Putting compassion back – improving the experience for staff and patients

Influencing and coordinating respiratory care in London

June 2013

NQB/DoH definition of patient experience (after the IoM and Picker)• Respect for values, preferences, and expressed needs• Coordination and integration of care• Information, communication, and education• Physical comfort• Emotional support• Welcoming the involvement of family and friends• Transition and continuity• Access

Patients’ experiences are a mix of the ‘what’ (T) and the ‘how’ (R)

• Respect for values, preferences, and expressed needs (R)

• Coordination and integration of care (T)

• Information, communication, and education (T+R)

• Physical comfort (T)• Emotional support (R)• Welcoming the involvement of

family and friends (T + R)• Transition and continuity (T)• Access (T)

Transactional (T) and relational (R) dimensions of care

relational

tran

sacti

onal

3

High

Low High

The combination of transactional (T) and relational (R) dimensions is often difficult

High

HighLow

T

R

Efficient and impersonal

Efficient and warm

Chaotic and rude, indifferent

Chaotic and warm

Staff experience and patient experience are linked

Management & quality of HR practice linked to mortality and other quality measures (West et al (2009)

National staff & patient experience surveys: the two sets of experience are related (Raleigh et al 2010)

Quality of staff experience precedes quality of patient experience (Maben et al 2012)

The health care professional does a job, and for many people this job is pretty mundane. They’re doing the same kind of thing to the same kind of people pretty well every day. So for them that activity becomes completely routine. And some days rather dull

The health care professional does a job, and for many people this job is pretty mundane. They’re doing the same kind of thing to the same kind of people pretty well every day. So for them that activity becomes completely routine. And some days rather dull

“The health professional does a job, and for many people this job is pretty mundane. They’re doing the same kind of thing to the same kind of people pretty well every day. So for them that activity becomes completely routine. And in some cases rather dull.

For the individual patient it’s anything but that. Every individual that comes through a hospital is apprehensive. It’s a strange place, you lie in a strange bed, you have strange sheets, you have odd tea in a plastic cup. The whole thing is vibrantly different.”

The perennial ‘existential’ problem

6

Dr Kieran Sweeney GP, academic, patient

“Mesothelioma: A patient’s journey”Sweeney, Toy and Cornwell: BMJ 2009

H

PATIENT– FOCUSSED IMPROVEMENT METHODS

Patient and Family Centred Care (PFCC) and Experience Based Co-Design (EBCD)

Key activities1. Shadowing patients / structured

observation/interviewing and filming2. Setting patient based goals3. Using driver diagrams to decide what to do4. Using measures for improvement5. Working with patients on the changes

Mapping process and touch points

Measures tell teams how they are doing- COPD example

Indicator Frequency Numerator Denominator Target

% pts discharged from resp. ward

Monthly No of pts discharged from res ward

Total no discharged from trust with COPD acute exacerbation

70%

% of pts who some offered smoking cessation

Monthly No of smokers offered cessation

No of smokers 100%

% pts with COPD with low BMI offered referral to dietician

Weekly No of pts with MUST scores referred to dietcn.

No of pts. with MUST scores

100%

% offered emergency oxygen correctly

Weekly No of pts with correct oxygen adminstrtn

No of pts with COPD

100%

Pts with confidence in team

Monthly No of pts with confidence

No of pts with COPD admitted

100%

% pts offered GP/practice nurse follow up in 2 weeks

Monthly No of pts offered follow up in 2 weeks

No of COPD admissions

100%

H

In S London, the priorities of patients with breast and lung cancer were different

Lung cancer Breast cancerCommunication of

diagnosisFunctioning of day surgery unit

Information about treatment

Appointments system and conduct of OP clinics

Continuity and coordination of care

Communication

Information about symptoms

H

EBCD improvements at Guys and St Thomas and Kings College Hospital

Over 40 changes in service delivery for both lung cancer and breast cancer patients, including:1. Guidance on the correct procedure on tests and

diagnosis included in junior doctors’ induction2. Referral on diagnosis to lung Clinical Nurse Specialist

(CNS) for information and support3. New space for communicating diagnosis and CNS support4. Patients called to day theatre ‘just in time’5. Customer care training of receptionist and clerks6. A new space in OP for breaking bad news

www.institute.nhs.uk/theguide

Schwartz Center Rounds: space for reflection

Impact of Rounds

› Evaluation shows that Rounds have a positive effect› For individual› For teams› For organisation› Increased impact over time

Sanghavi DM (2006) What makes a compassionate patient-caregiver relationship? Joint Commission Journal on Quality and Patient Safety 32(5): 283-292.

Lown, BA, Manning, CF (2010) The Schwartz Center Rounds: Evaluation of an interdisciplinary approach to enhancing patient-centred communication, teamwork and provider support. Academic Medicine 85(6).

Format of Schwartz Round

• Lunch is offered before the start• Presenter/presenting team talk for 10-15

minutes • The audience is asked to share their thoughts,

ask questions, offer similar experiences • The discussion is facilitated • Round lasts for 1 hour in total

Selected titles• The patient I’ll never forget• Am I doing the right thing? • When doctors make mistakes• Human too – personal and professional

overlap • I’m the junior, what do I know?• Caring for a doctor colleague

Evaluation: pre and post- pilots

Staff who attend feel• More confident about handling sensitive

issues • More belief in the importance of empathy• More empathy for patients as people• Confident handling non-clinical aspects of care• More open to expressing thoughts, questions

and feelings about patient care

If Schwartz Rounds change the culture, it is not top down but through communities of influence