Background

Northumbria Healthcare Trust (Northumbria Healthcare) provides acute and community health services and adult social services to a population of over half a million in the North East of England. With an annual budget of around £500 million, Northumbria Healthcare operates nine hospitals (three general hospitals and six community hospitals). In addition to institutional care, Northumbria Healthcare delivers a broad range of community services, including nursing; health visiting; rehabilitation; public and sexual health services; and adult social care, such as day care, equipment services, home adaptation, occupational therapy and support for caregivers. Northumbria Healthcare is in the process of acquiring a trust in the North West that will result in a single organization providing acute and community services coast to coast across North England.

Northumbria Healthcare consistently rates among the best National Health Service (NHS) trusts in England. It has been in the top CHKS1 40 hospitals for five consecutive years, and is highly rated by all the relevant independent regulators: Care Quality Commission (CQC), National Patient Safety Agency (NPSA), National Health Service Litigation Authority and Monitor. In 2011, the CQC placed Northumbria Healthcare in the top five hospitals for quality of outpatient services, and in 2013, it was named Provider Trust of the Year at the prestigious HSJ awards. In addition, the NPSA awarded the highest marks possible to all nine Northumbria Healthcare hospitals. Northumbria Healthcare has also won national and regional awards for quality of management, quality of care, patient experience and innovations.

In the 2014–2015 annual NHS staff survey (mandated by the CQC), Northumbria Healthcare performed exceptionally well, with the majority of staff recommending it as a place to work or receive care, and 94% feeling their work makes a real difference. Staff engagement was ranked second in the country in 2013, and Northumbria Healthcare has achieved the highest response rate for national survey returns for the last four years. Eighty-four per cent of staff at Northumbria Healthcare believe that high-quality patient care is the organization’s number one priority, compared to a national average of 66%. The chief executive, Jim Mackey, has been recognized for his leadership of improvements in the quality of patient care across the North East, and patients have voted Northumbria Healthcare the best trust in the North East. As well, Northumbria Healthcare has won a regional Health and Social Care Award, and its community services have garnered awards for innovations in nurse-led care and bathing services. In 2015, Mackey moved from Northumbria to become the first Chief Executive of a newly created national regulator of NHS and independent healthcare providers in England.

Patient Engagement

Mackey traces Northumbria Healthcare’s strategic commitment to patient engagement back to the public consultation on the closure of a hospital at Morpeth in 2006–2007. The success of this consultation process led to the use of a similar approach later when Northumbria Healthcare had to make changes to emergency care. Input from members of the public helped the trust to refine and improve the original proposals, providing a higher level of understanding as well as building trust with the public.

In line with national policy, over the years, Northumbria Healthcare’s board’s efforts to focus on and improve quality have shifted from service access to patient safety and, more recently, to improving the quality of patients’ experience. According to Mackey, “We’re a service-oriented people business. All service businesses take customer service seriously.” In 2009, Northumbria Healthcare appointed a director of patient experience (DPE) who reports to the chief executive. The DPE’s primary responsibility is to improve the quality of patients’ experience. This is one of only four such positions at this level in NHS England, and the only one where the role is defined specifically in terms of quality improvement (QI).

Following her appointment, the DPE and the chief executive developed a strategy for QI, prioritizing improvement areas where increased patient engagement could accelerate improved care and patient experiences. Gradually, in a relatively short period of time, the twin aims of increasing patient engagement and improving patient experience have become central to Northumbria Healthcare’s strategic direction, reflected by changes on the executive team. In 2012, after three years, the DPE was appointed to the position of joint director of quality, a position she shares with one of the consultant orthopedic surgeons.

Key Strategies to Support Patient Engagement

User involvement in a variety of fora
The evolution of the stroke improvement work, and the spread of these methods to other service areas, illustrates how Northumbria Healthcare applies user involvement/patient engagement to improve care. Reflecting on the lessons learned from the growing participation and influence of voluntary organizations at the national level (notably the Stroke Association and Connect UK), in 2005, Northumbria Healthcare set out to enhance user involvement and give patients greater input into decisions about changes in care delivery. To that end, Northumbria Healthcare established an executive group for stroke improvement with user/patient members on the executive and the various working groups.

In the early stages of this effort, while many stroke activists were involved, some participants felt that it was difficult for them to voice their opinions. Gradually, however, the culture of the stroke services has changed, and the voice of the patient has become stronger. Today, a Living with Stroke group meets regularly and is involved in all of the decisions affecting Northumbria Healthcare’s stroke services.

In addition, Northumbria Healthcare developed a peer support program for stroke patients in which 24 patients have been trained to provide peer support to inpatients and communicate with staff. Peer supporters visit patients immediately after their strokes and operate a drop-in group for them in hospital, providing oral and written information. Staff are generally very positive about having these peer supporters on the ward.

Recently, staff noticed that caregivers to stroke patients were beginning to demonstrate stress. Staff recognized that they need to better prepare caregivers to support stroke patients at home, and to provide information on benefits, services and links to a local caregivers’ centre, which offers a six-week focus support group.

Measuring and improving patient experience
Measurement has played an important role in developing Northumbria Healthcare’s strategy for improving patient experience. In 2010, the newly appointed DPE introduced real-time data collection and reporting, interviewing approximately 600 patients a month while they are still in hospital. Interview results are fed back to the clinical teams within 24 hours of speaking to patients.

Initially piloted on eight wards and two hospital sites, Northumbria Healthcare’s 20-question survey has been rolled out across all hospital wards and sites. Real-time data are supplemented by a follow-up questionnaire sent to 1,000 inpatients and outpatients each month. Northumbria Healthcare recognizes these follow-up data as “right time” data, captured at a time when, statistically, patients are at their most dissatisfied and perhaps most free to explain why.

Northumbria Healthcare now has an eight-member patient experience improvement team that collects, analyzes and reports real-time patient feedback data to service managers. According to one of the orthopedic ward matrons (i.e., senior nurses), ward-based staff feel it is important to have dedicated QI staff to collect the data and provide the results to them within 24 hours in order to maintain their focus on what patients say about the service.

Impact

Within six months of implementing the measurement of the new stroke services, Northumbria Healthcare demonstrated statistically significant improvement in results across eight care domains identified by, and most important to, patients.2 These improvements include coordination of care, respect and dignity for patients, pain control, involvement in patients’ own care and medicines management. Real-time QI program rollout in the neighbouring trust has seen similar levels of meaningful change within a 12-month period in a very different and far more challenging organizational context.

On the stroke units at Northumbria Healthcare, the peer support program for stroke patients has strengthened the team-based approach to recovery and formally recognizes the contribution of a shared lived experience. For example:

• Over 90% of patient/carer respondents felt understood and listened to by volunteers, and that they were provided with useful information.
• One hundred per cent of staff felt that the volunteers have improved the patient experience.
• Ninety-five per cent of the volunteers felt adequately prepared for their role.
• One hundred per cent of the volunteers felt able to use their own experience to understand the needs of others.

Currently, patient experience data are reported by service and care team; individual consultants receive their own individual data, which are fed into performance appraisal systems. The DPE and others insist that using patient feedback to measure service performance be completely embedded in the way Northumbria Healthcare works; all new QI programs will incorporate a patient experience angle.

The DPE has a small budget (£15,000–£17,000) for allocation to care teams to support ideas for improving patients’ experience. The funds have been used, for example, to buy tablecloths to cover tables for inpatients dining on weekends. If the patient experience performance on a ward falls below 90%, the DPE can offer additional training and support to staff to drive the results back up.

Recognizing that many older patients and some other groups of patients cannot speak for themselves using the current tools, Northumbria Healthcare has partnered with a charity, Age UK, to address this issue. Age UK has a strong commitment to treating older people with dignity, involving them in decisions about their lives and spreading positive messages about the value of older people and their rights as citizens. Age UK volunteers visit Northumbria Healthcare hospitals to observe the care and communication occurring on the wards and to provide care teams with real-time feedback on the opportunities – taken and missed – to promote dignity and compassion. Program evaluation has illustrated that Northumbria Healthcare staff value this external validation of the care they provide.

Summary

Northumbria Healthcare has successfully integrated patient experience within its QI efforts. The creation of the DPE role and appointment of the DPE as joint director of quality optimized Northumbria Healthcare’s focus on QI areas where patient engagement efforts could support improved patient care and experiences. A variety of patient engagement methods are employed across Northumbria Healthcare, including consultations, peer support programs and patient auditors in collaboration with Stroke Association, Connect UK and Age UK. Finally, real-time data collection and analysis by a core patient experience improvement team grounds all efforts in incorporating the patient voice and provides timely individual and unit-level information to staff/front-line care provider teams to guide change, as well as to sustain and enhance QI.

This case study is based on research carried out in 2012. The case was revised and edited in 2015 as part of research commissioned by the Federal Advisory Panel for Healthcare Innovation to inform their report: Unleashing Innovation: Excellent Healthcare for Canada (https://www.healthycanadians.gc.ca/publications/health-system-systeme-sante/report-healthcare-innovation-rapport-soins/index-eng.php).

Notes

1. CHKS is an independent hospital-benchmarking agency that ranks organizations on the basis of 22 indicators of clinical effectiveness, health outcomes, efficiency, patient experience and quality of care.
2. These comprised seven core domains identified by Picker in Core domains for measuring inpatients’ experience of care, plus an eighth care domain around medicine communication that was particularly challenging at Northumbria Healthcare. 

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