Using co-design to improve healthcare services Professor Glenn Robert, Chair of Healthcare Quality & Innovation Florence Nightingale Faculty of Nursing & Midwifery twitter: @gbrgsy
The Experience-based Co-design process patients at the heart of the quality improvement effort - but not forgetting staff a focus on designing experiences, not just systems or processes where staff and patients participate alongside one another to co-design services Robert G, Cornwell J, Locock L, Purushotham A, Sturmey G and Gager M. (2015) ‘Patients and staff as co - designers of health care services’, British Medical Journal , 350:g7714
The Experience-based Co-design process
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.
Online toolkit: www.kingsfund.org.uk/projects/ebcd
Film 1 Toolkit
EBCD
The Experience-based Co-design process patients at the heart of the quality improvement effort - but not forgetting staff a focus on designing experiences, not just systems or processes where staff and patients participate alongside one another to co-design services Robert G, Cornwell J, Locock L, Purushotham A, Sturmey G and Gager M. (2015) ‘Patients and staff as co - designers of health care services’, British Medical Journal , 350:g7714
Setting up
Strategy and strategic questions • Is EBCD to be a standalone project or integrated with and part of other projects? • Is it going to focus just on experience or will it also take in efficiency, safety and wider improvement issues? • Is it going to focus on a pathway, department, area, speciality or particular group of patients? • What is the strategy for leading it? • How, and to whom, will it report back and be accountable?
Breast pathway
Engaging staff
Methods • value of patients, carers and staff experiences • stories not surveys • ‘ deep dives ’ and direct observation • ‘ touchpoints ’ and emotional mapping
Reception – patient experience
Reception – staff experience Reception – staff experience
The power of observation – an example blisters lumps ulcers polyp ‘warty things’ necrosis lesions ‘naughty tumour’ aggressive progressing carcinoma ‘pre - cancerous change’ cancer
Why start with staff? • The experience of giving the service is as relevant and important as the experience of receiving it • Important role to play in the early stages of an EBCD project (eg identifying patients and carers) • Understanding what EBCD is all about and the role they can play in shaping experience • Establish relationships: build trust to initiate/sustain EBCD process
Interviewing staffve ’
Engaging patients
Satisfaction ≠ experience Patient survey: Q: Overall, did you feel you were treated with respect and dignity while you were in hospital? A: Yes, always Q: Overall, how do you rate the care you received? A: Excellent Robert G. (2013) ‘Participatory action research: using Experience -based Co- design (EBCD) to improve health care services’. In: S Ziebland, J Calabrase, A Coulter and L Locock (eds). Understanding and using experiences of health and illness, Oxford; Oxford University Press
Satisfaction ≠ experience cont 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.’ Robert G. (2013) ‘Participatory action research: using Experience -based Co- design (EBCD) to improve health care services’. In: S Ziebland, J Calabrase, A Coulter and L Locock (eds). Understanding and using experiences of health and illness, Oxford; Oxford University Press
Emotional mapping exercise
Storytelling “The value of storytelling in healthcare is immense, and virtually untapped. If we don’t preserve the richness of narrative, we will fail to connect to our patients’ deepest experiences, and to our own.” “we need more firesides, not spreadsheets.” (Don Berwick, 2006)
Video brings fieldwork to you, so all can see! traditional Many video ethnography patients ethnography observation, shadowing video anecdote One storytelling patient Someone else sees, I see the care The whole team myself sees together then summarizes Source: Care Management Institute, Kaiser Permanente, http://kpcmi.org/about
Touchpoints • Critical points • Big moments (good and bad) • Moments of truth • Emotional hotspots
Film 2 Touchpoints
Some typical touch points of head and neck cancer patients
The patient event - Agenda Time Item [30 mins] Introductions [45 mins] Showing the film of patient interviews [30 mins] Discussion about the film [45 mins] Lunch [60 mins] Emotional Mapping exercise [30 mins] Working on priority areas [10 mins] Evaluation Close
Film 3 Emotional mapping
Co-design meeting
The joint patient – staff event • 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 joint patient – staff event - Agenda Time Item [5 mins] Introduction to patient film [30 mins] Patient film [10 mins] Brief discussion about film [10 mins] Patient priorities [10 mins] Feedback from staff event and staff priorities [10 mins] Break [50 mins] Group discussion Introductions around tables Agree priorities [10 mins] Feedback from groups [25 mins] Forming co-design groups [5 mins] Next steps and evaluation Close
Film 4 Joint event film
Small co-design teams
Doing the ‘ co-design ’ part of EBCD: 3 ways to do quality improvement 1. we don’t listen very much to our users and we do the designing 2. we listen to our users then go off and do the designing 3. we listen to our users and then go off with them to do the designing
Running the groups 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) Source: Donetto, S., Tsianakas, V. & Robert, G. (2014). Using Experience-based Co-design to improve the quality of healthcare: mapping where we are now and establishing future directions . London: King’s College London.
Running the groups 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) Source: Donetto, S., Tsianakas, V. & Robert, G. (2014). Using Experience-based Co-design to improve the quality of healthcare: mapping where we are now and establishing future directions . London: King’s College London.
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