New South Wales mounts “patient based care” challengeThe Clinical Excellence Commission in New...
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SPOTLIGHT: PATIENT CENTRED CARE New South Wales mounts “patient based care” challenge The Clinical Excellence Commission in New South Wales is driving person centred care by stimulating districts to compete to provide it. Karen Luxford and Stephanie Newell describe the integrated approach, its uptake, and encouraging early evidence of change Karen Luxford director patient based care, Stephanie Newell chair, partnering with patients advisory committee Clinical Excellence Commission, 227 Elizabeth Street, Sydney, New South Wales, 2000, Australia The principles of patient centred care and the mantra of “nothing about me without me” 1 have gained broad support, but its proving hard to adopt and embed them in routine practice. New ways of thinking and tackling resistance to change are needed, 2 and a range of initiatives are being pursued. 3-7 We describe the approach being taken in New South Wales, Australia’s most populous state, with 7.4 million residents and 1.66 million public hospital admissions a year. This has focused on the development of a “patient based care challenge” aimed at spurring system-wide integrated change to promote patient centred care. The term patient based care was introduced with the aim of making patient centred care more broadly recognised as everyone’s responsibility—from the executive through to frontline clinicians and staff—with care systems included as well as bedside care. We discuss how the health districts have responded to this challenge. Strategic and organisational change Healthcare services that have taken a strategic patient based approach to change have witnessed benefits for patients, clinicians, and managers, with improved staff satisfaction and retention rates and decreased absenteeism. 89 A 2013 systematic review highlighted the importance of taking an integrated organisational approach, noting the positive association between patient experience, clinical outcomes, and use of resources—for example, length of hospital stay. 10 Achieving patient centred care at the organisational level entails moving beyond the traditional focus of quality improvement on clinical measurement and audit. 11-14 Putting the challenge to New South Wales The Clinical Excellence Commission was set up in 2004 to promote and support improved clinical care, safety, and quality across New South Wales. The commission monitors state-wide incident reporting and implements quality improvement initiatives to address key safety and quality problems identified. In 2010, a consumer adviser panel was established to actively involve patients, carers, and community members in all aspects of the commission’s work. In 2011 the commission developed a “patient based care challenge” for district healthcare services in collaboration with a partnering with patients advisory committee, which comprised patients, clinicians, managers, and policy makers. 15 Patients and families highlighted the importance of engaging with patients in care at the bedside but also in health service governance and strategic decision making. The 26 strategies included were grouped under nine domains drawn from evidence of effective strategies used by leading patient based health services (box 1). 11-14 Although some strategies are specific to hospital settings, most can be used across a range of healthcare settings. We framed the overall strategy as a challenge to health services to reflect the difficulties of making system-wide change and to infuse a competitive aspect into the process. In 2012, the commission issued the challenge to all 15 local health districts across New South Wales. Each district is governed by a board appointed by the minister of health. To gain senior executive commitment and promote sustainability, boards were invited to sign-up to the challenge. Initially, we recommended that districts focused on up to three priorities from the 26 strategies in the first year. This was to ensure that change was seen as manageable and to promote ongoing commitment by creating short term progress. 16 The decision was also pragmatic because a shift towards patient based care tends to be incremental and typically takes 5-10 years. 12 Flexibility was also seen as important so that districts Correspondence to: K Luxford [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe BMJ 2015;350:g7582 doi: 10.1136/bmj.g7582 (Published 10 February 2015) Page 1 of 5 Analysis ANALYSIS on 26 January 2021 by guest. Protected by copyright. http://www.bmj.com/ BMJ: first published as 10.1136/bmj.g7582 on 10 February 2015. Downloaded from
Transcript of New South Wales mounts “patient based care” challengeThe Clinical Excellence Commission in New...
SPOTLIGHT: PATIENT CENTRED CARE
New South Wales mounts “patient based care”challengeThe Clinical Excellence Commission in New South Wales is driving person centred care by stimulatingdistricts to compete to provide it. Karen Luxford and Stephanie Newell describe the integratedapproach, its uptake, and encouraging early evidence of change
Karen Luxford director patient based care, Stephanie Newell chair, partnering with patients advisorycommittee
Clinical Excellence Commission, 227 Elizabeth Street, Sydney, New South Wales, 2000, Australia
The principles of patient centred care and the mantra of “nothingabout me without me”1 have gained broad support, but itsproving hard to adopt and embed them in routine practice. Newways of thinking and tackling resistance to change are needed,2and a range of initiatives are being pursued.3-7 We describe theapproach being taken in New South Wales, Australia’s mostpopulous state, with 7.4 million residents and 1.66million publichospital admissions a year. This has focused on the developmentof a “patient based care challenge” aimed at spurringsystem-wide integrated change to promote patient centred care.The term patient based care was introduced with the aim ofmaking patient centred care more broadly recognised aseveryone’s responsibility—from the executive through tofrontline clinicians and staff—with care systems included aswell as bedside care. We discuss how the health districts haveresponded to this challenge.
Strategic and organisational changeHealthcare services that have taken a strategic patient basedapproach to change have witnessed benefits for patients,clinicians, and managers, with improved staff satisfaction andretention rates and decreased absenteeism.8 9A 2013 systematicreview highlighted the importance of taking an integratedorganisational approach, noting the positive association betweenpatient experience, clinical outcomes, and use of resources—forexample, length of hospital stay.10 Achieving patient centredcare at the organisational level entails moving beyond thetraditional focus of quality improvement on clinicalmeasurement and audit.11-14
Putting the challenge to New SouthWalesThe Clinical Excellence Commission was set up in 2004 topromote and support improved clinical care, safety, and quality
across New SouthWales. The commission monitors state-wideincident reporting and implements quality improvementinitiatives to address key safety and quality problems identified.In 2010, a consumer adviser panel was established to activelyinvolve patients, carers, and community members in all aspectsof the commission’s work. In 2011 the commission developeda “patient based care challenge” for district healthcare servicesin collaboration with a partnering with patients advisorycommittee, which comprised patients, clinicians, managers, andpolicymakers.15 Patients and families highlighted the importanceof engaging with patients in care at the bedside but also in healthservice governance and strategic decision making.The 26 strategies included were grouped under nine domainsdrawn from evidence of effective strategies used by leadingpatient based health services (box 1).11-14 Although somestrategies are specific to hospital settings, most can be usedacross a range of healthcare settings. We framed the overallstrategy as a challenge to health services to reflect the difficultiesof making system-wide change and to infuse a competitiveaspect into the process.In 2012, the commission issued the challenge to all 15 localhealth districts across New South Wales. Each district isgoverned by a board appointed by the minister of health. Togain senior executive commitment and promote sustainability,boards were invited to sign-up to the challenge.Initially, we recommended that districts focused on up to threepriorities from the 26 strategies in the first year. This was toensure that change was seen as manageable and to promoteongoing commitment by creating short term progress.16 Thedecision was also pragmatic because a shift towards patientbased care tends to be incremental and typically takes 5-10years.12 Flexibility was also seen as important so that districts
Correspondence to: K Luxford [email protected]
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Box 1: Patient based care challenge15
1. Leadership commitment• Start each board meeting with a story of patient care from your service—told by a patient or carer face to face, recorded, or read bystaff
• Spend more than 25% of the board’s meeting time on quality—eg, put quality of care first on the agenda, create a quality dashboardfor review
• Arrange for board and executive members to visit wards regularly to talk with staff and patients—eg, conduct regular executive roundsand implement a process for the board to consider frontline concerns about patient care
• Provide training to senior leaders to promote recognition of their critical roles as opinion leaders and champions of patient centredcare
• Involve patient advisers in strategic planning processes—seek patient, family, or carer input through focus groups, committees, orelectronic methods to help set future priorities for the organisation
2. Communicate the mission• Develop and promote an organisational mission statement that embodies the values of patient based care—eg, “The patient at thecentre – every patient, every time”
• Communicate the mission to new staff at orientation—eg, get the chief executive to speak at staff induction sessions about theimportance of all staff in creating patient based care
• Share senior leaders’ personal stories to engage staff in patient based values—eg, training sessions in which senior clinicians orexecutives tell stories of where care could have been better for their patients, their loved ones, or themselves
3. Engage patients, family and carers• Involve patients, families, and carers in governance through committee membership, including quality and risk management andadvisory committees
• Involve patients, families, and carers in design of processes, new facilities, and staff interview panels• Implement a patient based visiting policy—consult with patients, families, and staff on current policies and consider more flexibleapproaches that recognise family and carers as integral team members
4. Support engagement to transform care• Encourage staff to view patients, family, and carers as care team members—eg, implement techniques that promote recognition ofpatient goals for care
• Implement processes that enables patients or family to seek urgent care if they have serious concerns about the status of the patient• Conduct handover at the bedside and include patients and carers• Involve patients in medication management and review—eg, conduct medication reconciliation processes with patients and carers tohelp avoid omissions and errors
5. Use patient feedback to drive change• Use patient feedback from a range of sources (surveys, focus groups, anonymous shoppers) to gauge service quality and inform allstaff—eg, get patient and family advisers to survey current or new patients in waiting rooms or work with junior medical staff to conducta patient shadowing project
• Review data on patient care experience at each meeting as an indicator of quality—eg, patient survey reports• Implement processes to provide real time feedback to staff to enable patient concerns to be resolved during care—eg, bedsideelectronic systems or “patient friend” models (where a former patient talks to ward patients and alerts management to concerns)
6. Focus on work environment• Regularly assess work culture and staff satisfaction—eg, conduct an annual staff survey to monitor staff engagement and use findingsto identify areas for improvement
• Celebrate staff successes visibly—eg, introduce a patient nominated award for staff member of the month.7. Build staff capacity
• Implement organisation-wide training in patient based values and associated communication skills techniques—eg, focused on effectivepatient and carer engagement techniques
• Involve patients and carers in staff education, including sharing stories of good and poor experiences of care8. Learning organisation culture
• Enable staff to identify problems with delivering care and solutions, focusing on priorities identified by patients• Ensure processes are in place to enable ongoing patient and family engagement in open disclosure after adverse events• Share the learning from tragic events to improve quality of care—eg, provide forums for staff to openly discuss key lessons fromincidents where patients have been harmed
9. Accountability• Include accountability for patient care experience in all job descriptions and provide feedback in performance reviews
could respond to local concerns identified by patient surveydata.We developed an online guide17 to the challenge and commissionstaff helped districts by providing advice on building staffcapacity (such as learning what quality care means from thepatient perspective and patient based communication skills) andprogrammes to support specific areas such as systems that allowpatients or family to escalate care for deteriorating patients (seebox 2).With guidance from the commission, districts establishedmultidisciplinary teams that included patients, carers, andcommunity members to identify local priorities and coordinatestrategy uptake.
Response so farThirteen of 15 local health districts committed to the challengein the first year. The two remaining districts wanted to completenew district-wide strategic plans before committing. Mostdistricts focused on two or three strategies, although six adoptedmore than three. The most common initial strategies selectedwere: start each board meeting with a story of patient care fromyour service (six districts), arrange for board and executivemembers to visit wards regularly (five), involve patients,families, and carers in governance through participation incommittees (five); encourage staff to view patients, family, andcarers as core members of the healthcare team (four); andimplement processes to support patient or family activatedescalation of care for deteriorating patients (two). By October2014, the 13 districts had adopted an average of 19 (range 13-25)
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ANALYSIS
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strategies (fig 1⇓). Box 2 gives examples of improvementsimplemented.
How the challenge is being assessedEvaluation of the challenge will include comparison ofquantitative and qualitative data from before and after itsintroduction. Data will come from:
• State-wide patient experience surveys18
• Annual staff workforce surveys (NSWYour SayWorkplaceCulture Survey including a validated staff engagementindex: www.health.nsw.gov.au/workforce/yoursay/2013/Documents/nsw-health-full.pdf)
• Patient complaints data (collected locally and through astate-wide incident database, www.cec.health.nsw.gov.au/clinical-incident-management)
• Annual safety and quality culture audit (NSW QualitySystems Assessment conducted in health care services)
Audits of clinician attitudes conducted in 2011 (before thechallenge) and again in 2012 and 2013 show an increase in theproportion of clinicians’ who think that patients, families andcarers are integral members of the healthcare team (from 79%in 2011 to 92% in 2013).19
As uptake of the challenge strategies is in the early stages it ishard to judge whether it has been a success. Introduction of newpolicies (such as patient directed visitation) by participatingdistricts indicates some benefit. Some improvements in areassuch as patient experience feedback and staff satisfaction havealso been reported. One district has noted patients reportinghigh levels of engagement in care decisions (93% v state average60%) and a high staff engagement index of 82% (state average67%). Qualitative information about barriers and enablers forimplementing the challenge is being collected to provide insightsfor future uptake.We will also look at the effect on length of stay in hospital andpatient mortality and financial implications of the implementingof specific strategies. Outcome reporting for REACH willinclude the costs and benefits to hospitals of averted patientdeaths and decreased transfers to intensive care becausedeterioration is detected earlier.Although the cost effectiveness of the challenge is not yetknown, so far the resources spent are modest and include thesalary of 3.5 full time CEC staff (1 director, 2 programcoordinators, 0.5 project support officer). Anecdotal feedbacksuggests costs to the districts have been minimal because thestrategies have mostly focused on improving communication,with staff attending education sessions that are already part oftheir normal development activities. One area flagged as havingpotential future resource implications is employing staff tosupport sourcing and briefing increased numbers of patient andfamily advisers participating on local committees and qualityinitiatives.
Lessons learnt and policy levers that willpromote changeThe role of clinical leaders and executives as champions ofchange seems pivotal. Health services have responded positivelyto the flexible and incremental approach used to improving careand the competitive nature of rising to the challenge. Key
supporting factors seem to include broad acceptance of patientinvolvement byAustralian clinicians and health services becauseof a long history of government mandated consumerrepresentation in governance of health agencies and nationalpolicy development. Uptake has been helped by the inclusionof patient centred care as a key national goal for safety andquality in health care.20 The introduction in 2013 of mandatoryaccreditation standards for health services, which stipulate thatconsumers should be engaged in organisational governance, hasdriven further interest in partnership approaches to change.21
Although these factors may have facilitated the local responseto the challenge, if long term evaluation shows success oursystem-wide approachmay also be applicable in other countries.Comparison with other approaches such as reimbursement andincentives may shed light on what contributes to effective,sustainable change.
We thank Andre Jenkins for the figure, Alison Lee, program coordinator,and Clifford Hughes for reviewing manuscript drafts and providingfeedback.Contributors: KL drafted initial manuscript and SN and KL revised themanuscript before submission.Competing interests: We have read and understood BMJ policy ondeclaration of interests and have no relevant interests to declareProvenance and peer review: Commissioned; externally peer reviewed.
1 Delbanco T, Berwick DM, Boufford JI, Edgman-Levitan S, Ollenschläger G, Plamping D,et al. Healthcare in a land called People Power: nothing about me without me. HealthExpect 2001;4:144-50.
2 Scott KW, Jha AK. Putting quality on the global health agenda.NEngl J Med 2014;371:3-5.3 Department of Health. High quality care for all: NHS next stage review final report. 2008.
http://webarchive.nationalarchives.gov.uk/±/www.dh.gov.uk/en/healthcare/highqualitycareforall/index.htm.
4 Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century.National Academies Press, 2001.
5 Australian Commission on Safety and Quality in Health Care. Patient-centred care:improving quality and safety by focusing care on patients and consumers. ACSQHC,2010.
6 King’s Fund. From vision to action. Making patient-centred care a reality. 2012. www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Richmond-group-from-vision-to-action-april-2012-1.pdf.
7 World Health Organization. People-centred care in low- and middle-income countries.WHO, 2010.
8 Charmel PA, Frampton SB. Building the business case for patient-centred care. HealthcareFinancial Manage 2008;March:1-6.
9 Luxford K. What does the patient know about quality? Int J Qual Health Care2012;24:439-40.
10 Doyle C, Lennox L, Bell D. A systematic review of evidence on links between patientexperience and clinical safety and effectiveness. BMJ Open 2013;3:e001570.
11 Shaller D. Patient-centered care: what does it take? Report for the Picker Institute andthe Commonwealth Fund. Commonwealth Fund, 2007.
12 Luxford K, Safran D, Delbanco T. Promoting patient-centered care: a qualitative study offacilitators and barriers in healthcare organizations with a reputation for improving thepatient experience. Int J Qual Health Care 2011;23:510-5.
13 Balik B, Conway J, Zipperer L, Watson J. Achieving an exceptional patient and familyexperience of inpatient hospital care. Institute for Healthcare Improvement, 2011.
14 Greene S, Tuzzio, L, Cherkin D. A framework for making patient-centered care front andcenter. Perm J 2012;16(3):49-53.
15 Clinical Excellence Commission. The patient based care challenge. 2010. www.cec.health.nsw.gov.au/pbcc.
16 Kotter JP. Leading change. Harvard Business School, 1996.17 Clinical Excellence Commission. Guide to the patient based care challenge. 2010. www.
cec.health.nsw.gov.au/pbcc.18 Jenkinson C, Coulter A, Bruster S. The Picker patient experience questionnaire:
development and validation using data from in-patient surveys in five countries. Int J QualHealthcare 2002;14:353-8.
19 Clinical Excellence Commission. Safer systems better care—quality systems assessmentstatewide report 2013. 2014. www.cec.health.nsw.gov.au.
20 Australian Commission on Safety and Quality in Health Care. Australian safety and qualitygoals for health care. ACSQHC, 2012.
21 Australian Commission on Safety and Quality in Health Care. National safety and qualityhealth service standards.ACSQHC, 2011.
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Box 2: Examples of change resulting from the challenge
Building staff capacity through trainingSeveral districts identified staff training as fundamental to long term success. This focus also supported compliance with new nationalgovernment standards for health service accreditation.For example, one district held training for all clinical leaders and managers, including board chairs, executives, senior clinicians, and safetyand quality experts. Training focused on research evidence, local success stories about patient engagement, and communication skills.Patients and carers shared their stories (both good and bad) firsthand. Participants consistently identified these as a key motivator forchange, with patients who had spent long periods in hospital and clinical staff who had become patients providing the greatest influence.A training film was made available for use by local champions and other districts. Changes put in place after staff training sessions haveincluded involvement of patients and families in design of new facilities and governance committees, moving nurse shift handover to thebedside, and including patients in medication reconciliation.
Changing visiting hours policyIn one district the board endorsed 24/7 patient directed visiting after a survey showed that patients, families, and carers found visiting hourstoo restrictive and wanted further recognition by staff that they were key members of the care team. Staff, however, soon expressedreservations about loss of devoted patient rest time and potential patient safety and privacy problems. A webinar was held in collaborationwith the US patient centred organisation Planetree and the CEC to find out how other healthcare facilities had introduced patient directedvisiting.The final agreement, reached in collaboration with local clinicians and patient advisers, was to allow patients to nominate carers who willhave 24/7 access as part of the formal care plan. Equally, some patients may want to have “no visitors” recorded in the care plan. Evaluationindicates 100% satisfaction of patients and visitors and 99% satisfaction of staff with the changes. Patient comments included: “I feel likedoctors and nurses are more interested in what my family and I think is important” and “Excellent. My daughter was visiting me last weekand noticed I was being given the wrong medication and was able to tell the nurse.”
Empowering patients and family to escalate careSeveral districts implemented a process to support patient or family escalation of care for deteriorating patients. Thirteen hospitals introducedREACH (Recognise, Engage, Act, Call, Help)—a stepped process that provides a safety net for patients and families with serious concerns.The model was developed and implemented with the involvement of patients, families who had experienced serious incidents, clinicians,and managers. It encourages patients and families to initially engage with their treating doctors and nurses while providing a route for action(“request a clinical review”) or call for emergency help (“call this number for a rapid response”) if still worried. CEC worked with each hospitalto decide on the local escalation process and responders (such as medical emergency team or intensive care outreach nurse). Educationsessions for all staff highlighted benefits and allowed clinicians to discuss concerns (such as fear of inappropriate use).
Patients and carers as team members
Insights from patients and carers have been fundamental in developing the patient based care challenge. For example, a patient with aprofessional background in the building industry where “safety was paramount” led the development and implementation of the REACH(Recognise, Engage, Act, Call, Help) model for accelerating care for deteriorating patients. Patients have also been involved in all aspectsof planning and evaluation. Feedback from clinicians has underlined the value of input from patients and lay advisers: “The consumer (ofhealth services) tends to see the problem and solution so much more simply and they ask reasonable questions—whereas the healthcareprofessional tends to drown in the complexity and what cannot be done.”The CEC has provided training for patient and carer advisory groups to support them to take on the role of members of health improvementcommittees and provides background on key issues and theories in safety and quality. Training involves advice from experienced patientsafety advocates about working collaboratively to bring about change. (www.cec.health.nsw.gov.au/pbcc/engage-patients-family-and-carers/involve-patients-families-and-carers-in-governance#content) Each district has tailored partnerships with patient, families and carer to addressthe health services priorities of their local community.Several districts have involved patients and carers in educating health staff by getting them to tell their stories face to face. This had givenhealth workers a clear picture of good and poor care within their health services. One district responded by including patientsand carers inthe governance of mental health and drug and alcohol services.
Figure
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Fig 1 Uptake of challenge strategies among districts in New South Wales, Australia (number of strategies at sign-up andprogress at October 2013 and October 2014)
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