Dr. Lynne Maher
Director for Innovation
Partners in Care Programme
October 2013
@LynneMaher1
Date: September 2013
Created by: Dr. Lynne Maher
Section Plan
• Demonstrate how you can improve health
services by focusing on the actual experiences
of patients, carers and staff
• Introduction to a few tools and techniques
that teams find helpful
• Share some stories
• There will be some interaction and table work
But why?
“we need to move from a
service that does things to
and for its patients to one
where the service works
with patients to supports
them with their health
needs”
We need to move away from
this....
We as clinicians and managers
worry about this ......
We think patients want this.....
What Matters to Patients
(England 2011)
•
•
•
•
•
Feeling informed and being given options
Staff who listen and spend time with me/patients
Being treated as a person, not a number
Being involved in care and being able to ask questions
The value of support services, for example patient and carer
support groups
• Efficient processes
(Robert, Cornwall, Brearley et al 2011)
Functional or Relational?
Two aspects of experience
need to be considered
The ‘relational’ aspects of care
(like dignity, empathy, emotional
support) are very significant in
terms of overall patient experience
alongside the ‘functional’
(sometimes referred to as
transactional’) aspects
(like access, waiting, food, noise)
Patient experience does affect
clinical outcomes
• Catheter-related bloodstream infections
occur 56% more frequently in hospitals
with low patient ratings for nurse or
doctor communication
Reed K. (2012) Health Grades Patient Safety and Satisfaction
We need to learn from …The
Garling Report
“Patient experience and satisfaction is one of
the most important indicators alongside access
to hospital services, clinical performance, safety
and quality of the clinical care, costs associated
with the provided clinical care, staff experience
and satisfaction and sustainability”.
Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals
(Commissioner Garling, 2009)
We need to learn from–Mid
Staffordshire, UK
• Need for a common culture of ‘putting patients
first’
• “Every single person serving patients needs to
contribute to a safe, committed and
compassionate and caring service”
• Need for strong, patient centred healthcare
leadership
Table task…..
• On your tables create a list of all of the ways
you/your organisation collects data that
provides insight into patient experience.
Table task…..
• What happens to that data?
A quick survey…
How satisfied were you with your journey to this
event?
A
Very Good
B
C
D
E
Very Poor
Table task…..
• Work in two’s or ‘threes’
• One person tell their story of their journey here
today- take 5 minutes
• The ‘listeners’ do just that; and particularly
‘tune in’ to any words that could depict
emotion.
Think carefully when you choose a mechanism
for capturing patients
experiences/feedback/satisfaction/views
© NHS Institute for Innovation and Improvement 2009
The ebd approach is…
…about using experience to gain insights
from which you can identify
opportunities for improvement
…about experiences not attitudes
or opinions
@LynneMaher1
The components of good design
Performance
How well it does
the job /is fit for the
purpose
Functionality
+
Engineering
How safe, well
engineered and
reliable it is
Safety
+
The aesthetics of
experience
How the whole
interaction with the
product/service
‘feels’/is experienced
Usability
Berkun, 2004 adapted by Bate
How might you use patient experience
methods
• As a regular way to understand patient
experiences
• In an area where you have challengesperhaps where you know you have a number
of complaints
• As a critical part of an improvement project
Oh gosh, is this yet another thing
I need to add to my workload?
“The biggest untapped resources in the health
system are not doctors but users (of the service).
We need systems that allow people and patients to be
recognised as producers and participants, not just
receivers of systems … At the heart of the approach
users will pay a far larger role in helping to identify
needs, propose solutions, test them out and implement
them, together.”
Source: Design Council, 2004
3 Ways to do service improvement
1. Don’t listen very much to our users and we do
the designing
2. Listen to our users then go off and do the
designing
3. Listen to our users and then go off with them to
do the designing
(Professor Paul Bate 2007)
© NHS Institute for Innovation and Improvement 2009
Understanding the needs of people living
with Multiple Sclerosis
“If I had an hour to save the
world,
I would spend 59 minutes
defining the problem
and one minute finding
solutions”
Albert Einstein
Experience Based Design is about
designing better experiences…
@LynneMaher1
© NHS Institute for Innovation and Improvement 2009
Engaging patients …
• You do not need high numbers of patients
• Develop information about what you are planning to do
and the role patients can play
• Talk to patients
• Identify patients who have recently complained
• Clinical staff might identify patients
• Use methods of engagement that are relevant to the
patient group.
@LynneMaher1
Gathering experience…
• Collect stories and thoughts from both patients and staff
– Structured conversations
– Story boards
– Still photography and film provides compelling
illustration
– Diaries
• Observe patients and staff delivering and receiving the
service
Getting patients and staff involved
Helping people tell their stories
Ruth Wickens and Nick White: Understanding and
improving patients’ experience of the
radiotherapy mask
4 in depth conversations
Norman
“There were two things that surprised me: one was the
size of it. When you think about a mask you think quite
small, just covering your face, whereas the mask that
was produced was a big mask that went right down
covering the shoulders. The other thing was that I
didn’t expect it to be attached to a horizontal position
– that was a surprise. Those two things made it hard to
cope with initially, from being told I needed a mask to
the actual reality of what that meant.”
Judy
“ Once again when that silence would kick in I’d
be saying to myself, “What’s happening?
Someone please talk to me”. It might seem a
very short time to someone who’s on the
other side of the wall and working on the
machine, but that silence can be a very long
time when you’re lying there and wondering
what on earth’s going on.”
Cheryl & Phil
“You’re
in, you’re bang, you’re on the table, your
mask is put on, I never had the chance to look
around the room.... Your head is fighting to say
I want to get out of this, I want to get away.”
“Your head is fighting to say I want to get out of
this, I want to get away, being nauseated, held
down, having something in your mouth – it was
horrible.”
Patient pictures/storyboards can be
highly impactful
© NHS Institute for Innovation and Improvement 2009
Film....an example coming later
Observation
People do not always do what they say they do
People do not always do what they think they do
People do not always do what you think they do
People cannot always tell you what they need
Observation lets you find out what people really do and
need
IDEO 2006
The story of the toilet roll holder
.
© NHS Institute for Innovation and Improvement 2009
Language
Blisters/Lumps/Ulcers/Polyp/
WartyThings/Necrosis/
Lesions/NaughtyTumour/
Aggressive/Progressing/
Precancerous
Hospital Portering services.
Healthcare Associated Infections, what did we
observe?
Inconspicuous gel dispenser
A notice about a notice
Staff and visitors more frequently use gel when leaving a ward or
department
Experience Questionnaire
This is a tool that can be used on it’s own or as a
starting point for understanding which part of
the pathway you might want to focus on…
Experience questionnairedeveloped by the NHS Institute for Innovation and
Improvement adapted by many
© NHS Institute for Innovation and Improvement 2009
Numbers, numbers…
Breadth
Depth
Interviews
Shadowing
Filming
Observation
Emotion
questionnaire
Focus groups
Observation
Experience Based Design is about
designing better experiences…
@LynneMaher1
© NHS Institute for Innovation and Improvement 2009
“It is more important to know what sort
of a person has a disease than to know
what sort of disease a person has.”
Hippocrates
Understand the experience
This part of the patient experience
approach is where you really begin to
understand your service in terms of how
patients, carers and staff experience it.
@LynneMaher1
Understand the experience
There are three phases– they are closely
linked and one leads naturally on to the
other:
• Identifying emotions
how people feel
through their journey
e.g. scared
Understand the experience
2) Finding the ‘touchpoints’
moments of engagement
How I feel at stages of my
journey
e.g. finding a car parking
space/ going into
surgery/going home
Understand the experience
3) Mapping the emotions (highs and lows) to the
touchpoints.
Delighted
Safe
Anxious
Angry
Confused
Identifying Emotions
Watch this film and write down the emotions that the
patient talks about.
Write positive emotions above the line and negative
emotions below the line
Remember that they may not be ‘pure’ emotion
words but that you are gathering the emotions
and memories from the patient story to
understand the experience
Shelia- video showing emotions
emotionvideo1.wmv
Emotional mapping
Patient
arrives at
car park
+ve
Patient
navigates
to clinic
Patient
arrives at
clinic
Patient
registers
with
reception
It took ages to find a car parking space
and then I found it was a 15 minute walk
to the outpatients clinic. How
frustrating!
Patient waits
to sees
consultant
Patient
sees
consultant
The room was cluttered with out of date
magazines and notices on the walls and I
was already feeling really nervous
Patient
navigates to
department
Patient goes to
different
department for
investigations (XRay/Pathology
I wasn’t sure where to
go – the signs were
difficult to follow
informed
pleased
relieved
upset
nervous
frustrated
worried
-ve
unsure
anxious
Emotion mapping and flow mappingChristchurch New Zealand
Themes from emotion mapping –
Christchurch New Zealand
Experience Based Design is about
designing better experiences…
@LynneMaher1
Improve the experience
“Experience based co-design positions
patients as active partners with staff
in quality improvement.”
(Tsianakas et al 2012)
@LynneMaher1
Improve the experience
• Involve patients/carers and staff
• Create ‘co-design’ teams
• Be clear about actions needed and impact
desired
• Use improvement tools and techniques
Co-design - turning experience
into action
Planning an experience
event
Working in partnerships with patients can create
some apprehension, but it has the potential to
transform health services
•Plan the date in advance
•Make sure everyone can get to the event
•Use ‘simple English’
•Staff are often as nervous as patients/family members
•Staff may try to ‘take control’ facilitation is important
•Do not leave without next action steps
An Experience Event
Problems cannot be solved by the same level
of thinking that created them.
Albert Einstein
Action Planning
A personal responsibility…
• Hugh McGrath-Patient
• Julie - Clinic Receptionist
• John Pickles-Consultant
What do we learn from
our experiences?
• Bust the myth – Patients do not want a ‘gold plated service’
• They want a good experience
• Patients and staff see each other in a
different way…as people
• Confidence for improvement action
grown for all
Experience Based Design is about
designing better experiences…
@LynneMaher1
© NHS Institute for Innovation and Improvement 2009
Measurement: Key to all improvement
work
AIM
What are we trying to accomplish?
What changes can we make that
will result in improvement?
CHANGE
MEASURE
How will we know if a change is an
improvement?
ACT
RAPID CYCLE
IMPROVEMENT
Langley et al. “The Improvement Guide: A Practical Approach to Enhancing
Organizational Performance.”
STUDY
PLAN
DO
Measure the improvement: the
quantitative perspective
• Reduction in Time
• Reduction in duplication
• Reduction in steps
• Increase in Safety: reduction in error and cost
• Improve Patient Experience:
• Reduction in handoffs
• Reduction in complaints
• Increase in Effectiveness
• Adherence to standards/protocols; reduction
in variation
Measuring
“what matters more than raw data is our ability to place these
facts in context and deliver them with emotional impact”
Daniel Pink –A whole new mind 2008
“the point is to emphasize that each of the cases involved an
actual human being. Describing them as a percentage would
dehumanize the physical impact on a real person, someone's
mother, father, sister, or brother”
Paul Levy CEO 2008
© NHS Institute for Innovation and Improvement 2008
Measure improvement: the
qualitative perspective
•
•
•
•
Collect stories
Observe
Use mapping techniques
Before and after – from and to
One word to depict how patients
feel about your care (before)
www.wordle.net
How patients felt about care
after improvements
www.wordle.net
Use Quantitative and Qualitative
reporting together
FROM
Registration:
frustrated, nervous
TO
Registration:
calm, understanding
“Nothing about me, without
me”
lynne.maher@middlemore.co.nz
@LynneMaher1
Further Reading
Bate, SP. Robert, G. (2007) Towards more user-centric organisational development:
lessons from a case study of experience-based design. J Appl Behav Sci 43(1):41–66
Boyd, H. McKernon, S. Mullin,B. Old, A. (2012) Improving healthcare through the use of codesign. NZMJ, Vol 125 No 1357
Dewar B et al (2009) Use of emotional touchpoints as a method of tapping into the experience of
receiving compassionate care in a hospital setting. Journal of Research in Nursing. Sage
Publications
Doyle. C, Lennox. L, Bell. D. (2013) A systematic review of evidence on the links between
patient experience and clinical safety and effectiveness. BMJ Open 2013;3:e001570.
doi:10.1136/bmjopen-2012-001570
Luxford, K. Piper, D. Dunbar, N. Poo,e. N. ( 2011) Patient Centered Care Improving quality and
safety through partnerships with patients and consumers. Australian Commission for
Quality and Safety in Healthcare. http://www.safetyandquality.gov.au/wp
Further Reading
Maben et al ( 2012) ‘Poppets and parcels’: the links between staff experience of work and
acutely ill older peoples’ experience of hospital care. International Journal of Older Peoples
Nursing. Blackwell Publishing
Piper, D. Iedema, R.(2010) Emergency department co-design stage 2 evaluation—report to
health services Performance improvement branch, NSW Health, Centre for Health
Communication. University of Technology, Sydney
Reeves, R. West, E. Barron, D. ( 2013) Facilitated patient experience feedback can
improve nursing care: a pilot study for a phase III cluster randomised controlled trial
BMC Health Services Research 2013, 13:259. http://www.biomedcentral.com/1472 6963/13/259
Tsianakas et al (2012) Implementing patient-centred cancer care: using experience-based
co-design to improve patient experience in breast and lung cancer services. Support
Cancer Care. DOI 10.1007/s00520-012-1470-3
Weiner, S. et al (2013) Patient-Centered Decision Making and Health Care Outcomes. Annals of
Internal Medicine Volume 158. Number 8 .p573
Our learning from previous
participants
This is a powerful way of understanding
consumers’ views and what their experiences of
healthcare services are really like. It is an
effective way of engaging consumers in
healthcare improvement from the outset and
provides a powerful method for engaging with
and gaining staff support.
Participants said ..
•
‘It’s been particularly exciting to discover a new perspective in the most routine
interactions’
•
‘This is a powerful process with the capability of enhancing services and outcomes for
clients’
•
‘Ebd can be applied in many varied instances to better a variety of services. It brings
fresh ideas and approaches outside the normal ways projects have been managed
before’
•
One team has already recognised the opportunities for ebd in future improvement
projects.
•
‘Undoubtedly EBD is going to be a common way of approaching planning for the
future with plans to incorporate it in a number of projects from here on in. ... the
changes promise to be profound’.
From the beginning
• ‘We possibly needed a clearer sense of purpose from the
beginning’
• ‘We had not devoted enough attention to the real aims
and what success would look like and how we will
measure this’
• ‘It is important to have succinct messages about the aims
of our project ready at hand for when there are
opportunities to communicate with staff and patients’
• If it is truly to be based on patient experience, they
(patients) need to identify what is a meaningful project
Time….
• ‘Team co-ordination of this project has been challenging because of time
constraints & the competing demands of a busy work and home life’
• ‘We must be realistic about how time consuming each task will be for each
stage and make generous allowances for time frames’
• ‘Time management – do not under-estimate the time required for a quality
approach to planning partnership projects’
• ‘Gaining simultaneous dedicated time from the consumer and clinician for
work on the project is proving problematical at present and delaying progress
to a degree’..
• ‘The time factor to achieve the cultural shift in thinking in our DHB was not
appreciated’.
• ‘We have significantly underestimated the time investment required’
Scope creep
• ‘It was decided quite early on that this was a massive
piece of work, probably outside our scope in this time
frame. We then agreed to select something more
manageable, something which we still felt would fit
within the framework concept’
• ‘Develop ‘bite size’ chunks that are more likely to
succeed’
• ‘A breaking down of the components of the project into
simpler, less complex stages needs to occur’
• ‘Starting small and allowing confidence to build was
important’
Challenges
Engaging leaders
• ‘Some of the senior management team were hard to pin
down and convince’
• ‘We have not yet had dedicated time to present EBD codesign concepts to all the members of the senior
management team’.
• ‘I under estimated just how long it took to gain approval
(from senior leaders) for the documentation I wanted to
use in the presentation folder for clients’
Engaging staff
• ‘Once we started disseminating information, we became a bit
overwhelmed with the enthusiasm across the teams. Everyone
wanted it now’
• ‘It seems that we have not ‘fired’ the staff with the concept of
consumer involvement
• ‘Staff can be nervous and harder to persuade than patients –
other staff are nervous at the prospect of being videoed
• ‘Staff can feel threatened by ‘outsiders’ undertaking a project on
‘their’ patients’
Communication and
relationships
• ‘The process of gaining senior leadership support showed
us the paramount importance of trust and the value of
relationships’
• ‘Without trust and established relationships, getting a
project started would have been much more difficult,
including time consuming’
• ‘Be aware to work on relationships first or be clear that
relationships as well as tasks are important’
Patient and family
engagement
• ‘Engagement with initial consumers enabled us to seek
their suggestions for other vital contacts to engage with
this project’
• ‘All the consumers have been absolutely fantastic,
obliging to get us going’.
• ‘Some natural leaders were ‘discovered’ through the
process. We will maintain relationships and
communications with these young people to keep them
engaged in the project going forward’
Patient and family
engagement
• ‘Could have identified more opportunities to engage with
consumers earlier. We will be ‘bolder’ in future but it
took some courage to approach consumers and ask for
their help in the first instance’.
• ‘Once out there discussing and introducing the model to
consumers there was a real enthusiasm for engaging
with this way of working’
• ‘Patients are keen to help – don’t hold back from asking
them’
lynne.maher@middlemore.co.nz
@LynneMaher1