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Quality Time: Experience Based Co-Design in the emergency department

Dr Liza Keating Royal Berkshire NHS Foundation Trust 06 March 2018

Dr Liza Keating writes about the Quality Time study, which used Experience Based Co-Design to deliver improvements for patients in the emergency department at the Royal Berkshire NHS Foundation Trust


Patients and carers meet during the EBCD process
Patients and carers at a meeting during the EBCD process

The concept that ‘the four hour wait’ is a measure of a good emergency department has been contentious for many years. The current targets for emergency departments were jointly published by the Department of Health and the Royal College of Emergency Medicine (RCEM) in 2011.

However, in addition to five numerical targets they also called for a number of measures which they acknowledged could be harder to record. They stated:

A good ED will obtain a deep understanding of what patients think of the service that has been provided and how they believe it can be improved, and will act upon this feedback to improve their service.”

The direction of travel at the time was relatively new and refreshing. Alluding to the limitations of surveys, complaints, compliments and other widely used records, they suggested that Experience Based Co-Design (EBCD) was an appropriate methodology by which service experience could be recorded. EBCD is a form of participatory action research that makes use of qualitative research methods enabling staff, patients and carers to work together to explore their experiences of clinical situations, identify shared challenges and, through working together, design service improvements.

Quality Time study

Around the same time, in the Royal Berkshire NHS Foundation Trust in Reading, Melanie Gager was facilitating the accelerated EBCD project. As the research facilitator working with the Health Experience Research Group from the University of Oxford, Melanie worked alongside a team from the King’s Fund on a novel research study to evaluate Accelerated Experience Based Co-Design in both Lung Cancer and the Intensive Care Unit (ICU). The combination of Melanie’s expertise, executive level support from the Trust, and an ambitious, forward thinking Emergency Department team, laid the groundwork for the Quality Time study.

In 2012 we received a research grant from the Royal College of Emergency Medicine, which enabled Quality Time to achieve NIHR Portfolio Status and allowed us to meet the study service support costs. Subsequently the Royal Berkshire NHS Foundation Trust Innovation Fund helped us to cover salary costs and in 2014, after a successful ethics application, Quality Time commenced.

We began with observation in the emergency department (conducted by patients and the research facilitator) followed by semi structured interviews with staff (topic guide from Kings Fund Toolkit) and the project culminated in filmed interviews of patients and carers. Transcription and thematic discourse analysis was undertaken to generate a trigger film used in the research (now available on the Healthtalk website). The film was viewed by staff then patients and their carers in July 2015. As per the methodology this was then followed by a combined patient-staff event where a vote took place to identify the top three priorities for service improvement going forwards.

Patient and staff focus areas

Three co-design teams, consisting of patients and staff working together, focused on the following areas: mental health and the elderly, volunteers, and information and communication. The over-arching strength of the Quality Time study has been that through staff working together with patients and their relatives on an equal footing we have been able to make significant changes that have had an impact on the department.

We have changed our processes, leading to an increase in space and calmer atmosphere. We improved communication both between patients and staff and between staff themselves, and staff report feeling valued and able to make a contribution. We have changed some of our staff training around vulnerable groups, in particular the elderly and patients with mental health problems. We have also focused on the information we give to patients to help them to understand the waiting times as well as what to expect when they come into the emergency department.

The pressures on the emergency department are still here, but the Quality Time study has led to a change. We have evolved into a more open culture, learning from what has gone well in addition to reflecting upon our mistakes and continually striving for improvement.

The Royal Berkshire NHS Foundation Trust has made three films about the Quality Time study, highlighting the impact that it had on staff, patients and volunteers. You can watch those films here.