of healthcare services Professor Glenn Robert, Chair of Healthcare - - PowerPoint PPT Presentation

Patients and staff as co-designers

• f healthcare services

Professor Glenn Robert, Chair of Healthcare Quality & Innovation Florence Nightingale Faculty of Nursing & Midwifery twitter: @gbrgsy

Structure

• What does co-design mean?
• What is Design theory?
• What is it like to co-design?
• What are impacts/outcomes?

What does co-design mean?

Different ways of involving patients

Complaints Information Surveys Consulting and advising Experience-based Co-design (EBCD) Patient blogs and web-based stories Staff and patients working together to redesign services

Adapted from Bate P, Robert G (2006). ‘Experience-based design: from redesigning the system around the patient to co-designing services with the patient’. Quality and Safety in Health Care vol 15 (5), pp 307–10

Hear the voices of the people served

The more patients and families become empowered, shaping their care, the better that care becomes, and the lower the costs. Clinicians, and those who train them, should learn how to ask less, “What is the matter with you?” and more, “What matters to you?” “Coproduction,” “co-design,” and “person-centered care” are among the new watchwords, and professionals, and those who train them, should master those ideas and embrace the transfer of control over people’s lives to the people.

Berwick D. (2016) ‘Era 3 for Medicine and Health Care’, JAMA 315(13): 1329-1330

What is Co-Design?

• co-design is a well-established approach to creative practice
• enables a wide range of people to make a creative contribution in the formulation

and solution of a problem

• builds and deepens equal collaboration between citizens affected by, or attempting

to, resolve a particular challenge; users, as 'experts' of their own experience, become central to the design process

• enables people to engage with each other as well as providing ways to

communicate, be creative, share insights and test out new ideas

• wide range of tools/techniques support co-design process: user personas,

storyboards, user journeys, prototyping and scenario generation techniques

Source: John Chisholm. ‘What is Co-Design?’ http://designforeurope.eu/what-co-design (accessed March 2016)

Co-design & healthcare quality improvement

• value in integrating human-centred tools and values of

co-design into quality improvement approaches in healthcare organisations

• a co-design approach (Experience-based Co-design) as

applied to quality improvement ‘work’ in healthcare services

Bate SP and Robert G. (2007) Bringing user experience to health care improvement: the concepts, methods and practices of experience-based design. Oxford; Radcliffe Publishing

EBCD: A participatory ry action research approach th that combines: a use ser-centred

• rientation (E

(EB) and a collaborative change process (C (CD)

The Experience-based Co-design process

Robert G, Cornwell J, Locock L, Purushotham A, Sturmey G and Gager M. (2015) ‘Patients and staff as co-designers of health care services’, British Medical Journal, 350:g7714

patients at the heart of the quality improvement effort - but not forgetting staff a focus on designing experiences, not just systems or processes where staff and patients participate alongside one another to co-design services

The Experience-based Co-design pr

proce

• cess

ss

Online toolkit: www.kingsfund.org.uk/projects/ebcd

What is Design theory?

Design theory

• Draws its inspiration from a subfield of the design sciences such as

architecture and software engineering

• Distinctive features are:
• direct user and provider participation in a face-to-face collaborative

venture to co-design services

• a focus on designing experiences as opposed to systems or processes

(thereby requiring ethnographic methods such as narrative-based approaches and in-depth observation)

Design theory

Berkun, 2004 adapted by Bate. Source: Bate P, Robert G (2006). ‘Experience-based design: from redesigning the system around the patient to co-designing services with the patient.’ Quality and Safety in Health Care vol 15 (5), pp 307–10

What makes a good service: designing experiences

Performance

Is it functional? Lean

Engineering

Is it safe and reliable? Safer Patients Initiative

The Aesthetics of Experience

What does it feel like?

Human environment Physical environment

Co-design

What is it like to co-design?

Staff views

‘It was one of the most meaningful things I’ve ever done in my entire career I think. That sounds really trite, but I really do mean it, it was wonderful. I am glad I had the opportunity even though I felt like an emotional ragdoll by the end of it. It was a great experience. If we could do more of it I think it would really help. It’s the level of engagement that we should do, but we just don’t invest the time, and the energy, and the money. We wait for complaints...’ (Interview#05) ‘I think the most important things were that staff really appreciated the time to think about the

• experience. It became apparent that they perhaps didn’t have or make time to reflect on what they

do in their daily workings, so I think they actually found it quite cathartic and therapeutic … the staff really appreciated that their point of view was being listened to because up until that point the political drive had always been patient experience and now all of a sudden we were interested in staff experience’. (Facilitator, interview)

Robert G. (2016) ‘Developing person-centred services: the contribution of Experience-based Co-design to high quality nursing care’. In: S Tee (ed.) Person-centred approaches in healthcare: a handbook for nurses and midwives. Buckingham: Open University press

Humanising healthcare

Forms of humanization insiderness agency uniqueness togetherness sense-making personal journey sense of place embodiement Forms of dehumanization

• bjectivication

passivity homogenization isolation loss of meaning loss of personal journey dislocation reductionist body

Adapted from Todres L, Galvin T and Holloway I. (2009) ‘The humanisation of health care: a value framework for qualitative research. Int J of Qualitative Studies on Health and Wellbeing, 4: 68-77

What are impacts/outcomes?

The primary strength of EBCD over and above other service development methodologies was its ability to bring about improvements in both the operational efficiency and the inter- personal dynamics of care at the same time.

Iedema R, Merrick E, Piper D et al (2010). ‘Co-designing as a discursive practice in emergency health services: the architecture of deliberation’. The Journal of Applied Behavioural Science, vol 46 (1), 73–91.

EBCD teaches project staff new skills; it enables frontline staff to appreciate better the impact of health care practices and environments on patients and carers; it engages consumers in ‘deliberative’ processes that were qualitatively different from conventional consultation and feedback.

Where has co-design reached in healthcare quality improvement? (1)

• includes: participatory design, creative design, co-production, co-design,

experienced-based co-design (EBCD) & ‘accelerated’ EBCD (AEBCD)

• identification of specific changes to services or to patients’ well-being that resulted

from the projects was limited in the majority of the studies

• reported ‘outcomes’ of the projects can be categorised in four main ways:
• patient and staff involvement in the co-production or co-design processes
• generating ideas and suggestions for changes to processes, practices and clinical environments

impacting on patients experiences of a service, (and often indirectly on staffs’)

• tangible change in services and their subsequent impact on patient experiences
• better understanding challenges involved in conducting co-production or co-design projects and

how to address these in research led or hospital staff led quality improvement initiatives

Clarke D, Jones F, Harris R and Robert G. (manuscript in preparation). ‘What outcomes are associated with developing and implementing co-produced interventions in acute healthcare settings? A rapid evidence synthesis’

Where has co-design reached in healthcare quality improvement? (2)

• lower levels of involvement in latter co-design stages;

patients feel that staff should implement QI solutions?

• further (creative) work needed to overcome tendency

towards administrative & bureaucratic processes

• for example, multiple sclerosis outpatients using

future groups, analogies & physical props

• interpersonal burden for patients, carers and staff in

speaking across socio-cultural & organizational boundaries

• emotional work: requires ongoing support to ensure

patients play a meaningful role as co-designers in QI

• facilitation role is critical

Embedding design(ers) in healthcare organisations

Developing and testing feasibility of complex interventions

Tsianakas V, Robert G, Richardson A et al. (In press) ‘Enhancing the experience of carers in the chemotherapy outpatient setting: an exploratory randomised controlled trial to test the impact, acceptability and feasibility of a complex intervention co-designed by carers and staff’, Supportive Care in Cancer

To develop and test a carer support package in the chemotherapy outpatient setting using EBCD:

• understand support provided by healthcare

professionals to carers

• develop a short film depicting carers’ experiences
• bring healthcare professionals and carers together in

co-designing components of an intervention for carers

• develop and implement a carer intervention.
• explore feasibility and acceptability, impact on carers’

knowledge of chemotherapy and on their experiences

• f providing informal care

Getting to the CORE: testing a co-design technique to optimise psychosocial recovery outcomes for people affected by mental illness

Palmer V, Chondros P, Piper D, Callander R, Weavell W, Godbee K, et al. (2015) The CORE Study protocol: a stepped wedge cluster randomized controlled trial to test a co-design technique to optimize psychosocial recovery outcomes for people affected by mental illness. BMJ Open

Research agenda …

• what does it feel like for nurses to take part in person-centred quality

improvement ‘work’?

• what does it means for person-centred quality improvement ‘work’ to be

‘humanising’?

• the adoption and implementation of co-design in public services requires critical

approaches to both organizational processes and design practice

• explore potential of co-design practice to bring about reconfigurations of power

relations, the appropriate role of design expertise within such processes and their eventual impact on the quality of patient care

Final thoughts

• co-design represents a radical reconceptualisation of the role of

patients and a structured process for involving them in all stages of quality improvement

• focus needs to shift away from collecting more data on patient

experience towards embedding co-design as a way of doing quality improvement ‘work’

• evidence is growing about the effectiveness of co-design approaches

but lack of evaluation of other approaches makes comparison difficult

Doctoral studies

• ‘Patient involvement for quality improvement’, Susanne Gustavsson, Chalmers University, Sweden
• ‘Patients at the centre of design to improve the quality of care; exploring the experience-based co-

design approach’, Liz Thorp, University of Leeds

• ‘Improving the experiences of palliative care for older people, their carers and staff in the

Emergency Department using Experience-based Co-design’, Rebecca Blackwell, King's College London

• ‘Enhancing Therapeutic Engagement in Acute Psychiatric Wards: an Experience-based Co-design

Project’, Sarah McAllister, King’s College London

• ‘Young people who offend: Understanding and meeting health and wellbeing needs using

Experience-based Co-design’, Melissa Girling, University of Newcastle

Further Reading

• Bate P, Robert G (2006). ‘Experience-based design: from redesigning the system around the patient to co-designing services with the

patient.’ Quality and Safety in Health Care vol 15 (5), pp 307–10.

• Bate P, Robert, G (2007). Bringing User Experience to Healthcare Improvement: The concepts, methods and practices of experience-based
• design. Oxford: Radcliffe Publishing.
• Tsianakas V, Robert G, Maben J, Richardson A, Dale C, Wiseman, T (2012). ‘Implementing patient-centred cancer care: using experience-

based co-design to improve patient experience in breast and lung cancer services’. Supportive Care in Cancer vol 20, pp 2639–47.

• Locock L, Robert G, Boaz A, Vougioukalou S, Shuldham C, Fielden J et al (2014). ‘Using a national archive of patient experience narratives

to promote local patient-centred quality improvement: an ethnographic process evaluation of “accelerated” Experience-based Co- design’. Journal of Health Services Research and Policy. First published on May 19, 2014 as doi: 10.1177/1355819614531565.

• Springham N, Robert G (2015). ‘Experience based co-design reduces formal complaints on an acute mental health ward’. BMJ Quality

Improvement vol 4 (1), pp 4.

• Donetto S, Pierri P, Tsianakas V & Robert G (2015). ‘Experience-based Co-design and Healthcare Improvement: Realizing Participatory

Design in the Public Sector’, The Design Journal, 18:2, 227-248

• *Robert G, Cornwell J Locock L Puroshotham A, Sturmey G, Gager M (2015) ‘Patients and staff as codesigners of healthcare services’.

BMJ, 10 February (BMJ 2015;350:g7714 )

• Van Deventer C, Robert G and Wright A. (2016) ‘Improving childhood nutrition and wellness in South Africa: involving

mothers/caregivers of malnourished or HIV positive children and health care workers as co-designers to enhance a local quality improvement intervention’, BMC Health Services Research, 16: 358

Further information

• EBCD toolkit: www.kingsfund.org.uk/projects/ebcd
• EBCD LinkedIn group:

www.linkedin.com/groups/Experiencebased-codesign- 6546554

• twitter: @gbrgsy, @PointofCareFdn
• Course team email: info@pocf.org.uk
• Glenn Robert email: glenn.robert@kcl.ac.uk