Key Words:Clinical handover, health systems, patient safety, quality improvement, non-communicable diseases, Mongolia

Supervisors:Dr Semira Manaseki-Holland – Senior Clinical Lecturer in Public Health, University of BirminghamDr Indermohan Narula – Health Sector Reform and Development Adviser, Mongolia Local Global Fund Agent

Clinical handover describes the transfer of patient-specific information and medical responsibility from one healthcare professional to another, between shifts or locations, for the purpose of ensuring care continuity and patient safety.1, 2 This fundamental stage has been recognised as a vulnerable part of the care process, during which information may be lost, distorted, or misinterpreted, posing a potential threat to patient safety. 3,4 A review of evidence in high-income countries showed that the consequences of ineffective handover include incorrect treatment, delays in medical diagnoses, life threatening adverse events, increased length of stay, increased re-admissions, and increased healthcare expenditure.3,4 No similar research has been conducted in lower and middle-income countries, though experience and discussions indicate that the rates of adverse events and other unwanted outcomes are even greater as a result of gaps in service integration. Unsurprisingly, the World Health Organisation Patient Safety Programme has identified clinical handover as a global priority.3

Patients with chronic non-communicable diseases – such as diabetes, stroke, asthma, and hypertension – are most likely to suffer the consequences of ineffective handover due to their need for on-going care and their reliance on various healthcare providers.5, 6 In other words, their high ‘handover rate’ puts them at the greatest risk of experiencing poor handover practice. For these patients the effective integration of community (primary) and hospital (secondary) healthcare services is essential, as it is between these settings in which they most commonly experience handover.1, 2 For example, handover is critical when a primary care doctor refers a patient, who they are unable to manage in the community, to hospital; similarly, handover is crucial in ensuring the continuation of medication in the community after discharge from hospital.

In the last century, population ageing and unhealthy lifestyles, such as cigarette smoking, have significantly increased the global burden of chronic non-communicable diseases.7 This trend has been increasingly observed in lower and middle-income countries7, 8, where service integration is often poor and handover ineffective. The consequences of inadequate handover are, therefore, likely to become even more of a problem, particularly for lower and middle-income countries, unless appropriate measures are taken to improve the integration of healthcare services. This is reflected in the current focus from the World Health Organisation on health systems development with a better response to the challenges of chronic non-communicable diseases.8

Since the recent healthcare system reforms and the introduction of Family Medicine in Mongolia there has been a need and an interest to improve the integration of primary and secondary healthcare services. 9

Unfortunately, there is no evidence to guide policy makers in developing interventions to improve handover practice and service integration. It is likely that considerable scope exists to improve patient safety and care in a way that is cost-effective, and potentially even cost releasing, by adapting methods that have been successfully implemented in high-income countries to improve the exchange of clinical information, such as training, checklists, and patient held records.10 Research regarding clinical handover in Mongolia will contribute towards efforts to produce informed recommendations of acceptable, affordable, and sustainable interventions to improve the integration of community and hospital healthcare services.

This study aims to establish the current handover practices, as well as to identify any barriers or facilitators to effective handover practice, in hospital outpatient clinics for outpatients with chronic non-communicable diseases in Ulaanbaatar, Mongolia. This will be the first time handover practices have been systematically investigated in this setting and so the immediate benefits of this development phase project will be for the local hospitals, family doctors, and policy makers, who will be able to use the findings to start addressing some of the simple issues and solutions identified. Ultimately, the patients will profit, as they will receive better,

PROJECT PROTOCOL 1

AN INVESTIGATION INTO THE CURRENT CLINICAL HANDOVER PRACTICES IN GOVERNMENT SECONDARY-CARE FOR OUTPATIENT WITH CHRONIC NON-COMMUNICABLE DISEASES IN ULAANBAATAR, MONGOLIA: DESCRIPTIVE CROSS-SECTIONAL STUDY

Introduction

more seamless healthcare through the development and implementation of interventions. The focus on patients with chronic non-communicable diseases, at a common ‘exchange site’, will make the results of this project especially useful, as they concern a group in particular need of effective healthcare service integration. The rationale for this study, based in Ulaanbaatar, Mongolia, is summarised below.

No previous research has systematically investigated handover practices in the outpatient setting The research will contribute towards efforts to improve patient safety in the growing group of patients

with chronic non-communicable diseases who experience a high ‘handover rate’ and therefore have a high risk of experiencing the dangerous consequences of ineffective handover practice

The research is timely given the recent healthcare system reforms and the introduction of Family Medicine that are calling for an increased level of service integration

The research questions of this study, based in Ulaanbaatar, Mongolia, and the outcome measures associated with each question are displayed in Table 1 below.

Table 1 - Research Questions and Associated Outcome MeasuresResearch Questions Outcome Measures

1o

1. What are the current handover practices in hospital outpatient clinics for outpatients with chronic non-communicable diseases?

Number and percentage of types of handover documents taken to and provided by hospital outpatient clinics

Number and percentage of specific details present on handover documents taken to and provided by hospital outpatient clinics

2o

2. What are the key patient and/or healthcare system factors that are facilitating/obstructing effective handover practice in hospital outpatient clinics for outpatients with chronic non-communicable diseases?

Number and percentage of requests for handover documents by healthcare providers at hospital outpatient clinics

Number and percentage of types of patient opinion on the importance of receiving handover documents from hospital outpatient clinics

3. Are there any relationships between the background characteristics of outpatients with chronic non-communicable diseases and the four outcome measures of research questions one and two?

Adjusted and unadjusted odds ratios, confidence intervals, and p-values of each predictor variable (age group, gender, educational attainment, and disease type) involved in the logistic regression analyses

The aims of this study, based in Ulaanbaatar, Mongolia, are detailed below.

1) To describe the current handover practices in hospital outpatient clinics for outpatients with chronic non-communicable diseases

2) To identify any patient and healthcare system barriers and facilitators to effective handover practice in hospital outpatient clinics for outpatients with chronic non-communicable diseases

3) To identify any relationships between the background characteristics of outpatients with chronic non-communicable diseases and the handover they experience at hospital outpatient clinics

PROJECT PROTOCOL 2

Rationale

Research Questions

Aims

This study will take place at two district hospitals in Ulaanbaatar, Mongolia. The country has a population of around 3,000,000, with approximately half of the populace residing in the capital city of Ulaanbaatar. 11

Mongolia, which was classified as a low-income country by the World Bank up until recently, now falls into the upper-middle income bracket.12 This change reflects the successful political, economic and social reforms that have taken place in the country since it gained independence from the Soviet Union in 1990.12, 13 Although development has been observed in almost all arenas, there is still significant progress to be made with regards to healthcare – specifically in response to the challenge of chronic non-communicable diseases. 13 The proportion of persons aged 60 years and above is set to double from 5.9% of the population in 2010 to 12% in 2030.14 This is likely to lead to a significant increase in the burden of non-communicable diseases, which already

constitute 93% of the overall disease burden.14 Research findings will primarily be generalizable to adult patients with chronic non-communicable diseases in Ulaanbaatar. However, it is likely that any significant results will also be applicable to other urban areas of the country. This patient group may or may not be reflective of the rural population: on one hand, the majority of healthcare services exist in urban areas and so it is reasonable to assume that healthcare needs of the whole population are dealt with in this context; on the other, differences in background demographics between urban and rural populations may limit the ability to draw inferences on a national scale. Any epidemiological trends

identified may have external validity in countries of a similar income status. This descriptive study will utilise a cross-sectional design and will employ quantitative methods.

The sampling frame of this study will be adults aged 18 years or more presenting to outpatient polyclinics (general clinics with a broad range of patients) at two district hospitals in Ulaanbaatar, Mongolia.

Inclusionary criteria: Patients aged 18 years or more at hospital outpatient polyclinics with one or more of the following chronic non-communicable diseases: diabetes, hypertension, stroke, cardiac disease, or chronic respiratory disease.

Exclusionary criteria: Patients that do not consent to participate.

There will be no sampling as such in that all patients in the outpatient polyclinics during the study period who meet the recruitment criteria will be eligible and will be approached until the sample size is reached.

A sample size calculation is difficult given that no prior work has been done in this country in this field. In the absence of previous evidence, a conservative sample size (population size 3,000,000 and response distribution 50%) for estimating a proportion was calculated (Raosoft sample size calculator15) A survey of 385 outpatients across both sites will enable estimation of the true rate of handover documents provided by outpatient polyclinics and the completeness of these documents, with ±5% accuracy at the 95% confidence level (α=0.05).

Two student researchers will attend outpatient polyclinics on appropriate clinic days until the sample size is achieved. All patients attending outpatient polyclinics will be given a study information sheet (appendix 2) as they arrive and then left alone, giving them time and space to process the information and make an informed decision on whether they would like to take part or not. As they leave the doctor’s room, the local (Mongolian speaking) co-researcher will identify patients who meet the recruitment criteria and who are willing to take part in the study. At this point, patients will have the opportunity to ask the local co-researcher any questions they may have. Eligible and willing patients will then be asked to sign a consent form (appendix 3) before commencement of the study.

Procedures are in place to ensure that illiterate patients (note that 98.4% of the population are literate 11 ) are not excluded: the local co-researcher will be trained to explain the study information sheet in sufficient detail to illiterate patients; if illiterate patients chose to participate they must give verbal consent; confirmation of verbal consent will require a signature from the local co-researcher declaring witness; after this point, data collection will continue as normal.

PROJECT PROTOCOL 3

Setting

Population

Methods: Sample

Methods: Design

Methods: Data Collection

Methods: Recruitment

Quantitative data will be collected in a private side room using a verbally administered questionnaire (appendix 4). The questionnaire has been designed based on a questionnaire used successfully in a similar project in India and has been edited by a local expert for appropriateness and cultural sensitivity. Given that it has not been validated in this population, the questionnaire will be piloted for five days prior to commencement of the study. The questionnaire will collect information regarding the patient’s background, medical condition, reasons for attending the outpatient clinic, plans for follow-up, and opinions on the importance of handover. Any documents taken into or out of the doctor’s room, as well as any patient held records, will also be examined by the researchers as part of the survey. The local co-researcher will note the type of handover document(s), assuming one exists, and its content, i.e. its completeness. If a patient appears or becomes distressed, they will be given time, reminded that they are able withdraw from the study, assisted in contacting a friend of family member, and asked if the local supervisor could be contacted for advice and/or support.The questionnaire data will be transferred to a spreadsheet stored in an encrypted part of the student researcher’s computer. To ensure data protection, only participant identification numbers will be recorded. The

paper questionnaires and consent forms will then be stored safely in a lockable file by the local supervisor. A key will be made correlating the participant names and identification numbers to allow for the consent forms (containing name only) and questionnaires (containing identification number only) to be matched if necessary (i.e. patient withdrawal). This key will be stored separately in a similar lockable filing cabinet by the local supervisor. The paper questionnaires and consent forms (the key will be sent electronically be email) will be returned to the UK and stored in a lockable filing cabinet by the University of Birmingham supervisor for 10 years, as per the University of Birmingham’s research policy.

To address research questions one and two, descriptive statistics, which are valid for cross-sectional data, will be utilised. As the data is categorical in nature, a number and percentage for each outcome measure (provision of handover documents, specific details provided on handover documents, requests for handover documents by healthcare providers at hospital outpatient clinics, and types of patient opinions on the importance on receiving handover documents from hospital outpatient clinics) will be reported.

To address research question three, inferential statistics will be used. The relationships between four categorical demographic variables (age group, gender, educational attainment, and disease type) and the four outcome measures of questions one and two will be measured using bivariate and multivariate logistic regression analyses. Adjusted and unadjusted odds ratios, confidence intervals, and p-values for each predictor variable will be reported. A difference will be considered statistically significant if p<0.05.

Discussion with local experts and supervisors indicate that the proposed study will be feasible: there are daily outpatient polyclinics, each lasting roughly 3 hours with an average of 250 patients presenting with a range of chronic non-communicable diseases, suggesting that the required sample size will be attainable in the study period by attending 26-33 clinics, if data is collected at a rate of 4-5 patients per hour and researchers collect data over the full length of the clinic; further, guarantees regarding the availability of a private side room for data collection and lockable filing cabinets for data management have been made; and finally, if the local co-researcher is unable to take part, assistance from another local co-researcher or hired help will be available. Ethical approval is required as this study involves living human participants. Approval will be applied for

through the University of Birmingham’s Internal Research Ethics committee (18/01/2016) and through the Mongolian National University of Medical Science’s Research Ethics Committee (14/12/2015).

This project will be conducted by an International Health BMedSc student from the University of Birmingham and a Health Management MSc student from the Mongolian National University of Medical Sciences.

The project will take place over 10-week period between January and March of 2016, excluding the Tsaagan Sar (Mongolian New Year) period. See appendix 5 for Gantt chart illustrating the complete project schedule.

PROJECT PROTOCOL 4

Methods: Data Management

Statistical Analysis

Feasibility

Ethical Approval

Procedure & Timeline

See appendix 6 for table documenting projected costs of the project.

Appendix 1. Bibliography Appendix 4. QuestionnaireAppendix 2. Information sheet Appendix 5. Gantt chart

Appendix 3. Consent form Appendix 6. Cost table Clinical ‘handover’ is the process in which a patient’s medical information is exchanged between doctors and nurses. Patients with long-term diseases (such as diabetes, stroke, and high blood pressure) experience the most handover because they require on-going care from various healthcare professionals. Studies have shown that bad handover practices put patient safety at risk and so good handover practice is important, especially for patients with long-term diseases. In Mongolia, there is an urgent need to improve handover practices because, due to increases in life expectancy and unhealthy behaviours such as cigarette smoking, the number of patients with long-term diseases has gone up. This study aims to establish the current handover practices for patients with long-term diseases in Ulaanbaatar, Mongolia. To do so, people with long-term diseases will be asked to answer a short questionnaire focussing on the information exchange surrounding their hospital visit. Handover documents will also be examined as part of the investigation. This research will contribute towards efforts of Mongolian doctors, hospitals, and policy makers to develop acceptable, affordable, and sustainable solutions to improve handover practices in Mongolia. Such solutions will lead to the improvements in the health system, ultimately enhancing patient care continuity and safety.

PROJECT PROTOCOL 5

Costs

List of Appendices

Appendix 1: References

1. The Royal Australian College of General Practitioners. Clinical handover. [Internet]. 2010 [cited 2015 Oct 1]. Available from URL: http://www.racgp.org.au/yourpractice/standards/standards4thedition/practice-services/1-5/clinical-handover/.

2. McKechnie, A. Clinical handover: the importance, problems and educational interventions to improve its practice. Br J Hosp Med. 2015; 76(6): 353-7.

3. World Health Organization. High 5s Project - Action on Patient Safety: Interim Report. [Internet]. 2013 [cited 2015 Oct 1]. Available from URL: http://www.who.int/patientsafety/implementation/solutions/high5s/High5_InterimReport.pdf?ua=1/.

4. Australian Council for Safety and Quality in Health Care. Clinical handover and patient safety - literature review report. [Internet]. 2005 [cited 2015 Oct 1]. Available from URL: http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/clinhovrlitrev.pdf/.

5. Berkman ND, Dewalt DA, Pignone MP, Sheridan SL, Lohr KN, Lux L, et al. Literacy and healthcare outcomes. [Internet]. 2004 [cited 2015 Oct 1]. Available from URL: http://archive.ahrq.gov/downloads/pub/evidence/pdf/literacy/literacy.pdf / .

6. National Lead Clinicians Group, Department of Health and Ageing. Patient Safety – handover of care between primary and acute care. [Internet]. 2013 [cited 2015 Oct 1]. Available from URL: http://www.leadclinicians.health.gov.au/internet/lcg/publishing.nsf/Content/0BC80B14F241017BCA257A590021F2E8/$File/Transitions%20of%20Care%20report%20FINAL%207May13.pdf/ .

7. Non-Communicable Disease Alliance. The Global Epidemic. [Internet]. 2015 [cited 2015 Oct 1]. Available from URL: http://www.ncdalliance.org/globalepidemic/.

8. Robinson HM, Hort K. Non-communicable diseases and health systems reform in low-and-middle-income countries. Pac Health Dialog. 2012; 18(1); 179-90.

9. World Health Organisation. Asia Pacific Observatory on Health Systems and Policies: Mongolia Health System Review. [Internet]. 2013 [cited 2015 Oct 1]. Available from URL: http://www.wpro.who.int/asia_pacific_observatory/hits/series/Mongolia_Health_Systems_Review2013.pdf/ .

10. Hesselink G, Schoonhoven L, Barach P, Spijker A, Gademan P, Kalkman C, et al. Improving patient handovers from hospital to primary care: a systematic review. Ann Intern Med. 2012; 157(6): 417-28.

11. Central Intelligence Agency. The World Factbook: East & Southeast Asia: Mongolia. [Internet]. 2015 [cited 2015 Oct 1]. Available from URL: https://www.cia.gov/library/publications/the-world-factbook/geos/mg.html/.

12. World Bank. Data: Countries and Economics: Mongolia. [Internet]. 2014 [cited 2015 Oct 1]. Available from URL: http://data.worldbank.org/country/mongolia/.

PROJECT PROTOCOL 6

13. World Health Organisation – Western Pacific Region. Health Service Delivery Profile, Mongolia. [Internet]. 2012 [cited 2015 Oct 1]. Available from URL: http://www.wpro.who.int/health_services/service_delivery_profile_mongolia.pdf/.

14. World Health Organisation – Western Pacific Region. Ageing and Health: Mongolia. [Internet]. 2015 [cited 2015 Oct 1]. Available from URL: http://www.wpro.who.int/topics/ageing/ageing_fs_mongolia.pdf/.

15. Raosoft. Sample size calculator. [Internet]. 2015 [cited 2015 Oct 1]. Available from URL: http://www.raosoft.com/samplesize.html/.

Appendix 2: Information Sheet

Study Title An investigation into the current handover practices in hospital outpatient clinics for chronic non-communicable diseases in Ulaanbaatar, Mongolia

Researchers Mr Hussein Ibrahim – University of BirminghamMs Uyanga Munkbayar – Mongolian National University of Medical Sciences

Institution School of Public Health, Mongolian National University of Medical Sciences

You are invited to take part in this research study. Participating in a research study is not the same as getting regular medical care. The purpose of regular medical care is to improve your health; the purpose of a research study is to gather information to improve care for everyone in the future.

It is your choice to participate in this study. There will be no effect on your treatment or the care you will receive in hospital or outside the hospital if you do not want to take part. Before you decide to take part you need to understand this study and what it will involve for you. Please take time to read this information or ask to have the information explained to you. Please feel free to ask questions until you are satisfied.

You may withdraw from the study after having agreed to take part up until the end of March 2016 by contacting the researchers (see below) and stating your name. If you do withdraw, any information you provided will be removed from the study and deleted.

Why is this study being done? This study is investigating clinical handover, the process of information exchange between healthcare professionals, in Ulaanbaatar, Mongolia. Clinical handover is how doctors and nurses communicate with each other, directly or indirectly, to make sure that you get the best possible care. One way to do this is if doctors write notes or letters to each other. We want to find out what happens in Ulaanbaatar, Mongolia, that we can improve this communication and improve your care.

What does this study involve?If you agree to take part in this study, we will want to ask you a few questions. Once your appointment is over, we will ask you for some background information and for the reason why you have come to hospital. We will then ask you questions about your visit to the outpatient department and ask to see any medical notes or documents you take into or out of the doctor’s room. There is no drug or test being performed.

What benefits can you expect from this study?This study will be used to try and help improve the healthcare system in Mongolia and other countries in the future. It could improve the way information is given to you in the future by your doctors or the way doctors and nurses communicate with each other. There will be no immediate benefit to you, however, from taking part.

How will answers be kept and who will have access to them?All information that is collected about you during the study will be kept anonymously and will only be used by the study team. Your doctor or other people will not see the information you have given us. We will add your information to everyone else’s information and will not report your individual answers. The researchers will store the consent form and completed questionnaire safely for 10 years as part of the research requirements.

PROJECT PROTOCOL 7

Who should you contact if you have questions?If you have any questions, if you would like to make a complaint, if you wish to withdraw from the study, or if you wish to follow up the outcome of the study, please contact us by phone (900-97699170640), text (900-7699119512), or email (hxi287@bham.ac.uk/uyanga.m@gtc.mnums.edu.mn).

Who has approved this study? This study has been reviewed and approved by the Ethics Committee at the School of Public Health, Mongolian National University of Medical Sciences, which is constituted as per the Mongolian Council of Medical Research guidelines and is recognised by the Government of Mongolia, as well as the University of Birmingham’s Internal Ethical Review Committee. Both of these committees are made of doctors, scientists and ordinary persons who care about your rights and wellbeing.

Appendix 3: Consent Form

Title: An investigation into the current handover practices in hospital outpatient clinics for chronic non-communicable diseases in Ulaanbaatar, Mongolia

(TICK AS APPROPRIATE)

1. I have read and understand the written information sheet (or have had the information explained to me by study personnel) in a language that I understand.

2. I confirm that my decision to participate in this study is entirely voluntary.

3. I confirm that I have had the opportunity to ask questions about this study and I am satisfied with the answers and explanations that have been provided.

4. I understand that taking part means allowing the researchers to access my medical records as described in the information sheet.

5. I confirm that I have been given sufficient time to consider taking part in this study.

6. I understand that I have the right to change my mind about taking part without giving any reason and I know how to contact the researchers in order to withdraw.

7. I agree to participate in this study.

Name of participant Date and time Signature

PROJECT PROTOCOL 8

(If the patient is unable to read the written information sheet, he/she must have the information explained fully in a language they understand and must give verbal consent. The local researcher must sign to declare witness of verbal consent.)

I attest that I have explained the study information fully and accurately and was understood, to the best of my knowledge, by the participant. He/she has freely given consent to participate.

Name of person gaining consent Date and time Signature

Appendix 4: Participant Questionnaire

Title: An investigation into the current handover practices in hospital outpatient clinics for chronic non-communicable diseases in Ulaanbaatar, Mongolia

PATIENT STUDY NUMBER

DATE (DD/MM/YYYY)

TIME (24h)

HOSPITAL NUMBER

RESEARCHER

Instruction to the researcher:

Tell patients all information given will be anonymised and will be stored in a safe and secure place and remind them that they do not have to answer a question if they do not want to. Please complete all sections. Tick the appropriate space that suits the participant’s response to each question or write in as appropriate. Make sure you hand the questionnaire and consent form to your supervisor as soon as you finish each day.

PROJECT PROTOCOL 9

SECTION A: DEMOGRAPHICS

1. How old are you, either exactly or roughly, in years? (Choose one only)

1 _________________

2 I do not know3 I’d rather not say

2. Sex? (Choose one only)

1 Male2 Female

3. Marital status? (Choose one only)

1 Single2 Married3 Living with a partner4 Divorced5 Widowed6 I’d rather not say

4. Ethnicity? (Choose one only)

1 Khalkh2 Kazak3 Dorvod4 Bayad5 Buryat-Bouriates6 Other (please specify) _______________7 I’d rather not say

5. Highest level of education? (Choose one only)

1 Illiterate2 Literate but not completed primary school3 Primary school completed 4 Secondary school completed 5 High school completed 6 Technical school completed 7 Professional school completed 8 Undergraduate degree completed 9 Postgraduate degree completed

PROJECT PROTOCOL 10

10 I’d rather not say

6. Are you currently working/employed? (Choose one only)

1 Yes [Go to Q.8]2 No [Go to Q.7]

7. If you are not working, what is the reason for it? (Choose one only)

1 Student

2 Retired3 Unable to work4 Housewife5 Could not find a suitable job6 Registered at job centre and looking for job7 Not registered at job centre and looking for job8 I do not want to work9 Other (please specify) __________________10 I’d rather not say

8. How long did it take you to reach this hospital? (Choose one only)

1 within 1 hour2 1-4 hours3 >4 hours4 I’d rather not say

9. Other than you, how many adults (aged 18 and over) live with you in your house, apartment, or ger? (Choose one only)

1 _________________

2 Don’t know3 I’d rather not say

10. How many children (aged 17 and under) live with you in your house, apartment, or ger? (Choose one only)

1 _________________

2 Don’t know3 I’d rather not say

11. How many rooms do your have where you live, including the kitchen and sitting room but excluding the bathroom/toilet? (Choose one only)

1 House ____________ rooms2 Apartment ________ rooms3 Ger _____________ walls4 Homeless 5 I’d rather not say

PROJECT PROTOCOL 11

SECTION B: MEDICAL DISEASE

12. Why did you come to the OPD today? (You may choose more than one)

1 Diabetes2 Hypertension/high blood pressure3 Heart disease (other than hypertension alone)4 Brain stroke5 Long-term breathing problems (not heart problem, things like asthma or COPD e.g. having inhalers/puffs)6 I do not know7 Other (Please specify) __________________

13. Did you go to any other healthcare person before you came here today? (You may choose more than one)

1 No, this is the first time I have presented to anyone with this illness2 Government family doctor or nurse3 Private family doctor or nurse4 This hospital OPD5 Other government hospital OPD6 Private hospital OPD7 This hospital IPD8 Other government hospital IPD9 Private hospital IPD10 Pharmacist/chemist 11 Religious or traditional healer (shaman/lama/spa) 12 Other (please specify) ______________________

14. Who sent you here? (Choose one only)

1 No-one told me and I decided to come to hospital myself 2 Government family doctor or nurse3 Private family doctor or nurse4 This hospital OPD5 Other government hospital OPD6 Private hospital OPD7 This hospital IPD8 Other government hospital IPD9 Private hospital IPD10 Pharmacist/chemist 11 Religious or traditional healer (shaman/lama/spa) 12 Other (please specify) ______________________

PROJECT PROTOCOL 12

15. When you came here today, did you bring any paper document (i.e. prescription, letter, health booklet, test results, or piece of paper) that lists your medicines? (Choose one only)

1 Yes2 No, I do not have a note or document that lists my medicines3 No, I had one but I did not bring it4 No, I had one but I lost or misplaced it

16. When you came here today, did you bring your medicines with you? (Choose one only)

1 Yes2 No 3 I did not have medicines to bring

17. When you come here today, did you bring any paper document (other than a list of your medicines i.e. letter, health booklet, test results, or piece of paper) from your previous healthcare person to this hospital? (Choose one only)

1 Yes [Go to Q.19]2 No, I was given one but I did not bring it [Go to Q.18, skip Q.19, 20, 21, 22, 23, 24, 25]3 No, I had not been given anything to bring [Go to Q.26]

18. If you had a paper document (i.e. prescription, letter, health booklet, test results, piece of paper) but did not bring it today, please provide a reason why not? (You may choose more than one)

1 I forgot it at home2 I lost it3 I have always had it before but never used it so I did not bring it this time4 I did not think that it was relevant to bring it with me to hospital5 I have never been asked for it here so I did not bring it this time6 My children/spouse handle such documents, so I do not know7 Other (please specify)

19. If you have a paper document and brought it with you today (i.e. prescription, letter, health booklet, test results, piece of paper), did the doctor look at and use it? (Choose one only)

1 Yes2 No 3 I do not know

20. Have you ever visited a private healthcare facility before? (Choose one only)

1 Yes [Go to Q.21]2 No [Go to Q.23]

21. When you were at the private healthcare facility, did the doctor look at your health booklet or any paper document? (Choose one only)

1 Yes2 No 3 I do not know

PROJECT PROTOCOL 13

22. When you were at the private healthcare facility, did the doctor write in your health booklet or any paper document? (Choose one only)

1 Yes2 No 3 I do not know

23. If you have a paper document and brought it with you today (i.e. prescription, letter, health booklet, test results, piece of paper), please can I see it? (Choose one only)

1 Yes [Go to Q.24] 2 No [Go to Q.26]

SECTION C: FOR THE RESEARCHER – EXAMINE DOCUMENT(S) BROUGHT TO OPD BY THE PATIENT TODAY

24. Researcher, please ask to see any documents carried by the patient and check what type of document it is: (You may choose more than one; complete one column per document; use column C for discharge summary and note date of discharge)

A B C*

1 1 1 Discharge summary* (please specify date) ____________________2 2 2 OPD card/paper of other hospital/clinic3 3 3 OPD card/paper of this same hospital/clinic4 4 4 Prescription card/note5 5 5 Letter from one doctor to another6 6 6 Standard referral form7 7 7 Patient’s health booklet (AM-20)8 8 8 Other health booklet8 8 9 Scrap of paper 10 10 10 Other (please specify) __________________

25. Researcher, please look at the document(s) brought by the patient and check if any of the following is written in it: (You may choose more than one; complete one column per document)

A B C

1 1 1 Clinical notes are not readable2 2 2 Name of the doctor/person to contact at the hospital3 3 3 Date on notes4 4 4 Name of the patient5 5 5 Age of the patient6 6 6 Sex of the patient7 7 7 Past medical history for this disease8 8 8 Past medical history for other diseases9 9 9 Patient’s symptoms, signs and problems when admitted10 10 10 Tests (no results)11 11 11 Tests (with results)12 12 12 Diagnosis13 13 13 Medication to take at home 14 14 14 Information on how long to take the medication and what to do in the long term 15 15 15 Lifestyle changes (e.g. diet, tobacco, alcohol and exercise)16 16 16 Advice to return to OPD or other doctor for a review17 17 17 Other (please specify) __________________

PROJECT PROTOCOL 14

SECTION D: PLANS FOR AFTER VISITING THIS OPD

26. After today’s visit to the OPD, where will you visit for your next consultation or check-up? (Choose one only)

1 Government family doctor or nurse2 Private family doctor or nurse3 This hospital OPD4 Other government hospital OPD5 Private hospital OPD6 This hospital IPD7 Other government hospital IPD8 Private hospital IPD9 Pharmacist/chemist 10 Religious or traditional healer (shaman/lama/spa) 11 Other (please specify) ______________________

27. How will you tell them what was done to you here in this OPD today? (You may choose more than one)

1 The doctor here told me so I can tell other doctors I may see 2 The doctor here wrote in my health booklet or another document so I can show other doctors I may see3 The doctor here told my child/spouse/person who is with me and they will tell other doctors I may see 4 I do not know5 Other (please specify)

28. Did the doctor explain your disease to you? (Choose one only)

1 Yes2 No3 I do not know

29. What were you asked to do after leaving here? (You may choose more than one)

1 Come back for a check-up at this OPD2 Go to local hospital or doctor for a check-up3 Get some new medication4 Continue with old medication5 Do some tests6 Make a lifestyle or behavioural change (e.g. diet, tobacco, alcohol, exercise)7 I do not know8 Other (please specify)

PROJECT PROTOCOL 15

30. Do you or your carer ever look at the information contained in any document(s) (i.e. prescription, letter, health booklet, test results, piece of paper) given to you by doctors in the OPD? (Choose one only)

1 Yes2 No 3 I do not know

31. Did the OPD doctor today write in your health booklet or give you a paper document (i.e. prescription, letter, health booklet, test results, or piece of paper) to give to your local doctor or family doctor? (Choose one only)

1 Yes2 No 3 I do not know

32. Did the OPD doctor today write in your health booklet or give you a paper document (i.e. prescription, letter, health booklet, test results, or piece of paper) to return to this outpatient department clinic again? (Choose one only)

1 Yes2 No 3 I do not know

33. Do you think it is important to get a written explanation of what happened today and what you should do next in your health booklet or on another document? Why? (You may choose more than one)

If yes, why?1 I do not know2 It helps to understand my disease and tell it to others, including the next doctor3 It helps me to get attended to faster when I visit local/family doctor or outpatients next time4 I feel it’s more professional5 I have to submit this for claiming insurance6 Other (please specify)If no, why?7 I do not know8 The note gets lost9 Everyone receives the same standard of care regardless of any notes or records or documents10 Other (please specify)

34. If you have a health booklet or a paper document (i.e. prescription, letter, health booklet, test results, or piece of paper) from todays OPD doctor, please may I see it? (Choose one only)

1 Yes [Go to Q.35]2 No [Go to end]

PROJECT PROTOCOL 16

SECTION E: FOR THE RESEARCHER – EXAMINE DOCUMENT GIVEN TO THE PATIENT FROM OPD TODAY

35. Researcher, please ask to see any documents given to the patient by the doctor in the OPD today and check what type of document it is: (You may choose more than one; complete one column per patient)

A B C

1 1 1 OPD card/paper of other hospital/clinic2 2 2 OPD card/paper of this same hospital/clinic3 3 3 Prescription card/note4 4 4 Letter from one doctor to another5 5 5 Standard referral form6 6 6 Patient’s health booklet (AM-20)7 7 7 Other health booklet8 8 8 Scrap of paper 9 9 9 Other (please specify) __________________

36. Researcher, look at the document(s) given to the patient by the doctor in the OPD and check if any of the following is written in it: (You may choose more than one)

A B C

1 1 1 Clinical notes are not readable2 2 2 Name of the doctor/person to contact at the hospital3 3 3 Date on notes4 4 4 Name of the patient5 5 5 Age of the patient6 6 6 Sex of the patient7 7 7 Past medical history for this disease8 8 8 Past medical history for other diseases9 9 9 Patient’s symptoms, signs and problems when admitted10 10 10 Tests (no results)11 11 11 Tests (with results)12 12 12 Diagnosis13 13 13 Medication to take at home 14 14 14 Information on how long to take the medication and what to do in the long term 15 15 15 Lifestyle changes (e.g. diet, tobacco, alcohol and exercise)16 16 16 Advice to return to OPD or other doctor for a review17 17 17 Other (please specify) __________________

PROJECT PROTOCOL 17

Thank you for your time.

PROJECT PROTOCOL 18

Appendix 5: Timetable Sheet

Task Timeline – Week Commencing25/01/2016 01/02/2016 08/02/2016 15/02/2016 22/02/2016 29/02/2016 07/03/2016 14/03/2016 21/03/2016 28/03/2016 04/04/2016 11/04/2016 18/04/2016 25/04/2016 02/05/2016 03/05/2016

Travel to Mongolia

Familiarisation

Staff training

Pilot study

Data collection

Travel to UK

Data analysis

Write up project

Poster presentation

Paper submission

PROJECT PROTOCOL 19

Appendix 6: Cost Table Sheet

Resource CostStudy materials – questionnaire, information sheet, consent forms £50Flights to Mongolia £850Maintenance – accommodation and food £500Immunisations £100Emergency funds £100

Estimated Total £1500

PROJECT PROTOCOL 20