Animation Supported Consent is a digital online platform (www.explainmyprocedure.com) that allows patients to watch videos of their forthcoming procedure, in multiple languages, before consent. Designed and written by clinicians, animated by graphic designers and checked by patients before introduction, this is a collaborative effort that places patient understanding at the centre of the consent process.
An audit showed that less that one one-third of patients completely understand their procedure, its benefits, risks and alternatives before signing their consent form. Use of animations increased this to 90% and has led, through a multidisciplinary effort at Barts Health NHS Trust, to implementation of a new Animation Supported Consent initiative within cardiac services. Elective patients watch the animations at home weeks before their procedure and have multiple opportunities to ask questions before consent.
Emergency patients watch the animations in hospital in the days before their transfer to the tertiary hospital where the procedures take place. The project has been widely endorsed at Barts, supported by the GMC as an example of how to implement its new guidance on consent and is supported by NHS Resolution. The vision is to make Animation Supported Consent accessible across all medical specialties and NHS Trusts.
This initiative arose after a patient complaint in 2017. A Bengali-speaking gentlemen developed an arterial complication following angiography. He required surgery and recovered but later complained he had not understood that this was a recognised complication. The case highlighted the need to improve communication before consent.
Time constraints and language barriers were identified as obstacles. Animations describing the procedure, its benefits, risks and alternatives, in multiple-languages was proposed as a possible digital solution (please visit www.explainmyprocedure.com). The vision is for animation-supported consent to become embedded routinely in the patient pathway using an online platform; to inform, empower and support shared decision-making before consent.
Four workstreams followed:
(i) A quality improvement project (2018) to develop and introduce animations for the 10 most commonly performed cardiac procedures at the Barts Heart Centre.
(ii) An audit to assess whether the animations improved understanding of the benefits, risks and alternatives to angiography (target of >50% improvement)
(iii) Research to determine the cost to Barts Health and to the wider NHS where a failure to inform before consent was the cause of a settled claim
(iv) An assessment of the potential to reduce costs based on the observed increase in understanding and the costs incurred.
(i) Animation-supported consent for 8 procedures (exceeding target in first 6 months) have been created and introduced into elective and emergency care pathways (Appendix A in attached pdf). Animations, in 5 languages, have been viewed over 8,000 times, equivalent to about 660 hours (8000x5 minutes) of face-to-face explanation time, increasing efficiency and standardising the quality of information.
(ii) The audit conducted before and after introduction of the first animation www.explainmyprocedure/angiography-angioplasty - showed an increase in complete understanding of the procedure (from 30% to 90% (p<0.01) of patients) exceeding the 50% target (Appendix B). This result, together with testimonials (Appendix C) indicate an enhanced patient experience.
(iii) Research showed that £6.3million were paid in claims by Barts because of alleged uninformed consent (2013-2018). A Freedom of Information request (NHS Resolution) showed this was a general problem; £144million paid across all NHS Trusts (2016-2018) where a failure to inform before consent was the cause (Appendix D).
(iv) Based on the observed 3-fold improvement in understanding and the £45million/year claim cost, routine animations before consent has the potential to reduce NHS costs by about £30million/year and achieve efficiency savings by supporting/replacing face-to-face explanation time. These estimates, even if half that predicted, represent substantial value for money.
Animations to support consent have been created and introduced across three sub-specialities within cardiology (Intervention, electrophysiology and cardiac surgery) and the initiative is being shared across the Trust with a view to extending the service to other specialities.
(i) the General Medical Council (joint conference in January 2018),
(ii) the National Safety Conference (seminars May 2018) and NHS Resolution have helped disseminate the initiative which is regarded as an example of excellence in implementing the new GMC Guidance on Consent.
The project is also being presented at the British Cardiovascular Society Annual Meeting in June 2018 and has been short-listed as one of three finalist entries in the “Best Ever Practice” category (Appendix B). The process for creating animations simplifies with every animation that is produced, because concepts (such as risk) once animated can be reused in subsequent animations.
Systems for introducing the animation into the patient pathway are replicable and have been introduced across 8 referring hospitals, using the online platform. The service is scalable across disciplines and NHS Trusts and could in the future be commissioned as a routine service.
The service is highly valued by patients, staff and students. Questionnaires to 60 patients showed that all but one found the animation improved their understanding. There were no negative comments. Testimonials (Appendix C) together with the increasing number of online views, indicate that this is an appreciated digital innovation.
Feedback also indicated that 16% of patients were unable to view the animation at home, so we manufactured video-brochures (Appendix E) which are now available in preassessment clinics and referring hospitals to provide access without an internet connection and ensure equality in access to the service. A subtitled animation was developed for deaf people, following a specific patient request.
A combined presentation with the General Medical Council (Jan 2019), attended by 300 staff, provided widespread support. Letters of senior support (Appendix C) helped secure pilot funding. Introduction of the service has not replaced face-to-face contact but it has reduced explanation time and improved the quality of the discussion when staff meet patients before their procedure.
The project has received £50,000 support from the Barts Charity and delivered 8 out of the intended 10 animations in the first 6 months, representing significant value for money and a platform to extend this across specialties within the Trust.
The project involves a close cooperation between “explainmyprocedure” – the animation production team, and Barts Health NHS Trust. Production requires a partnership between clinicians and animators and implementation requires collaboration between senior management, administrators and medical staff on the front line. The structural framework (Appendix F) shows the interlinked and multidisciplinary approach that has enabled this initiative to embed in existing patient pathways. Production of an animation is a process that involves clinical experts, animators and patients.
Animations are tested in an audit to obtain feedback on content and clarity and this guides improvement before introduction into practice. Patient involvement is central to design and development. Animations in languages other than English are translated by native speakers, recorded and tested independently to ensure clarity and colloquial acceptability before general release.
The founder of explainmyprocedure.com and Director of the Animation Supported Consent initiative is a practicing Cardiologist who works closely with the clinical and managerial teams at Barts Health NHS Trust – to oversee quality and identify the appropriate time-points in the patient pathway to show the animations without the need for new infrastructure, so keeping costs low.