Eaton and colleagues identify a number of concerns about quality of care, particularly in the UK’s NHS. They note that (sadly) “people who work in healthcare often seem to be immune to anxiety, excessive waiting, and impersonal and unnecessarily distressing experiences .... and participate in care that isn’t delivering a good experience”. (1) That quality needs to be improved is undeniable. The question is how, and what do efforts to improve need to based upon?
Eaton and colleagues have somewhat simplistically latched onto NICE’s Guidance and quality standards on patient experience. They note that “improvements will not be seen unless we understand and improve the attitudes and behaviours of healthcare professionals as well as systems and structures of care. Key to this will be reliable and consistent measurement of patient experience..... The detailed quality measures included in the quality standards document are a good place to start.” (1)
Notwithstanding that the concluding statement of the summary article (2) that “robust measures of the experience of patients still need development and validation to achieve this aim” the views of Eaton and colleagues betray an incomplete perspective on the problems and the solutions. Their comments imply that measurement – and likely documentation and analysis – of variations in patient experience are the key towards planning and delivering improvements. Bench-marking, ‘score-card’ feedback, and indeed incentivisation of good performance against scoring methods are all possible levers for change if measurement is implemented more widely.
However the measurement paradigm misses out a further important influence and barrier to improvement – understanding the culture and day-to-day situation of clinicians. Those who interview for medical or nursing schools, and for training for the range of allied health professions, would attest to the caring aspirations and motivations of would-be students. Are Eaton and colleagues sure that they know what is going wrong after graduation, in the ‘swamp’ of everyday healthcare, that impairs previously motivated and able individuals from providing the quality of care to which they aspired? More than measurement, we need to undertake well-designed mixed methods research, likely principally qualitative, to understand the lived-world experience, limitations and barriers, constraints and competing pressures that are adversely influencing quality of care. In the light of such evidence we may then have a basis for more insightful efforts to improve quality and patient experience.
Fundamentally, the issue is about the nature of leadership to effect change. What is missing in the editorial is a sense of trying to take clinicians with us as we strive to drive up quality and patient experience. If the general clinician workforce, of which I am one, might be regarded as the sheep, the analogy stretches to a consideration of the style of shepherding. In some parts of the world, the shepherd leads (usually) his sheep. In other parts of the world, shepherds follow on behind, perhaps ‘helping’ their sheep to move forward by the ‘facilitation’ of a stick or a dog. Both may be effective, but we have a very large flock of clinicians in healthcare, and here we have yet to show the most effective way of shepherding them to the pastures of greater quality and better patient experiences.
The measurement paradigm is part of the ‘stick’ approach, but may be at risk of failing to understand, recognise and utilise the clinician perspective, and ultimately be at risk of failure. Given that healthcare is not like a restaurant or a retailer in the marketplace, to which Eaton and colleagues refer (1), there needs to be greater consideration of the problems and issues for everyday clinicians trying to deliver (at least reasonable) quality care and patient experiences. It is likely that the ‘stick’ approach needs to be complemented by more positive leadership that takes clinicians forward with it, harnessing their motivations and trying to overcome the barriers to wider adoption of patient involvement and participation that would improve the experience of healthcare for patients and carers.
1. Eaton S, Collins A, Coulter A, Elwyn G, Grazin N, Roberts S. Putting patients first: NICE guidance on the patient expereince is a welcome small step on a long journey. British Medical Journal. 2012;344:e2006.
2. O'Flynn N, Staniszewska S, Guideline Development Group. Improving the experience of care for people using NHS services: summary of NICE guidance. British Medical Journal. 2012;344:d6422.
Rapid Response:
Re: Putting patients first
Eaton and colleagues identify a number of concerns about quality of care, particularly in the UK’s NHS. They note that (sadly) “people who work in healthcare often seem to be immune to anxiety, excessive waiting, and impersonal and unnecessarily distressing experiences .... and participate in care that isn’t delivering a good experience”. (1) That quality needs to be improved is undeniable. The question is how, and what do efforts to improve need to based upon?
Eaton and colleagues have somewhat simplistically latched onto NICE’s Guidance and quality standards on patient experience. They note that “improvements will not be seen unless we understand and improve the attitudes and behaviours of healthcare professionals as well as systems and structures of care. Key to this will be reliable and consistent measurement of patient experience..... The detailed quality measures included in the quality standards document are a good place to start.” (1)
Notwithstanding that the concluding statement of the summary article (2) that “robust measures of the experience of patients still need development and validation to achieve this aim” the views of Eaton and colleagues betray an incomplete perspective on the problems and the solutions. Their comments imply that measurement – and likely documentation and analysis – of variations in patient experience are the key towards planning and delivering improvements. Bench-marking, ‘score-card’ feedback, and indeed incentivisation of good performance against scoring methods are all possible levers for change if measurement is implemented more widely.
However the measurement paradigm misses out a further important influence and barrier to improvement – understanding the culture and day-to-day situation of clinicians. Those who interview for medical or nursing schools, and for training for the range of allied health professions, would attest to the caring aspirations and motivations of would-be students. Are Eaton and colleagues sure that they know what is going wrong after graduation, in the ‘swamp’ of everyday healthcare, that impairs previously motivated and able individuals from providing the quality of care to which they aspired? More than measurement, we need to undertake well-designed mixed methods research, likely principally qualitative, to understand the lived-world experience, limitations and barriers, constraints and competing pressures that are adversely influencing quality of care. In the light of such evidence we may then have a basis for more insightful efforts to improve quality and patient experience.
Fundamentally, the issue is about the nature of leadership to effect change. What is missing in the editorial is a sense of trying to take clinicians with us as we strive to drive up quality and patient experience. If the general clinician workforce, of which I am one, might be regarded as the sheep, the analogy stretches to a consideration of the style of shepherding. In some parts of the world, the shepherd leads (usually) his sheep. In other parts of the world, shepherds follow on behind, perhaps ‘helping’ their sheep to move forward by the ‘facilitation’ of a stick or a dog. Both may be effective, but we have a very large flock of clinicians in healthcare, and here we have yet to show the most effective way of shepherding them to the pastures of greater quality and better patient experiences.
The measurement paradigm is part of the ‘stick’ approach, but may be at risk of failing to understand, recognise and utilise the clinician perspective, and ultimately be at risk of failure. Given that healthcare is not like a restaurant or a retailer in the marketplace, to which Eaton and colleagues refer (1), there needs to be greater consideration of the problems and issues for everyday clinicians trying to deliver (at least reasonable) quality care and patient experiences. It is likely that the ‘stick’ approach needs to be complemented by more positive leadership that takes clinicians forward with it, harnessing their motivations and trying to overcome the barriers to wider adoption of patient involvement and participation that would improve the experience of healthcare for patients and carers.
1. Eaton S, Collins A, Coulter A, Elwyn G, Grazin N, Roberts S. Putting patients first: NICE guidance on the patient expereince is a welcome small step on a long journey. British Medical Journal. 2012;344:e2006.
2. O'Flynn N, Staniszewska S, Guideline Development Group. Improving the experience of care for people using NHS services: summary of NICE guidance. British Medical Journal. 2012;344:d6422.
Competing interests: No competing interests