1. www.england.nhs.uk
Does the NHS measure quality
effectively and reliably for
people with mental health
conditions and / or a learning
disability to deliver positive
experiences of care?
Scott Durairaj Head of Patient
Experience: Mental Health &
Learning Disability
Head of NHS England Workforce
Equality and Inclusion
June 2015
3. www.england.nhs.uk
1 Hitting the Target
Missing the Point
2 Features of NHS
Quality
3 NHS model
4 Latent Errors,
Healthcare Deviation
5 Dimensions of
experience
6 Interlude: you have a go
7 Metric can portray a
truth
8 Transformational
Change
9 Considerations for
improvement
Contents
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Patient Experience – NHS Model
There isn't a model – but often a pattern
The size of a Trust, dispersal of sites, history, demographics and
corporate culture play a huge part in how well the work is
undertaken.
Critical success factors include:
• Clarity of the patient experience team’s role and purpose
• Embedded within wider Strategic governance and
performance structures (e.g. service improvement, corporate
services, Clinical and medical leadership and communications,
membership and volunteering, Complaints or PALS
information services)
• Supportive culture - leadership
• Ability to make space for work on service improvement (rather
than merely focusing on data gathering and reporting)
10/07/2015
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The purpose of the paper was to analyse how the NHS
measures quality in general with an emphasis on how
this relates to people with mental health conditions or a
learning disability.
The examination of academic and policy research
demonstrates a significant lack of research into quality
for people with mental health conditions or a learning
disability in an Healthcare setting.
The paper also suggests that quality measurement
research is often focused on the metrics used and
minimum compliance standards rather than the
cultures and values that would lead to innovation and
improved quality of care.
Research Purpose
I Feel…..
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‘What begin as deviations from standard operating rules
become, with enough repetitions, ‘‘normalized’’ practice
patterns’ (Vaughan, Gleave, & Welser, 2005).
At this juncture, personnel no longer regard these acts as
untoward, but rather as routine, rational and entirely
acceptable. These latent errors become entrenched in the
system’s operational architecture and dramatically enhance its
vulnerability when a future, active error is committed. (Banja,
2010)
Staff who may be well trained and well meaning can find
themselves working in an environment where their colleagues
and teammates are ambivalent to health or professional
standards, feeling that they get in the way of effective clinical
practice; in many cases some of the deviances highlighted are
perpetrated “in the best interest” of the patient. However the
cumulative outcome of this type of organisational culture can
lead to systemic quality and safety failures.
Patient Experience – NHS Model
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It is useful to note the research of Grönroos (1993)
who suggests that service attributes might be divided
into two groups:
Functional (process) such as ambiance and provider
attentiveness that describe how the service is
delivered; and
Technical (outcome) such as outcomes that describe
the quality of what is delivered.
Developing understanding
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Carman’s paper empirically investigates acute hospital services
and demonstrates that consumers evaluated the technical
dimensions of nursing care, physician care and outcome as
more important than the functional accommodation of hospital
environments.
He suggested that the six dimensions that seemed to offer the
greatest reliability in measuring quality accurately across studies
were: nursing care; accommodation; physician care; food
service; preparation for discharge; and outcome (health status
after hospitalisation)
Patient Experience – Dimensions
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Interlude: What's the solution ?
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2015
1. Numerous complaints and PALS approaches complaints of Bins
slamming shut at night, disturbing patients sleep
2. Patients negatively commenting on that whilst they are stuck in bed the
only thing to look at is a clock placed right in front of them
3. Patients complain about the noise staff make at night
4. Patient experience from Bevan ward is very sporadic from very bad to
very good, we cant make any sense out of it
Consider what needs to be done, with who, how and where and how do you
report progress?
Consider Transactional change V Transformational Change
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The literature suggests there is a need to dimensionalise
categories of care quality measurement, that will enable
organisations to focus on specific areas for quality improvement.
Accommodation or estates and facilities were not as important in
patient opinion from the research yet this is often given a high
priority in healthcare quality improvements, perhaps because it’s a
tangible measure and change.
Pros and cons of “you said, we did”
Positives Potential challenges
Increases staff motivation Doesn’t explore underlying issues
Build patient/SU confidence One ward/department at a time?
Demonstrates action/listening Focus on transaction rather than
transformational change
Tangible Focus on the less important but
easier to identify
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Friends and Family Test
FFT results is a great resource to gain the rich
information from the free text. How that information is
‘processed’ is key to driving real improvements for all
patients.
One of the consistent features of quality that
emerges from retail and healthcare research is the
importance of personal relationships and clinical
or medical interactions for a meaningful measure
and perception of quality from the point of view of the
patient or service user.
This factor increases with the length of contact
involved, which is a important consideration for
interpreting FFT within inpatient areas.
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A total of 1,080 words were themed. Each word was
only themed once under each model. An NPS score
was applied as an indication of the performance for
that data set against A&E, Inpatients and then the
two departments combined.
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Figures 23 and 24 demonstrate the same data set and breakdown the percentages of promoter, passive
and detractor responses. In Carman’s adapted healthcare dimensions, ‘health outcome’ received the
most detractors, whereas ‘food quality and service’ received the most passive responses, which ties in
with Carman’s finding that technical aspects of care are more important than affective aspects.
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2015
• Gathering an ever-increasing amount of data
• Coordinating and keeping up with data-related activities
across the organisation
• Bringing data into one place or inputting it into central
systems
• Keeping up with reporting requirements and ad-hoc
requests for data
• Having the time to make sense of data (particularly
qualitative, and that coming via informal routes)
• Capacity and capability to analyse data and generate
insights
• Engaging staff in improvement work
Patient experience challenges:
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• Making relevant data available at team and ward level
• Persuading staff that patient experience is as valuable
as – and can contribute to clinical outcomes and safety
• Supporting and engaging with staff – building
relationships and using influencing skills
• Project-based approaches whereby staff carry out
patient experience work (gathering and using data)
• Local leadership – from clinicians and/or senior
managers
• Involving patients and carers in dialogue about what
data means and what can be done about it
There are many things that can
help:
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Patient Experience Suggestions
1. Ensure your FFT and patient experience efforts are inclusive and accessible
2. Results used beyond ward or department – strategy
3. What transformational change is required
4. Organisation patient experience results mapping (free text)
5. Consider dimensionalising the free text
6. Consider how you address and report progress on intangible
7. How does patient experience results map to SUI / Staff FFT / Infection rates / Staff sickness /
Agency spend in department or ward / Complaints
8. Do your other strategies / business priorities help or hinder?
9. How can you limit CIP (Cost Improvement Plan) effects on staff and patient experience
10. Examine weekend quality data separately
See the ‘Making FFT Inclusive’ resource: www.england.nhs.uk/ourwork/pe/fft/fft-inclusive/
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“You may never know what
results come of your action,
but if you do nothing there will
be no result”
Mahatma Gandhi
“You may never know what
results come of your action,
but if you do nothing there will
be no result”
Mahatma Gandhi
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Thank You
Scott Durairaj
Head of Patient Experience
Mental Health and
Learning Disability
Nursing Directorate |
NHS England
Mobile: 07876 851794
(Text Relay calls welcome)
E-mail:
scott.durairaj@nhs.net
28
@ScottDurairaj
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Recommendations From Hitting the Target Missing the
Point
1. Commission further research to establish whether staff FFT experiences
can be ‘dimensionalised’ or themed to allow comparative analysis with
service user FFT
2. Review available service user led quality measures for Learning Disability
services to evaluate the appropriateness for the NHS with a view to
developing a model to empower individuals and improve care quality that
could then form part of a commissioning standard.
3. Commission further research into measuring the experiences of people
with mental health conditions and / or a learning disability using co-
located services (e.g. Psychiatric liaison teams within A&E or GP practice
based community psychiatric nurses)
4. Commission further research into the cultural experience of patients with
mental health conditions and / or a learning disability and the value placed
upon different healthcare dimensions and aspects of care that may
straddle more than one dimension (e.g. the appropriateness of single-sex
accommodation within inpatient settings for transsexual patients, or the
experiences of food quality for observant Muslim and Jewish patients)’).
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5. Commission further research the effects of literacy, cognition,
English verbal capacity and clinical and emotional factors upon
adopting a keyword approach to analysing and understanding
mental health and learning disability service user experience.
6. Commission research into effective ways for staff to identify,
report and understand deviations from safe practice (‘latent
errors’)
7. Review commissioning intentions to ensure that services for
people with mental health conditions and / or learning disability
measure healthcare quality in its entirety (especially patient
satisfaction) and that these intentions align with financial
incentives to encourage cultural change.
8. Trial analysis of mental health and learning disability service
users' FFT experiences to test the validity of the adapted Carman
healthcare dimensions to report the free-text and NPS
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9.Follow-up review in 6-12 months with Healthcare Communications
UK and the 36 trusts receiving FFT reports using the 6Cs and
Carman’s adapted healthcare dimensions to analyse how patient and
staff FFT data was used to implement and deliver improvements.
9.Conduct a trial of the NHSERVQUAL (Appendix 4) service user
quality measurement tool and further adapt it for use by people with a
learning disability. ‘Easy Read’ format would also benefit some people
with mental health conditions.
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SERVQUAL
Works on the basis of a
disconfirmation paradigm
that reflects the fact that,
to understand satisfaction
or dissatisfaction of a
service user, one needs
to determine the degree
of confirmation or
disconfirmation of the
expected experience of a
service in light of
the actual service
experienced. That is,
service users are asked
to judge the service in
advance of using it and
again discharge
