Author: Vanesther Hamer

As with any member of our team, public contributors need to be properly valued and respected for the role they play in shaping and delivering our work, and need to be effectively managed. Here Hildegard Dumper draws on her professional experience to share her tips on how to achieve a successful working relationship with public contributors.

Here at the West of England AHSN we work with a wonderful group of individuals we call public contributors (also known as lay representatives, experts by experience and patient reps). Selected from people who have expressed an interest in our work with the regional healthcare community, their role is to provide the much valued voice of a critical friend, asking the questions that need to be asked and reflecting back to us things we hadn’t thought of.

The whole system works well but we have learnt that this is dependent on some essential ingredients.

Because of our experience in this area, I occasionally get asked by colleagues from other organisations to mediate between themselves and their public contributors when there has been a breakdown in the relationship. Over time, some common themes have emerged, which I thought I would share in case others find these insights useful.

I’ve chosen to illustrate these themes in the form of a story; a composite drawn from real events with names and identifiable features changed.

Pamela contributes as a member of the public to a project looking to improve health services for people with chronic obstructive pulmonary disease (COPD). She was invited to join the project after attending a public meeting to hear the views of users of existing services and their families. Pamela’s husband had recently died of a COPD related condition and she was keen to contribute her ideas based on her experience of caring for him through his illness.

The meeting was held one morning in a community hall near to where Pamela lives. There were about six people or so there who, like Pamela, were retired. The facilitator seemed unused to running such a group. There were no refreshments and no introductions, so Pamela found the meeting quite awkward. However, she is a retired teacher and very confident in social situations. This is perhaps why, at the end of the meeting, she was invited to join the project steering group.

Pamela was very excited to be on the steering group as she had lots of ideas about how things could be improved. At her first meeting, the project manager greeted her and invited her to join the others seated round a table. Several were engrossed in their laptops and the others avoided eye contact when she approached. The project manager was chairing and started the meeting assuming everyone knew each other. Pamela didn’t know anyone and felt at a disadvantage. In spite of her natural confidence, she didn’t want to create a fuss at her first meeting so didn’t say anything.

The meeting was conducted in a very formal way. The language used was undecipherable for ‘outsiders’, with lots of acronyms and specialist terms. Added to which, the people around the table continued to avoid eye contact or display any other encouraging body language. When Pamela said anything most people looked down at their papers and laptops, so she had no idea whether her comments made sense or not.

At the end of the meeting everyone rushed off. The project manager thanked her for coming and told her she would be receiving details of the next meeting.

The whole experience left Pamela feeling completely disempowered.

The meetings were held monthly and though Pamela had struggled with that first meeting, she told herself to persevere and that it could only get better. During the course of one meeting, Pamela volunteered to help out at the COPD stall being held at a health fair. Her offer was accepted enthusiastically as they were short staffed and didn’t have enough people to cover the stall for the whole day.

All the slights she felt she had received through her involvement in the project rose in her mind: the rude way she had been treated by not being introduced to other members of the project team; the lack of eye contact or welcoming smiles; the lack of reassurance that her views were valued, either through simple body language or spoken affirmations, all built up into a rage.

While at the stall, she got talking to some public contributors who were involved in projects elsewhere. She learnt that they were getting paid for their time on the stall as well as receiving travel expenses. She was surprised to hear this. No one had talked to her about claiming for travel expenses, let alone for her time.

As she started to think about this, she began to feel angry. All the slights she felt she had received through her involvement in the project rose in her mind: the rude way she had been treated by not being introduced to other members of the project team; the lack of eye contact or welcoming smiles; the lack of reassurance that her views were valued, either through simple body language or spoken affirmations, all built up into a rage.

 At the next meeting, she asked the project manager whether she could claim expenses for travel and her time on the stall, pointing out she had given a lot of her time to the project already. The manager looked horrified. “We don’t have a budget for this,” she explained. Pamela lost her temper. She stormed out and threatened to complain to the Chief Executive, her MP and others. The project manager told her line manager about this, who then asked me to help.

In disputes such as this, it is possible to see both sides. On one hand there is the hurt Pamela experienced, at being treated in such an excluding way. On the other side, overstretched health professionals are being asked to involve patients and the public in their work without any proper resources, training or guidance.

We identified two key areas for change going forward:

Put in place a role description spelling out the required time commitment and payment being offered

One of the first things I asked when I met with the project manager was whether there was a role description. This is essential for the smooth management of public contributors. It states the requirements of the role, the time commitments expected and the payments available. Any changes to this would have to be negotiated. So, for example, any extra activities or duties, whether initiated by a member of staff or by the public contributor, would be discussed and negotiated against the role description.

When Pamela volunteered to help with the stall, a role description would have made it easier for the project manager to discuss with Pamela whether she was prepared to do it in a voluntary capacity.

Make meetings feel welcoming and inclusive to all

Sometimes it feels like a revolution is required to change the way many meetings are conducted in the health sector. I sometimes fantasise about what it would be like if all meetings, from board meetings to team catch-ups, began with an ice-breaker, and whether this would help create the cultural change we are trying to achieve. But that feels like a pipedream. Instead, let’s aim for everyone to be treated with respect and courtesy, some human warmth and a more creative environment for the exchange of ideas.

In this case, the project manager put in place a ‘no jargon or acronym’ ruling for the meetings and reminded everyone that no question was too stupid to ask. She also introduced a less formal structure to the meetings, allowing space for the exchange of ideas, which gave Pamela the space to contribute.

Together, we managed to come to an understanding. The project manager found some funds to pay Pamela’s expenses and a role description was drawn up.

After a year, Pamela is still with the group. Her role is regularly reviewed and amended as the needs of the group changes. As a result of her contribution, the patient experience feedback for the service is now extremely positive, with the service regularly reaching their targets. In addition, she has been asked to participate as a public contributor in the respiratory steering group of the Sustainability Transformation Partnership (STP).

Getting involved in the group has lessened Pamela’s grief at losing her husband and she no longer feels so lonely. She once told me: “I never expected new doors to open for me at this stage of my life.”

Our Director of Quality Anna Burhouse shares eight simple techniques for how to improve patient focused care in any organisation…

I have been working with the University of Bath to design a free Future Learn course on Quality Improvement (QI) for healthcare professionals.  It has now run twice and goes live for a third time in May.  Over 7,000 people have taken part and I have felt particularly moved by how much people shared about their own experience of being a patient, family member or carer and their observations of the health and social care systems they found themselves in. It was a really rich source of examples about how important it is to have person-centred care and how we must have patient experience at the core of our improvement efforts.

I also enjoyed the discussions about how to be an improvement leader in your local team, no matter what your formal role is in an organisation, especially the need to ‘walk the talk’ and demonstrate through personal actions the improvement you want to see manifested in the organisation. All of this made me think about some simple practical ways that we, as improvement leaders, could use to encourage a culture where patients are at the heart of our health systems.

So here are eight, tried and tested ideas that might help improve the type of patient-focused care offered by your organisation:

1. Focus on the patient journey

An important element of QI is always to think about the patient journeys through your system. One simple, but effective, way to really get to know the patient journey is to experience it in ‘real time’, by asking permission to accompany a patient as they travel through your system. You will see and, more importantly feel, how they move through the care pathway. You will see how smooth, efficient and effective the care is and what really matters from the patient’s perspective. Often this process will help you to see things from a different perspective, noticing both the ‘flow’ through the system and ‘emotional touchpoints’ of the journey, the elements where the patient is pleased, frustrated, bored, vulnerable, empowered etc. This method enables you to collect powerful data and can assist you combine a process map of the patient journey with the experience of the journey.

2. Value added time

Once you have mapped the whole patient journey, you can start to ask a range of questions like:

“What parts of the journey really add value to the patient?”

“Is there any unnecessary duplication or waste?”

“Can we make the experience of the journey better?”

You can then ask both patients and staff what ideas they would suggest  to speed up this process and eradicate unnecessary steps in the journey that don’t add value. You have then started a process of co-production of improvement ideas that can be tested using Plan Do Study Act cycles. This is a quick and effective method to reduce steps in the process and can also be used to improve patient experience and safety.

3. Ask for feedback

Every NHS organisation has processes in place to gain feedback from patients about their experience of care, like the Friends and Family Test. This can help to give organisational feedback. However, what happens if you are trying out a new improvement idea in your team or microsystem and just want some very quick and direct feedback from patients as part of your improvement measures?

There are really creative ways of obtaining immediate feedback at a microsystem level, such as in a busy outpatient clinics or wards.

For instance waiting rooms can be great environments for feedback and measuring patient experience using more engaging and unique metrics. A simple yet effective technique is to give either your patient or their relatives or carers a token and ask them to drop it into one of two jars in the waiting room as they exit. You can label the jars according to the question you want answered. For instance if you were aiming to improve the running time of the clinic you might ask “Did you wait more than 5 mins after your scheduled appointment time?” and put out two jars, one labelled “yes” and one labelled “no”. This simple feedback can help you see how you are doing.

For younger patients, we recently asked them to help us generate improvement ideas by providing drawings of magic wands to colour in. We then asked “If you could make our service better today by magic, what would you do?” The children loved this idea and were colouring and writing on their wands in no time. These ideas can them be taken forward to be tested.

This type of feedback is a great option for those of you who love to get creative, as the only limit here is your own imagination!

4. Share patient’s stories

Patient stories are a core element of QI techniques and should never be underestimated. Their experiences can be a powerful way to inspire change at all levels of an organisation from a busy clinic right up to the board. Use them wisely to get buy in and describe why change is needed. Here is one we recently developed at the West of England AHSN to explain why using the National Early Warning Scores can save people’s lives.

5. Get social!

Social media is a great way both to get feedback and to help test change ideas through crowdsourcing. Often people are really keen to help and you can reach a wider and more diverse audience who have a broad range of ideas. This is an effective way of seeking active engagement on how to improve both hospitals and/or care settings.

6. Be a fantastic listener

If you are leading improvement, don’t forget that you can improve yourself too! Ask yourself do you really and truly listen to people to understand what they are saying, even when it’s a difficult conversation to have? Or do you habitually listen to answer? Be brave and ask for feedback from colleagues and patients about their experience of you.

The art of active listening is crucial for QI leaders and it’s a skill that can be learnt and improved. An easy exercise to help you understand the power and importance of this skill is to find a friendly QI colleague and both take turns to tell each other something important while the other person tries as hard as they can not to listen. It’s a good technique to show how not listening to someone impacts on us emotionally.

7. Don’t underestimate the power of a question

If you unearth a patient experience issue in your team you can help to better understand it by using the ‘Five Whys’ technique. This is a very simple QI method based on asking “why?” five times to take you on a deep dive to the root cause of the issue.  This can then help you see if this was an unfortunate ‘one-off’ variation to the norm or a systemic issue that will require wider improvement.

8. Appreciative Inquiry

Appreciative Inquiry is a technique developed by Cooperrider et al (2010). It can be used across an organisation or in a single team, for staff and patients, carers and families. It asks ‘appreciative’ questions about what’s working well and why. It is a strengths and asset led model where you actively seek to build on what you’re good at rather than ‘problem solve’ by looking only at deficits.  This doesn’t mean that you don’t uncover things that need improvement; in fact it asks people to dream about what the organisation could look like in the future in order to continuously improve and transform.

I hope you have enjoyed reading these techniques, and are inspired to give one of them a go. I’d love to hear your ideas too so that together we can spread ideas about how to improve patient-centred care approach and leadership skills. I believe no matter what your role is in your healthcare environment, we are all leaders for improvement. Please feel free to tweet us at @annaburhouse or @weahsn with your suggestions.