Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
03/11/2014 
1 
ENGAGING SERVICE USERS AND HEALTHCARE 
STAFF IN QUALITY IMPROVEMENT: A 
PRACTICAL INTRODUCTION TO EXPERIENC...
03/11/2014 
2 
What makes a good service: designing experiences 
Performance 
Is it 
functional? 
Lean 
Engineering 
Is it...
03/11/2014 
3 
For me, this is about ‘Oh God, they’re our patients, aren’t 
they?’ When people watch the film, they might ...
03/11/2014 
4 
Methods 
• Value of patients, carers and staff experiences 
• Stories not surveys 
• ‘Deep dives’ and direc...
03/11/2014 
5 
Reception – staff experience 
Reception – staff experience Carrying out observations 
Sequence of feedback ...
03/11/2014 
6 
Touchpoints 
• Critical points 
• ‘Big’moments (good and bad) 
• Moments of truth 
• Emotional ‘hotspots’ 
...
03/11/2014 
7 
Running the co-design event 
Co-design event – patients and staff together 
• Watch film of patient 
storie...
03/11/2014 
8 
Multiple models of emergency and short-stay 
services: Luton and Dunstable 
Testing solutions – personas 
D...
03/11/2014 
9 
EBCD in Australia 
• EDs in seven hospitals in NSW 
– 3 EDs (stage 1) 
– 4 EDs partnered with another depar...
03/11/2014 
10 
Carers of patients receiving outpatient 
chemotherapy 
Leaflet DVD 
Group 
consultation 
Delivering the in...
03/11/2014 
11 
Thinking about your project/s, what were the strengths of the EBCD 
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%...
03/11/2014 
12 
‘Accelerated’ EBCD: improvement 
activities and cost 
• similar improvement activities to 
standard EBCD p...
03/11/2014 
13 
We got together and we discussed the narratives and 
we tried to identify, in collective discussion, where...
Upcoming SlideShare
Loading in …5
×

Engaging service users and healthcare staff in quality improvement: a practical introduction to experience based co-design

824 views

Published on

This presentation by Glenn Robert from the National Nursing Research Unit and King's College London looks at what experience based co-design is, and why do it.

It was presented at the MS Trust Annual Conference in November 2014.

Published in: Health & Medicine
  • Be the first to comment

Engaging service users and healthcare staff in quality improvement: a practical introduction to experience based co-design

  1. 1. 03/11/2014 1 ENGAGING SERVICE USERS AND HEALTHCARE STAFF IN QUALITY IMPROVEMENT: A PRACTICAL INTRODUCTION TO EXPERIENCE-BASED CO-DESIGN Florence Nightingale Faculty of Nursing GLENN ROBERT & Midwifery National Nursing Research Unit Overview ① What is Experience Based Co-design, and why do it? ② Method ③ Evidence base ④ The case of the disappearing co-design phase ... What is Experience-based Co-design … and why do it? A participatory action research approach that combines: a user-centred orientation (EB) and a collaborative change process (CD) Online toolkit Design theory • draws its inspiration from a subfield of the design sciences such as architecture and software engineering • distinctive features are: – direct user and provider participation in a face-to-face collaborative venture to co-design services, and – a focus on designing experiences as opposed to systems or processes (thereby requiring ethnographic methods such as narrative-based approaches and in-depth observation)
  2. 2. 03/11/2014 2 What makes a good service: designing experiences Performance Is it functional? Lean Engineering Is it safe and reliable? Safer Patients Initiative The Aesthetics of Experience What does it feel like? Human environment Physical environment EBCD Berkun, 2004 adapted by Bate Healthcare quality improvement from a design perspective • must obviously fulfil the core task and be safe (performance and engineering) • must ‘appeal’ at the emotional and sensory level (aesthetic) • patients & carers need to be active rather than passive, using their specialist form of knowledge (experience) The biggest untapped resources in the health system are not doctors or nurses but users. We need systems that allow people and patients to be recognised as producers and participants, not just receivers of systems… At the heart of [co-design], users will play a far larger role in helping to identify needs, propose solutions, test them out and implement them, together. Cottam H, Leadbeate, C (2004). Health: Co-creating services. RED Paper 01. London: Design Council. Available at:www.designcouncil.info/mt/red/health/redpaper01.pdf FFFFeeeeaaaattttuuuurrrreeeessss ooooffff EEEEBBBBCCCCDDDD A focus on designing experiences, not just improving performance or increasing safety Putting patient experiences at the heart of the quality improvement effort – but not forgetting staff Where staff and patients do the designing together (co-design rather than re-design) And, in the process, improving day-to-day experiences of giving and receiving care Complaints Information Surveys 12 Consulting advising Experience- Based Co- Design (EBCD) Adapted from Bate Robert, Quality Safety in Health Care, (2006) Different ways of involving patients Patient blogs and web-based stories Staff patients working together to redesign services
  3. 3. 03/11/2014 3 For me, this is about ‘Oh God, they’re our patients, aren’t they?’ When people watch the film, they might think ‘I remember that lady.’ They know they’re our patients – they can’t get away from the fact – but it actually makes it more real for them. Whatever way they’re captured, it’s about capturing it so that people recognise ‘These are patients I have cared for, nursed, met, who are saying this’… and I think that’s what is so different from other improvement work. in terms of things like discovery interviews and focus groups. It’s that direct connection between them. The method
  4. 4. 03/11/2014 4 Methods • Value of patients, carers and staff experiences • Stories not surveys • ‘Deep dives’ and direct observation • ‘Touchpoints’ and emotional mapping Experience 7 sa8sfac8on Patient survey Overall, did you feel you were treated with respect and dignity while you were in hospital? Yes, always Overall, how do you rate the care you received? Excellent “The other thing I didn’t raise and I should have done because it does annoy me intensely, the time you have to wait for a bedpan. ….elderly people can't wait, if we want a bedpan it’s because we need it now. I just said to one of them, ‘I need a bedpan please.’ And it was so long bringing it out it was too late. It’s a very embarrassing subject, although they don't make anything of it, they just say, ‘Oh well, it can't be helped if you’re not well.’ And I thought, ‘Well, if only you’d brought the bedpan you wouldn't have to strip the bed and I wouldn't be so embarrassed.’ Humanising healthcare Forms of humanization insiderness agency uniqueness togetherness sense-making personal journey sense of place embodiement Forms of dehumanization objectivication passivity homogenization isolation loss of meaning loss of personal journey dislocation reductionist body Todres L, Galvin T and Holloway I. (2009) ‘The humanisation of health care: a value framework for qualitative research. Int J of Qualitative Studies on Health and Wellbeing, 4: 68-77 Staff: a ‘deep dive’ Reception – patient experience
  5. 5. 03/11/2014 5 Reception – staff experience Reception – staff experience Carrying out observations Sequence of feedback events Emotional mapping exercise Carrying out patient interviews
  6. 6. 03/11/2014 6 Touchpoints • Critical points • ‘Big’moments (good and bad) • Moments of truth • Emotional ‘hotspots’ Some typical touch points of head and neck cancer patients Extract from patient film – a touchpoint
  7. 7. 03/11/2014 7 Running the co-design event Co-design event – patients and staff together • Watch film of patient stories • Hear what the patients have prioritised • Hear what staff have prioritised • Patients and staff agree on priorities • Form working co-design groups to make these improvements The co-design event Prototyping Building prototypes helps a group to move beyond talking and thinking about a problem to actually making progress toward action. Perhaps most important, they are real and physical –that is, they assume some material manifestation. • Building to think • Learning faster by failing early (and often) • Giving permission to explore new behaviours Coughlan P, Suri JF, Canales D (2007). ‘Prototypes as (design) tools for behavioral and organisational change: a design-based approach to help organizations change work behaviors’. The Journal of Applied Behavioral Science, vol 43, pp 122–24
  8. 8. 03/11/2014 8 Multiple models of emergency and short-stay services: Luton and Dunstable Testing solutions – personas Do the second design solutions work for: • an old person with dementia • a car accident victim in and out of consciousness • a person for whom English is not the native tongue • a young adolescent (or others) It was quite funny to see them lifting up their chairs … It’s a symbol of the project that those chairs are those patients’ seats, and it’s about the staff and the patients together, just moving everything around, so it becomes the symbol for the whole project. Where user and provider can work together to optimise the content, form and delivery of services. At its most highly participative extreme, this process is referred to as co- design and entails service development driven by the equally respected voices of users, providers and professionals. Bradwell P, Marr S (2008). Making the Most of Collaboration. An international survey of public service co-design. London: Demos. The evidence base
  9. 9. 03/11/2014 9 EBCD in Australia • EDs in seven hospitals in NSW – 3 EDs (stage 1) – 4 EDs partnered with another department (stage 2) • variation in implementation: – 16-40 patient interviews (mean 24) – 21-53 staff interviews (mean 37) – 0-41 hours of observation (mean 10) EBCD in Australia Common improvement priorities in all seven EDs: • Patient and carer comfort and privacy • Physical space for staff and patients • Communication and information flow For example: • Designated nurse to manage waiting room and communicate with patients • ‘Informed waiting’ training for all staff • ED redesigned to ensure both triage nurse and clerical staff have clear view of the waiting area Piper D, Iedema R, Gray J et al (2012). ‘Utilizing Experience-based Co-design to improve the experience of patients accessing emergency departments in New South Wales public hospitals: an evaluation study’. Health Services Management Research, vol 25, pp 162–72. The primary strength of EBCD over and above other service development methodologies was its ability to bring about improvements in both the operational efficiency and the inter-personal dynamics of care at the same time. EBCD teaches project staff new skills; it enables frontline staff to appreciate better the impact of health care practices and environments on patients and carers; it engages consumers in ‘deliberative’ processes that were qualitatively different from conventional consultation and feedback. Iedema R, Merrick E, Piper D et al (2010). ‘Co-designing as a discursive practice in emergency health services: the architecture of deliberation’. The Journal of Applied Behavioural Science, vol 46 (1), 73–91. Breast lung cancer services, London • Knowledge skills transfer: – trained 2 in-house QI specialists – mentored through the process • Fieldwork involved: – 36 filmed narrative patient interviews – 219 h of ethnographic observation – 63 staff interviews – a facilitated EBCD process over 12-month period • Mapped quality improvements and studied sustainability • 7 co-design groups • 56 quality improvements implemented • 19-22 months after initial implementation, 66% of improvements sustained – ‘Quick fix’ solutions: 28 with 24 sustained – ‘Process redesign’ solutions: 9 with 5 sustained – Cross service or interdisciplinary solutions: 14 with 8 sustained – Organisational level solutions: 5 with 2 sustained • Crucial role of facilitators in determining staff experiences of the EBCD approach Tsianakas, V., Robert, G., Maben, J., et al. (2012). ‘Implementing patient centred cancer care: using experience-based co-design to improve patient experience in breast and lung cancer services’. Journal of Supportive Care in Cancer, published online DOI 10.1007/s00520-012-1470-3 The aim To develop and test a carer support package in TTTooo dddeeevvveeellloooppp aaannnddd ttteeesssttt aaa cccaaarrreeerrr sssuuuppppppooorrrttt pppaaaccckkkaaagggeee iiinnn tttthhhheeee cccchhhheeeemmmmooootttthhhheeeerrrraaaappppyyyy oooouuuuttttppppaaaattttiiiieeeennnntttt sssseeeettttttttiiiinnnngggg uuuussssiiiinnnngggg EEEEBBBBCCCCDDDD • Understand support provided by healthcare professionals to carers • Develop a short film depicting carers’ experiences • Bring healthcare professionals and carers together in co-designing components of an intervention for carers • Develop and implement a carer intervention. • Explore feasibility and acceptability, impact on carers’ knowledge of chemotherapy and on their experiences of providing informal care. Developing the support package • Support package developed through ongoing co-design meetings. • Carers and staff reviewed package and decided how, where, when and by whom it would be delivered • New scripted 25-minute film (on DVD), grounded in carer experiences using their quotes/stories about situations that may arise. Healthcare professionals on film offering advice and strategies on how to cope in these situations • Written resource provided alongside DVD
  10. 10. 03/11/2014 10 Carers of patients receiving outpatient chemotherapy Leaflet DVD Group consultation Delivering the intervention • Delivered by a chemotherapy nurse in one-off consultation of no more than five carers • Provided an opportunity for carers to watch a DVD developed specifically for this purpose • Engage in conversation facilitated by chemotherapy nurse • Carers given ‘Take care’ leaflet and sections explained • Carers’ role in process acknowledged and opportunity to talk about effects and own concerns • Carers given own copy of DVD and leaflet and encouraged to consult throughout chemotherapy process Outcome measures Survey, 2013 • Online survey to 107 practitioners and researchers • 18 follow-up telephone interviews • 59 EBCD projects implemented in 6 countries worldwide (2005–13) and further 27 in planning • Implemented in a variety of clinical areas (including emergency medicine, drug and alcohol services, cancer services, paediatrics, diabetes care and mental health services) • Projects typically take 6–12 months to complete • Free-to-access online toolkit ‘a helpful resource’ Donetto S, Tsianakas V and Robert G (2014). Experience-based Co-design: Mapping where we are now and establishing future directions. London: King’s College London. 5 3 6 1 25 2 8 Survey summer 2013
  11. 11. 03/11/2014 11 Thinking about your project/s, what were the strengths of the EBCD 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% It really engaged patients/carers It really engaged straff It allowed discussion of difficult topics in a supportive environment It led to clear improvement priorities It really made a difference to the way we do things around here approach? Answered: 41 Skipped: 20 Thinking about your project/s, what were the weaknesses of the 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% It took too long It was too compilicated It cost too much Staff did not engage with the project Patients/carers did not engage with the project EBCD approach? Answered: 41 Skipped: 20 Survey findings • Training and support: 50% of those who have led EBCD projects did not receive any formal training • Role of non-participant observation: relatively under used as an approach • Role of film: 50% of projects included filming patients • The scale of change: ‘sweating the small stuff’ • Co-design: a complex social intervention that is challenging to implement whose impact and outcomes are difficult to evaluate • Evaluation: less than half were aware of the costs of their project(s); no formal cost-benefit or cost-effectiveness studies of EBCD have been undertaken Evaluations of EBCD • Suggest it is an effective way to make improvements and leave a legacy of cultural change • But – costly and time intensive • Can we make it cheaper and faster? Testing the use of trigger films made from a national archive alongside EBCD techniques • Re-analysis of lung cancer and intensive care transcripts from HERG/Healthtalkonline collections Our research questions • Is the accelerated approach acceptable to staff and patients? • How does using films of national rather than local narratives affect the level and quality of engagement with service improvement by local NHS staff? • How well do national narratives capture and represent themes important to local patients’ own experience? • What improvement activities does the approach lead to? • What are the costs compared to EBCD?
  12. 12. 03/11/2014 12 ‘Accelerated’ EBCD: improvement activities and cost • similar improvement activities to standard EBCD projects • 48 improvement activities in total: – 21 small scale changes – 21 process redesign within teams – 5 process redesign between services/activities – 1 process redesign between organisations • costs of AEBCD are around 40% of EBCD (excluding one-off costs of developing a national trigger film) EBCD in mental health settings • Sunshine Acute Adult Psychiatric Unit, North Western Mental Health, Melbourne (2008) • South London and Maudsley NHS Foundation Trust, eg self-injecting addictions service (2011/12) • MH ECO (2006 onwards) and CORE study in community mental health (2013–16), Victoria • Oxleas NHS Foundation Trust (acute mental health unit, 2012/13) Getting to the CORE: testing a co-design technique to optimise psychosocial recovery outcomes for people affected by mental illness The case of the disappearing co-design phase What worked for us was the frequent short meetings, and keeping in close contact. And I think for the patients and relatives to be there kind of held the staff to account, and to their action points. I mean they did divvy things up… there was something about, definitely for staff because of that thing that I said before about that humanistic kind of connection that it really drove them to complete actions. (Interview #08) I think I would probably do more co-design events and sort of do more feedback as you go along really. I think definitely I would have benefitted from more co-design. (Interview#05) I think that it worked because it was collaborative and there were mixed groups of people doing the work, they held each other to account. And kept people on track where perhaps it might have slid… I think that it's harder to do the co-design or collaboration after that initial problem solving phase because I think health professionals are used to being in charge of making things happen.(Interview #10) I think there's a very big recognition of co-design as a way to go forward with things, but a lot of the services are steeped in the processes they've already got. And I think they're finding it hard to see where does it fit in with what we currently do. And it's about that medical model I think, where you've got the patient [and] carers who are just the receivers of service, ‘what do they know?’ (Interview#07)
  13. 13. 03/11/2014 13 We got together and we discussed the narratives and we tried to identify, in collective discussion, where or how things could be improved, but when it then came down to what they were actually going to do, those decisions were taken by the frontline managers, the nursing managers, and their line managers. So there was certainly no co-design at that point... I think you can then identify how the hierarchies worked within the organisation, co-designed up to a point, and then it reverted back to a much more hierarchical way of organising things... a workshop with a draft action plan which was then taken away and worked on behind closed doors. (Interview#02) [The co-design group was] nerve wracking ... I was sitting across a [meeting] table from a woman that I knew, I’d looked at her scan and I was going to have to tell her that her cancer had come back in the next clinic … and she’s telling me how brilliant her life is … (Adams et al, forthcoming) Service designers health care organisations ‘Service design is entering the fields of organisational studies and social change with little background knowledge of their respective theories and principles’ ... (and practices??) ‘our own expectations (as participatory designers) about trajectories of change can also be naive when working in unfamiliar and complex organizational contexts. The slow (and uneven) progress from ideas to implementation, and the way that project proposals have been adapted and fused with other inputs to stimulate the actual changes, challenged our own morale and confidence about the impact of the work.’ Sangiorgi, (2010) International Journal of Design; Bowen et al, (2013) CoDesign Much is to be gained from effective integration of evidence-based and user experience-based approaches to design for healthcare services (Hagen, 2014). Requires ‘some collaboration and open thinking’ to bridge the different philosophical stances of the two approaches, there is great value in integrating ‘the human-centred tools and values of user experience design into existing processes and models that already have leverage within organisations’ (ibid.). Further information • EBCD toolkit: www.kingsfund.org.uk/projects/ebcd • EBCD LinkedIn group: www.linkedin.com/groups/Experiencebased-codesign-6546554 • twitter: @gbrgsy, @PointofCareFdn • Glenn Robert email: glenn.robert@kcl.ac.uk

×