It can be easy to make assumptions about what matters most to patients. The Always Events® approach to co-design compels health care providers to hear directly from patients and families about the aspects of the care experience that are so important they must be performed consistently for every individual, every time. In the following interview, Helen Lee, Experience of Care Professional Lead, and David McNally, Head of Experience of Care, explain why Always Events has spread to 135 organizations throughout NHS England.
Different from Traditional QI
Helen Lee: Always Events is a quality improvement methodology which turns our traditional approach to QI on its head. Rather than health care organizations determining what we think will make the biggest difference for patients, you start with a blank piece of paper and ask people who use [your] services, their families, and [care providers] what matters to them. It brings together this magic mix of people with staff at the point of care. If you ask them what the challenges are, they’ll tell you and they have great ideas about how to make improvements. Always Events gives them the space to test those ideas and make a real difference together.
David McNally: It’s an improvement methodology based on the Model for Improvement. We use PDSA cycles, we use measurement. All of that is in there, but it has that fundamental difference that it starts from that conversation with a group of people who use the services.
Works in a Variety of Settings
David McNally: In England, we’ve now reached 135 health care provider organizations over four years. That’s over 50 percent of providers. This includes acute hospitals, mental health trusts, community provider organizations, and an ambulance trust. It’s beginning to be used in primary care and in care homes.
Puts Patients at the Center
Helen Lee: It starts with a conversation with patients and families. You co-produce every step of the way. Your change ideas are co-produced. You co-produce your [plans for] measurement, evaluation, and review.
David McNally: People often say to us, “We know we should have patients right in the heart of the way we do QI. We don’t know how to do it.” Always Events are not the only way of doing it, but they demonstrate that it’s possible.
Simple by Design
Helen Lee: People ask, “How do we find out what matters to people?” We say, “You tell us. You know who you need to connect with in your care setting. Are there any groups and communities that you can tap into? Don’t expect people to come in to you.” For example, there was a maternity service that wanted to learn what new mothers thought of them. Women who’ve just had a baby are busy people. They don’t want to come back into a hospital setting to give feedback, but they’re more than happy to share online. They used a closed Facebook group and got a wealth of information about what really mattered to them. This included women who wanted their partner to support them while they are in hospital. The resulting change ideas included ending strict visiting times and starting open access for partners.
Helen Lee: In the past we’d presume that we know what matters most to patients and change things we thought weren’t working, but if you ask people they’ll say, “Actually, that bit’s not that bad. You really need to get that other bit right because that’s the bit that’s the problem.” By co-producing improvement, you focus on the things that really matter, rather than wasting your time. Health care professionals are busy people and asking them to think and do their work differently can be challenging. One team leader said, “We were quite worried about the time this would take, but it’s been small tweaks and changes in what we do that have had massive impact.”
Promotes Joy in Work
Helen Lee: It’s a great way to engage and motivate health care professionals because they’re hearing success stories and the significant improvements not just for people using the services and families, but also in staff experience as well. It’s about joy in work and being connected back to your core purpose, to why you chose to come into health care. We encourage people to include staff experience as a balancing measure and, universally, we’ve found staff experience improves. It’s a win-win, and the improvements are being sustained because they’re designed right, by the right people, at the point of care, together.
Low Cost or Free
Helen Lee: It’s not uncommon for staff to be anxious about asking patients about what matters most to them. Staff often presume they know the answer they’ll get. “People are going to ask for something outside our control.” But it’s not about building a new hospital. Very often, the things that matter to people are the relational aspects of care: “I care how you made me feel, how you communicated with me.” There was a team that was convinced that patients were going to ask for more staff. When they asked, the people who were using the service said, “We know we’re getting the best care and we don’t mind waiting if we need to, but could you just tell us if there’s going be a delay and I can go and get a coffee or I can put money in the car parking machine.” Those little things are absolutely free and won’t take too much effort for the team to improve.
David McNally: It’s a much more adaptable methodology than I think we’d appreciated at the very beginning. We knew it worked in small-scale ways, but we’re starting to see organizations use it on a larger scale. We’re seeing integrated care systems, for example, working on improving their hospital discharge process. They tell us that Always Events will help them bring in the perspectives of the people using their services. There’s a frailty program that’s designed a sophisticated program of change, but they haven’t yet got patients involved, but learning about Always Events helped them see how they can just plug the methodology into different parts of their program to get the patient perspective and get patient help to co-design the improvements. For a lot of the provider organizations in England, Always Events have become central to their quality strategies. It’s become an explicit part of the way they go about doing, describing, and reporting on quality. There are integrated care systems seeing it as part of their bigger transformation programs. It’s not an add-on. It’s very much at the center.
Editor’s note: This interview has been edited for length and clarity.
To learn more, join Helen Lee, Paul Batalden, and others at the IHI National Forum for session MF07: Healthcare Service Co-Production and its Improvement: How Does it Work? on Monday, December 9, 2019 from 8:30 AM4:00 PM
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More about Always Events from IHI and NHS England