Implementing online patient feedback in a ‘special measures’ healthcare organisation
18 December 2019
A recent evaluation looked at how an acute hospital trust placed into special measures implemented online patient feedback. Its author shares some of her findings.
‘Have a look online’ is a common phrase in the ever-evolving world of social media and online platforms. Patient feedback has not been immune to this development, with patients increasingly sharing their healthcare experiences online via websites such as Care Opinion and IWantGreatCare. However, despite their increasing use, there has been significant variability in how healthcare organisations have responded to, and embedded online feedback. But why? What motivates healthcare organisations to implement such feedback? What factors facilitate or inhibit its implementation, and what impacts does such implementation have on staff members involved?
I recently interviewed a variety of stakeholders involved in the implementation and/or use of online patient feedback at the Royal Cornwall Hospitals NHS Trust, an acute hospital trust which was rated as ‘inadequate’ in July 2017 and placed into ‘special measures’ by the CQC as a result. At the time of analysis, the Trust had had a full subscription with the online feedback provider Care Opinion for just over a year, providing an opportune moment to evaluate its implementation, use and perceived impacts. Frazer Underwood, Associate Clinical Professor in Integrated Services for Older People and Consultant Nurse at the Royal Cornwall Hospitals NHS Trust, oversaw the patient and family experience team at the time of the research.
Stakeholders described a number of reasons for implementing online patient feedback. Those most frequently described centred around notions of learning, change and improvement, with the recent CQC assessment often described as a catalyst for change, shifting the existing culture towards one of learning to improve, with patient feedback and experience at the heart of it.
Other motivations identified included having the opportunity to hear the patient voice in near ‘real time’, providing an alternative, ‘less formal’ way of providing patient feedback, service failure prevention, and reputational management. The motivation to work with patient feedback as a way to celebrate and motivate at a particularly difficult time was also repeatedly identified as later discussed.
While staff members often favourably described the informality of online patient feedback, they also repeatedly stressed the importance of taking it as seriously as other types of feedback, such as complaints and the Friends and Family Test.
How did the trust encourage engagement with the implementation of online patient feedback?
The trust described a number of actions that were designed to facilitate staff engagement with online feedback. This included moving online patient feedback from the communications team to the patient and family experience team, because the communications team had a huge remit and were only able to look at online feedback on an ad hoc basis – typically when the trust was receiving critical, as opposed to positive feedback.
Other actions taken by the trust included developing an active network of individuals across the organisation to facilitate staff engagement and ownership. Importantly, responsibility for online feedback was not seen to be that of the patient experience team alone. The trust sought to ‘sell’ online feedback engagement to staff members, particularly senior staff members, by emphasising its ability to support patient centred care, patient safety and care quality, while simultaneously highlighting the ability to publicly share and respond to online feedback and celebrate good practice. Actions taken by the trust were typically intended to reinforce the view that patient feedback is an integral part of every job role, and not an unnecessary ‘add on’.
What factors facilitated the implementation of online patient feedback?
Helping to achieve the desired shift in culture, staff members described a number of factors that facilitated the implementation and use of online patient feedback. This included using national league tables to drive engagement and enthusiasm; providing responder training to develop staff confidence and maintain responding consistency; encouraging staff members to sign up to feedback alerts; encouraging responses from those on the ‘front line’; showcasing both positive and critical feedback on social media and display spaces to raise awareness, encourage openness and transparency; describing and sharing improvement actions in response to feedback; achieving wider organisational buy in, particularly at senior level, to ensure patient feedback and learning from feedback remained a priority; and emphasising the benefits and relevance of online feedback for staff development.
Linked to the importance of providing responder training was the provision of support from the patient experience team and occupational health so staff members felt supported. One colleague identified the practice of thanking staff members for their compassionate responses as a key way to support staff, implementation and use.
What factors inhibited feedback implementation?
Following this, factors found to inhibit the implementation of online feedback centred around initial staff anxiety regarding time pressures, responding, and external moderation processes. Such anxieties often diminished once staff had engaged with online feedback, or received responder training where the moderation process was clearly explained. Staff members repeatedly identified the provision of response training as a beneficial way to reduce staff anxiety, increase staff confidence, and instil a sense of pride in their involvement.
Other techniques used by the organisation to reduce staff anxiety included getting ‘staff talking to staff’. One interviewee from the patient experience team explained:
…when it came from us [patient experience team], it was a bit like, ‘oh, well you’re admin, you don’t really understand the clinical pressures’ … But now they’re talking to each other and realising that actually it doesn’t take a huge amount of time … We’re seeing more and more staff being happy to be involved.”
The organisation also provided examples of people already working with online feedback, particularly in busy departments, to address staff concerns. As one interviewee explained:
A barrier with our staff is that they think it’s going to take a long time to reply to people, and they’re going to be flooded with stories, but in reality, it’s not. So we always try to use examples of people that are using it really well in their area. We’ve got a clinical matron in ED, who feels like she’s going to be the most busy person in the hospital, but she uses it all the time, she’s constantly on their responding straight away.”
How do people view the value (or not) of online feedback?
So, what was the overall opinion of stakeholders about online feedback? Our evaluation found staff members to be overwhelmingly positive about the value of online patient feedback, specifically Care Opinion. Some of the positive appraisals made by staff members interviewed included:
- The provision of rich, less structured narrative feedback that ‘prompts dialogue’ and conversation
- The ability to publicly respond and demonstrate change, creating a desired feedback loop that is often unobtainable through other, often paper based methods
- Enhanced accessibility and ease of use, typically for both patients and staff
- The opportunity to hear from a greater range of people including carers, visitors, family and staff members
- Enhanced opportunity to receive and share feedback in near real time
- Improved reporting and ability to evidence change
- Opportunity to publicly demonstrate being a compassionate organisation
The opportunity to do many of these things so publicly was often cited as one of the main benefits of online patient feedback. This may be surprising given the context in which online patient feedback was being implemented at this healthcare organisation. However, it was clear that the trust saw their recent rating as an opportunity to do things differently, and in a way that may not have been possible following more traditional approaches to patient feedback and experience.
Staff resilience, morale and pride
One of the positive appraisals most frequently described by staff members included the ability of online patient feedback to improve staff morale, resilience, and pride through celebration and motivation. This is often an unreported element of online patient feedback, particularly the ability to foster resilience. As one clinical manager interviewed describes:
I really love it, I do, because for me working in the Emergency department, you see a lot of terrible things happen, you see a lot of sick patients, a lot of illness, and really poorly patients. The staff here have to, on a daily basis, see things that you wouldn’t want anyone to see. So for me, it’s such a refreshing change because we predominantly get positive responses and feedback. It’s just so nice to be able to cling on to that and share the feedback to the staff, those really nice, positive things. I think it helps improve morale. It helps people’s resilience as well, to know there are actually some really grateful people out there and you know what, you are doing a good job and sometimes you just need that bit of a reminder. And when I see comments like that, that helps me to deal with the everyday situation. Generally, it makes people feel appreciated in what is a really hard, difficult working environment, it’s morale boosting … for me personally, it’s that little glimmer of hope that you hold onto amongst a multitude of horrible things.”
Notions of celebration and motivation was also reflected in the trust’s decision to work with online feedback to inform internal awards recognising, as one non-clinical staff member pointed out, that individuals are typically “very quick to say you haven’t done this or you don’t do that, but we’re not very quick to say guess what, you did a really great job yesterday.”
In summary, our evaluation provided rich insight into how a healthcare organisation recently placed into special measures can successfully implement online patient feedback, by creating conditions within the organisation to facilitate the process.
While the organisation achieved rapid progress, obtaining milestones other organisations often take years to achieve, the difficulties of implementing online patient feedback should not be underestimated. Patients are increasingly sharing their healthcare experiences online. This activity is only likely to increase. Understanding the factors that support and inhibit its effective implementation is therefore imperative. Staff need to feel supported and empowered in working with, and responding to online patient feedback.
This often means redefining feedback as an integral component of everyone’s role, a ‘gift’ that can not only improve healthcare services, but can also celebrate and motivate the fantastic individuals that work tirelessly to deliver such services to the best of their ability. Support needs to be provided to staff members, particularly around responding to, and dealing with online feedback so staff members feel confident and assured of their ability to tackle this rapidly evolving area of healthcare. The support offered, and attitudes towards online feedback often hinges on the culture of the healthcare organisation more widely.
It is hoped that the information shared in this blog may benefit other healthcare organisations looking to implement, continue, or improve their current use of online patient feedback. Online patient feedback may be that “glimmer of hope” people hold onto amongst a sea of difficult and turbulent times.
Why not ‘have a look online’?