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Using co-design to improve healthcare services Professor Glenn - - PowerPoint PPT Presentation

Mar 23, 2024 401 likes •1.23k views

Using co-design to improve healthcare services Professor Glenn Robert, Chair of Healthcare Quality & Innovation Florence Nightingale Faculty of Nursing & Midwifery twitter: @gbrgsy The Experience-based Co-design process patients at the

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Using co-design to improve healthcare services

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

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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

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The Experience-based Co-design process

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For me, this is about ‘Oh God, they’re our patients, aren’t they?’ When people watch the film, they might think ‘I remember that lady.’ They know they’re our patients – they can’t get away from the fact – but it actually makes it more real for them. Whatever way they’re captured, it’s about capturing it so that people recognise ‘These are patients I have cared for, nursed, met, who are saying this’… and I think that’s what is so different from other improvement work. in terms of things like discovery interviews and focus groups. It’s that direct connection between them.

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

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Film 1 Toolkit

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EBCD

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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

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Setting up

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Strategy and strategic questions

  • Is EBCD to be a standalone project or integrated with and part of
  • ther projects?
  • Is it going to focus just on experience or will it also take in

efficiency, safety and wider improvement issues?

  • Is it going to focus on a pathway, department, area, speciality or

particular group of patients?

  • What is the strategy for leading it?
  • How, and to whom, will it report back and be accountable?
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Breast pathway

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Engaging staff

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Methods

  • value of patients, carers and staff

experiences

  • stories not surveys
  • ‘deep dives’ and direct observation
  • ‘touchpoints’ and emotional mapping
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Reception – patient experience

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Reception – staff experience

Reception – staff experience

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The power of observation – an example

blisters lumps ulcers polyp ‘warty things’ necrosis lesions ‘naughty tumour’ aggressive progressing carcinoma ‘pre-cancerous change’ cancer

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Why start with staff?

  • The experience of giving the service

is as relevant and important as the experience of receiving it

  • Important role to play in the early

stages of an EBCD project (eg identifying patients and carers)

  • Understanding what EBCD is all

about and the role they can play in shaping experience

  • Establish relationships: build trust to

initiate/sustain EBCD process

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Interviewing staffve’

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Engaging patients

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Satisfaction ≠ experience

Patient survey: Q: Overall, did you feel you were treated with respect and dignity while you were in hospital? A: Yes, always Q: Overall, how do you rate the care you received? A: Excellent

Robert G. (2013) ‘Participatory action research: using Experience-based Co-design (EBCD) to improve health care services’. In: S Ziebland, J Calabrase, A Coulter and L Locock (eds). Understanding and using experiences of health and illness, Oxford; Oxford University Press

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Satisfaction ≠ experience cont

The other thing I didn’t raise, and I should have done, because it does annoy me intensely: the time you have to wait for a bedpan. Elderly people can’t wait. If we want a bedpan, it’s because we need it now. I just said to one of them, ‘I need a bedpan please.’ And it was so long bringing it out, it was too late. It’s a very embarrassing subject, although they don’t make anything of it, they just say, ‘Oh well, it can’t be helped if you’re not well.’ And I thought, ‘Well, if only you’d brought the bedpan you wouldn’t have to strip the bed and I wouldn’t be so embarrassed.’

Robert G. (2013) ‘Participatory action research: using Experience-based Co-design (EBCD) to improve health care services’. In: S Ziebland, J Calabrase, A Coulter and L Locock (eds). Understanding and using experiences of health and illness, Oxford; Oxford University Press

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Emotional mapping exercise

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“The value of storytelling in healthcare is immense, and virtually untapped. If we don’t preserve the richness of narrative, we will fail to connect to our patients’ deepest experiences, and to our own.” “we need more firesides, not spreadsheets.”

(Don Berwick, 2006)

Storytelling

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Source: Care Management Institute, Kaiser Permanente, http://kpcmi.org/about

Video brings fieldwork to you, so all can see!

Many patients One patient Someone else sees, then summarizes I see the care myself The whole team sees together traditional ethnography anecdote

  • bservation,

shadowing video ethnography video storytelling

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Touchpoints

  • Critical points
  • Big moments (good and bad)
  • Moments of truth
  • Emotional hotspots
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Film 2 Touchpoints

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Some typical touch points of head and neck cancer patients

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The patient event - Agenda

Time Item [30 mins] Introductions [45 mins] Showing the film of patient interviews [30 mins] Discussion about the film [45 mins] Lunch [60 mins] Emotional Mapping exercise [30 mins] Working on priority areas [10 mins] Evaluation Close

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Film 3 Emotional mapping

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Co-design meeting

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The joint patient–staff event

  • Watch film of patient stories
  • Hear what the patients have

prioritised

  • Hear what staff have prioritised
  • Patients and staff agree on

priorities

  • Form working co-design groups

to make these improvements

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The joint patient–staff event - Agenda

Time Item [5 mins] Introduction to patient film [30 mins] Patient film [10 mins] Brief discussion about film [10 mins] Patient priorities [10 mins] Feedback from staff event and staff priorities [10 mins] Break [50 mins] Group discussion  Introductions around tables  Agree priorities [10 mins] Feedback from groups [25 mins] Forming co-design groups [5 mins] Next steps and evaluation Close

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Film 4 Joint event film

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Small co-design teams

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1. we don’t listen very much to our users and we do the designing 2. we listen to our users then go off and do the designing 3. we listen to our users and then go off with them to do the designing

Doing the ‘co-design’ part of EBCD: 3 ways to do quality improvement

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What worked for us was the frequent short meetings, and keeping in close contact. And I think for the patients and relatives to be there kind of held the staff to account, and to their action points. I mean they did divvy things up… there was something about, definitely for staff because of that thing that I said before about that humanistic kind of connection that it really drove them to complete actions. (Interview #08) I think I would probably do more co-design events and sort of do more feedback as you go along really. I think definitely I would have benefitted from more co-design. (Interview#05)

Running the groups

Source: Donetto, S., Tsianakas, V. & Robert, G. (2014). Using Experience-based Co-design to improve the quality of healthcare: mapping where we are now and establishing future directions. London: King’s College London.

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I think that it worked because it was collaborative and there were mixed groups of people doing the work, they held each other to account. And kept people on track where perhaps it might have slid… I think that it's harder to do the co-design or collaboration after that initial problem solving phase because I think health professionals are used to being in charge of making things happen.(Interview #10) I think there's a very big recognition of co-design as a way to go forward with things, but a lot of the services are steeped in the processes they've already got. And I think they're finding it hard to see where does it fit in with what we currently do. And it's about that medical model I think, where you've got the patient [and] carers who are just the receivers of service, ‘what do they know?’ (Interview#07)

Running the groups

Source: Donetto, S., Tsianakas, V. & Robert, G. (2014). Using Experience-based Co-design to improve the quality of healthcare: mapping where we are now and establishing future directions. London: King’s College London.

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We got together and we discussed the narratives and we tried to identify, in collective discussion, where or how things could be improved, but when it then came down to what they were actually going to do, those decisions were taken by the frontline managers, the nursing managers, and their line

  • managers. So there was certainly no co-design at that point... I

think you can then identify how the hierarchies worked within the organisation, co-designed up to a point, and then it reverted back to a much more hierarchical way of organising things... a workshop with a draft action plan which was then taken away and worked on behind closed doors. (Interview#02)

Running the groups

Source: Donetto, S., Tsianakas, V. & Robert, G. (2014). Using Experience-based Co-design to improve the quality of healthcare: mapping where we are now and establishing future directions. London: King’s College London.

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[The co-design group was] nerve wracking

... I was sitting across a [meeting] table from a woman that I knew, I’d looked at her scan and I was going to have to tell her that her cancer had come back in the next clinic … and she’s telling me how brilliant her life is … Running the groups

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Film 5 Co-design groups

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Generate first ‘design’ solutions

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Prototyping

Building prototypes helps a group to move beyond talking and thinking about a problem to actually making progress toward action. Perhaps most important, they are real and physical –that is, they assume some material manifestation.

  • Building to think
  • Learning faster by failing early (and often)
  • Giving permission to explore new behaviours
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Prototypes

  • allow the design team to test and refine their solutions with potential users
  • build buy-in from partners and other stakeholders
  • making prototypes ‘early, ugly & often’ is important in the design process.

Create something quickly, test it, and then iterate the design

  • lots of different methods: can vary from paper sketches, to a physical model,

to a fully acted out service (role play)

  • generally, most prototypes combine physical mock-ups and some elements
  • f role-play to recreate the service experience
  • important part of Experience Prototyping is gathering feedback; testing

should ideally happen with potential users of the service and may take place

  • ver a number of hours, days or weeks
  • unlike a pilot the goal is to learn quickly and iterate a revised solution.
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Prototyping

http tp://www.nes esta.org.uk/sit ites/default lt/file les/prototypin ing_framework.pdf

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Multiple models of emergency and short-stay services: Luton and Dunstable

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Testing solutions – personas

  • an old person with dementia
  • a car accident victim in and out of consciousness
  • a person for whom English is not the native tongue
  • a young adolescent (or others)

Do the second design solutions work for:

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Testing solutions

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Prototyping

http://www.designkit.org/resources/1

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Prototyping

ht http:/ ://www.servicedesigntools.org

Case studies: prototyping for service design https://vimeo.com/20823686 https://vimeo.com/46812964

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It was quite funny to see them lifting up their chairs … It’s a symbol

  • f the project that those chairs are

those patients’ seats, and it’s about the staff and the patients together, just moving everything around, so it becomes the symbol for the whole project.

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Randomised trials Designing and evaluating a Quality Improvement intervention using EBCD (without designers)

(based on Tsianakas et al, 2015)

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

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The aim

To

  • develop an

and test a a car arer su support pac ackage in in th the ch chemotherapy

  • u
  • utpatie

ient se setting usin sing 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
  • f chemotherapy and on their experiences of providing informal

care.

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Leaflet DVD Group consultation

Carers of patients receiving outpatient chemotherapy

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Delivering the intervention

  • delivered by a chemotherapy nurse in one-off consultation of no

more than five carers

  • provided an opportunity for carers to watch a DVD developed

specifically for this purpose

  • engage in conversation facilitated by chemotherapy nurse
  • carers given ‘Take care’ leaflet and sections explained
  • carers’ role in process acknowledged and opportunity to talk

about effects and own concerns

  • carers given own copy of DVD and leaflet and encouraged to

consult throughout chemotherapy process

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Outcome measures

Intervention Control Mean difference 95% CI p value

Baseline Follow

  • up

Baseline Follow- up

Practical advice about managing cancer symptoms 48.5 69.8 50.1 43.9 26.8 14.4 to 39.1 <.001 Information Needs Scale 2.81 1.10 2.77 3.23

  • 2.15
  • 3.22 to
  • 1.07

<.01 Confidence in supporting patient if their health gets worse 5.6 6.4 6.5 5.4

  • 1.643
  • 2.96 to
  • 0.32

.016

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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

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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

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Celebration event

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Celebrate

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Film 6 Celebration

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What do patients actually do?

Boaz A et al. (In press) ‘What patients do and their impact on implementation: an ethnographic study of participatory quality improvement projects in English acute hospitals’, Journal of Health Organization and Management

  • sharing experiences (acting as a source
  • f expert, experiential knowledge

through attendance and contributions at the patient events)

  • identifying priorities for quality

improvement in their local services (attending the joint event with staff and first co-design meetings)

  • developing potential solutions through

working alongside staff (bringing innovative ideas and solutions as part

  • f the co-design group work)
  • helping to implement and evaluate

these solutions (through ongoing engagement with the Trust)

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Adaptations

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Survey, 2013

  • 59 EBCD projects implemented in 6 countries worldwide

(2005-2013); further 27 projects in planning

  • EBCD implemented in a variety of clinical areas (incl.

emergency medicine, drug & alcohol services, range of cancer services, paediatrics, diabetes care & mental health services)

  • EBCD projects typically take between 6-12 months to complete
  • free-to-access, online EBCD toolkit is a helpful resource

Donetto S, Pierri P, Tsianakas V and Robert G. (2015) ‘Experience-based Co-design and healthcare improvement: realising participatory design in the public sector’, The Design Journal, 18(2): 227-248

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5 3 6 1 25 2 8 Survey summer 2013

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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% It really made a difference to the way we do things around here It led to clear improvement priorities It allowed discussion of difficult topics in a supportive environment It really engaged straff It really engaged patients/carers

Thinking hinking about bout your pr

  • ur project/
  • ject/s,

, wha hat t wer ere the e the str trengths engths of

  • f the

the EBCD BCD appr pproac

  • ach?

h?

Answered: 41 Skipped: 20

Source: Donetto, S., Tsianakas, V. & Robert, G. (2014). Using Experience-based Co-design to improve the quality of healthcare: mapping where we are now and establishing future directions. London: King’s College London.

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0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Patients/carers did not engage with the project Staff did not engage with the project It cost too much It was too compilicated It took too long

Thinking hinking about bout your pr

  • ur project/
  • ject/s,

, wha hat t wer ere the e the weaknes eaknesses es of

  • f the

the EBCD BCD appr pproac

  • ach?

h?

Answered: 41 Skipped: 20

Source: Donetto, S., Tsianakas, V. & Robert, G. (2014). Using Experience-based Co-design to improve the quality of healthcare: mapping where we are now and establishing future directions. London: King’s College London.

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74

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‘Accelerated’ EBCD: improvement activities and cost

  • similar improvement activities to

standard EBCD projects

  • 48 improvement activities in

total: – 21 small scale changes – 21 process redesign within teams – 5 process redesign between services/activities – 1 process redesign between

  • rganisations
  • costs of AEBCD are around 40% of

EBCD (excluding one-off costs of developing a national trigger film)

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New ‘trigger’ films (ESRC)

  • Asthma
  • Atrial fibrillation
  • Autism
  • Caring for someone with dementia -

dealing with the system

  • Caring for someone with dementia - the

experience of carers

  • Diabetes type 2
  • End of life care
  • Experiences of unexpected maternity

care

  • Intensive care unit
  • Improving care for people with an

indwelling urinary catheter

  • Intermediate care following a stroke
  • Learning disabilities & the health

service

  • Lung cancer
  • Psychosis
  • Young parents
  • Young people and depression

http://www.healthtalk.org/peoples-experiences/improving-health-care/trigger-films-service-improvement/topics

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Resources

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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

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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
  • f 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

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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