The contribution of ethnography to the evaluation of quality improvement in hospital settings : reflections on observing co-design in intensive care units and lung cancer pathways in the UK

This project was funded by the UK National Institute for Health Research Health Services and Delivery Research Programme (Project Number 10/1009/14). This study was approved by the National Research Ethics Committee North West, reference 11/NW/0653. At the time of writing Louise Locock was supported by the NIHR Oxford Biomedical Research Centre. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS & DR Programme, NIHR, NHS or the Department of Health.Peer reviewedPostprin

How do frontline staff use patient experience data for service improvement? Findings from an ethnographic case study evaluation

Funding Information: The authors would like to thank the following: the ward teams and senior management teams at the six participating case study sites. Neil Churchill, Angela Coulter, Ray Fitzpatrick, Crispin Jenkinson, Trish Greenhalgh and Sian Rees who were co-investigators on the study, contributing to the original design and conduct of the study. Esther Ainley and Steve Sizmur from Picker Institute Europe, who contributed to data collection and analysis. Prof. John Gabbay and Prof. Andr? le May, University of Southampton, for facilitating the learning community meetings. The members of the lay advisory panel: Barbara Bass, Tina Lonhgurst, Georgina McMasters, Carol Munt, Gillian Richards, Tracey Richards, Gordon Sturmey, Karen Swaffield, Ann Tomlime and Paul Whitehouse. The external members of the Study Steering Committee: Joanna Foster, Tony Berendt, Caroline Shuldham, Joanna Goodrich, Leigh Kendall, Bernard Gudgin and Manoj Mistry. At the time of conducting the research LL and SP were employed by the University of Oxford. Preliminary findings from the study have been presented publicly at the following conferences: European Association for Communication in Healthcare 2016; The International Society for Quality in Healthcare 2017; Health Services Research UK 2017; Medical Sociology 2018. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. Publisher Copyright: © The Author(s) 2020. Copyright: Copyright 2020 Elsevier B.V., All rights reserved.Peer reviewedPublisher PD

Understanding how front-line staff use patient experience data for service improvement: an exploratory case study evaluation

Background and aim: The NHS collects a large number of data on patient experience, but there are concerns that it does not use this information to improve care. This study explored whether or not and how front-line staff use patient experience data for service improvement. Methods: Phase 1 – secondary analysis of existing national survey data, and a new survey of NHS trust patient experience leads. Phase 2 – case studies in six medical wards using ethnographic observations and interviews. A baseline and a follow-up patient experience survey were conducted on each ward, supplemented by in-depth interviews. Following an initial learning community to discuss approaches to learning from and improving patient experience, teams developed and implemented their own interventions. Emerging findings from the ethnographic research were shared formatively. Phase 3 – dissemination, including an online guide for NHS staff. Key findings: Phase 1 – an analysis of staff and inpatient survey results for all 153 acute trusts in England was undertaken, and 57 completed surveys were obtained from patient experience leads. The most commonly cited barrier to using patient experience data was a lack of staff time to examine the data (75%), followed by cost (35%), lack of staff interest/support (21%) and too many data (21%). Trusts were grouped in a matrix of high, medium and low performance across several indices to inform case study selection. Phase 2 – in every site, staff undertook quality improvement projects using a range of data sources. The number and scale of these varied, as did the extent to which they drew directly on patient experience data, and the extent of involvement of patients. Before-and-after surveys of patient experience showed little statistically significant change. Making sense of patient experience ‘data’ Staff were engaged in a process of sense-making from a range of formal and informal sources of intelligence. Survey data remain the most commonly recognised and used form of data. ‘Soft’ intelligence, such as patient stories, informal comments and daily ward experiences of staff, patients and family, also fed into staff’s improvement plans, but they and the wider organisation may not recognise these as ‘data’. Staff may lack confidence in using them for improvement. Staff could not always point to a specific source of patient experience ‘data’ that led to a particular project, and sometimes reported acting on what they felt they already knew needed changing. Staff experience as a route to improving patient experience Some sites focused on staff motivation and experience on the assumption that this would improve patient experience through indirect cultural and attitudinal change, and by making staff feel empowered and supported. Staff participants identified several potential interlinked mechanisms: (1) motivated staff provide better care, (2) staff who feel taken seriously are more likely to be motivated, (3) involvement in quality improvement is itself motivating and (4) improving patient experience can directly improve staff experience. ‘Team-based capital’ in NHS settings We propose ‘team-based capital’ in NHS settings as a key mechanism between the contexts in our case studies and observed outcomes. ‘Capital’ is the extent to which staff command varied practical, organisational and social resources that enable them to set agendas, drive process and implement change. These include not just material or economic resources, but also status, time, space, relational networks and influence. Teams involving a range of clinical and non-clinical staff from multiple disciplines and levels of seniority could assemble a greater range of capital; progress was generally greater when the team included individuals from the patient experience office. Phase 3 – an online guide for NHS staff was produced in collaboration with The Point of Care Foundation. Limitations: This was an ethnographic study of how and why NHS front-line staff do or do not use patient experience data for quality improvement. It was not designed to demonstrate whether particular types of patient experience data or quality improvement approaches are more effective than others. Future research: Developing and testing interventions focused specifically on staff but with patient experience as the outcome, with a health economics component. Studies focusing on the effect of team composition and diversity on the impact and scope of patient-centred quality improvement. Research into using unstructured feedback and soft intelligence

Recovery, rehabilitation and follow-up services following critical illness: an updated UK national cross-sectional survey and progress report

Objective: To comprehensively update and survey the current provision of recovery, rehabilitation and follow-up services for adult critical care patients across the UK. Design: Cross-sectional, self-administered, predominantly closed-question, electronic, online survey. Setting: Institutions providing adult critical care services identified from national databases. Participants: Multiprofessional critical care clinicians delivering services at each site. Results: Responses from 176 UK hospital sites were included (176/242, 72.7%). Inpatient recovery and follow-up services were present at 127/176 (72.2%) sites, adopting multiple formats of delivery and primarily delivered by nurses (n=115/127, 90.6%). Outpatient services ran at 130 sites (73.9%), predominantly as outpatient clinics. Most services (n=108/130, 83.1%) were co-delivered by two or more healthcare professionals, typically nurse/intensive care unit (ICU) physician (n=29/130, 22.3%) or nurse/ICU physician/physiotherapist (n=19/130, 14.6%) teams. Clinical psychology was most frequently lacking from inpatient or outpatient services. Lack of funding was consistently the primary barrier to service provision, with other barriers including logistical and service prioritisation factors indicating that infrastructure and profile for services remain inadequate. Posthospital discharge physical rehabilitation programmes were relatively few (n=31/176, 17.6%), but peer support services were available in nearly half of responding institutions (n=85/176, 48.3%). The effects of the COVID-19 pandemic resulted in either increasing, decreasing or reformatting service provision. Future plans for long-term service transformation focus on expansion of current, and establishment of new, outpatient services. Conclusion: Overall, these data demonstrate a proliferation of recovery, follow-up and rehabilitation services for critically ill adults in the past decade across the UK, although service gaps remain suggesting further work is required for guideline implementation. Findings can be used to enhance survivorship for critically ill adults, inform policymakers and commissioners, and provide comparative data and experiential insights for clinicians designing models of care in international healthcare jurisdictions

Patients and staff as codesigners of healthcare services

Glenn Robert and colleagues describe an approach that aims to ensure that healthcare organisations realise the full potential of patients—the biggest resource they have for improving the quality of care

Life after critical illness: a guide for developing and delivering aftercare services for critically ill patients

No abstract available

What patients do and their impact on implementation

Purpose The potential for including patients in implementation processes has received limited attention in the literature. The purpose of this paper is to explore the different roles adopted by 63 patients that emerged during and after four participatory quality improvement interventions, and the nature of their impact upon implementation processes and outcomes. Design/methodology/approach A cross-case ethnographic comparison of Experience-based Co-design in two clinical pathways in two UK NHS Trusts. Findings Two key themes emerge from the data. First, the authors found a range of different roles adopted by patients within and across the four projects; some were happy to share their experiences, others also helped to identify improvement priorities alongside staff whilst others were also involved in developing potential solutions with the staff who had cared for them. A few participants also helped implement those solutions and became “experts by experience” through engaging in the whole co-design process. Second, in terms of the impact of patient engagement with the co-design process whilst the changes championed by patients and carers were often small scale, as co-designers patients provided innovative ideas and solutions. Through their involvement and contributions they also acted as catalysts for broader change in the attitudes of staff by providing a motivation for wider organisational and attitudinal changes. Research limitations/implications The research was conducted in two clinical pathways in two NHS trusts. However, the findings complement and add to the growing body of knowledge on experience based co-design. Practical implications Patient engagement is likely to require support and facilitation to ensure that patients can play a meaningful role as partners and co-designers in service improvement and implementation. Different roles suited particular individuals, with participants stepping in and out of the co-design process at various stages as suited their needs, capacities and (albeit sometimes perceptions re) skills. In this context, facilitation needs to be sensitive to individual needs and flexible to support involvement. Social implications Patients and carers can play active roles in service improvement, particularly where the approach facilitate active engagement as co-designers. Originality/value Analysis of the role patients and carers in implementation and improvement