Using patient feedback to drive improvement

The NHS is sometimes held up as a shining beacon when it comes to gathering patient feedback and countries around the world have sought to emulate how it does this. But how good is the NHS at using feedback from hospital patients to improve its services?

This is a question that colleagues and I from The King’s Fund and Picker Institute Europe have tried to answer, by examining trends in patient-reported experiences from the 2005–13 inpatient surveys for all acute trusts in England.

The vast quantity of data collected in the inpatient survey is potentially of use to multiple audiences – primarily trusts for monitoring and improving quality of care, but also regulators for quality assurance, commissioners for monitoring contracts, managers (locally and nationally) for performance assessments, the government and the public for accountability, and patients for informed choice.

While the data is ostensibly being used for all these purposes, how far are the survey results translating into improved services at a local level – and how much are they valued as a resource by trusts, clinicians and those directly responsible for ‘patient experience’?

The short answer is ‘not enough’ on both counts. Our research project – involving analysis of 28,000 data points (20 questions, at 9 annual points, for 156 trusts) – showed that patient-reported experience of inpatient care in acute trusts remains high and there have been some improvements over the 8-year period. But these improvements are comparatively modest and arguably driven by national initiatives and policies to tackle high-profile problems, such as health-care acquired infections. Given the financial challenges faced by the NHS and the wider system pressures in the health and care landscape – it is positive that patient-reported experience in acute trusts is not deteriorating (overall), and has even seen some improvement.

To investigate why this may be the case, we also ran a small qualitative study of patient experience leads at five trusts. Our conversations with them revealed various, inter-related challenges faced by trusts in using the inpatient survey data to improve services. Chief among these were resource and system pressures (including financial pressures); ‘blame cultures’ inhibiting staff from engaging with poor results; a lack of co-ordination across the trust; scepticism among clinicians about survey validity and relevance; and competing priorities within trusts.

The patient experience leads we spoke to highlighted the struggle to make patient experience everyone’s responsibility. Patient experience is typically seen as a ‘nursey’ thing. Unclear responsibility for the data was another major barrier. One interviewee said that as the data comes to the nursing team, the trust sees it as the responsibility of nurses alone.

Our conversations also offered some examples of how trusts are using the data effectively to improve quality. Interviewees described how one trust uses its own locally led surveys to track performance in worst-performing areas to drive more focused change. Another had identified that patients were dissatisfied about delayed discharges and noise at night. It developed specific policies to tackle these, including stopping internal transfers after 8pm to reduce disturbance. Another trust used the survey to discover that ‘information on discharge’ needed improvement. It developed a comprehensive discharge pack for patients, including danger signs to look out for and key contact numbers.

We wanted to know what enabled these trusts to take this data, understand it, work with it, and use it to improve patient experience overall. Three key themes came up time and again in our interviewees’ replies.

Organisational leadership and a patient-centred culture were critical. A champion with dedicated time, responsibility and interest in promoting the use of patient experience data was also seen as fundamental to effective use of the data. Staff engagement, training and support for improvement – not punishment for poor results – were considered key to enabling trusts to make the most use of survey data, and for encouraging all staff to engage in the concept of patient experience. Finally, trust-wide reporting and co-ordination of data were vital in drawing all this together, with the patient experience lead deployed to highlight issues and ensure they are tackled.

The NHS inpatient survey has been running for more than a decade now – and throughout this time it has been underutilised both locally and nationally. Our analysis – both of the survey and the discussions – offers new insights into this trove of data and into how it can be better used to improve patient experiences.

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Comments

#545232 Marie Casey
CEO
seAp Advocacy

As an long established advocacy provider, we recognise the value of learning from patient experience. Most people who complain, want their views to be respected and for action to be taken to avoid the same thing happening again. We agree that patient feedback needs to be a priority at the highest level and that actions needs to be monitored at Board level to ensure that learning is sustained. It is also important to let people know what has happened as a result of their feedback

#545233 Pearl Baker
Independent Mental Health Advocate & Advisor/Carer
Independent

Having just returned form an open Board Meeting of the NDCCG, there was no mention that those who suffer from Schizophrenia or Bipolar are considered as suffering from a LTC, the conversations was about the elderly, cared for not the elderly Carer.

The 'Better Care Fund' was mentioned where it soon became clear it was not used for the Mentally Ill.

The subject of the 'obese' patient and their referral mechanism, but no mention of the mentally Ill being referred?

Another conversation regarding patients managing their own health and social care, but failed to elaborate how those with LTC ie Schizophrenia or Bipolar would participate in this exercise, most have no idea they do have a choice? or how rehabilitation would be needed for them to take part in this latest scheme.

My FOI to the NDCCG went like this: the GP said they have been informed they are too discharge patients from section 117 (free aftercare) if they are stable, the CCGs said it is not us! so who was it? my next concern how can the CCGs possible be able to have the correct data for the LTC patient now without a 'Care Plan' and now it would appear unable to obtain a Personal Budget? The CQC would not know the patient now without a 'Care plan' has now been discharged illegally from Section 117, as they still receive care and treatment as part of their 'Care Plan' which has now disappeared.

The NDCCG also state that all section 117 Patients are to receive an Annual Review? but how will this take place if the GP the RMO in this case has discharged them from any 'Care Plans'.

The NDCCGs spoke of 'integration' but what 'integration'
and with whom?

The KIngsFund Conference on 'integration' was excellent, good idea like:

A Voluntary sector agency had been set up to help the elderly in an 'Holistic' manner that means (everything) changing light bulbs, helping arrange gardening service, helping with Insurance etc., and this was funded from PHE it saved around £4000.000 thousand it my memory is correct, why am I sat listening to a CCG trying to implement the same, you can only ask a question at the end of the meeting, no participation here.

If all CCGs operate their open Board Meetings in this way, and you can only speak when spoken to, and only ask a question, what is the purpose of going? to find out how terrible they are, and who really is benefitting from the 'Better Care Fund'? they refused to supply a breakdown of how the fund was used, it soon became clear it was not in Adult Mental Health, perhaps I should enquire with the 'MONITOR'?

#545663 anne montgomery
research associate
University of Leicester

Where might I get access to the small qualitative study of patient experience leads at five trusts?

#545926 Tony T
CRM Consultant

It is not unusual to experience tokenism when looking to see if improvement occurs following feedback surveys. For those who really want to improve it is an ideal opportunity to do just that; for those who are not really bothered it is too easy to kick unwelcome results and comments into the LONG-GRASS!! Pity the Patients affected.

#545930 Prof.Minesh Khashu

Joni

To see significant improvement we need a paradigm shift; a major culture change wherein using feedback becomes part of the day to day working and DNA of an organisation. It is everyone's business to ensure that the climate is right for patients and families to give feedback and the culture within teams and organisations is appropriate such that they value this feedback as 'gold' to make services better as well as pass on appreciation back to staff for positive feedback.

The best way to make this happen is to have front line teams own and run it rather that it becoming just part of an EXECUTIVE DASHBOARD.

Also if staff feel they are heard and their views respected, they are more likely to do the same for patients and families.

#547574 Wael Arab
patient

I am 68 years old and a wheelchair user. My experience with Camden ccg and CamdenHealthwatch is that they ignore feedback and complaints online and at meetings. They get away with that because the CQC is either too busy or simply reluctant to give time to an individual such as I to tell them about my experiences.

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