Patient participation for safe service re-design
16 September 2023
This year's theme for the World Health Organization's World Patient Safety Day (17 September) is Engaging Patients For Patient Safety, in recognition of the crucial role patients, families and caregivers play in the safety of health care. Active patient involvement, both in their own personal care as well as at a strategic organisational level, is vital to help improve healthcare provision, and the RCSEd is delighted to support this year's WPSD theme.
The RCSEd Patient Safety Group have produced a number of blogs as part of a campaign to mark World Patient Safety Day. In this blog, Andrew Martindale, Consultant Urologist and College Regional Surgical Advisor, discusses the key role that patients play in service redesign.
Quality improvement is embedded in the culture of continuous change in healthcare services. QI methodologies are widely used in with aim of improving patient outcomes, system performance and professional development of the multidisciplinary healthcare team. Patient safety is paramount in assessing outcomes in healthcare, and this includes diagnostic pathways as well as therapeutic interventions.
The principle of patient involvement in both their individual safety and, through partnership, that of the organisation is well established, in the NHS England Patient Safety Strategy and the Scottish Patient Safety Programme. With safety at the core of all service redesign it is important that healthcare planners look to the best way to actively involve patients.
Definitions of QI include statements such as ‘delivery of improved outcomes through continuous redesign’, ‘systematic methodology to improve patient experience and outcome’ and ‘make a difference to patients by improving the safety and effectiveness of complex healthcare systems’. Change carries inherent risk and the potential for worsening outcomes from system change, the opposite of that intended, re-enforces the relationship between patient safety methodology and QI work. The six pillars of Realistic Medicine in Scotland focus on safe, individual care including shared decision making, personalised approach to care, better management of risk whilst encouraging innovation and improvements and reduce variation with reduced harm and and waste. If healthcare QI is to meet these tenets, patients must be a the centre of both their own healthcare provision but also its planning with ‘what matters to you?’ a question to be applied to stages of the journey.
Amongst the principles of QI is the empowerment of frontline staff and service users with the skills required to perform improvement work and so own the outcomes and resultant service improving satisfaction, morale, and investment in a project’s success. The recurring theme of safety and the goal of the best possible patient experience suggests that patient participation in all forms of QI, alongside staff and other stakeholders is vital to ensuring successful, acceptable services fit for providers and service users.
How to best hear form patient and their relatives as part of a quality improvement pathway can be challenging. There are many ways in which the views of the service users can be canvassed or inferred from data sources. That healthcare services need to listen to the communities they serve is understood but the terminology such as engagement, participation and involvement are often used interchangeably with limited clarity of meaning. The ‘what matters to you?’ initiative highlights that individuals are best placed to know what will make a difference in their lives. User experience is a key component of QI. This mainly is used in identifying those areas in need of improvement and how it might be achieved. Patient safety and other markers of quality care are strongly linked to positive experiences of a healthcare event.
National data source can provide very useful feedback from measures such as the Friends and Family test and the large number of patient reported outcome measures (PROMS) now collected. Locally, both qualitative data collection: patient stories, patient group discussions and more data driven qualitative surveys provide huge insight into both satisfaction but also lived experience of a service.
A recent transformative improvement project in Urology in NHS Tayside greatly enhanced efficiency by creation of improved outpatient pathways and a ‘Onestop’ outpatient and diagnostic centre at Perth Royal Infirmary. Feedback on patient experience in the centre has been overwhelmingly positive. Patient engagement prior to this transformation was by survey aimed at acceptability of the main perceived issue, movement of the regional service to specific hospital, a decision driven by available hospital estate in which to base a high turnover clinical space. Patients responded that travel to a more distant location was acceptable for an improvement in service provision. This is backed up by later surveys of barriers to attendance; patients from more distant locations being less likely to not attend than those living more locally. Qualitative patient stories however highlighted that once on the hospital site the unit is distant from carparks, main entrance and the outpatient check-in. An unreliable lift along the route heightened frustration, not with clinical care but with the visit as a whole. This often means patients are anxious or agitated on arrival in the clinic itself, diminishing the satisfaction of patients and staff. These varying sources of feedback have given a more rounded picture of patients lived experience of the facility. This feedback has informed the next step of the project, a new location, purpose designed for patient flow, close to the patient arrival point in the hospital and other facilities, due to open October 2023.
Patient feedback is by its nature retrospective, although knowledge of reported experience in one setting can inform other improvement elsewhere. This has led to the concept of co-production. This aims to gain the input of patients and carers from the inception a project as equal partners in the processes. This is not an easy ideal to meet, there has to be equity of involvement so as not to increase healthcare inequality.
Better, safer healthcare is enhanced when the voices of those for whom the service is designed are heard throughout the process of continuous quality improvement.
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