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Coproduction and improving people’s experiences of care
www.picker.org
27th January 2020
Chris Graham
@ChrisGrahamUK
Picker Institute Europe
Our vision: the highest quality health and social care for all, always.
We:Influence policy and practice so that health and social care systems are always centred around people’s needs and preferences.
Inspire the delivery of the highest quality care, developing tools and services which enable all experiences to be better understood.
Empower those working in health and social care to improve experiences by understanding, measuring, and acting upon people’s feedback.
Picker Institute Europe 2
Person-centred care
Understanding co-production
Valuing what matters
Always Events
Picker
Contents
Person centredness is a desired quality of care; patient experience provides a means of measuring it
Co-production is closely associated with person centredness: both prioritise doing with not to or for
Patient experience is widely and effectively measured
Measurement is necessary but not sufficient for improvement.
Co-production methods like Always Events® can support person centred improvement in practice
Key messages
Person centred care and patient experience
www.picker.org
EnglandNational Survey Programme since 2002FFT – mandatory requirement for every contactPatient experience part of nationally accepted definition of healthcare quality1-2
United StatesHCAHPS used since 2006 – linked to payments10m questionnaires circulated annually
Major patient experience programmes operating worldwide
1. Darzi, A. (2008a). Quality and the NHS next stage review. Lancet, 371(9624), 1563, &
2. Darzi, A. (2008b). High quality care for all: NHS next stage review final report. London: Department of Health.
Patient experience in 2020
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1950 1960 1970 1980 1990 2000 2010 2020
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"Patient satisfaction" "Patient experience"
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Changing roles of patients & clinicians
Passive
Vulnerable
Dependent
Deferential
Active
Knowledgeable
Authoritative
Powerful
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Ignores non-medical factors
“we were trained for seven straight years… to think disease, diagnosis, and treatment as the sole means of managing illness. The model is embedded in our very bones, and… We focus far more on the “disease” or the “psychopathology” than we do on the person who has it.
Even when the illness is caused primarily by human situations, we reduce it to names and nostrums. Or, if we can’t make a diagnosis, or the patient fails to improve, we may still believe that we are “doing all that can be done” by ordering more tests and more treatments.”
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Criticism of the medical model (1)
The expertise of the physician is seen as being inherently more valuable than that of the patient
Carel (2008) describes this as an “epistemic injustice”:
“In certain extreme cases of paternalistic medicine patients might simply not be regarded as epistemic contributors to their case in anything except the thinnest manner (egconfirming their name or ‘where it hurts‘)”
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Criticism of the medical model (2)
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Privileging of technical knowledge permits secrecy about performance and encourages ‘blind trust’ – patients have no way of understanding quality
Coulter (1999):“paternalism is endemic in the [national health service]. Benign and well intentioned it may be, but it has the effect of creating and maintaining an unhealthy dependency which is out of step with other currents in society”
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Criticism of the medical model (3)
Puts users ‘at the heart of services’
Encourages view of patients as:
Participants, not recipients
Active, not passive
Seeks to empower users to be involved…
…and services to be built around patients’ needs and preferences
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Person centred care
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Picker Principles
Darzi, A. (2008a). Quality and the NHS next stage review. Lancet, 371(9624), 1563.
Darzi, A. (2008b). High quality care for all: NHS next stage review final report. London: Department of Health.
Picker Darzi, A. (2008a). Quality and the NHS next stage review. Lancet, 371(9624), 1563.
Darzi, A. (2008b). High quality care for all: NHS next stage review final report. London: Department of Health.
“If quality is to be at the heart of everything
we do, it must be understood from the
perspective of patients.”
Lord Darzi, NHS Next Stage Review
18
Understanding co-production
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Many and varied definitions
Can include individual and/or collective action
Can be about ‘influence’ or ‘power’
It is not engagement, consultation, feedback, or even co-design – it is all of these and more
The idea of coproduction has developed gradually and has its roots in theories of citizen participation
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Understanding co-production
Source: Arnstein, S. R. (1969). A Ladder Of Citizen Participation. Journal of the American Institute of Planners, 35(4), 216–224.
https://doi.org/10.1080/01944366908977225
Arnstein (1969): “A Ladder of Citizen Participation”
Source: Hart, R. A. (1992). Children’s participation: From tokenism to citizenship (Essay No. 4; Innocenti Essays). UNICEF.
Hart (1992): Children’s Participation
Source: https://www.thinklocalactpersonal.org.uk/co-production-in-commissioning-tool/co-production/In-more-detail/what-makes-co-production-different/
TLAP: “Ladder of Co-production”
Experiences of involvement
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Inpatients: “Were you involved as much as you wanted to be in decisions about your care and treatment?”
52%
50%
57%54%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
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Barriers to use
Research shows “clinicians often ignore survey evidence”1. Commonly cited barriers include:
Defensive reactions to bad news2
Findings not sufficiently specific3
Concern that results will be very negative4
Mistrust of the findings/methods2
Limited [statistical] expertise1, 3
Narrow focus on measurement, not improvement5
Lack of time6
1 Coulter, A., Locock, L., Ziebland, S., & Calabrese, J. (2014). Collecting data on patient experience is not enough: they must be used to improve care.
BMJ, 348(mar26 1), g2225–g2225. https://doi.org/10.1136/bmj.g22252 Asprey, A., Campbell, J. L., Newbould, J., Cohn, S., Carter, M., Davey, A., & Roland, M. (2013). Challenges to the credibility of patient feedback in
primary healthcare settings: a qualitative study. British Journal of General Practice, 63(608), e200–e208.3 Reeves, R., & Seccombe, I. (2008). Do patient surveys work? The influence of a national survey programme on local quality-improvement initiatives.
Quality and Safety in Health Care, 17(6), 437–441. https://doi.org/10.1136/qshc.2007.0227494 Graham, C., Kaesbauer, S., Cooper, R., King, J., Sizmur, S., Jenkinson, C., & Kelly, L. (2018). An evaluation of a near real-time survey for improving
patients’ experiences of the relational aspects of care: a mixed-methods evaluation. Health Services Delivery Research, 6(15)5 Sheard, L., Peacock, R., Marsh, C., & Lawton, R. (2018). What’s the problem with patient experience feedback? A macro and micro understanding,
based on findings from a three-site UK qualitative study. Health Expectations https://doi.org/10.1111/hex.128296 Gleeson H, Calderon A, & Swami V. (2016) Systematic review of approaches to using patient experience data for quality improvement in health care
settings. BMJ Open (2016)6 e011907.
Barriers to use (2)
Sheard et al (2018) argue that there are distinct micro and macro level barriers:
Macro level: “intense focus on the collection of patient experience feedback… is at the expense of pan-organizational learning or improvements”
Micro level: “ward staff struggle to interact with feedback due to its complexity [and question] the value, validity and timeliness of data sources”
1 Sheard, L., Peacock, R., Marsh, C., & Lawton, R. (2018). What’s the problem with patient experience feedback? A macro and micro understanding,
based on findings from a three-site UK qualitative study. Health Expectations https://doi.org/10.1111/hex.12829
What does it take to improve?
Shaller, D. (2007) Patient-centered care: what does it take? Retrieved from http://tinyurl.com/shaller2007.
Cultural factors,
including
co-production
Measurement
Infrastructure &
environment
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Always Events®
Defined as:
“those aspects of the patient and family experience that should always occur when patients interact with healthcare professionals and the delivery system.”
Piloted and evaluated in the NHS
Four phases completed – more than 100 organisations involved to date
Always Events®
Important: Patients and families have identified the event as fundamental to their care
Evidence-based: The event is known to be related to the optimal care of and respect for patients and families
Measurable: The event is specific enough that it is possible to accurately and reliably determine whether or not it occurs
Affordable and sustainable: The event can be achieved without substantial capital expense
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Criteria for Always Events®
Always Events are not done ‘for’ patients – they are co-designed with patients, families and carers to ensure changes are happening in areas which really matter to service users.
Always Events are not simply the opposite of Never Events – Never Events focus primarily on breaches in patient safety and operational issues. Always Events focus on making changes to standard working procedures and behaviours which have real impact on the quality of patient experience.
They are not isolated, provider-specific initiatives –the programme is designed to foster learning between healthcare providers so innovative solutions can be easily disseminated.
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How are Always Events® different to other initiatives?
Understand “What Matters to Patients?”
Co-Design an Always Event®
Co-Design an Always Event® to Address “What Matters?”
Translate the Always Event® into Standard
Work Processes
Reliably Implement Standard Work Over Time
Communicate Standard Work Processes
Use Process Measures to Assess Progress
PLAN
Implement Standard Work
DO
Observe & Redesign Standard Work as
Needed to Increase Reliability
STUDY/ACT
Test the Components and the Composite of
the Always Event®
Alw
ays
Even
t
Four phases now completed
More than 100 providers actively involved
Continuing commitments to co-production in the NHS Mandate – 2020 target is to:
“Ensure that patients, their families and carers are involved, through co-production, in defining what matters most in the quality of experience of services and assessing and improving the quality of NHS services.”
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Always Events® in England
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Co-design with service users and staff
Engage frontline teams
Understand the importance of measurement
Maintain momentum
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Tips for successful implementation of improvement initiatives
Conclusions
www.picker.org
Person centredness is a desired quality of care; patient experience provides a means of measuring it
Co-production is closely associated with person centredness: both prioritise doing with not to or for
Patient experience is widely and effectively measured
Measurement is necessary but not sufficient for improvement.
Co-production methods like Always Events® can support person centred improvement in practice
Key messages
Picker Institute Europe
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Tel: + 44 (0) 1865 208100
Fax: + 44 (0) 1865 208101
www.picker.org
Charity registered in England and Wales: 1081688
Charity registered in Scotland: SC045048
Company limited by guarantee registered in England and Wales
