What about the patients? Experience is the weakest of the three arms of quality

What have you done?

In 2009, we were doing work on patient experience, but we weren’t always measuring the right things, it wasn’t timely enough and we weren’t getting feedback to staff in ways that enabled them to act on it. 

We designed a comprehensive way of understanding the quality of patient experience across our 11 hospital sites. We set out to really understand quality in real time and with enough granularity to inform improvement.  

We are able to share performance at a hospital, site, team, and ward level. Having individual consultant-level data to inform annual appraisals is relatively unique in the NHS, but it really elevated the programme and helped to ensure that patient experience has senior medical ownership.

To make this work, our team carries out 700 face-to-face interviews every month whilst patients are still with us; and results are shared with staff within three to four hours. We balance these real-time reports with reflective feedback from patients once they were home. We deliberately survey individuals two weeks after leaving hospital, because we know that this is when people are likely to be at their most dissatisfied. 

In this way we actively ask ourselves the hard questions; but what other way is there to get the real facts?

What was your motivation?

I’m an improver at heart. For me, patient experience is not separate from culture, quality improvement, or staff experience. All these things should be strongly integrated. 

As a clinician, I have always been keen on robust measurement and evidence. As a speech and language therapist, I was sensitive to the needs of people who have lost their “voice” and influence.   

Don Berwick’s publication What patient-centred should mean: Confessions of an extremist in 2009, inspired me to challenge myself, and my organisation, about what we were really doing about person-centred care. Subsequent discussions with Jim (Sir James Mackey, trust CEO) led to the development of a board-level role – the first of its kind in the NHS.

How were patients and families involved?

You need to measure what matters and involve people in defining what counts. We used metrics developed by the Picker Institute then tested and refined them with our own population.

We have actively involved people in a variety of ways. We invited older people, as advocates, to visit our wards and observe the dignity of our care when communicating with people with dementia and delirium. We involved people with learning disabilities in training our staff and improving signage and have supported the development of patient leaders in improvement work. 

I’m a big fan of experience based co-design too – it allows us to make respectful partnerships more routine.   

What was the impact?

It’s been a 10-year journey. Our patient experience results got better. In 2009 we were worse than average. Now, for several years, we have been in the top 10 per cent of trusts beaten only by single speciality organisations. 

We’ve become more responsive. For instance, the number of complaints we received were down 15 per cent last year, and have almost halved since 2014. 

Our programme has really caught our staff’s imagination. In the staff survey, the percentage agreeing that high quality care is the trust’s top priority has doubled from 43 per cent in 2007 to 86 per cent last year. 

We celebrate excellence and we take improvement opportunities. It feels second nature to us now.  

One other side effect is that we’ve become emboldened to change things – even when it costs the trust. For example, we had a big problem with parking. Our outsourced provider was chasing fines aggressively and patients and families hated it. The resulting deterioration in inpatient experience was, in itself, enough for the board to sever the contract.

What have you learned?

At the start, I hadn’t realised just how much it would mean to staff.  

Now I understand that staff experience precedes patient experience. If you don’t invest in your staff, any positive changes in patient experience won’t be sustained.  

I learned the importance of reliable measurement. If you are going to be transparent, your methods and data need to be robust and open to scrutiny. Accordingly, our data is externally audited on an annual basis.

Then we humanise the data. Complementing our analysis with representative case studies – real peoples, real stories – has proven to be highly effective in influencing change.

I’m glad we started small and grew the work incrementally. We didn’t rush it and we didn’t get blown off course. We did it in ways that were respectful to patients and staff. We avoided a punitive, judgemental response to the results.

What next?

Since last year, my role has changed. As chief experience officer, I have responsibility for bringing together patient and staff experience. It’s a challenge I relish and I’m really excited! Our real-time staff experience programme is well underway and early improvement work with teams is looking promising.

What’s your message to HSJ readers?

In my view, patient experience remains the weakest of the three arms of quality. It doesn’t get the same attention as safety and clinical effectiveness and still tends to be seen as a nice add-on. This needs to change.

Don’t measure, unless you’re willing and able to improve. 

Start small, but start. Don’t be focussed on the barriers. Measure well. Feedback responsibly, link it to improvement and find the joy in improving for frontline teams. You will reap the rewards of energised staff and improved staff experience. 

Don’t worry about unleashing high patient expectations that can’t be met. In more than 15 years of working in this way, I’ve yet to see the evidence for that. Patients don’t want the earth and, in my experience, are deeply respectful and supportive of NHS staff.

I’m conscious of how lucky I am to work in this organisation – I’ve benefitted massively from a supportive board who took a decision a long time ago to invest in a unique board level position. My remit is clear, I’m not burdened by a wide portfolio and competing demands that take my attention elsewhere. 

The deterioration in this year’s national patient experience results are perhaps an important reminder that this work needs to be protected and prioritised more than ever?