How do we optimise NHS investment in patient feedback and quality improvement ?

Jocelyn Cornwell 07 February 2019

Following recent meetings which brought together our HOPE network with the NHS Improvement Directors’ Network, Jocelyn Cornwell argues that, for high quality personalised care to become the norm across the NHS, quality improvement and patient experience teams need to work together.

Last week, NHS England promised that in ten years’ time, universal personalised care will be ‘business as usual’ across the health system. It’s a huge ambition but we shouldn’t ignore the fact that we’ve been here before. ‘High Quality Care for All’ in 2008 committed to making high quality care the number one NHS priority, defining quality as care that is “as safe and effective as possible, with patients treated with compassion, dignity and respect. … care that is personal to each individual.”

Personalisation of care will only be a reality when health professionals understand it, accept it, are persuaded of its value (for themselves and for their patients) and when they feel supported by the system – administration, management, training and education, HR finance, IT, quality improvement etc. – to deliver it.

The Point of Care Foundation convenes and supports HOPE, a peer learning and support network for heads and managers of patient experience, which is one of those support functions in NHS trusts. From our work with the network, and from research, we can see that the resources trusts currently invest in collecting patients’ feedback could be put to better use if the patient experience and quality improvement (QI) functions worked more closely together.

Last month, with this in mind, we worked with NHS Improvement to bring HOPE and the Improvement Directors’ Network together in Leeds and London with the aim of providing an environment in which patient experience and QI people could meet and reflect together on how they might combine resources to improve patient experiences.

The turnout was good: 58 trusts were represented, with almost equal numbers of patient experience and quality improvement people. About one in five (18%) came from trusts where patient experience and quality improvement functions are managed separately and not aligned; 39% were from trusts where there has been talk of working together but it hasn’t happened yet; 37% were from trusts where one or more projects are aligned; and a tiny minority, three percent, were from trusts where the patient experience and QI teams are completely integrated. At the Royal United Hospitals in Bath, for example, everyone who works on patient experience, PALS, complaints, quality improvement, patient safety and clinical audit trains together, shares a single office in the Quality Improvement Centre, and reports to the same executive director.

For me a few issues stood out from both days:

Co-design means co-design

The words co-design and co-production are in danger of losing their meaning. We are unashamed co-design purists at the Point of Care and hate to see the terms de-valued. We teach ‘real’ experience based co-design and help multi-professional teams in a variety of clinical areas engage fully with patients as equal partners apply the step-by-step structured methodology that produces improvements in care experiences. Real co-design is a world away from inviting one patient to join a committee or working group, or to participate in a QI project that was commissioned without their input and where staff don’t have the time or the resources to engage them fully.

Real co-design is a world away from inviting one patient to join a committee or working group, or to participate in a QI project that was commissioned without their input and where staff don’t have the time or the resources to engage them fully.

The best shouldn’t be the enemy of the good

There is a repertoire of established, tried, tested and effective techniques to help staff empathise with and connect to patients’ experiences, including direct observations of care, patient shadowing, focus groups with patients, and conversations with patients and patient groups. These are reliable and effective techniques that are under-used in QI and patient safety projects. All the techniques, if adopted as part of quality improvement and patient safety projects, will, inevitably, strengthen the work by bringing patients’ experiences into it, and in some cases, will help to avoid unintended consequences.

What we heard was that these techniques are not used as often as they might be, partly because the pressure to involve patients drives out alternatives. Is the best in danger of becoming the enemy of the good? Even if involving patients is the ideal, it is being allowed to get in the way of people using and valuing cheaper and less time consuming techniques that provide insights into patients’ experiences.

Complaints are valuable

I was struck by the fact that no one in my hearing at the meetings spontaneously mentioned any of the routine sources of patient feedback available in trusts – patient surveys, the Friends and Family Test and patients’ complaints – as sources of evidence for QI. The feedback data aren’t perfect, but trusts are asking patients to give them their views and using precious resources to collect the data, so it seems morally as well as financially negligent not to use that evidence for improvement.

The power of stories to motivate is well-known and patients’ complaints are a fund of stories that could be used for improvement. Complaints generally provide a huge amount of detail on the work as experienced by the end user and ‘work as done’, as compared with the ‘work as imagined’ by the people who provide the service. No-one likes being the subject of a complaint and we know that many staff suffer from stress when they are named. Not surprisingly, research tells us, professionals rarely see complaints as useful for improvement. But that does not mean to say that organisations should overlook them as a valuable resource and fund of useful data: many patients’ complaints actually provide deep insights into whole journeys of care that are otherwise difficult to come by.

Leadership matters

It is of course an obvious thing to say but people in both networks felt that if the executive directors and Board in their organisation were to insist on patients’ perspectives being incorporated into QI and patient safety, and were to frame patient experience data as useful for improvement, it would make a massive difference at the front line and liberate new resources to work on this aspect of care.

Pledges to improve

At the end of the meeting we asked people to say what, if anything, they would do differently when they went back to base? Here, in no particular order, and without knowing whether the pledge came from a patient experience or a QI person, is a small selection from the multitude of commitments.

“Discuss joint working between Qi and Pt Exp with trust quality lead”
“QI lead to find out who patient experience lead is! And explore opportunities for collaboration as we roll out QI programme.”
“Joint training session for QI and Pat Exp teams to work and share together”
“Include joint working with QI lead patient experience in my objectives at appraisal”
“Communication between teams – face to face / email / online platform etc”
“Lock into always events as a way to work together”
“Find synergies with people in the counterpart department, do QI huddles with them.”
“Create a single point of access for front line staff to the multiple QI teams.”
“Embed patient experience at the beginning rather than the end of quality improvement projects.”
“Historically we’ve seen patient experience in a very transactional way. Start thinking about it in much more relational terms.”

Such a range of pledges from across a large number of trusts could amount to significant change if widely implemented. However, as we’ve observed above, leadership is important, so we hope that people higher up in organisations will support their teams in improving practices through making these changes.

Our HOPE network continues to support patient experience professionals to learn from each other as they seek to make improvements in their organisations. We will look forward to hearing more about how these pledges are implemented in the future.