Human interaction between patients and carers is central to the quality of experience and outcomes. Robert Warwick finds out how to make this part of an organisation’s culture.
The Care Quality Commission has been consulting on what excellence means in adult social care. While many healthcare pathways lend themselves to a clear definition of excellence – for example hip or heart valve replacement – and can be measured with statistical outcome tools, social care emphasises the human nature of excellence; a definition that is subjective and invariably varies from one person to another.
In delivering excellence across both the health and social care fields human interaction between the cared for and the carers is absolutely central to the quality of experience and outcome. How do we bring this to life as part of organisations’ routine culture?
What is excellence?
The Social Care Institute for Excellence defines excellence as being “rooted in a whole-hearted commitment to human rights, and a continuous practical application of that commitment in the way that people who use services are supported. People who use services are demonstrably placed at the heart of everything that an excellent service does”. In practice this means:
- having choice and control over day to day and significant life decisions;
- maintaining good relationships with family, partners, friends, staff and others;
- spending time purposefully and enjoyably doing things that bring them pleasure and meaning.
On the one hand driving excellence requires familiar organisational systems of policy, planning, audit, inspections, training, key performance indicators and so on. But this alone is not enough. Excellence is experienced and valued in those day to day relations between carers and cared for, staff and managers and families.
So there needs to be explicit recognition that both organisational systems and those very human local interactions have to be present together. One without the other at best makes the experience of excellence accidental, at worst it can promote a deteriorating cycle that can lead to harm.
A workshop at City University’s Centre for Better Managed Health and Social Care explored what can be done in practical terms to make excellence a reality for those being cared for. The workshop included commissioners, providers and regulators.
The following insights can help managers, commissioners, stakeholders and staff start the workshop on what excellence can mean in their local situation and to start the process of its recognition and promotion.
A theme that struck a chord with workshop participants was that excellence is an experience and that “you know it when you see it”. Put another way, it was felt and seen in the actual present, defying being pinned down in organisational policy and targets other than in an abstract sense.
To enable excellence to have contextual meaning it is important for staff, managers and others to talk through what it means in practice. As a framework this might practically mean working as a group to:
- Describe the pathway, either in words or as a chart. The purpose of this is to jointly understand the range and scale of interactions that a client may come face to face with. The pathway should highlight who clients come into contact with, where and how and what the experience of this journey might be like for people using services.
- This can then be used as a basis to understand with those users, staff, managers and purchasers what excellence means in these local interactions, by developing stories that all in the room can relate to. Early on there may be some reluctance for different groups to work on this together; this needs to be understood, but the process should not be forced.
- With this understanding very local definitions can be worked on, including how they are to be brought to life.
It is the process of going through this that is important, rather than just the formal output. Therefore, instead of something that is done once, it should be repeated and participants encouraged to explore excellence with anecdotes and narratives about their day to day activity, to explore what went well and what didn’t.
In addition, this process should be built on to discuss how excellence was recognised and rewarded, in other words to focus on how the cycle of improvement was promoted and enforced.
This is a dialogue, a negotiation and a conversation, not a one-off and episodic event.
The provision of broad external requirements, for example commissioning specifications and outcomes, legal standards, and industry practice supports this process, but in itself is not adequate.
Introducing the idea of excellence in this sense should be thought of as facilitating a self examination and local definition, rather than an abstract application of a fixed external view, and therefore promoting a culture that makes a real difference to clients.
Centre of Excellence case study: CuroCare
Several important themes emerged in a conversations with Renos Sideras and Carol Haynes, managing director and director of mental illness, personality disorder and learning disability service provider CuroCare.
Central to excellence is employing the right people. Assessing values, aptitude and potential are more important sometimes than experience and qualifications. This starts with recruitment, where prospective staff are encouraged to spend time at the homes to experience the culture of where they might be working as part of the selection process.
From day one, developing an understanding of the care pathways and bringing them to life with real examples that were current to people’s actual experience were seen as vital. In a less formal way, clients, families and others are involved in training, exploring in a practical sense with staff what excellence means. At these sessions the importance of the attendance of senior managers and directors is stressed to develop a sense that everyone is part of this together and reinforce a culture of relationship based care.
An understanding of what excellence looks like was also linked with how this would be recognised and supported. For example staff remuneration was linked with outcomes, there was a robust workforce development programme and unsatisfactory practice was challenged. In other words, there was practical clarity of what excellence was that was shared by all.
The experiences of clients, residents and users were also discussed in relation to the mandatory requirements, for example safeguarding and good clinical governance, again within practical situations.
Culture changes and develops. Care that was thought to be excellent becomes standard and the debate moves on, defining new levels of excellence, once more in the context of local context set against mandatory requirements.