Optimising elective surgery patient correspondence

Aim

Our aim was to support reduced disruptions to elective surgery waiting lists at The Prince Charles Hospital (TPCH) by ensuring patients confirm their need for surgery, follow instructions to prepare for and recover from surgery appropriately, attend any necessary pre-surgery appointments, and plan for discharge in advance.

Outcomes

• Reduction of the use of long sentences by almost 100%
• 18% improvement in the readability score (64/100 to 76/100)
• Major reductions in the use of passive voice
• Average reading grade level improved from 7.23 to 5.15 (28% improvement)
• Enhanced visual design and the inclusion of specific instructions and concrete deadlines reduces cognitive load
• Move from deficit- to strength-based messaging
• Formal evaluation yet to be conducted as the project is still ongoing at TPCH

Background

Surgical waitlists, cancellations and delays remain major challenges for healthcare systems. Evidence shows pre-operative preparation, including patient education about the surgical journey, is essential to reducing these disruptions. This phase also offers a unique opportunity to optimise patients'' physical, psychological and social health, which can lead to better surgical outcomes.

During the coronavirus pandemic, elective surgery letters needed to be re-written to incorporate safety and prevention measures such as physical distancing, being COVID-free before surgery etc. Whilst there aren't standardised templates for patient letters, the Elective Surgery Coordinators group (ESCs) is managed and supported by the Healthcare Improvement Unit (HIU). HIU led the review of the letters and provided recommendations to hospital and health services as to what changes should be made to their patient correspondence. This process was supported by the former CEQ-Engage team, a communications team within Clinical Excellence Queensland. The team provided advice around messaging and how to best communicate the changes.

Since that time, CEQ-Engage was disbanded and absorbed into the Strategic Communications Branch (SCB) following a Business Case for Change. This meant communications wasn't involved in any post-pandemic review of the letters.

Having reviewed the letters in the pandemic, I approached the ESC project officer (Katrina Cook) and asked if any of the HHSs would be open to SCB reviewing their current letter suite. Coincidentally, Katrina advised that The Prince Charles Hospital (TPCH) was in the process of reviewing their elective surgery patient letters and linked us in with Jennifer Gray, Registered Nurse in the Surgical Procedure Allocation Centre. Jennifer agreed to involve SCB in their review.

TPCH's initial review found their letters were out of date in terms of formatting and clinical information, patients were often given inconsistent advice from the various teams involved in the surgical journey, and patients wanted information to be more specific to their situation.

SCB undertook a communications, behaviour change, health literacy, and design review of seven of the hospital's elective surgery letters and found major issues with readability and comprehension. This has a major impact on their readiness for surgery.

Discussion

The process was challenging at times because some words that are considered difficult to read are those with three syllables or more. For example, while medicine is an improvement on medication, it still has three syllables so it brings down the comprehension score. This is particularly challenging because some words can't be replaced such as information, surgery, and appointment.

Another challenge was the use of passive voice, particularly for GP correspondence because we are referring to their patient's third person - which restricts the ability to use active voice. The process also highlighted the sheer volume of information patients receive in the lead-up to surgery and across a variety of modes - email, print and/or SMS. We recommend exploring opportunities to streamline communication and use more visuals. For example, providing a wayfinding hospital map is a better alternative than incorporating the text in the letter. We must also be cognisant of what information patients need at what stage. For example, including information about transport and preparing for your stay isn't appropriate in early correspondence, as patients aren't in that mindset yet and it isn't relevant to them at that time. Including QR codes is also recommended for those who are more digitally-literate.

The core issue we identified though was that we (as in, ''the system'') put the onus on patients to navigate said system but we use language that:

• is very difficult to comprehend
• is often deficit-based and risks inducing feelings of shame and guilt (for example, ''you have failed to respond'')
• does not promote a safe and inclusive culture.

This means not only are we are not adequately preparing patients for their surgical journey, but we're also not:

• setting the foundation for them to want to engage with the health system
• empowering patients to take control of and better manage their health.
  • This is particularly true for First Nations peoples and culturally or linguistically diverse people, which is problematic given these populations often experience poorer health outcomes and are less likely to engage with the health system as it is.

  These issues have significant repercussions on the health system both in the immediate term (not being prepared for surgery) and the longer-term (higher likelihood of re-presenting). With a strong push to overhaul elective surgery (for example, moving more cases to day surgery and introducing criteria-led discharge and handover), Queensland Health is in a valuable position to also overhaul patient correspondence and introduce statewide standards. This process can also aid in shifting patients' thinking from 'hospitals are for convalescing' to 'home is best' and to be receptive to new models of care whereby they may not see their surgeon before they are discharged.

The added benefit of this process is no additional investment or funding is required by any HHS or the Department. It's a low-cost, low-risk initiative that has potential to have significant impacts on Queensland Health's elective surgery waitlists and overall waitlist and referral management.

References

Williams, C. J., Duff, J., & Tanagan, C. (2024). Australian elective surgery patients'' pre-operative preparation, health literacy, learning preferences and knowledge resource health literacy, learning preferences and knowledge resource needs: A cross-sectional survey. Journal of Perioperative Nursing, 37(1), 1-10.

Michie, van Stralen and West (2011)