Issue/Problem

In NHS GGC, we have established improvement methods, which are capable of improving the quality of care experience and person-centred care at an individual clinical team level. This model includes a combination of semi-structured conversations in ‘real-time’ to obtain narrative feedback from patients and families. This is followed-up each month with a reflective meeting with clinical staff to review and analyse the qualitative narratives and design improvements for testing and implementation using the application of formal quality improvement methods.

However, the role and behaviours of departmental clinical and managerial leads is under developed leading to variation in support and prioritisation of improvement, which reduces the ability to achieve a level of quality for person-centred care at scale.

Background

Care experience is a key component of how we define quality care and acknowledged as a priority in both the Scottish Government’s 2020 vision(1) and the Healthcare Quality Strategy for Scotland(2). Better care experiences is also evidenced to correlate to quicker recovery from illness, and closer engagement with care(3). Furthermore, measuring care experience can reveal defects in care that can harm patient outcomes as well as evoke opportunities for improvement(4).

While improving patient experience is a key strategic aim within NHS Scotland(2) clinical and managerial staff frequently struggle to make sense of what feedback is telling them(5) and translating this into improvement actions, which are sustainable and reliable(6).

The Institute of Healthcare Improvement (IHI) emphasise the strong empirical evidence that leadership engagement and focus drives improvements in health care quality and reduces patient harm(7). However, they further advise that leaders at all levels in care delivery organisations are struggling with how to focus their leadership efforts and achieve ‘triple aim’ results for the population they serve.

What are we trying to accomplish?

Key to our enquiry is to understand how the application of structured behaviour change techniques (BCT) will help to standardise every day practice and behaviours in clinical and managerial leads, which sustain improvements in person-centred care experience?

The identification of effective behaviour change techniques (BCT) are cited by Michie et al to be advantageous in a variety of context to increase improvement in a range of health and well-being activities as well as developing change in professional behaviour(8). Examples are also well documented in the literature from industry where standardised behaviour practices with a focus on continuous improvement has a positive impact on improved productivity, quality of customer care and employee satisfaction(9).

What changes will we make to result in improvement?

We plan to standardise every day practices of clinical leads by testing a range of behaviour change techniques using improvement methodology(10) to facilitate them to communicate and share improvement opportunities emergent from care experience feedback and share learning of improvements implemented to increase the positive benefits of person-centred care experience, staff confidence and job satisfaction within the immediate clinical team and across the service.

Understanding which behavioural change techniques when applied using a structured approach to develop practice and behaviour in clinical leads, will be important to assist quality improvement leads to identify which practice behaviours are most effective to support the spread of person-centred care improvements at scale and impact the quality of care experienced by the people accessing our health and care services.

How will we know that change is an improvement?

A combination of quantitative and qualitative approaches will be utilised to assess if the behaviour change intervention results in more effective communication about care experience findings; identification of opportunities for improvement; learning from improvement and if this increases the spread of improvement across the service. This will be assessed at different levels of the leadership hierarchy using an enquiry approach such as semi-structured interviews, reflective practice exercises and focus groups. In addition, confidence levels of staff will be measured before and after the change intervention to assess if confidence levels increase when the behaviour intervention is standardised. Observation of practice will be used to take a closer look at what actually happens in practice, to identify gaps between what we say and what we do and identify learning and action points for further improvement.

Impact and benefits

Our core proposal is to understand if the application of behaviour change techniques used to standardise the every day practices among clinical leads and proven successful in other industry settings can be effective in healthcare to produce high quality person-centred care at scale.

The research question recognises that the way the NHS could employ these practices is poorly developed and seeks to understand how and which behaviour change techniques are most effective.

We hope to be able to develop a package of interventions, which will be generalizable across health and social care settings.

The following are anticipated benefits of the approach:

1. Standardisation of behaviour and practice to produce high quality person-centred care at scale and reduce variability.
2. Increased knowledge and understanding among clinical staff, leaders and managers about what care experience feedback is telling them.
3. Increased opportunities for clinical staff to discuss ideas for improvement and be involved in testing and implementation phases – staff members will be encouraged to express their ideas throughout the change process and have their input incorporated into the change using co-design principles.
4. Actions based on the care experience feedback will be acted on more effectively and efficiently – reduce waste and time doing the wrongs things.
5. Improvement actions and behaviours will be more visible to clinical leaders and managers and learning can be shared across the wider service to spread improvement.
6. Increase in positive tone of quality of care experience reported by people using health and care services.
7. Increase in staff confidence to talk about care experience findings and improvement process.

Dissemination Plan

1. Share learning internally within NHSGGC via organisational meeting structures and forum.
2. Share learning externally with other health and care organisations.
3. Publication of an evaluation report.
4. Publication of a journal article.
5. Conference oral and poster presentation.

References

1. Scottish Government. 2020 Vision. (2011). Available from: http://www.gov.scot/Topics/Health/Policy/2020-Vision [accessed 5th April 2018].
2. Scottish Government. Healthcare Quality Strategy for Scotland. (2010). Available from: http://www.gov.scot/resource/doc/311667/0098354.pdf [accessed 5th April 2018].
3. Chatterjee P, Tsai TC, Jha AK. Delivering value by focusing on patient experience. Am J Manag Care 2015; 21:735–7.
4. Browne K, Roseman D, Shaller D, et al. Analysis & commentary measuring patient experience as a strategy for improving primary care. Health Aff 2010; 29:921–5.
5. Membership Engagement Services and In Health Associates. Making Sense and Making Use of Patient Experience Data (2015). Available from: http://www.membra.co.uk/blog/making-sense-and-making-use-patient-experience-data [accessed 5th April 2018]
6. Sheard L., Marsh C., O’Hara J., Armitage G., Wright J., Lawton R. The Patient Feedback Response Framework e Understanding why UK hospital staff find it difficult to make improvements based on patient feedback: A qualitative study. Social Science & Medicine 2017 178 19 – 27.
7. Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2013. Available from: http://www.ihi.org/resources/Pages/IHIWhitePapers/HighImpactLeadership.aspx [accessed 5th April 2018].
8. Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, Eccles MP, Cane C, Wood CE. The Behaviour Change Technique Taxonomy (v1) of 93 Hierarchically Clustered Techniques: Building an International Consensus for the Reporting of Behaviour Change Interventions. Ann. Behav. Med. 2013; 46(1): 81-95. doi: 10.1007/s12160-013-9486-6
9. Liker JK, Convis GL. The Toyota Way to Lean Leadership: Achieving and Sustaining Excellence through Leadership Development. 2012 McGraw-Hill, New York.
10. Institute for Healthcare Improvement. How to Improve. Available from http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx [accessed 5th April 2018]