Understanding how front-line staff use patient experience data for service improvement: an exploratory case study evaluation

Abstract

Background and aim The NHS collects a large number of data on patient experience, but there are concerns that it does not use this information to improve care. This study explored whether or not and how front-line staff use patient experience data for service improvement. Methods Phase 1 – secondary analysis of existing national survey data, and a new survey of NHS trust patient experience leads. Phase 2 – case studies in six medical wards using ethnographic observations and interviews. A baseline and a follow-up patient experience survey were conducted on each ward, supplemented by in-depth interviews. Following an initial learning community to discuss approaches to learning from and improving patient experience, teams developed and implemented their own interventions. Emerging findings from the ethnographic research were shared formatively. Phase 3 – dissemination, including an online guide for NHS staff. Key findings Phase 1 – an analysis of staff and inpatient survey results for all 153 acute trusts in England was undertaken, and 57 completed surveys were obtained from patient experience leads. The most commonly cited barrier to using patient experience data was a lack of staff time to examine the data (75%), followed by cost (35%), lack of staff interest/support (21%) and too many data (21%). Trusts were grouped in a matrix of high, medium and low performance across several indices to inform case study selection. Phase 2 – in every site, staff undertook quality improvement projects using a range of data sources. The number and scale of these varied, as did the extent to which they drew directly on patient experience data, and the extent of involvement of patients. Before-and-after surveys of patient experience showed little statistically significant change. Making sense of patient experience ‘data’ Staff were engaged in a process of sense-making from a range of formal and informal sources of intelligence. Survey data remain the most commonly recognised and used form of data. ‘Soft’ intelligence, such as patient stories, informal comments and daily ward experiences of staff, patients and family, also fed into staff’s improvement plans, but they and the wider organisation may not recognise these as ‘data’. Staff may lack confidence in using them for improvement. Staff could not always point to a specific source of patient experience ‘data’ that led to a particular project, and sometimes reported acting on what they felt they already knew needed changing. Staff experience as a route to improving patient experience Some sites focused on staff motivation and experience on the assumption that this would improve patient experience through indirect cultural and attitudinal change, and by making staff feel empowered and supported. Staff participants identified several potential interlinked mechanisms: (1) motivated staff provide better care, (2) staff who feel taken seriously are more likely to be motivated, (3) involvement in quality improvement is itself motivating and (4) improving patient experience can directly improve staff experience. ‘Team-based capital’ in NHS settings We propose ‘team-based capital’ in NHS settings as a key mechanism between the contexts in our case studies and observed outcomes. ‘Capital’ is the extent to which staff command varied practical, organisational and social resources that enable them to set agendas, drive process and implement change. These include not just material or economic resources, but also status, time, space, relational networks and influence. Teams involving a range of clinical and non-clinical staff from multiple disciplines and levels of seniority could assemble a greater range of capital; progress was generally greater when the team included individuals from the patient experience office. Phase 3 – an online guide for NHS staff was produced in collaboration with The Point of Care Foundation. Limitations This was an ethnographic study of how and why NHS front-line staff do or do not use patient experience data for quality improvement. It was not designed to demonstrate whether particular types of patient experience data or quality improvement approaches are more effective than others. Future research Developing and testing interventions focused specifically on staff but with patient experience as the outcome, with a health economics component. Studies focusing on the effect of team composition and diversity on the impact and scope of patient-centred quality improvement. Research into using unstructured feedback and soft intelligence. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Using online patient feedback to improve NHS services: the INQUIRE multimethod study

“…143 In particular, we worked with HSDR project 14/156/06 (hosted within the same university department), which was also developing an online resource. 144 Together with this other project, we concluded that although 'toolkits' are increasingly used for dissemination, both researchers and funders appear to have reservations about them, not least relating to the word 'toolkit' itself. The key messages that both of our projects took from these initial discussions were that these outputs were likely to be more useful if designed iteratively, produced with professional design and marketing input, and disseminated by a trusted 'champion'.…”

“…A second parallel NIHR HSDR study, led by Louise Locock, who is a co-investigator on the present study, found that within NHS trust organisations, survey data remained the most recognised and valued form of patient experience data and that online feedback was rarely visible or used. 144 Online patient feedback was seen as interesting, but staff often felt that they did not have organisational endorsement to engage with it. Also relevant here is the boundary between feedback and complaints: in many organisations these are dealt with separately, by different teams and, as Locock and colleagues 144 found, there can be pressure to turn something into a complaint so that action could be taken.…”

“…144 Online patient feedback was seen as interesting, but staff often felt that they did not have organisational endorsement to engage with it. Also relevant here is the boundary between feedback and complaints: in many organisations these are dealt with separately, by different teams and, as Locock and colleagues 144 found, there can be pressure to turn something into a complaint so that action could be taken. These findings link to our ethnographic study and the new practices of responsibility, responsivity and responseability that organisations need to address in order to harness online feedback.…”

“…These findings link to our ethnographic study and the new practices of responsibility, responsivity and responseability that organisations need to address in order to harness online feedback. In the Sheard and colleagues study, 153,154 at the micro level, it observed that the majority of largely positive feedback is generic and difficult for staff to take action on, in contrast with the smaller amount of negative feedback, which was usually more precise and actionable, although staff sometimes questioned the validity of patient experience data and were unsure how to interact with it, or, as Locock and colleagues 144 found, they lacked confidence to do so. In line with our own findings, these and other studies have shown that although many professionals are positive about the principles of patient-centred care, many are sceptical regarding the value of online feedback, especially about its 'representativeness'.…”

Implementing online patient feedback in a ‘special measures’ acute hospital: A case study using Normalisation Process Theory

“…The importance of supporting and empowering staff members during the implementation and continued use of online feedback appears integral to implementation processes and sustainability. 27 – 30 …”