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Executive Summary
Introduction
1. This research was commissioned by the Scottish Government as part of Better Together Scotland's Patient Experience Programme. Better Together is NHS Scotland's programme to improve patient experience. It will build upon the improvements already happening across the health service by working with patients, carers and staff to further enhance the quality of care. The programme will support NHS Scotland to make year-on-year improvements for patients. This research explores Scottish Health Boards' current uses of and attitudes towards patient experience information
2. The objectives of this work were to document Scottish Health Boards' current patient experience activities and Boards representatives' experiences of and attitudes towards patient experience. The research also examined expectations of the Scottish Patient Experience Programme and beliefs about patients' priorities.
Methods
3. Thirty-five telephone interviews were carried out with NHS (National Health Service) Board staff between September 2007 and February 2008. All of them were checked by the interviewee and approved by them. The interviewees were from the 18 Health Boards which provide services directly to patients, and included 16 Chief Executives and 19 members of staff who were identified as having primary responsibility for implementing and co-ordinating patient involvement and patient feedback.
Main findings
Patient experience activities
4. Almost all Boards that participated were currently engaged in a variety of patient experience activities. There was wide variation among Boards in the extent of their patient experience activities. Smaller rural boards tended to be less active in this area, but this was also true of some of the larger Boards.
5. Patient experience activities included self-completion questionnaire surveys, suggestions boxes, complaints and compliments, patients' panels and forums, patients as members of governing bodies, focus groups, collecting patient stories and patient diaries. The most common patient feedback activity was self-completion questionnaire surveys. For some surveys, questionnaires were handed out on-site, while others carried out postal surveys, many of them are undertaken with the help external survey contractors.
6. Most of the reported patient experience activity was in secondary care.
Preferences for types of patient experience information
7. Most interviewees said it was important to use both qualitative and quantitative information to obtain a full understanding of patients' experiences. Of those that expressed a preference for one type of information, more preferred qualitative information than quantitative information. However, most interviewees thought that a full understanding of patients' experiences could only be achieved by looking at a variety of different sources of information.
8. It was considered important that patient feedback tools focus on issues that are known to be important to patients. The criterion perceived to be most important for useful patient feedback tools was that they should provide actionable feedback: that is, they should provide information about what needs to be done to improve services.
9. Many interviewees were concerned that patient feedback tools should conform to rigorous methodological standards. For example, they should use representative sampling techniques. The importance of patient feedback tools in assessing the "softer " issues of patient experiences, as opposed to clinical outcomes was mentioned by many respondents.
10. While there seemed to be a general overall preference for qualitative information, surveys were the single most trusted source of information about patients' experiences, followed by patients' representatives' feedback through panels and forums, feedback through suggestions boxes, letter and compliments, and formal complaints. Other trusted information sources included focus groups and patient stories. Interviewees recognised the limitations of "patient satisfaction" surveys, and they tended to prefer to use a "patient experience" question style, focussing on "what happened" to patients, rather than asking them to rate their satisfaction with services.
Learning and development of patient experience activities
11. When asked what they had learned as a result of implementing patient experience activities, many said that their main learning had been simply to discover the importance and benefits of doing it.
12. Some had changed the way they asked questions, involving patients in the development of measurement tools and focusing on experience and actionable feedback, rather than patient satisfaction. Other interviewees said they had learned the importance of following up on results by implementing quality improvements, and feeding results back to front-line staff.
Benchmarking
13. Almost all interviewees said they would be interested in some form of benchmarking of their Board on patient experiences, but their main concern was that it might be difficult to make fair comparisons among different types of organisation. Another concern was that benchmarks could lead to complacency if an "above average" score was thought to be acceptable, particularly if standards were generally low among comparator organisations.
14. Many Board representatives thought that the best comparator group for their Board would be the rest of the Scottish Boards, but an approximately equal number thought that the best comparators would be Boards like themselves (in terms of urban/rural and size). Interviewees from Special Boards tended to think it would be difficult to find a suitable comparator and some suggested comparator organisations outside Scotland.
15. Most would be interested in three types of comparison: comparisons among Scottish Boards, tracking changes in their own Board over time and comparing different units within their Boards. Where interviewees expressed a preference for one type of comparison, within-Board comparisons over time were the most popular, with almost half of the interviewees saying that information would be the most valuable to them. Many also thought that comparisons of different units or departments within their Board would be particularly useful for quality improvements.
Motivations and barriers to implementing patient experience activities
16. Almost all interviewees saw patient experience activities as central to their roles, and to the overall aims of their Boards.
17. The most important barriers to implementing changes as a result of patient feedback were thought to be defensiveness from clinical staff and a lack of a patient-centred culture within the Board. Many also said that capacity was an important barrier: they did not have enough time, or the right skills, or there were too many other competing priorities. Not knowing what to do with patient experience findings was also an important barrier to implementing changes.
Examples of measured quality improvements
18. Many interviewees volunteered interesting and inspiring examples of changes they had implemented as a result of patient feedback.
19. About half of the changes implemented were supported by evidence of improvement in patients' experiences, but many responses indicated that it was not central to the Board's culture routinely to measure the effects of quality improvement interventions.
Expectations of forthcoming Scottish Patient Experience Programme
20. There was wide variation in interviewees' knowledge of the Programme, but most had positive expectations of it. They hoped it would provide rigorous, reliable tools with which to measure patients' experiences, and that the tools would be standardised across Boards so that they could make reliable comparisons and it would provide benchmarks. They wanted support for making quality improvements and sharing best practice. Several people thought the Government programme would help them to promote the importance of patient experience.
21. The main concern about the programme was that there would be too strong a focus on targets at the expense of improving patients' experiences. However, some cautiously welcomed the setting of standards for patient experience. There were also worries that the programme would impose too high a bureaucratic burden on Boards, there would be a loss of autonomy, the cost of the programme would be too high, that the methods would not be sufficiently rigorous, and that there would be unfair adverse media coverage of results.
Views on patients' priorities
22. There was considerable consensus among interviewees in their views on the issues that matter most to patients. Top patient priorities were perceived to be: high quality safe care; being treated with respect and dignity; prompt access; clear communications about their condition and treatment; being involved in treatment decisions; being treated as individuals and avoiding hospital-acquired infections.
Conclusions
23. Patient experience activities were viewed positively by Scottish NHS Board representatives and, on the whole, Boards welcome the forthcoming Patient Experience Programme. The main concerns about the Programme were that there would be too strong a focus on targets and it would impose too great a bureaucratic burden.
24. There was a demand for both quantitative and qualitative information about patients' experiences. Qualitative information was thought to be particularly useful for inspiring and driving quality improvements, while quantitative information was valued for its use in benchmarking and highlighting areas of concern or excellence. Patient surveys were the single most common patient experience activity currently taking place in Scottish NHS Boards.
25. Most Board representatives would be interested in benchmarks, either with the rest of Scotland, or with Boards similar to their own. Most would also be interested in using the results of standardised quantitative patient experience tools to compare their own organisations performance over time, and to compare different units within their Board.
Recommendations
- Standard patient experience tools for use across NHS Scotland should provide reliable robust measures of patient experience. Self-completion postal questionnaire surveys would fulfil this function.
- The standard patient experience tools should focus on the issues that are known to be important to patients, and should be designed such that the results offer actionable feedback.
- To ensure reliable comparisons, sampling techniques should be explicit and standardised across Boards, and should ensure that sampled patients are representative of the populations of patients treated.
- For the fourteen geographical Boards, benchmarks should allow them to compare themselves with all other Scottish boards as a group, and with subsets of other similar Boards and/or with particular single Boards.
- Boards should be offered support for collecting qualitative information about patients' experiences and analysing it.
- Boards should be offered support in understanding the implications of their patient feedback and implementing changes.
- Boards should be offered support in sharing best practices among Scottish Boards, and from wider sources.
- It may be possible and desirable to benchmark some Special Boards' services against those of geographical Boards, but for some types of care ( e.g. ambulance care) this will not be appropriate.
- Special Boards providing services directly to patients are likely to need targeted support for patient experience activities, particularly where their services are very different from those of the other Boards.
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