[The development of a hospital service for planning and organizing the care of cancer patients in the staging phase: the example of Novara hospital]. / Lo sviluppo di un servizio di accoglienza per i pazienti oncologici in stadiazione: l'esempio del Centro Accoglienza e Servizi della Azienda Ospedaliera Universitaria Maggiore della Carità - Novara.

. The development of a hospital service for planning and organizing the care of cancer patients in the staging phase: the example of Novara hospital. INTRODUCTION: Any disease, but specifically cancer, creates anxiety and patients enter a new path where they need to be accompanied. AIMS: To describe the organisation of a reception and service centre (CAS) for cancer patients at the Novara Hospital. METHODS: The Piedmont Oncology Network has set up the CAS, but each hospital, following common principles, has organised its own CAS, based on the collaborations and resources made available. RESULTS: Since 2015 the following services have been activated in the CAS of Novara: a nursing assessment chart (available in the computerised patient documentation system); the regular monitoring of cancer patients that access to the hospital and the times needed to carry out examinations and to organize exams and visits; a nursing clinic for the insertion of central venous catheters; a counter under the responsibility of the local patronages for support in bureaucratic procedures; an app has been created to make information available and allow patients direct contact with the service. CONCLUSIONS: There is still room for improvement but our experience shows that it is possible to create and operate services to accompany the patient through the path of illness and guarantee the right to be cared for.

A quantitative assessment of the parameters of the role of receptionists in modern primary care using the work design framework.

BACKGROUND: Amidst increased pressures on General Practice across England, the receptionist continues to fulfil key administrative and clinically related tasks. The need for more robust support for these key personnel to ensure they stay focussed and motivated is apparent, however, to be effective a more systematic understanding of the parameters of their work is required. Here we present a valuable insight into the tasks they fulfil, their relationship with colleagues and their organisation and their attitudes and behaviour at work collectively defined as their 'work design'. METHODS: Our aim was to quantitatively assess the various characteristics of receptionists in primary care in England using the validated Work Design Questionnaire (WDQ) a 21 point validated questionnaire, divided into four categories: task, knowledge and social characteristics and work context with a series of sub-categories within each, disseminated online and as a postal questionnaire to 100 practices nationally. RESULTS: Seventy participants completed the WDQ, 54 online and 16 using the postal questionnaire with the response rate for the latter being 3.1%. The WDQ suggested receptionists experience high levels of task variety, task significance and of information processing and knowledge demands, confirming the high cognitive load placed on receptionists by performing numerous yet significant tasks. Perhaps in relation to these substantial responsibilities a reliance on colleagues for support and feedback to help negotiate this workload was reported. CONCLUSION: The evidence of our survey suggests that the role of modern GP receptionists requires an array of skills to accommodate various administrative, communicative, problem solving, and decision-making duties. There are ways in which the role might be better supported for example devising ways to separate complex tasks to avoid the errors involved with high cognitive load, providing informal feedback, and perhaps most importantly developing training programmes.

' but I just prefer to treat everyone the same ': general practice receptionists talking about health inequities.

General practice receptionists are positioned at the beginning of a patient's journey within the healthcare system, yet their influence on a patient's experience is unknown. The limited data on, and research involving, general practice receptionists both in New Zealand and internationally is evidence of this. This research undertook an exploration of the discourses used by a group of general practice receptionists in Wellington, New Zealand to discover how they talk about, and represent, health inequities. Eight in-depth semi-structured interviews were conducted, guided by Social Constructionism and Decolonising Theory. Three reoccurring patterns of discourse were identified: discourses about the social determinants of health; discourses about Maori culture and behaviour; and discourses about egalitarianism. Further, narratives that could be seen as deficit-focussed or victim-blaming were identified. Racism was not directly discussed by participants as a health determinant. The findings support the need for training guided by cultural safety and anti-racism principles to be available for all general practice receptionists.

The Impatient Patient and the Unreceptive Receptionist: Darnley v Croydon Health Services NHS Trust [2018] UKSC 50.

In Darnley v Croydon Health Services NHS Trust [2018] UKSC 50, the Supreme Court held that a hospital receptionist's misleading statement about A&E waiting times constituted a breach of duty and that the claimant's decision, based on this misinformation, to leave the hospital did not break the chain of causation when he was left paralysed as a result of a head injury. In this commentary, I argue that while the Supreme Court's treatment of duty of care and breach is, for the most part, a model of doctrinal clarity, its treatment of the causation issue is problematic as it elides the test of whether there has been a break in the chain of causation with that for remoteness. I then comment on the Supreme Court's construction of the patient in medical negligence cases.

Receptionists' role in new approaches to consultations in primary care: a focused ethnographic study.

BACKGROUND: The receptionist is pivotal to the smooth running of general practice in the UK, communicating with patients and booking appointments. AIM: The authors aimed to explore the role of the receptionist in the implementation of new approaches to consultations in primary care. DESIGN AND SETTING: The authors conducted a team-based focused ethnography. Three researchers observed eight general practices across England and Scotland between June 2015 and May 2016. METHOD: Interviews were conducted with 39 patients and 45 staff in the practices, all of which had adopted one or more methods (telephone, email, e-consultation, or internet video) for providing an alternative to face-to-face consultation. RESULTS: Receptionists have a key role in facilitating patient awareness regarding new approaches to consultations in primary care, while at the same time ensuring that patients receive a consultation appropriate to their needs. In this study, receptionists' involvement in implementation and planning for the introduction of alternative approaches to face-to-face consultations was minimal, despite the expectation that they would be involved in delivery. CONCLUSION: A shared understanding within practices of the potential difficulties and extra work that might ensue for reception staff was lacking. This might contribute to the low uptake by patients of potentially important innovations in service delivery. Involvement of the wider practice team in planning and piloting changes, supporting team members through service reconfiguration, and providing an opportunity to discuss and contribute to modifications of any new system would ensure that reception staff are suitably prepared to support the introduction of a new approach to consultations.

Physician Time Burden Associated with Querying Prescription Drug Monitoring Programs.

Objective: Prescription drug monitoring programs (PDMPs) enable prescribers to review patient prescription histories, and their use is mandatory in many states. We estimated the cost of physicians retrieving PDMP patient reports compared with a model where a delegate (i.e., administrative staff) retrieves reports. Methods: We performed a cost analysis with a one-year time horizon, from the perspective of physicians' employers. We obtained specialty-specific estimates of controlled substance prescribing frequency from the National Ambulatory Medical Care Survey, 2012-2014. We defined three PDMP usage cases based on the frequency of queries: comprehensive (before every Schedule II-IV controlled substance prescription), selective (before new Schedule II-IV prescriptions and every six months for continuing medications), and minimal (before new Schedule II or III prescriptions and annually for continuing medications). Results: The delegate model was less costly for all specialties in the comprehensive usage case and most specialties in the selective usage case, and it was similar to physician model costs in the minimal usage case. Estimated annual costs of the physician model to a large health care system (1,000 full-time equivalent physicians) were $1.6 million for comprehensive usage, $1.1 million for selective usage, and $645,313 for minimal usage. The delegate model was less costly in the comprehensive (savings of $907,283) and selective usage cases (savings of $156,216). Conclusions: Relying on delegates vs physicians to retrieve reports is less costly in most cases. Automation and integration of PDMP data into electronic health records may reduce costs further. Physicians, health care systems, and states should collaborate to streamline access to PDMPs.

Between demarcation and discretion: The medical-administrative boundary as a locus of safety in high-volume organisational routines.

Patient safety is an increasing concern for health systems internationally. The majority of administrative work in UK general practice takes place in the context of organisational routines such as repeat prescribing and test results handling, where high workloads and increased clinician dependency on administrative staff have been identified as an emerging safety issue. Despite this trend, most research to date has focused on the redistribution of the clinical workload between doctors, nurses and allied health professionals within individual care settings. Drawing on Strauss's negotiated order perspective, we examine ethnographically the achievement of safety across the medical-administrative boundary in key high-volume routines in UK general practice. We focus on two main issues. First, GPs engaged in strategies of demarcation by defining receptionist work as routine, unspecialised and dependent upon GP clinical knowledge and oversight as the safety net to deal with complexity and risk. Receptionists consented to this 'social closure' when describing their role, thus reinforcing the underlying inter-occupational relationship of medical domination. Second, in everyday practice, GPs and receptionists engaged in informal boundary-blurring to safely accommodate the complexity of everyday high-volume routine work. This comprised additional informal discretionary spaces for receptionist decision-making and action that went beyond the routine safety work formally assigned to them. New restratified intra-occupational hierarchies were also being created between receptionists based on the complexity of the safety work that they were authorised to do at practice level, with specialised roles constituting a new form of administrative 'professional project'. The article advances negotiated order theory by providing an in-depth examination of the ways in which medical-administrative boundary-making and boundary-blurring constitute distinct modes of safety in high-volume routines. It also provides the basis for further research and safety improvement to maximise team-level understandings of the pivotal role of medical-administrative negotiations in achieving safety and mitigating risk.

Exploring the clinically orientated roles of the general practice receptionist: a systematic review protocol.

BACKGROUND: The receptionist is the focal point of the practice, undertaking an array of clinically orientated roles such as triaging patients for GP consultations or managing repeat prescribing. However, the full nature and extent of the receptionist's clinical activities is unknown as are the implications for patients. The aim of the proposed review is to explore the nature of the receptionist's clinical roles, their extent and their implications for patients. In doing so, we will highlight any gaps in the evidence base which future research may explore. METHODS: The databases Medline/PubMed, Ovid, Cinahl, ASSIA, Cochrane, EMBASE and Science Direct will be searched for relevant literature. We will look at both qualitative and quantitative research on GP receptionists, based within primary care to explore their roles within the primary care team, the clinically relevant roles they undertake, the extent of these roles and any implications these roles might have. No limits are placed on the date or place of publication; however, only research published in English will be included. Screening, quality assessments and data extraction will be carried out by two reviewers, who are not blinded to study characteristics. Analysis follows a four-stage method, established by Whittemore and Knafl (2005). DISCUSSION: The review will explore existing research covering the clinically orientated roles of the GP receptionist. The findings of the review will be important for healthcare professionals and academics working within primary healthcare. It will highlight and for the first time synthesise research relating to the complex and essential work of the GP receptionist. Our findings will inform the direction and focus of further research, as gaps in the knowledge base will be uncovered. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no: CRD42016048957 .

Why do patients seek primary medical care in emergency departments? An ethnographic exploration of access to general practice.

OBJECTIVES: To describe how processes of primary care access influence decisions to seek help at the emergency department (ED). DESIGN: Ethnographic case study combining non-participant observation, informal and formal interviewing. SETTING: Six general practitioner (GP) practices located in three commissioning organisations in England. PARTICIPANTS AND METHODS: Reception areas at each practice were observed over the course of a working week (73 hours in total). Practice documents were collected and clinical and non-clinical staff were interviewed (n=19). Patients with recent ED use, or a carer if aged 16 and under, were interviewed (n=29). RESULTS: Past experience of accessing GP care recursively informed patient decisions about where to seek urgent care, and difficulties with access were implicit in patient accounts of ED use. GP practices had complicated, changeable systems for appointments. This made navigating appointment booking difficult for patients and reception staff, and engendered a mistrust of the system. Increasingly, the telephone was the instrument of demand management, but there were unintended consequences for access. Some patient groups, such as those with English as an additional language, were particularly disadvantaged, and the varying patient and staff semantic of words like 'urgent' and 'emergency' was exacerbated during telephone interactions. Poor integration between in-hours and out-of-hours care and patient perceptions of the quality of care accessible at their GP practice also informed ED use. CONCLUSIONS: This study provides important insight into the implicit role of primary care access on the use of ED. Discourses around 'inappropriate' patient demand neglect to recognise that decisions about where to seek urgent care are based on experiential knowledge. Simply speeding up access to primary care or increasing its volume is unlikely to alleviate rising ED use. Systems for accessing care need to be transparent, perceptibly fair and appropriate to the needs of diverse patient groups.

Protocol for using mixed methods and process improvement methodologies to explore primary care receptionist work.

INTRODUCTION: The need to cope with an increasingly ageing and multimorbid population has seen a shift towards preventive health and effective management of chronic disease. This places general practice at the forefront of health service provision with an increased demand that impacts on all members of the practice team. As these pressures grow, systems become more complex and tasks delegated across a broader range of staff groups. These include receptionists who play an essential role in the successful functioning of the surgery and are a major influence on patient satisfaction. However, they do so without formal recognition of the clinical implications of their work or with any requirements for training and qualifications. METHODS AND ANALYSIS: Our work consists of three phases. The first will survey receptionists using the validated Work Design Questionnaire to help us understand more precisely the parameters of their role; the second involves the use of iterative focus groups to help define the systems and processes within which they work. The third and final phase will produce recommendations to increase the efficiency and safety of the key practice processes involving receptionists and identify the areas and where receptionists require targeted support. In doing so, we aim to increase job satisfaction of receptionists, improve practice efficiency and produce better outcomes for patients. ETHICS AND DISSEMINATION: Our work will be disseminated using conferences, workshops, trade journals, electronic media and through a series of publications in the peer reviewed literature. At the very least, our work will serve to prompt discussion on the clinical role of receptionists and assess the advantages of using value streams in conjunction with related tools for process improvement.

The care work of general practice receptionists.

INTRODUCTION The care work of general practice receptionists has received limited research attention, despite receptionists position at the beginning of patients' journeys in many health care systems. We examine receptionists' perceptions of their work and the opportunities and constraints they experience in caring for patients while providing administrative support to practices. METHODS Data were collected in focus group interviews with 32 receptionists from urban and rural general practices in the Auckland and Northland regions of New Zealand. We employed tools from inductive thematic analysis and Straussian grounded theory in interpreting the data. FINDINGS We found that the way receptionists identified with a caring role strongly challenged the pejorative view of them in public discourse. Receptionists provide care in two key ways: for the practice and for patients. The juggling they do between the demands of the practice and of patients creates considerable work tensions that are often invisible to other staff members. CONCLUSION Receptionists have a critical role as the first step in the patient care pathway, bridging health care system and community. For general practice to be patient-centred and improve accessibility for the most vulnerable, the care work of receptionists must be considered core. KEYWORDS Receptionists; general practice; care; New Zealand.

Calling the GP surgery: patient burden, patient satisfaction, and implications for training.

BACKGROUND: Good communication is central to the effectiveness of GP service provision, as well as to patient satisfaction with surgeries, but very little is known about the actual communication that occurs between patients and surgeries. AIM: This study was carried out to examine, for the first time, how receptionists interact with patients on the telephone, to identify features of communication associated with efficacy and patient satisfaction. DESIGN AND SETTING: A qualitative conversation analysis of incoming patient telephone calls, recorded 'for training purposes', in three English GP surgeries. METHOD: Data were analysed qualitatively to identify effective communication, then coded to establish the relative prevalence of communication types across each surgery. RESULTS: Analysis identified a burden on patients to drive calls forward and achieve service. 'Patient burden' occurred when receptionists failed to offer alternatives to patients whose initial requests could not be met, or to summarise relevant next actions (for example, appointment, call-back, or other query) at the end of calls. Coding revealed that 'patient burden' frequency differed across the services. Increased 'patient burden' was associated with decreased satisfaction on published satisfaction survey scores. CONCLUSION: Patients in some practices have to push for effective service when calling GP surgeries. Conversation analysis specifies what constitutes (in)effective communication. Findings can then underpin receptionist training and improve patient experience and satisfaction.

Service factors causing delay in specialist assessment for TIA and minor stroke: a qualitative study of GP and patient perspectives.

OBJECTIVE: To understand how service factors contribute to delays to specialist assessment following transient ischaemic attack (TIA) or minor stroke. DESIGN: Qualitative study using semistructured interviews, analysis by constant comparison. SETTING: Leicester, UK. PARTICIPANTS: Patients diagnosed with TIA or minor stroke, at hospital admission or in a rapid-access TIA clinic (n=42), general practitioners (GPs) of participating patients if they had been involved in the patients' care (n=18). DATA: Accounts from patients and GPs of factors contributing to delay following action to seek help from a healthcare professional (HCP). RESULTS: The following categories of delay were identified. First, delay in assessment in general practice following contact with the service; this related to availability of same day appointments, and the role of the receptionist in identifying urgent cases. Second, delays in diagnosis by the HCP first consulted, including GPs, optometrists, out-of-hours services, walk-in centres and the emergency department. Third, delays in referral after a suspected diagnosis; these included variable use of the ABCD(2) (Age, Blood pressure, Clinical features, Duration, Diabetes) risk stratification score and referral templates in general practice, and referral back to the patients' GP in cases where he/she was not the first HCP consulted. CONCLUSIONS: Primary and emergency care providers need to review how they can best handle patients presenting with symptoms that could be due to stroke or TIA. In general practice, this may include receptionist training and/or triage by a nurse or doctor. Mechanisms need to be established to enable direct referral to the TIA clinic when patients whose symptoms have resolved present to other agencies. Further work is needed to improve diagnostic accuracy by non-specialists.

Patient burden during appointment-making telephone calls to GP practices.

OBJECTIVE: This study addresses, for the first time, the effectiveness of receptionists handling incoming calls from patients to access General Practice services. METHODS: It is a large-scale qualitative study of three services in the UK. Using conversation analysis, we identified the issue of 'patient burden', which we defined based on the trouble patients display pursuing service. We quantified instances of 'patient burden' using a coding scheme. RESULTS: We demonstrate how 'patient burden' unfolds in two phases of the telephone calls: (i) following an initial rejection of a patient's request; and (ii) following a receptionist's initiation of call closing. Our quantitative analysis shows that the three GP services differ in the frequency of 'patient burden' and reveals a correlation between the proportion of 'patient burden' and independent national satisfaction scores for these surgeries. CONCLUSION: Unlike post-hoc surveys, our analysis of live calls identifies the communicative practices which may constitute patient (dis)satisfaction. PRACTICE IMPLICATIONS: Through establishing what receptionists handle well or less well in encounters with patients, we propose ways of improving such encounters through training or other forms of intervention.