Why would we not ask our patients about their experiences?

The second post in our Quality Improvement blog is by Lisa Elliott & Vanessa Blanchard, who have 46 years of NHS experience between them. They now run their own QI/change agency, Elliott Blanchard Ltd.

Whenever quality improvement methodologies are mentioned, the first thing that people talk about are PDSA (plan, do, study, act) cycles. But if you want to improve quality in a sustainable way, PDSA cycles are actually the end point of the process.

The beginning of every QI journey needs to be about working out exactly what it is you are trying to achieve, and why.

Patient stories are extremely powerful in healthcare when doing quality improvement. This is the most useful source of information we have to understand what our patients and service users think about what we do and whether it meets their expectations.

Starting with the patient voice is the key to success

In our experience, from 10 years of doing quality improvement work, the most powerful driver for change is when that one single story really touches a clinician’s heart and motivates them to want to change something. A story like that often describes an everyday event from a new perspective and makes staff realise that they just haven’t seen it that way before. Starting with the patient voice is the key to success when it comes to making improvements that are ‘quality’.

Recently we were working in an NHS acute trust where the CQC inspection had stated: ‘requires improvement’. Alongside this, the local press had been publishing very negative stories which significantly affected staff morale. One of our first engagement sessions with the multidisciplinary team was to engage hearts and minds in the need for change and the belief that change could be achieved. We began by looking at the many trust datasets and defining where the service / team was now and where staff wanted to be in the future.

At the start of the session, with a room full of consultants, managers, nurses, midwives, other frontline staff and administrators, we needed to bring everybody together to find a single reason for change. We wanted this ‘why’ to be so powerful that energy for change was generated. We did this by using stories about the service which had been posted on Care Opinion.

As each story was told you could sense the emotion in the room

When we run this type of workshop we always ask the clinicians to read out the stories to each other. This was very powerful: clinicians heard themselves telling a person’s story, instinctively developing a sense of identification and ownership of what they were reading. Some of the stories were positive and some were extremely negative. As each story was told you could sense the emotion in the room. People didn’t quite know how to react to their own colleagues telling the story, often with their own emotional reaction showing, creating a strong sense of compassion simultaneously for both the patient and the staff member.

At the end of the review of stories, discussion focused around two questions: where had the stories come from? And was one negative story really representative of all patients and service users? But very quickly the mood shifted to: ‘It doesn’t matter how many people this happened to, it shouldn’t even happen to one person. We need to change’.

Good quality improvement methodology is always based on data. The data that is most valued is that which can be plotted over time using run charts or even statistical process control (SPC) charts. Although such techniques are vital in identifying whether your change work is making a difference, noticing improvement, deterioration, variation or no change, there is also a need to gather qualitative data. Patient stories are the only way to really get a sense of what it is like to be that patient in a bed, that carer visiting for long hours or that family waiting for information or appointments.

So why would we not ask our patients about their experiences?

NHS England requires all NHS trusts to consult with their patients and public. This has been reiterated in the national nursing and midwifery strategy, launched in 2016, which is clear that we need to treat every patient as an individual and we need to make changes based on what matters most to them.

So why would we not ask our patients about their experiences? We want to know what it has been like for them, so why limit our patient feedback to questionnaires? Let’s encourage stories and let’s have conversations that allow us to work in partnership with patients, service users, carers, families and staff to bring about quality improvements that really matter and changes that can last.

Top tips

1. Always collect patient stories either face-to-face, online or written.
2. Triangulate stories with other datasets in order to quantify which themes in stories are occurring for more people more of the time.
3. Never just depend on numbers, listen to the patient. Read the actual words they use to understand the emotions linked to their experience.
4. Share the stories. The more people who hear the story, the bigger the impact it can have and the more likely it is to lead change.
5. Commitment to change is just as important as compliance to change. If you don’t have both you will not be able to sustain any improvement.