Putting compassion back – improving the experience for staff and patients Influencing and coordinating respiratory care in London June 2013

NQB/DoH definition of patient experience (after the IoM and Picker) Respect for values, preferences, and expressed needs Coordination and integration of care Information, communication, and education Physical comfort Emotional support Welcoming the involvement of family and friends Transition and continuity Access

Patients’ experiences are a mix of the ‘what’ (T) and the ‘how’ (R) Respect for values, preferences, and expressed needs (R) Coordination and integration of care (T) Information, communication, and education (T+R) Physical comfort (T) Emotional support (R) Welcoming the involvement of family and friends (T + R) Transition and continuity (T) Access (T) Transactional (T) and relational (R) dimensions of care relational transactional 3 High Low High

The combination of transactional (T) and relational (R) dimensions is often difficult High Low T R Efficient and impersonal Efficient and warm Chaotic and rude, indifferent Chaotic and warm

Staff experience and patient experience are linked  Management & quality of HR practice linked to mortality and other quality measures (West et al (2009)  National staff & patient experience surveys: the two sets of experience are related (Raleigh et al 2010)  Quality of staff experience precedes quality of patient experience (Maben et al 2012 )

The health care professional does a job, and for many people this job is pretty mundane. They’re doing the same kind of thing to the same kind of people pretty well every day. So for them that activity becomes completely routine. And some days rather dull “The health professional does a job, and for many people this job is pretty mundane. They’re doing the same kind of thing to the same kind of people pretty well every day. So for them that activity becomes completely routine. And in some cases rather dull. For the individual patient it’s anything but that. Every individual that comes through a hospital is apprehensive. It’s a strange place, you lie in a strange bed, you have strange sheets, you have odd tea in a plastic cup. The whole thing is vibrantly different.” The perennial ‘existential’ problem 6 Dr Kieran Sweeney GP, academic, patient “Mesothelioma: A patient’s journey” Sweeney, Toy and Cornwell: BMJ 2009

PATIENT– FOCUSSED IMPROVEMENT METHODS H

Patient and Family Centred Care (PFCC) and Experience Based Co- Design (EBCD) Key activities 1.Shadowing patients / structured observation/interviewing and filming 2.Setting patient based goals 3.Using driver diagrams to decide what to do 4.Using measures for improvement 5.Working with patients on the changes

Mapping process and touch points

Measures tell teams how they are doing - COPD example IndicatorFrequencyNumeratorDenominatorTarget % pts discharged from resp. ward MonthlyNo of pts discharged from res ward Total no discharged from trust with COPD acute exacerbation 70% % of pts who some offered smoking cessation MonthlyNo of smokers offered cessation No of smokers100% % pts with COPD with low BMI offered referral to dietician WeeklyNo of pts with MUST scores referred to dietcn. No of pts. with MUST scores 100% % offered emergency oxygen correctly WeeklyNo of pts with correct oxygen adminstrtn No of pts with COPD 100% Pts with confidence in team MonthlyNo of pts with confidence No of pts with COPD admitted 100% % pts offered GP/practice nurse follow up in 2 weeks MonthlyNo of pts offered follow up in 2 weeks No of COPD admissions 100%

In S London, the priorities of patients with breast and lung cancer were different Lung cancerBreast cancer Communication of diagnosis Functioning of day surgery unit Information about treatment Appointments system and conduct of OP clinics Continuity and coordination of care Communication Information about symptoms H

EBCD improvements at Guys and St Thomas and Kings College Hospital Over 40 changes in service delivery for both lung cancer and breast cancer patients, including: 1.Guidance on the correct procedure on tests and diagnosis included in junior doctors’ induction 2.Referral on diagnosis to lung Clinical Nurse Specialist (CNS) for information and support 3.New space for communicating diagnosis and CNS support 4.Patients called to day theatre ‘just in time’ 5.Customer care training of receptionist and clerks 6.A new space in OP for breaking bad news H

Schwartz Center Rounds: space for reflection

Impact of Rounds › Evaluation shows that Rounds have a positive effect › For individual › For teams › For organisation › Increased impact over time Sanghavi DM (2006) What makes a compassionate patient-caregiver relationship? Joint Commission Journal on Quality and Patient Safety 32(5): Lown, BA, Manning, CF (2010) The Schwartz Center Rounds: Evaluation of an interdisciplinary approach to enhancing patient-centred communication, teamwork and provider support. Academic Medicine 85(6).

Format of Schwartz Round Lunch is offered before the start Presenter/presenting team talk for minutes The audience is asked to share their thoughts, ask questions, offer similar experiences The discussion is facilitated Round lasts for 1 hour in total

Selected titles The patient I’ll never forget Am I doing the right thing? When doctors make mistakes Human too – personal and professional overlap I’m the junior, what do I know? Caring for a doctor colleague

Evaluation: pre and post- pilots Staff who attend feel More confident about handling sensitive issues More belief in the importance of empathy More empathy for patients as people Confident handling non-clinical aspects of care More open to expressing thoughts, questions and feelings about patient care

If Schwartz Rounds change the culture, it is not top down but through communities of influence