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.

Primary care office responses to a stroke scenario.

PURPOSE: One previous study found that healthlines affiliated with academic neurology programs recommended non-emergent treatment for a hypothetical stroke scenario almost one quarter of the time, which could contribute to patients presenting too late for time dependent stroke therapies. We assessed the treatment advice given in a hypothetical stroke scenario by primary care physician offices across the United States. METHODS: We obtained a national listing of United States primary care physician offices from Yellowpages.com, and selected a systematic random sample of numbers to call. The respondent answering the phone was presented with a standardized, scripted stroke patient scenario, and asked to choose one of four responses that could be provided (wait for symptom resolution, attempt to schedule an office appointment later in the day, schedule an office visit within two days, call 911 for ambulance transport to a hospital). RESULTS: Forty-two respondents completed the survey (average age = 43 years; 88% female), with 29% (95% CI 17%-44%) recommending scheduling an appointment later in the day if symptoms do not resolve. The remaining respondents recommended calling 911. When presented with a heart attack scenario, 100% of respondents recommended calling 911. CONCLUSIONS: Almost one third of the primary care physician offices recommended scheduling an appointment later in the day for a hypothetical stroke case, despite always giving the correct answer of call 911 for a classic heart attack scenario. These results suggest that stroke education with specific emphasis on the need to call 911 may be needed for primary care physician office receptionists.

Monthly communication skill coaching for healthcare staff.

OBJECTIVE: To promote monthly interpersonal skill communication role-play and coaching for front-office staff. METHOD: For 15 min a month, during staff meetings, healthcare staff such as receptionists and medical assistants should participate in communication skill coaching. Participants should discuss a recurring communication challenge (e.g., patients irritated by repeated requests for health histories), role-play options for communication, and receive feedback. RESULT: Interpersonal communication skills such as acknowledging the concerns of others are acquired slowly. Repeated practice and supportive feedback increase the likelihood that these skills will be valued and mastered. CONCLUSION: Research shows communication skills develop when they are modeled and role-played frequently and are less likely to develop with occasional interventions. PRACTICE IMPLICATION: Health care professionals should devote time to role-playing interaction with patients for brief intervals at least monthly. Staff should give one another feedback on the best options for managing challenging communication situations.

Improving access for patients - a practice manager questionnaire.

BACKGROUND: The administrative and professional consequences of access targets for general practices, as detailed in the new GMS contract, are unknown. This study researched the effect of implementing the access targets of the new GP contract on general practice appointment systems, and practice manager satisfaction in a UK primary health care setting. METHODS: A four-part postal questionnaire was administered. The questionnaire was modified from previously validated questionnaires and the findings compared with data obtained from the Western Health and Social Services Board (WHSSB) in N Ireland. Practice managers from the 59 general practices in the WHSSB responded to the questionnaire. RESULTS: There was a 94.9% response rate. Practice managers were generally satisfied with the introduction of access targets for patients. Some 57.1% of responding practices, most in deprived areas (Odds ratio 3.13 -95% CI 1.01 - 9.80, p = 0.0256) had modified their appointment systems. Less booking flexibility was reported among group practices (p = 0.006), urban practices (p < 0.001) and those with above average patient list sizes (p < 0.001). Receptionists had not received training in patient appointment management in a quarter of practices. Practices with smaller list sizes were more likely than larger ones to utilise nurses in seeing extra patients (p = 0.007) or to undertake triage procedures (p = 0.062). CONCLUSION: The findings demonstrated the ability of general practices within the WHSSB to adjust to a demanding component of the new GP contract. Issues relating to the flexibility of patient appointment booking systems, receptionists' training and the development of the primary care nursing role were highlighted by the study.

Accurate sampling in general practice waiting room surveys: methodological issues.

OBJECTIVES: This is a pilot study to test the validity of using one research assistant to train and support reception staff at five clinics to obtain waiting room data in general practice surveys. DESIGN: A research assistant trained reception staff at five randomly chosen general practices to administer a survey to all eligible women over a two-week period. Practices were audited daily by their appointment books and where possible by billing records to check total numbers of eligible women to determine the denominator of the sample. SETTING: Five metropolitan general practices in one divisional area. PARTICIPANTS: Twenty-five receptionists distributed surveys to 1,298 women. MAIN OUTCOME MEASURES: Number of eligible women missed at each clinic. RESULTS: The number of potential subjects missed by the reception staff ranged from nil to 18% with the appointment book audit. A second audit using billing records at three clinics revealed inaccuracies of up to 50%. The ability to accurately capture eligible patients for waiting room surveys depends on good administrative systems within the practice and motivated staff. CONCLUSIONS: It is important for general practice researchers to consider and account for eligible participants who are missed from the denominator with a waiting room survey method. Valid sampling using this method can be achieved in certain practices, however this may limit the generalisability of the findings.

A workshop for receptionists in mental health settings.

This article addresses an area which has received little attention in the mental health field--the education and training needs of receptionists. Factors that can assist or impede the contribution of this important position are identified. The authors describe the process used to design and deliver a one-day workshop to enhance receptionists' interpersonal skills, and to increase their understanding of mental health issues. The benefits of this experience for the individual and for mental health organizations are described.

General practice receptionists' attitudes and beliefs towards preventive medicine before and after training and support interventions.

OBJECTIVES: Receptionists are an integral part of the primary care service. We aimed to discover their views on preventive medicine issues. METHOD: One hundred and fifty receptionists from general practices in Sydney, Australia, completed a questionnaire on their attitudes and beliefs towards preventive medicine and brief intervention for alcohol. They were matched according to practice variables into a control, no, minimal, or maximal training and support condition. In all conditions except the control condition, receptionists received 5 minutes of initial training in implementing a brief intervention programme; the amount of ongoing support varied across conditions. Attitudes and beliefs were re-assessed 3 months later. RESULTS AND CONCLUSIONS: The results indicated that when no training and support were given, receptionists developed negative views towards being involved in preventive medicine activities. When training and support were provided, these negative effects were abolished.

GP receptionists: their work and training.

A postal questionnaire was circulated to 90 receptionists working in general practices in a single health unit and produced an 80 per cent usable return rate. The questions asked included items relating to their work and training. Over half the respondents gave advice to patients on medicine matters for which they were not trained. Deciding upon the urgency of home and surgery appointments were the two tasks which were most disliked by the receptionists. Receptionists thought patients would find them helpful and few receptionists found patients aggressive. Many receptionists agreed that they should have training before they start work and even more agreed that they needed in-service training.

Practice receptionists: poorly trained and taken for granted?

Seventy receptionists from 20 general practices in Newcastle upon Tyne were interviewed using a questionnaire to determine their demographic and social characteristics, tasks performed and training experience. The majority of receptionists were mature married women working part-time; only 13% had received any formal training. Most receptionists had no career structure and only 9% had ever been given a written job description. Thirty-one per cent of receptionists did not feel appreciated by their general practitioners and more (49%) felt unappreciated by the general public. However, they believed their main function was to help patients. From the description of their work receptionists are clearly integral and essential members of the primary health care team.To achieve the development of primary care services it is likely that practices will need to employ more ancillary staff, and these staff will require more pre-service and in-service training.

Evaluation of a training scheme for receptionists in general practice.

Two training courses for receptionists in general practice were evaluated by questioning participants and doctors before and after the course took place. The results indicated that the training had been enjoyed and that participants had acquired a good deal of knowledge which they would be able to use effectively in their jobs. The courses and the evaluation exercise are described.

A broader training for medical receptionists.

A course for 40 medical receptionists working in general practice was arranged at a local postgraduate centre. The curriculum was divided into two sections. The first dealt with the traditional, factual side of medical reception work and the second was concerned with the human behaviour aspect of a receptionist's work. It seems that there was some benefit to the receptionists from their experience of both aspects of this course.