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How patient perspectives can help improve service design

Patient opinions are a precious source of information. Natalie Cook and Keith Miller explain how to make listening to them a fundamental part of service design.

Looking at service quality from the patient’s perspective to inform and direct development has become an integral part of  NHS activity in recent years. The reason is simple: acknowledging patients’ views helps prevent senior staff from becoming dissociated from the experiences of those using the services – and the highly negative impact that can result from this.

The patient experience programme at Oxleas Foundation Trust in south east London has become a central component of its quality push. As part of this work, an innovative methodology has been developed to measure qualitative and quantitative aspects of service user and carer experience in both mental health and community health services within the trust.

At Oxleas, trained volunteers administer a questionnaire during a one-to-one interview with service users and carers. The volunteers follow the Oxleas patient experience questionnaire – a measure designed to meet the need for a standardised document, structured around the trust’s “must-do” priorities for improving patient care. It covers a systematic set of questions, yet also allows service users to find their own voice when responding.

This methodology differs from the quantitative methods usually employed by the NHS:

  • Rather than professional staff, the questionnaire is administered by volunteers from various groups including service users, carers, governors and non-executive directors.
  • Service users are invited to give an overall sense of their experiences at the beginning of the questionnaire without being constrained by closed questions.
  • A rapport is developed during one-to-one interaction with a non-staff member through which service users feel that their opinions and experiences are truly valued by the trust.

Using this inclusive approach, service users and carers feel able to speak more freely to those who have experience of using services, rather than those providing it. They have less fear of being judged, so they feel able to speak more freely.

As a result, the programme’s response rate is typically above 70 per cent compared to the national average of around 33 per cent obtained in the national patient experience survey.

Extensive interviews

Each interview takes five to 10 minutes to complete, and is usually conducted while service users are waiting for their appointment. Using this approach, the trust has interviewed almost 1,000 service users and carers across 20 teams since September 2010.

The questionnaires are completed during carefully coordinated patient experience visits. Clinics are identified where volunteers have the opportunity to approach service users and carers to take part in an anonymous interview. The patient experience coordinator assigned to the project then works closely with the teams being assessed, and provides extensive support to volunteers throughout the process.

Since the structures of the visits are tailored to each team being assessed, volunteers are thoroughly briefed before each visit. In addition, the volunteers also attend an intensive training session before beginning the interviewing process.

During this training, the importance of patient experience within the trust is discussed, questionnaire demonstrations are practised, interviewing skills are rehearsed, and volunteers are prepared for any challenging situations that could arise as an interviewer. After completing interviews with each team, the questionnaires are analysed, and themes are extracted that represent common experiences of service users and carers. These are combined with observations from volunteers who provide additional insight into the dynamics of the team.

Perceptions of Oxleas’ services

Themes from service usersObservations from volunteers
Most of the staff are perceived as helpful by service usersClean and bright surroundings with well maintained garden
Service users feel they are enabled to settle in well to the rehabilitation environmentThere was some variability in staff attitude
Service users are unclear what information is included in clinical notesListening skills training would be beneficial to staff

Service users were interviewed using the questionnaire in a mental health rehabilitation unit over four days between July and August 2011.

As a result of this feedback, the following improvements have been implemented by this team:

  • Service users will be presented with a leaflet about information sharing at the beginning of their admission. Staff will also be encouraged to be more thoughtful around the process of writing clinical notes, including positive information alongside the negative.
  • Staff acknowledged the challenges and barriers to good communication between staff and service users. This has resulted in a request for further training in listening skills for residential staff, as well as motivational interviewing and interactional skills training. This training will also be implemented in other rehabilitation wards across the trust.

These findings are fed back to directorate-specific patient experience groups within the trust, who work alongside staff to produce locally derived action plans to be implemented within the teams.

The methodology has encouraged a more honest and open exchange of information between service users and trust staff at all levels, and provided a more accurate picture of the trust’s services. Most importantly, it has enabled targeted actions to be taken to improve services.

Patient experience volunteers have also derived personal benefits from being involved in this unique project. Many volunteers have gained tremendously in confidence as a result of their participation and have acquired numerous transferable skills, which have enabled those who are service users to enhance their own recovery journey.

Others have also commented on how fulfilling they feel the project has been as a volunteer, and are particularly encouraged by the direct implementation of service development from their interviews. One said: “Volunteering has really helped my self-confidence. I would never have dared to do this before. And the trust gets a truer picture of what clients think because talking to people face to face is much better than just filling in a form.”

As a direct result of the programme, the trust has made key changes. These include:

  • changing shift patterns in an acute ward to enable qualified staff to spend more time with service users;
  • implementing a new appointment system for service users of health visitor clinics;
  • clarifying the signage within a podiatry clinic.

The methodology produces a high response rate, encourages volunteer development and is a cost-effective way of collecting patient experience data which can be acted on at all levels of the organisation. Knowledge of patients’ direct experience of services is a unique and precious source of information which must be placed at the core of service development.

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