A person centred approach to quality · person centred care is fundamental in the delivery of improved quality, as is a lack of understanding of how ... such as dementia care, end

00Picker Institute Europe - Annual Report 2013/14

Annual Report 2013-2014

www.pickereurope.org

A person centred approach to quality

01

The Principles of Patient-Centred CareOur work reflects and builds upon the Picker principles of patient-centred care that derive from empirical research originally conducted by the Picker Institute in the USA.

Fast access to reliable health advice

Effective treatment delivered by trusted professionals

Continuity of care and smooth transitions

Involvement of, and support for, family and carers

Clear, comprehensible information and support

for self-care

Involvement in decisions and respect

for preferences

Emotional support, empathy, and respect

Attention to physical and environmental needs

Contents

2 Foreword from the Chairman and CEO

6 When transparency met clarity

10 Measuring integrated care; from rhetoric to reality

14 Developing reliable measures of healthcare quality: the Friends and Family Test

18 A reflection on personal practice

24 Achieving actionable insight for community healthcare providers

28 Can values based interviewing help deliver better quality care?

32 Commissioning for quality

36 Measures of safety

40 Looking to the year ahead

44 Accounts

45 Board of Trustees

The principles of patient centred care Our work reflects and builds upon the Picker principles of patient centred care that derive from empirical research originally conducted by the Picker Institute in the USA.

Picker Institute Europe – Annual Report 2013/14

Growing in more ways than one My first year as Chairman of Picker Institute Europe has seen new executive leadership in our Chief Executive Dr Andrew McCulloch, previously Chief Executive of the Mental Health Foundation. I am delighted to welcome Andrew as Chief Executive; his long experience of leadership in the healthcare charitable sector and his breadth of international knowledge is sure to be of immeasurable value to the Picker Institute as we continue our mission over the coming years.

Stuart Bell CBE, Chairman

This year we also welcomed our first international board member, Professor Edmund Neugebauer.

Edmund’s career credits to date include; Chair of Surgical Research & Director of the Institute for Research in Operative Medicine, Dean of Research at the Faculty for Health University Witten/Herdecke; Chair of the German Network of Evidence Based Medicine and current Chair of the German Network of Health Services Research.

The addition of both Andrew and Edmund to the Picker Institute demonstrates both the calibre of the individuals chosen to join our team, and the importance and attractiveness of the charity as a mechanism for such individuals to influence health and social care quality.At present the Picker Institute Europe family stands at 55 people, with flagship offices in both the UK and Germany. We have grown significantly over the last 13 years, but one thing has remained constant, our passion for, and impact on the quality of health and social care. 2013-14 saw the board and the wider team committing to this shared purpose through a process of redefining our vision and mission, alongside reiterating our values based culture as an organisation.

We have also continued to grow in terms of reach and impact both in our traditional European health and social care jurisdictions and more widely, with our tools and approach being used to measure and improve care quality on a global level in countries such as Oman and Australia.

Despite this growth there remains much to be done. In many areas there is still a lack of acceptance that person centred care is fundamental in the delivery of improved quality, as is a lack of understanding of how to deliver it.

Whilst we have seen increasing numbers of well-intended initiatives that have proposed bringing peoples’ experiences to the forefront of delivering high quality health and social care provision, these have often been poorly designed and therefore unable to deliver the intended benefits.

As we move forwards, we will continue to work to ensure that health and social care systems are always structured around the needs of the people they set out to serve and that the initiatives and tools used to measure the users’ experiences always result in robust and representative data that are used to improve care quality.

03Picker Institute Europe – Annual Report 2013/14

04 Picker Institute Europe – Annual Report 2013/14

One of the things that first drew me towards Picker

Institute Europe was that it is not only an organisation

focused on people, but more importantly on

empowering people. When I therefore reflect on

my first 6 months as Chief Executive there are two

key areas that stick in my mind; our continued

commitment to people and quality.

Dr Andrew McCulloch, CEO

It is clear the organisation is committed to and succeeding in maintaining the extremely high quality of its work. This is a true reflection of our team. Their passion for furthering the implementation of person centred care, combined with their skill in developing a strong evidence base to drive change in health and social care policy and practice, is second to none. This was made clear to me when each and every one of our team was willing and able to input into the redevelopment of the charity’s vision, mission and values. This commitment and strength of purpose from our team is the driving force behind what has been another solid year for Picker Institute Europe.

We have made significant headway in expanding our reach as a charity. In the private sector our work with providers such as Celesio and leading insurers like Simplyhealth and Bupa International, has supported and galvanised key players in the private sector to adopt an evidence based, user led approach to their service delivery. Internationally we have made significant developments in central European jurisdictions such as Germany, where the focus has been on understanding and developing the potential to use people’s experiences to tackle the issue of safety.

Additionally, our research and policy work has continued to develop knowledge and influence at a system level. In 2013-14 the second phase of our work to establish effective experience measures of integrated care helped to expand this important conversation, developing a questionnaire tool kit to support future service redesign and care quality improvement.

Equally strong steps have been made at the opposite end of the spectrum. Firstly, the formal launch of our Individual Clinician Feedback programme, which supports health and social care professionals to both gather and act on patient feedback that relates to their individual behaviour and approach

to care delivery. Add to this continued developments in the understanding of the needs of specific care groups, such as dementia care, end of life care and children and young people, and we are starting to paint a picture of delivering person catered care that can be understood at all levels whether you are a policy maker, practitioner or patient.

Supporting people to deliver the highest quality across all areas of health and social care will remain at the core of our work moving forward. After all, health and social care is about more than just policies, procedures and practices, it’s about people.

05Picker Institute Europe – Annual Report 2013/14Picker Institute Europe – Annual Report 2013/14

00 00Picker Institute Europe - Annual Report 2013/14 Picker Institute Europe - Annual Report 2013/1406

When transparency met clarity

07Picker Institute Europe – Annual Report 2013/14 Picker Institute Europe – Annual Report 2013/14

Transparency must go beyond simply making data and information available. To be truly transparent there must also be a commitment to ensuring the data are authoritative and accessible.

08 09Picker Institute Europe – Annual Report 2013/14 Picker Institute Europe – Annual Report 2013/14

In short, achieving clarity about what lies on the other side of the wall requires much more than the simple act of making it visible. Transparency must go beyond simply making data and information available. It is also a commitment to ensuring that the data and information are both robust and representative; authoritative. As well as relevant to, and understood by its audience; accessible.

When these three elements exist, the potential benefits of transparency within health and social care are significant. They can:

Increase understanding of the quality and efficacy of care provision, making it easier to hold providers and regulators to account.

Support those delivering care to improve quality by comparing and assessing performance against that of similar professionals and organisations.

Increase people’s ability to make informed choices about their care.

Whether clinical outcomes data, mortality rates, peoples’ experiences of care, or the results of improvement initiatives, sharing these freely allows others to see the data upon which decisions are made, or performance is judged.

Unfortunately more often than not the potential of transparency is undermined by making data available that are neither authoritative nor accessible. When this happens the data can be both misleading and misunderstood resulting in inaccurate assessments and/or poor decisions. We can no longer trust what we are being shown and are left with no more clarity than we had before the data were made available. Heightened levels of public scrutiny and general awareness of differing levels of quality in healthcare are driving an increasing demand for transparency; a trend already evident in other sectors, such as finance and education. Combine this with an unprecedented level of social media interaction that produces a huge amount of anecdotal and informal data, and it has never been more important to realise the potential of and embrace transparency in a health and social care setting. But to improve care quality and allow patients’ to make informed decisions about their own care, transparency has to be built upon data that is more than just available but also authoritative and accessible, whether at an individual or systems level.

When we think of transparency, we often associate it with clarity. For example, using a pane of transparent glass to replace a solid wall in a room gives us the ability to see what lies on the other side of that wall. However, just because you can now see what lies beyond the wall, does not necessarily mean you can understand what is happening or what is present.

Make data availableAllowing this type of open access and scrutiny by proactively making data available, shows that there is nothing to hide. Furthermore, doing this whether or not the data relate to a positive or negative outcome or experience, starts to make it feel like those doing so, are doing so honestly. Add to this openness about the results of any actions taken and the act of making data available can start to build trust, not only in the quality of the care itself, but also the individuals and organisations delivering it.

Ensure data is authoritativeMaking data available, can go a long way in starting to help develop trust in decisions, activity, and behaviour. But how do we know the data can be trusted? For this to happen data need to be authoritative. They must be robust; created using proven methods and tools (whether quantitative or qualitative) where any limitations are known and communicated.

They must be reliable; free from bias and/or unstated outside influences. And they must be as representative as possible, whether revealing the care experiences of a particular group, or the clinical outcomes and mortality rates for a particular procedure. If the data are robust, reliable and representative it is data and information that can be trusted.

Ensure data is accessibleYet for transparency to have real value the data must also be accessible. If we cannot interpret and act on the data that are presented, then all efforts to ensure they are available and authoritative will have been wasted. We must look to present data in a way that is both understood and relevant to those using it, increasing the opportunities for people to engage with them and act on the lessons.

Available

Authoritative

“Transparency is more than just making data and

information available; it is also ensuring it is authoritative and

accessible”

Accessible


Measuring integrated care; from rhetoric to reality A lot is written and said about the importance of integrated care. With growing pressure on health expenditure in many countries, there is considerable demand to develop models of care that are both efficient and effective.



Whilst the term ‘integrated care’ is widely used, it has been the subject of many competing definitions. It’s only recently that policy makers have begun to reach consensus that integrated care should involve systems of delivery where the patient perspective is the organising principle.

In January 2014 we published two reports commissioned by the Department of Health in England, focusing on the measurement of integrated care. Firstly we undertook an options appraisal on the measurement of peoples’ experiences of integrated care.

This study, a collaborative effort by the Picker Institute, the King’s Fund, National Voices, and the Nuffield Trust, concluded that:

Integrated care should be defined as “person centred coordinated care” as per the National Voices/Think Local Act Personal ‘narrative’ on co-ordinated care.

No single indicator was currently suitable for measuring user experience of integrated care.

Existing interim measures, whilst useful for immediate quality improvement, are not suitable for longer term use and the development of a new survey specifically to cover integrated care would not offer value for money.

The recommendation made was to add a small set of questions on integrated care to a range of existing national survey collections.

Developing measures of people’s self-reported experiences of integrated care.

Following on from this options appraisal, the Department of Health commissioned the University of Oxford and the Picker Institute to develop a set of measures that can be added to existing national collections to measure components of integrated care.

The study builds on work previously completed by National Voices to set out the components of person centred co-ordinated care, focusing on measuring people’s understanding and experience over traditional measures of the interactions between the specific services themselves.

In all, a set of eighteen questions was developed, with a smaller number identified as most useful for national indicator purposes.

Further testing is being carried out to ensure the effectiveness of these questions across a range of care settings. However, outside of the UK the research has already been picked up in Canada, Australia and by a number of European countries.

Evidence review

Focus groups

Stakeholder workshops

Cognitive testing with

patients

Final question recommendations

Final questions and response options were developed using a five phase approach:

“We are delighted by the early interest and uptake across such a range of health and social care jurisdictions. It is clear that the

challenge of integrated care is front of mind. Our hope is that the intelligence gained as a

result of effectively measuring people’s experiences of integrated care is used to plan

and implement improvements, in not just experiences but the systems, processes, and

outcomes that shape them.”

Chris Graham, Director of Research and Policy, the Picker Institute


Developing reliable measures of healthcare quality: the Friends and Family TestWhile the importance of monitoring and measuring health and social care quality is now widely acknowledged, developing and implementing reliable measures remains a challenge.


The final results showed significant differences in the way people respond when different methods are used. There were consistent differences in responses related to their age and sex.

For example, when analysing the methods used to collect feedback, online responses were significantly less positive than postcard responses, while telephone responses proved more positive than postcards.

Women were found to give less positive responses than men, while the general likelihood of positive responses increased with a patient’s age, except amongst the oldest age groups (75+).

These differences make meaningful comparisons between organisations impossible. As a result, the Friends and Family Test cannot be used as originally intended – that is, as a “single measure of care quality” and a “simple” means of assessing and comparing services.

Commenting on the implications of the newly published research in June 2014, Chris Graham, Director of Research & Policy at the Picker Institute said “Though the widespread roll-out of the test is impressive, our research shows that it does not deliver against its original ambitions. The Friends and Family Test is fundamentally flawed as a comparative tool, and simply cannot be used as a reliable performance measure – and nor should patients use scores from the test to choose

their hospital.”

While the Friends and Family Test has clear limitations, we support its focus on peoples’

experiences and argue that it has a different value. Whilst answers to the Friends and Family

Test’s closed question may be of little value, many providers have found the comments people leave alongside these to give When analysing the methods used to collect feedback, online responses were

significantly less positive than postcard responses, while telephone responses proved more positive than postcards.


Many NHS services in England are now expected to give every patient the opportunity to complete the Friends and Family Test. The test is based on a single question: “How likely are you to recommend our ward/A&E department to friends and family if they needed similar care or treatment?”

Patients are invited to give a rating from ‘extremely likely’ to ‘extremely unlikely’. Results are collated and reported at ward level every month. Originally, this data was intended to be used to measure and compare the performance of different wards and organisations across the country.

From the outset, the test has met widespread criticism of everything from the structure of the question itself, to the tool’s overall purpose.

A specific area of concern, and one that the Picker Institute has highlighted, relates to the test’s reliability and validity when used as a benchmarking tool and performance management measure.

The Picker Institute conducted an independent study investigating whether patients’ age, sex and the method used to carry out the survey had any significant impact on the results of the NHS Friends and Family Test initiative.

A secondary analysis was conducted on the data collected during the period of April-August 2013. A mixed mode approach had been used and feedback gathered from a total of 38,998 inpatients and 29,610 A&E attendees from 429 wards/units in 32 individual hospitals.

constructive information that helps to target service improvements locally.

The Friends and Family Test can be highly useful for this

purpose, fuelling discussion about patient experience and the awareness of the priorities that matter most to them.

For example, feedback from NHS trusts shows that

patient comments collected via this tool are proving useful

for identifying improvements locally. We should therefore celebrate

this success and focus on making best use of these comments rather than counting

recommendations.

We welcome the recent review (July 2014) by NHS England, accepting the unsuitability of the NHS Friends and Family Test to be used as comparative performance management measure. We agree that focusing on its ability to provide formative feedback to drive local service improvement is the best way to make use of the Friends and Family Test.

The recognition that the Friends and Family Test works best as a tool for collecting formative and localised feedback gives it a useful role alongside other efforts. Meanwhile, the need for high-quality, comparable data on organisational performance is met by other collections such as the long established national patient survey programme. However, in an era where ever more data exists it is vital to remember that it is not the data alone that is going to make the difference.

The Picker Institute will continue to champion the collection and use of the highest quality patient and service user experience data. We will also be focusing our efforts on the provision of support and education services, alongside dedicated improvement interventions, to help those working in health and social care capitalise on the insight gained from their data, ensuring lasting service improvements are realised.

Women were found to give less positive responses

than men, while the general likelihood of positive responses increased with a patient’s age,

except amongst the oldest age groups (75+)

Intended as “a national single measure (for) quality of care”, the NHS Friends and Family Test launched on 1st April 2013, and represents data collection on a whole new scale.


A reflection on personal practice

18

“When you ask, ‘are you a good doctor?’ The answer is, more often than not, ‘yes.’

When you ask ‘how do you know?’ answers can involve anecdotes, cards from patients, exam success, lack of complaints or a proven ability to jump through hoops.

But this information isn’t helpful to a clinician looking to learn why a patient had a high quality patient experience, or how they might identify and target areas for improvement.”

Professor Ben Bridgewater, Consultant Cardiac Surgeon at University Hospital of South Manchester

Picker Institute Europe – Annual Report 2013/14 19Picker Institute Europe – Annual Report 2013/14

Professor Ben Bridgewater, Consultant Cardiac Surgeon at University Hospital of South Manchester, on how individual clinicians assess their own performance.

“Constantly requesting and responding to patient feedback is what makes a good doctor. But this is not something we see happening widely in health and social care. The Medical School experience is based on acquiring and assessing knowledge for future use. Once a clinician is qualified and working, distractions can prevent an individual from learning what it would really take for them to improve as a doctor – pressures, unrealistic targets and applying skills on a mass scale divert from the consideration of how care is experienced from a patient’s perspective.” “Doctors who are already really good at what they do, are given the opportunity to be even better.

My colleagues and I, partnering with the Picker Institute, conducted a pilot at the University Hospital of South Manchester. Every time we saw a patient or performed a consultation, a system automatically identified that patient by name and address, and sent them a questionnaire inviting their comments on their experience.

“Patient experience, feedback

and measurement gives you a specific

direction in how to improve.”


For us as doctors the most seemingly pressing thing we have to do, day-to-day, is ensuring clinical effectiveness and safety. But having these feedback systems in place meant we owned the really relevant, specific information we needed to get better at our jobs. Every time I receive my patient experience feedback and measurement I pick up a different area where I am perhaps not scoring as highly as I could be. As a doctor you say, ‘How can I be better – deliver better care and improve that grade?’ Sometimes it’s by speaking more clearly or providing more emotional support, but whatever the improvement needed is, feedback and measurement gives you a specific direction in how to improve.”

“Patients are looking for increased transparency from the NHS to demonstrate that quality of care is good and getting better. Quality should incorporate excellent outcomes for patients, and good experience of care. This system, pioneered by UHSM, Stockport and Picker Institute Europe, is a great example to the wider NHS. By doing this, organisations will improve the care that they give, and patients, their families and their carers can be reassured about quality.”

Sir Bruce Keogh, Medical Director, NHS England


“Proactive feedback research should be carried out on an appropriate scale – continually.

That way, you will be able to extract a summary of that data and learn from it in terms of best practice, and it will still feed into annual appraisal and five yearly revalidation. I think it’s good that annual appraisals are now essential. I think it’s good that professional revalidation is now essential every five years. I think it’s disappointing that current data processes for appraisal are not robust enough to allow for real, long-term improvement. The motivation for measurement should be that you want the feedback to do a better job, not because if you don’t do it every five years you won’t get the revalidation you need to practice.”

“There seems to be a culture where the people dealing with potential problems in the quality of care have to believe beyond reasonable doubt that there is a need to act before any action can be taken. This belief is totally out-of-sync with patient reality. We need to change the concept of clinical professionalism to be about individual doctors delivering an even better consultation to their next patient, and the patient after that, and the patient after that…”

The Picker Institute has already run Individual Clinician Feedback programmes with practitioners at the University Hospital of South Manchester (UHSM), the Stockport NHS Foundation Trust, Lancashire Teaching Hospitals NHS Foundation Trust, as well as a number of GP practices across the country.

Teaching TeachersThe Oxford Deanery, NHS Health Education, Thames Valley

The concept; better teachers improve the quality of the clinicians they teach, and in turn, the experiences of patients treated.

The purpose of Individual Clinician Feedback at The Oxford Deanery was to provide trainee doctors with the opportunity to respond to their training experience: not only their training from named Educational and Clinical Supervisors, but from any clinician providing daily formal or informal training. The organisation gained insight into its learning environments, seeing where good teaching practice was occurring and which areas required attention. Individualised reports to consultants clarified where they excelled and where they could improve.

On working with us at the University Hospital of South Manchester; Ben Bridgewater comments,

“It’s excellent that NHS England now recognise the importance of measuring the quality of care. This is the first hurdle. But we have to get better at using those measurements – how we do it, how frequently we do it and whether we are asking the right questions. Which is why I think Picker Institute Europe are such a fantastic organisation, and why I think they are playing a key role in transforming healthcare services, through measurement.

They understand that patients should be at the heart of everything a doctor does, and deliver the materials and programmes to get that understanding back at the top of the priority list and help it bring about action.”

In the future, Individual Clinician Feedback will have further uptake, and also be tailored to help distinctive doctoring groups working in contrasting clinical specialisms; such as paediatrics, geriatrics and psychiatry. Its tools and methodologies will be adapted for these groups to enable reliable feedback that supports real improvement in the quality of care.

Contact us at [email protected] to find out more


Achieving actionable insight for community health care providersWhen the services you provide range from paediatric care through to offender health, measuring their quality becomes increasingly difficult. Different resource requirements, locations and staff skills all need to be recognised and taken into account. However, one thing remains constant; the people. It is their experiences of care that can hold the key to unlocking service improvements large and small.


When care services range from district nursing to palliative care and offender health, an intimate knowledge of how to access and measure each group’s experiences is required. The Health Experiences team at Picker Institute Europe is dedicated to this task, focusing on developing the knowledge and tools required to understand and measure peoples’ experiences regardless of their care needs or setting.

During 2013 Central London Community Healthcare NHS Trust (CLCH) the largest community healthcare organisation in London, approached us to design and deliver an effective patient experience feedback programme.

CLCH provide

community healthcare services in four London

boroughs across 64 different service delivery units, seeing more

than 150,000 people each year in over 160 sites. Their community healthcare includes an extremely wide-ranging

array of services, from paediatric wards to offender health units,

from podiatry practices to sexual health clinics.

Community healthcare encompasses a huge variety of services. Securing robust, reliable and representative data to understand and measure patient and service user’s experiences in this setting can become highly complex.

“It is a refusal to accept the tick-box dataset status quo that marks the Picker Institute out from the rest... Using the best methods and available technology to extend this passion across professional and patient communities is what the Picker Institute do best.”

Ian McDowell, Head of Patient and Public Engagement, CLCH, 2013


The aim was to enable CLCH to collect high quality patient experience data from across their organisation, supporting staff to act on the intelligence gained to improve care quality.

“Initially a key challenge was to help the trust understand that collecting experience data through a range of technologies most appropriate for each service user group, would ensure the most robust and representative data. However the trust needed to accept that in doing so they would not be able to reliably compare across services that used different data collection methods. It was agreed, whilst a trust wide overview was important, the focus for CLCH was achieving excellence in the delivery of each and every service, so high quality data at the service level was the top priority.“

Bridget Hopwood, Director of Health Experiences, Picker Institute Europe

In order to ensure service user groups had access to the most suitable feedback tools we created a hybrid system of paper, telephone, online and smartphone surveys. Collecting both qualitative and quantitative data, described by CLCH’s CEO James Reilly as “getting the basics right while remaining relentlessly innovative.”

Choosing an approach that is right for the service user has resulted in consistently strong response rates from patients across service delivery units. With findings uploaded onto the trust IT system, staff are able to quickly access, assess and act on intelligence.

“It’s about getting the basics right while remaining relentlessly innovative.” James Reilly, CEO, CLCH

For example opportunities to help reduce falls were identified, with the trust introducing “ward deep dives” and creating “patient stories” to better inform staff and patients of the risks and actions to take to avoid them.

The Picker Institute were also able to support the trust to harness the power of free text comments, introducing coding, using a “sentiment analysis” approach to highlight key areas of excellence and those to be improved.

“Some of the low-cost changes are really inspiring. Psychological Services bought sweep second hand clocks for waiting areas because anxious patients were becoming agitated by ticking second hands. Child friendly maps and clock faces are being added to appointment letters in Children’s Services to make them more accessible. The Friends and Family Test question is being animated to make it accessible for people with learning disabilities. All of these changes have only been possible due to the high quality feedback data we are now getting from our patients and service users.”

Ian McDowell, Head of Patient and Public Engagement, CLCH, 2013

The Picker Institute are proud to continue to support CLCH as they endeavour to deliver the highest quality care for all their patients and service users. We continue to work with a variety of community providers to support their patient and service user initiatives. For more information please visit www.pickereurope.org or email [email protected]


Can values based interviewing help deliver better quality care?Those choosing to work in health and social care often describe their choice as a vocational commitment; a personal drive to care for others when they need it the most. When values seem to be such a motivating factor in peoples’ decision to work in this setting, we ask whether focusing on matching individual and organisational values in the recruitment process could help improve care quality?



For the hospitals receiving an inadequate quality rating, only 52% of staff reported they would be happy for a friend or relative to receive the standard of care provided by their employer. This compares with 66% of staff in those hospitals rated as good and 85% rated as outstanding.*

It is no secret that organisations with more engaged staff, who report better work experiences, are more productive and deliver better quality care. However, staff are identified and recruited to health and social care organisations using a wide range of different techniques and using different criteria, some with more success than others.

While there is no way to know whether an employee will thrive in a role or certain work environment, rigorous interview procedures should provide guidance and indicate whether or not a candidate really is the right person for a specific job. Aligning potential employees to an employer with a focus on common values, motives and attitudes is a practice known as values based interviewing.

In 2013 the Picker Institute worked in partnership with Oxford University Hospitals to conduct a study into the impact of using values based interviewing to recruit new staff. The work set out to show that the values based interviewing:

enables recruitment decision-making aligned with the Oxford University Hospitals values;

provides robust evidence to minimise “gut feelings;”

helps obtain more information about candidates’ suitability; and,

contributes to safer recruitment and selection practice internally and externally.

The study both uncovered and evidenced the potential benefits of the values based interviewing approach to recruitment, offering recruiting organisations the opportunity to underpin and share their commitment to organisational values.

The aim of the value-based interviewing (VBI) approach is to recruit people into the Oxford University Hospitals who share the organisation’s values ensuring that they are dedicated to “Delivering Compassionate Excellence,” an approach where they deliver the type of care they would like to receive for themselves or a member of

their family. Further aims include the absorption of their core values across the whole organisation and the ability to evidence values in practice in a

common organisational culture.***

In 2014 the regulator for the English National Health Service (NHS) rated hospitals across the country from outstanding to inadequate, which was then linked to staff members’ feelings about their place of work using data from the national NHS staff survey.


Crucially, it also helped those organisations to select candidates, not just because they have the correct competencies or skill-set required for a role, but because they have the right attitudes and motivations.** The pattern of responses was the same between the two groups. This was a key factor as despite using different methods of recruitment, the staff experiences were not in themselves different. It was the reported positivity of those same experiences that varied.

On every question on the Welcome Questionnaire, staff who reported that they had a values based interview were more positive about their experience than those who did not. Staff reported more positively in areas such as:

managers and colleagues;

career advancement; and,

how their roles contribute to organisational success and delivering compassionate excellence.

Staff were asked about their intended length of stay as employees and on average, a staff member hired using a values based interview intended to stay 2 years and 7 months longer than one hired as the result of a non-values based interview.

Managers reported in appraisals for staff recruited using values based interviewing a high propensity to:

treat people with dignity and respect;

fit in with the team and organisational culture; and, role model the values of Oxford University Hospitals.

By employing people with the focus and values to match that of their employer, health and social care organisations are more likely to maintain a more engaged and committed workforce. But perhaps more importantly, these staff will possess the attitude and behaviours needed to deliver high quality, attentive care in challenging, pressurised working conditions. Without question, good news for the care service, but even better news for the people who rely on it.

These results only consider a single organisation over a set period of time, and we present them as a suggestion of potential benefit. We look forward to adding to this early research, covering different organisations, longer term assessments and potentially adding patients’ experiences in to assessments of individual clinicians.

If you are interested in finding out more please contact us at [email protected] or visit www.pickereurope.org

The study measured staff responses using the following mechanisms:

• A “Welcome Questionnaire”, which asks all new starters about their experiences at the OUH.

• The results of values based interviews carried out during the period, as noted by the interviewer.

• An evaluation of staff who were hired using a value based interview (VBI) by their manager, approximately 12 months after they were hired.

*http://bit.ly/1uvwddW **http://bit.ly/1vEHBuJ *** http://bit.ly/1v2QOvj

Commissioning for qualityTraditional audit measures can go a long way towards supporting better commissioning decisions. However, to truly understand and improve the quality of health and social care services we must listen to and act upon the experiences of those that use them.



Ultimately, a service being commissioned and ‘available’ did not necessarily guarantee patient accessibility. The first project revealed that, whilst on the surface the CCG was providing and tailoring services to each community group’s individual needs and requirements, when probed in more depth there were many avoidable glitches in the details that were collectively causing fundamental roadblocks to the quality of the care services available.

Translation services were a communication issue that affected two prominent ethnic communities. Participant data showed that 98% of one of the CCG’s ethnic groups spoke one regional dialect; however the translation services for these communities were provided in another. Though ‘quality care’ was available to them, it was basically unattainable, as they were unable to understand the language it was provided in or to read the available translated health literature. The results went on to reveal valuable insights for clinicians and commissioners as to the quality and

effectiveness of the support services they were commissioning. Translators were perceived

by the patients, (who were supposed to benefit from them), to be more of a

hindrance than a help: Complaints included taking “too active a

role in consultations” and “not relaying patient

feedback correctly.”

Service user experiences of specific conditions, care services and how they navigate care pathways need to be accounted for and understood when developing commissioning strategies. Even after commissioning decisions are made peoples’ experience of care services remain a key component in informing the quality of and access to the commissioned services themselves.

In 2013 the Picker Institute worked with two of London’s largest Clinical Commissioning Groups (CCGs) to improve primary care quality in the area by studying patients’ experience of access to local services. Although the objectives and approaches of each project differed, the findings revealed common themes, such as appropriate communication, service flexibility, support and education, all playing a massive role in a patient’s choice to use, or in some cases, not use a service.

With reports of translators’ comments like; “don’t be too much trouble” and “you can only discuss one problem”, leaving patients’ feeling like a service burden, rather than a priority.

The CCG was also able to identify the potential training required for front-line staff to improve care delivery. Effective communication and engagement were revealed to be affecting other patient group relationships and impacting service accessibility, especially for Lesbian, Gay, Bi and Transgender communities (LGBT). Some patients complained that they felt they had to “teach” their GP and other healthcare professionals how to speak to an LGBT person. This apparent stigma and discomfort often resulted in them going to their local LGBT forum for medical advice instead of, or before, visiting their GP directly. Even if LGBT specific services were apparently provided, they were not trusted. A similar story was evident for Mental Health services where service users report difficulty in speaking with their GP about mental health concerns and in securing referrals.

The second project looked at the use of unscheduled care services from the patients’ perspective. Both appropriate and effective communication alongside flexibility were revealed as a massive patient concern and a key motivation for the over use of unscheduled care services.

A lack of flexibility in obtaining appointments and the way that such appointments could be booked especially for ‘working people’ were found to be key factors in why patients’ chose A&E or a walk-in centre over a GP. However, some patients maintained they would use A&E regardless of other services available if they felt significantly concerned about their health.

Factors outside of the healthcare setting were also shown to impact burden on urgent care services and need to be addressed when commissioning care. This highlighted the need for the CCG to establish better links outside of a primary care setting and to utilise wider networks such

as Health Watch to support education. For example, a high volume of A&E referrals were found to be being

made by local schools and this likely played a part in the number of inappropriate A&E referrals.

From the results the CCG were able to see the need for better education

around the purpose of A&E, and when and when not to

attend. However, when a community service was well known and trusted it was seen as a first choice for patients, demonstrating the importance of not only establishing effective

options for patients to access urgent care

services, but the fact that effective commissioning can

have an impact on reducing burden on local A&E departments.

Of all the urgent care services in the CCG, a long-standing, local out-of-hours GP service

was – excluding the patient’s own GP surgery – revealed to be the most widely understood and trusted service in the area. Improvement recommendations included expanding that model, by labelling walk-in centres with a similar branding, to help to build awareness of other available unscheduled care options. If awareness and trust of a particular service were not achieved, the study showed that patients would bypass that service regardless of quality.

While national initiatives have a greater impact in terms of the number of organisations they affect; realistic, long-term progress requires individual service providers and CCGs to uphold their responsibility for improving the quality of the care available. Each individual organisation must take the opportunity to reflect on their current services, working with the patients to address the community concerns that impact their primary care experience and will deliver long-term quality improvement solutions. In short, patient involvement in healthcare improvements can be the difference between getting the commissioning balance right and getting it very wrong.

The effective commissioning of a health and social care service is a significant challenge. Decisions around service availability, quality and utility are often complex and multi-layered. But it becomes increasingly difficult for commissioners to provide high quality services, if they are not in touch with the experiences of the people using, and in need of them.

Often healthcare providers think they know what

patients want from a health and social care service, but often the gap between their perception and “getting it right” is bigger than health

professionals think.


Measures of safety With clinical risk management systematically incorporating the evaluation of complaints and adverse events, it poses the question of whether safety measures can be improved by focusing on peoples’ experiences of care?



do have poor experiences of healthcare and that many people want to complain about this: but we don’t know enough about how ‘lower level’ complaints, particularly verbal complaints, are being handled and resolved on a day-to-day basis. Because of that, it’s clear that the recorded numbers of written complaints are a poor basis for estimating quality of care.”So how can peoples’ experiences act as an effective marker for safety?

For example, on the usefulness of measuring the number of recorded complaints as a measure of safety, Chris Graham Director of Research and Policy shares: “There are undoubtedly many more complaints made verbally and never recorded. But it’s difficult to make any meaningful estimate of how many people feel ‘unable’ to complain for whatever reason: there are too many confounding factors and the data we have is too limited. It’s clear that a very sizeable number of people

Research from the Picker Institute Europe team based in Hamburg has started to answer this question. Patient experience tools have been used to highlight feedback across three key areas that relate to patient safety: Communication

Medical complications

Care process Communication failure is often the root cause of many adverse events, and remains one of the main reasons for patients feeling both unsafe and complaining about health professionals. Experience data in this area help providers highlight whether staff are communicating in a way that is understood and whether information was given in a comprehensive and timely manner.

The insight in relation to effective communication goes further, providing evidence as to whether information was adequately communicated in key areas relating to successful discharge. These include information on medication and side effects, danger signals, and appropriate activity levels post discharge. Similarly, patients are able to report back on medical complications such as infections, falls and correct drug administration, alongside feedback relating to the care process itself. Reporting whether their medical history and case file were ready at admission through to hospital cleanliness and hand hygiene. When it comes to safety this perspective is vital. Whilst an audit log may state that the information about medication and side effects had been given, if care users report that the information was either not communicated in a way they could understand or that they cannot recall receiving the information, we have a significant difference in reported versus actual quality of service.

A recent Picker Institute study carried out at a large German teaching hospital showed more than half of all patients reporting that they did not receive enough

information about medication and side effects, nor when to resume normal daily

activity. Here the potential for an adverse event is identified as

higher than would be normally recorded through a standard

service led audit.

Of this work, Katja Stahl Head of Product Development and Research comments:

“Looking at patient experience data with

a focus on safety has highlighted how important

this type of information is. The insight gained in regard to quality

of communication, process and practice helps us to uncover areas most

likely to be a factor when it comes to peoples’ safety. Regularly collecting and acting on such evidence plays a key role in preventing issues in the first place. This has to be the priority over responding to issues once they have happened.”

We will continue this work, supporting further measurement as to the success of improvement initiatives undertaken on the back of the initial research in Germany. More broadly, we aim to share this approach across other healthcare systems and to share findings alongside our work in both real-time and individual clinician feedback. Routinely measuring peoples’ experiences in this way not only helps to support traditional audit process in identifying when events or interactions did or did not happen, but provides an additional measure of their effectiveness versus actual quality and risk.

Despite the fact that patients are willing and able to feedback on patient safety issues, often traditional measures of tracking complaints and complaint resolution can fall short of being representative.

Routinely measuring peoples’ experiences in

this way not only helps to support traditional audit

process in identifying when events or interactions did or did not happen, but provides

an additional measure of their effectiveness and therefore

their quality.


Looking to the year aheadAs we look towards the year ahead at Picker Institute Europe, we are presented with an opportunity to take stock of all that we have achieved to date as a charity. A time to both celebrate our successes and ask ourselves the all-important question; where do we go from here?

40 Picker Institute Europe – Annual Report 2013/14 41Picker Institute Europe – Annual Report 2013/14

In the UK we are proud to have played a major part in embedding patient experience as one of the three key markers for quality care, designing and establishing the first ever NHS national survey programme for patient experience. In mainland Europe our work has established a foot print for a person centred approach to care delivery in Germany, Austria and Switzerland. Combine this with dedicated work in the needs and experiences of specific types of care users and we have started to develop the understanding and measurement systems to really affect change.

When reflecting on the last decade at Picker Institute Europe we have seen:

An acceptance in major health jurisdictions such as the USA and the English NHS that people’s experiences are a fundamental part of care quality alongside clinical effectiveness and safety.

The realisation and continued implementation of national level quality initiatives such as HCAPS in the USA and the regulator led NHS patient experience programmes.

When Picker Institute Europe was founded back in 2000, it was tasked with extending the excellent work already started by Picker Institute Inc. in the United States, to European healthcare systems. That work meant fostering a broader understanding of the theoretical and practical changes needed to implement a person centred approach to healthcare.

VISION:

The highest quality health and social care

for all, always.

MISSION:

We are here to:

Influence policy and practice so that health and social care systems are always centred

around people’s needs and preferences.

Inspire the delivery of the highest quality care, developing tools and services which enable all

experiences to be better understood.

Empower those working in health and social care to improve experiences by effectively

measuring, and acting upon, peoples’ feedback.


The development of high quality tools to measure those experiences, deployed across health jurisdictions around the world.

An increased awareness and understanding of lesser heard groups experiences of care, from children and young people to people living with specific long-term conditions.

Yet developing the understanding of, and case for person centred care, is only half of this story. While we continue to build knowledge in this area, we must also increase our efforts to translate this into real improvements in the quality of health and social care. This is reflected in the redevelopment of our vision and mission, ensuring we are both aligned as a team and clear in sharing our purpose with the outside world.

Over the next year one of the main organisational priorities will be embedding a better use of the robust quality information already available. Where it is not available, we will ensure the focus remains on the appropriateness of new initiatives and the quality of their outputs.

Our programme to develop an increased understanding of peoples’ needs and experiences of care will continue to grow. Projects are already planned in condition specific areas such as sickle cell disease, child and adult mental health, dementia, end of life care and transition.We will also be launching an international improvement initiative in collaboration with the Institute for Healthcare Improvement called Always Events™*. Alongside this we aim to further develop our already impactful work, using peoples’ feedback to drive improvements in both personal practice and safety.


Accounts Board of Trustees PatronSir Donald Irvine, CBE, MD, FRCGP, FRCP, FMedSciEx-President of the General Medical Council, UK ChairmanStuart Bell, CBEChief Executive of Oxford Health NHS Foundation Trust TreasurerChris Gale, FCMAChief Financial Officer of Allocate Software Members of the BoardDr Ann Abraham, BA Hons, DMS, Hon LLDNon-executive Director of Health Education England Professor Ben Bridgewater, PhD, FRCS, (CTh)Consultant cardiac surgeon, University Hospital of South Manchester Professor Gillian Hundt, MA, MPhil, PhDProfessor of Social Sciences in Health, University of Warwick Univ.-Prof. Dr. Prof. h.c. Edmund A. M. Neugebauer Chair, German Network of Health Services Research Professor Mike Pringle, CBE, MD, FRCGP, FMedSci, FRCPHon, FFPHHonEmeritus Professor of General Practice at the University of Nottingham Madeleine Wang, BAPatient advocate

2014 2013

All Funds All Funds

£ £

Income resources

Incoming resources from generated fundsInvestment income 30,553 50,285

Incoming resources from charitable activities

Surveys and survey development 4,208,519 3,885,797

Research 242,260 395,510

Quality improvement 170,262 216,797

Policy - -

Total incoming resources 4,651,595 4,548,390

Resources expended

Charitable activities

Surveys and survey development 4,325,477 3,973,083

Research 183,594 218,597

Quality improvement 159,481 473,688

Policy 97,927 104,542

Governance costs 31,995 37,379

Total resources expended 4,798,474 4,807,290

Net incoming/(outgoing) resources (146,879) (258,900)

Translation costs (2,763) 1,104

Net movement in funds (149,642) (257,796)

Total funds brought forward 1 April 2013 2,736,292 2,994,088

Total funds carried forward 31 March 2014 2,586,650 2,736,292

Picker Institute EuropeBuxton Court3 West WayOxford OX2 0JB Tel: + 44 (0) 1865 208100Fax: + 44 (0) 1865 208101 [email protected]

Charity registered in England and Wales: 1081688Company limited by guarantee registered in England and WalesCharity registered in Scotland: SC045048

Documents

A person centred approach to quality · person centred care is fundamental in the delivery of improved quality, as is a lack of understanding of how ... such as dementia care, end