting areas Another unmet need was insufficient waiting space and uncomfortable seating. Rheumatology patients may be in wheelchairs or have other mobility aids and they

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may have children accompanying them. Insufficient space may be due to various factors other than actual physical space such as patients turning up too early, patients visiting outpatients for reasons other than the clinic appointment or too many clinics running at the same time. Given the user groups’ special outpatient needs and requirements, we feel that rheumatology services should be provided from a dedicated unit as it is difficult to provide specialised facilities for patients with musculoskeletal problems in a general setting. Dynamic multidisciplinary rheumatology units are involved not only with patient care but also with training and education, research and clinical trials. Many services are offered to rheumatology patients, including: . Specialist diagnostic and treatment services for patients with all forms of rheumatic conditions including inflammatory arthritis, osteoarthritis, osteoporosis, and specialised clinics for paediatric rheumatology, spondyloarthritis, early arthritis and connective tissue diseases. . Nurse-led clinics for patients who need education, support and advice. . Increasing biologic therapies (given their nature and increasing use across rheumatological conditions, administration mode, high cost and safety profile) has resulted in a need for additional specialist nurse personnel for assessing, monitoring and treating. . A teaching service for undergraduate students, trainee rheumatologists, primary care physicians and other health professionals. Waiting times and interruptions One dissatisfaction in our survey, were waiting times; 55.7 per cent reported waiting for more than 30 minutes from registration at the reception until review by a healthcare professionals. Few patients were informed about delays and how long these would be. Waiting longer than expected upsets patients, as they might think that their turn has been skipped or they might genuinely have other commitments such as work or childcare that need rearranging. They might also fear that they will now be seen in a hurry and not given the necessary attention. It is considerate to inform patients about delays on arrival or as soon as possible (Joint Working Party, Royal College of Physicians, 2004). A white board with doctors’ names and the waiting times/delays may be helpful in busy clinics. Outpatient team members should ensure that clinics start on time and appointment timings are maintained. Allowances when planning the clinic template should be made if there are students or junior staff, and if the consultant is covering other sessions such as specialist nurse clinics. Special interest clinics or certain conditions such as connective tissue disease patients or urgent referrals for unexpected problems may require longer clinic slots than the standard 30 minute new-patient and 15 minute follow-up slots. Auditing waiting time will provide useful information. Interruptions from staff and telephone calls should be kept to a minimum. In a teaching hospital, experiential learning for doctors is important. Rheumatology is an outpatient-based speciality and teaching needs to be carried out in an outpatient setting. A good balance between training and service is important to allow adequate time for teaching and appraising trainees and students (McDonagh, 1997). Reducing the consultant-trainer’s outpatient workload is required to allow adequate teaching (British Society for Rheumatology, 1990). If a specialist trainee is available in an outpatient clinic then the workload should ideally be increased by only 25 per cent for training requirements (British Society for Rheumatology, 1990).

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Staff Putting clinic staff names on boards may help patients to remember who they saw. Patients may see different doctors on follow-up visits and it might be difficult for them to recall who they saw, particularly when junior staff are involved, who often move to other specialities. Also, patients might not realise the different services offered. Outpatients staff have different skills and have their own remit and responsibilities. Regular discussions about operational procedures, improvements, complaints or incidents etc., might help teamwork and ultimately service quality. An induction and communication skills training programme for staff may improve service efficiency. Communication Patients are more likely to be satisfied when physicians adopt a caring, positive and empathic approach (Froehlich and Welch, 1996). Time pressures are not uncommon in clinical practice and physicians find delivering a high-quality service in the least time with the available resources challenging. Lack of time with staff, particularly a visit duration less than ten minutes, was the main reason for dissatisfaction (Rao et al., 2004). Understandably, patients might feel hurried, have less time to voice their concerns and needs, and do not have the time to take in the information given. However, there are other factors; e.g. those who felt less pain over the previous months were less likely to report an unmet expectation. Other confounding issues influencing a patient-doctors relationship are power, likeability and trust (Thom et al., 2002). Interactions are not static and changing illness, circumstances, treatment failure and success are factors (Ward, 2004b). Addressing patients’ questions and concerns is fundamental for a patient-centred approach (Roter, 2000). An interesting suggestion is teaching patients about prioritising and how to express concerns and thoughts in a comfortable way (Daltroy, 1993). Additionally, they should be educated about which services they need, when and how to access them. It would also be interesting to look at physicians’ viewpoints and how much they felt that patients’ expectations were met. Patients and physicians may have different concerns (Starfield et al., 1979). Patients might think that certain questions could be answered by the specialist, when it would be more appropriate to discuss this with the primary care physician. Helping patients to understand these differences may lessen confusion and improve satisfaction. This could be done through written information, during educational sessions or as part of the consultation with the nurse specialist. Information Many patients reported that they would like more information about their illness in leaflet form and educational sessions. This continued need is not unexpected in chronic conditions (Neame et al., 2005; Meesters et al., 2009). Chronic illnesses tend to fluctuate, resulting in new or different needs over time. Additionally, over time, there have been radical changes in therapeutic strategies and surgical procedures. Unfortunately, to date, information leaflets are not widely available in outpatient clinics and even less in the Maltese language. Leaflets are unlikely to cover and discuss all issues during a clinic visit, and it is unrealistic to expect patients to retain all information given orally. Leaflets ensure that the appropriate information is delivered and patients can read and refer to as needed.

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Medication Most patients appreciated being educated about their medications, whether by the consultant, specialist nurse or pharmacist. Collaboration between different team members and patients will ensure better treatment outcomes (Mahmud et al., 1995; Treharne et al., 2006). Most felt that they were given clear instructions about the need for and instructions about how to take their treatment. Interestingly, when asked specifically about side effects, only a small number were able to mention any potentially serious ones. Other important issues mentioned included compliance, persistence and medication errors. This highlights the need to keep addressing these issues with patients, re-check their understanding and provide aids that may help improve persistence. Follow up Ideally, patients are seen in a timely and appropriate fashion. Certain conditions need regular monitoring as complications might initially be asymptomatic. In other conditions, a direct access system might be as or more effective. An interesting care-model has been proposed by Berry et al. (2003) and Hewlett et al. (2005) who describes a patient-centred care-model characterised by availability, appropriateness, preference and timeliness. A similar model is direct access for rheumatoid arthritis (Davis et al., 2001), which offers patients the advantage to be seen when needed rather than regular pre-determined appointments. Direct-access patients show greater satisfaction in the healthcare system compared with the traditional regular follow-up. Additionally, the former used one third fewer appointments while clinically they were equally well. This system may accommodate more appropriate follow-ups by allowing patients who are stable and need no treatment changes from taking clinic slots for patients more in need at that time. Non direct-access patients may have to wait longer as direct-access patients are given priority. Also, direct-access planning is needed so that slots are not left empty. System success is dependent on patients knowing when and how to access help. Other services, such as telemedicine, may be considered, especially in areas where access to secondary care is difficult. Davis et al. (2001) found that patients felt it was acceptable and satisfactory; 84 per cent reporting it was as good as an “in person” visit. Overall satisfaction was high compared to other studies. One third of the patients in the Kjeken et al. (2006) study reported dissatisfaction and unmet healthcare needs. Possibly, the overall disability in our population was different compared to other studies given that we had patients with wide-ranging rheumatological conditions and varying severity. A more plausible reason may be that most were reviewed by the consultant, which provides a greater continuity. Limitations Our study’s limitations include the cross-sectional design, which makes it difficult to determine cause and effect relationships. Confounding factors include the rapport between patient and medical team. Although we only included rheumatology patients, the disease spectrum is still heterogeneous in nature and severity, which calls for different approaches. Comparison with other studies is difficult, as the local setting might differ from other models. Other areas that we have not explored are access to rheumatology services, access when diseases exacerbate, referrals to therapists, education level, social support and psychological backgrounds.

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Conclusions Health service research is important for patients, clinicians and policy makers alike. An easily accessible, user-friendly healthcare delivery is key in a patient-centred care system. Overall, this study indicates that there is a potential for further improvement in the way arthritis care is delivered. A few proposals may need extra resources, but some require few additional means. Obtaining specialist, primary care physician, patient and their advocates’ perspectives ensures that services are built around our patients’ needs and expectations. References Berry, L.L., Seiders, K. and Wilder, S.S. (2003), “Innovations in access to care: a patient-centered approach”, Annals of Internal Medicine, Vol. 139 No. 7, pp. 568-574. Brekke, M., Hjortdahl, P. and Kvien, T.K. (2001), “Involvement and satisfaction: a Norwegian study of health care among 1,024 patients with rheumatoid arthritis and 1,509 patients with chronic non-inflammatory musculoskeletal pain”, Arthritis and Rheumatism, Vol. 45 No. 1, pp. 8-15. British Society for Rheumatology (1990), British Society for Rheumatology Service Provision in Rheumatology: Outpatient Services, British Society for Rheumatology, London. Daltroy, L.H. (1993), “Doctor-patient communication in rheumatological disorders”, Clinical Rheumatology, Vol. 7 No. 2, pp. 221-239. Davis, P., Howard, R. and Brockway, P. (2001), “An evaluation of telehealth in the provision of rheumatologic consults to a remote area”, Journal of Rheumatology, Vol. 28 No. 8, pp. 1910-1913. Donabedian, A. (1986), “Criteria and standards for quality assessment and monitoring”, Quality Review Bulletin, Vol. 12 No. 3, pp. 99-108. Froehlich, G.W. and Welch, H.G. (1996), “Meeting walk-in patients’ expectations for testing: effects on satisfaction”, Journal of General Internal Medicine, Vol. 11 No. 8, pp. 470-474. Guadagnoli, E. and Ward, P. (1998), “Patient participation in decision-making”, Social Science and Medicine, Vol. 47 No. 3, pp. 329-339. Hewlett, S., Kirwan, J., Pollock, J., Mitchell, K., Hehir, M., Blair, P.S., Memel, D. and Perry, M.G. (2005), “Patient initiated outpatient follow up in rheumatoid arthritis: six year randomised controlled trial”, British Medical Journal, Vol. 330 No. 7484, p. 171. Jackson, J.L., Chamberlin, J. and Kroenke, K. (2001), “Predictors of patient satisfaction”, Social Science Medicine, Vol. 52 No. 4, pp. 609-620. Joint Working Party, Royal College of Physicians (2004), “How user friendly is your outpatient department? A guide to improving services”, Royal College of Physicians, London. Kjeken, I., Dagfinrud, H., Mowinckel, P., Uhlig, T., Kvien, T.K. and Finset, A. (2006), “Rheumatology care: involvement in medical decisions, received information, satisfaction with care, and unmet health care needs in patients with rheumatoid arthritis and ankylosing spondylitis”, Arthritis and Rheumatism, Vol. 55 No. 3, pp. 394-401. McDonagh, J.E. (1997), “Rheumatology outpatient training: time for a re-think?”, Annals of the Rheumatic Diseases, Vol. 56 No. 12, pp. 701-704. MacKay, C., Devitt, R., Soever, L. and Badley, E.M. (2005), “An exploration of comprehensive interdisciplinary models for arthritis”, working report 2005-03, Arthritis Community Research & Evaluation Unit (ACREU), Toronto. Mahmud, T., Comer, M., Roberts, K., Berry, H. and Scott, D.L. (1995), “Clinical implications of patients’ knowledge”, Clinical Rheumatology, Vol. 14 No. 6, pp. 627-630.

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Meesters, J.J., Vliet Vlieland, T.P., Hill, J. and Ndosi, M.E. (2009), “Measuring educational needs among patients with rheumatoid arthritis using the Dutch version of the Educational Needs Assessment Tool (DENAT)”, Clinical Rheumatology, Vol. 28 No. 11, pp. 1073-1077. National Institute of Clinical Excellence: Guideline 79 (2012), “The management of rheumatoid arthritis in adults”, available at: www.nice.org.uk/nicemedia/pdf/ CG79NICEGuideline.pdf (accessed December 2012). Neame, R., Hammond, A. and Deighton, C. (2005), “Need for information and for involvement in decision making among patients with rheumatoid arthritis: a questionnaire survey”, Arthritis and Rheumatism, Vol. 53 No. 2, pp. 249-255. Petersson, I.F. (2005), “Evolution of team care and evaluation of effectiveness”, Current Opinion in Rheumatology, Vol. 17 No. 2, pp. 160-163. Rao, J.K., Weinberger, M., Anderson, L.A. and Kroenke, K. (2004), “Predicting reports of unmet expectations among rheumatology patients”, Arthritis and Rheumatism, Vol. 51 No. 2, pp. 215-221. Roter, D. (2000), “The medical visit context of treatment decision making and the therapeutic relationship”, Health Expectations, Vol. 3 No. 1, pp. 17-25. Sixma, H.J., Spreeuwenberg, P.M. and van der Pasch, M.A. (1998), “Patient satisfaction with the general practitioner: a two-level analysis”, Medical Care, Vol. 36 No. 2, pp. 212-229. Starfield, B., Steinwachs, D., Morris, I., Bause, G., Siebert, S. and Westin, C. (1979), “Patient-doctor agreement about problems needing follow- up visit”, The Journal of the American Medical Association, Vol. 242 No. 4, pp. 344-346. Thom, D.H., Kravitz, R.L., Bell, R.A., Krupat, E. and Azari, R. (2002), “Patient trust in the physician: relationship to patient requests”, Family Practice, Vol. 19 No. 5, pp. 476-483. Treharne, G.J., Lyons, A.C., Hale, E.D., Douglas, K.M. and Kitas, G.D. (2006), “Compliance is futile but is concordance between rheumatology patients and health professionals attainable?”, Rheumatology (Oxford), Vol. 45 No. 1, pp. 1-5. Ward, M.M. (2004a), “Patient-centered care and health outcomes”, Current Opinion in Rheumatology, Vol. 16 No. 2, pp. 89-90. Ward, M.M. (2004b), “Rheumatology care patient expectations, and the limits of time”, Arthritis and Rheumatism, Vol. 51 No. 2, pp. 307-308. Wressle, E., Eeg-Olofsson, A.M., Marcusson, J. and Henriksson, C. (2002), “Improved client participation in the rehabilitation process using a client-centered goal formulation structure”, Journal of Rehabilitation Medicine, Vol. 34 No. 1, pp. 5-11. Corresponding author Andrew A. Borg can be contacted at: [email protected]

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Listening to patients: improving the outpatient service.

This paper assesses the patients' healthcare information needs and expectations when they attend a rheumatology outpatient clinic. It proposes that ob...
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