Week 4 Paper: Improving Patient Satisfaction
Complete the Jones Bartlett Navigate 2 simulation scenario “Customer Satisfaction”. (See COMPLETED Attachment)
Customer Satisfaction Introduction: The Chief Executive Officer of Bright Road Health Care System wants to improve patient care survey results in the urgent care facilities within the Health Care System. The perceived quality of service is the lowest rated area on the survey. As a Change and Process Management consultant, you will work with the Director of Quality Improvement of the Health Care System to analyze the current structure, process, and outcomes of the urgent care facilities. Based on the information you gather; you will provide current quality improvement data and make a recommendation for improvements.
Characters:
1. James Melbourne, Director of Urgent Care Facilities
2. Thomas Rogers, Director of Quality Improvement
3. Jason Bartman, Nurse Administrator of Urgent Care Facilities
4. Charlie Moore, Director of Medical Records
5. Tanya Morales, Student’s Mentor
Complete the final assessment, which asks you to make improvements and recommendations to the CEO. This should be done in the form of an email.
Capture a screen image of your quiz score and paste it into your assignment as an appendix.
HCM520: Quality & Performance in Healthcare
HCM520: WEEK 4 Paper
Week 4 Paper: Improving Patient Satisfaction
Complete the Jones Bartlett Navigate 2 simulation scenario “Customer Satisfaction”. (See COMPLETED
Attachment)
Customer Satisfaction Introduction: The Chief Executive Officer of Bright Road Health Care System wants to improve
patient care survey results in the urgent care facilities within the Health Care System. The perceived quality of service is
the lowest rated area on the survey. As a Change and Process Management consultant, you will work with the Director
of Quality Improvement of the Health Care System to analyze the current structure, process, and outcomes of the
urgent care facilities. Based on the information you gather; you will provide current quality improvement data and make
a recommendation for improvements.
Characters:
1. James Melbourne, Director of Urgent Care Facilities
2. Thomas Rogers, Director of Quality Improvement
3. Jason Bartman, Nurse Administrator of Urgent Care Facilities
4. Charlie Moore, Director of Medical Records
5. Tanya Morales, Student’s Mentor
•
Complete the final assessment, which asks you to make improvements and
recommendations to the CEO. This should be done in the form of an email.
o
•
**Completely RE-WORD, but use the same recommendations in the attached
EXAMPLE**
Capture a screen image of your quiz score and paste it into your assignment as an appendix.
o (Included)
Submission Requirements:
You may format the final assessment to the CEO, as an email, as shown in EXAMPLE.
Your email should meet the following requirements:
•
•
Be 500-700 words.
A minimum of three references with associated in-text citations.
Page 1
HCM520: Quality & Performance in Healthcare
Week 4: Discussion Post ~ 400-500 words.
In this discussion, you will explore examples of quality improvement in healthcare and how patient
satisfaction can be measured.
Review the following article:
Robinson, Å., Finizia, C., & Gustavsson, S. (2020). Involving patients in quality improvements – a case
study. TQM Journal, 32(2), 348-361. https://doi.org/10.1108/TQM-04-2019-0116
After reviewing the article, answer the following questions:
Describe the case example, setting, and who was included.
What was the overall objective or goal of the case example?
If mentioned, what research instruments were used in the case example to gather data? If not
mentioned, what would you have used?
4. What, if any, are the drawbacks or disadvantages of the EBCD design?
5. What were the results of the case example? Any important gaps and opportunities for
improvement?
6. What recommendations do you have based on the conclusion of the case results?
1.
2.
3.
Page 2
The current issue and full text archive of this journal is available on Emerald Insight at:
www.emeraldinsight.com/1754-2731.htm
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Involving patients in quality
improvements – a case study
348
Department of Otorhinolaryngology, Head and Neck Surgery,
Capio Lundby Sjukhus, Goteborg, Sweden
Åsa Robinson
Received 3 May 2019
Revised 12 August 2019
Accepted 2 September 2019
Caterina Finizia
Department of Otorhinolaryngology, Sahlgrenska University Hospital,
Goteborg, Sweden, and
Susanne Gustavsson
Department of Quality and Development, Skaraborg Hospital, Skövde, Sweden and
Centre for Health Care Improvement (CHI), Chalmers University of Technology,
Gothenburg, Sweden
Abstract
Purpose – The purpose of this paper is to illuminate strengths and limitations in quality improvement work,
when involving patients.
Design/methodology/approach – The experience-based co-design (EBCD) method was used when
improving care for patients undergoing otosclerosis surgery. Individual interviews and focus groups were
interpreted using qualitative content analysis.
Findings – Strengths mentioned by patients were that their participation made a difference. The first steps
were found effective in giving an in-depth view of patients’ experiences and the staff got an increased
understanding about specific patient needs. However, weaknesses were found in the latter phases, those
of improving and follow-up, health care staff had difficulties to keep their focus on patients’ experiences
and invite patients to be involved. Patients’ participation decreased, and there was a lack of tools to support
the process.
Research limitations/implications – The content in this paper is mainly based on one case. However, the
findings are in congruence with earlier research and add further knowledge to the research area.
Practical implications – The findings can be used in healthcare when involving patients in improvement work.
Originality/value – There is no earlier study which involves patients with otosclerosis when using EBCD.
Furthermore, this paper illuminates that there is a need to increase collaboration with patients. The latter
phases often seem to be handled by health care professionals without involving patients; this paper suggest a
development using dedicated quality tools.
Keywords Health care, Quality improvement, Experience-based co-design, Patient involvement,
Improvement work, Otosclerosis
Paper type Case study
The TQM Journal
Vol. 32 No. 2, 2020
pp. 348-361
© Emerald Publishing Limited
1754-2731
DOI 10.1108/TQM-04-2019-0116
1. Introduction
There is an intention to strengthen the patient’s role in today’s healthcare (Crawford et al.,
2002; Iedema et al., 2010; Gustavsson et al., 2016b). However, change is slow and governments
throughout North America and parts of Europe are initiating various projects to speed up the
process (Crawford et al., 2002; The Commonwealth Fund, 2016). Due to these interventions, the
patient’s role is slowly changing from being a passive object that moves through the system to
become an actor fully involved in not only her/his own healthcare but also in improving
healthcare systems in general (Bate and Robert, 2006; Robert et al., 2015; Snyder and
Engstrom, 2016). In comparison to other countries, Swedish healthcare is characterized as
having weaker result in areas concerning patients’ experiences of participation, information,
accessibility and coordination of care (Commonwealth Fund, 2016).
One way of strengthening the patients’ role in the healthcare is to invite them to become
involved in current and planned healthcare quality improvement projects (Olsson et al., 2014;
Snyder and Engstrom, 2016). A method called experience-based co-design (EBCD) was
launched in the English healthcare sector by Bate and Robert (2006) and first studied in a
head and neck cancer care clinic (Bate and Robert, 2007). Later on, the EBCD method has
been spread and used as an approach to involve patients in healthcare quality
improvements (Iedema et al., 2010; Gustavsson, 2014; Robert et al., 2015; Donetto et al.,
2015; Maher et al., 2017). In Sweden, EBCD has been launched by the Swedish Association
of Local Authorities and Regions (2011) as a suggested way of increasing patient
participation during healthcare quality improvement projects. EBCD has been used
worldwide in relation to different patient groups; however, there are no examples of
studies connected to care of patients undergoing otosclerosis surgery which is presented
in this paper. The EBCD is an experience-based method for quality improvement, and
builds on a tight collaboration between patients, sometimes relatives and healthcare
professionals (Bate and Robert, 2007; Gustavsson et al., 2016a). Examples of EBCD are
often referred to as successful, and there are lots of in-depth descriptions of patients using
their experience of care to help healthcare professionals identify improvement areas and
prioritizing their urgency for change. The method seems to offers a lot of opportunities to
gain understanding of the patients’ perspective that could be used when improving a
patient process (Iedema et al., 2010; Tsianakas et al., 2012; Bak et al., 2014; Gustavsson,
2014; Robert et al., 2015; Maher et al., 2017).
Involving patients in healthcare improvements is believed to be a key to successfully
increase their experience of participation and information. But research of when and how
to use patients’ experiences as a base for collaborative improvements is still scarce, and
questions concerning when and how to involve patients have been raised (Crawford et al.,
2002; Bate and Robert, 2006; Coulter et al., 2014; Snyder and Engstrom, 2016; Gustavsson
and Andersson, 2017). This paper is intended to illuminate strengths and limitations in
quality improvement work when involving patients, using a case from Swedish health
care, an improvement project engaging patients undergoing otosclerosis surgery, using an
EBCD methodology.
2. Theoretical background
2.1 A need for improvement knowledge
During the last two decades, there has been a strong focus on quality improvements in
healthcare (Institute of Medicine, 2000; Berwick, 2002; Varkey et al., 2007; Atkinson et al.,
2010). It has been suggested that healthcare professionals, e.g. physicians and nurses not
only need professional knowledge, but also knowledge of how to improve the healthcare
they function within, named improvement knowledge (Figure 1) (Batalden and Stoltz, 1993).
However, it is not just up to professional individuals, the organization’s drive for
change is also very important for improvement efforts (Batalden and Stoltz, 1993;
Bergman et al., 2015). Batalden and Davidoff (2007) stated that quality improvement
within healthcare means an unceasing effort of everyone – healthcare professionals,
patients and their families – to make the changes that will lead to better patient outcomes,
better processes and better professional learning.
Methods like Six Sigma, Lean and PDSA were developed within the production industry
to aid the continuous work with quality improvements within these industries. The methods
have since then been adjusted to fit in the healthcare sector (De Souza, 2009; Lifvergren et al.,
2010). Quality improvement projects vary in design and method, but even if countries,
regions, hospitals and departments use different methods for their projects, there are sets of
tools/ techniques that can be used independently of the method. These tools can be used for
planning, analysing and for constructing the improvements. They include root-cause
analysis, cause-and-effect diagram, brainstorming and control charts, just to name a few
(Batalden and Stoltz, 1993; Bergman and Klefsjo, 2010; Bergman et al., 2015). All of these
Patients in
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improvements
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Figure 1.
The linkage of
knowledge required
for continual
improvement
Professional
knowledge
Improvement
knowledge
Improvement of
diagnostic and
treatment procedures
+
Improvement of
processes and
systems
Increased value for patients
Source: Adapted from Batalden and Stoltz (1993)
techniques have been shown to be useful in healthcare improvements in general and
clinicians need to have a basic knowledge of them and how to use them systematically to
effectively work with quality improvement in their environment (Varkey et al., 2007).
2.2 Involving patients in quality improvements
Patient involvement has been suggested as an appealing approach to the continuous
quality improvement work. There are many areas within the healthcare where an
understanding of the patient’s needs and expectations would facilitate quality
improvement. A deeper understanding of these needs makes it easier to steer and
prioritize when improving health care quality. The patients carry unique experience
which can be used to identify strength and quality gaps of current processes that the
professionals are not aware of (Bate and Robert, 2007; Donaldson, 2008; Iedema et al.,
2010; Cordero-Ampuero et al., 2012). It is believed that if patients are given a strong voice
during the design and delivery of care, the result will be better outcomes and value in the
delivery of health care (Bate and Robert, 2006; Bak et al., 2014; Gustavsson et al., 2016a).
However, with the growing emphasis of patient involvement in quality improvement
within healthcare comes a need to develop methods and tools supporting both healthcare
professionals and patients in their collaborative efforts. Research is also needed in
regards to when and how to best involve patients in different quality improvement works
(Crawford et al., 2002; Coulter et al., 2014).
2.3 Experience-based co-design
EBCD is a method for quality improvement developed by action researchers in association
with English NHS National Health Service (Bate and Robert, 2006). The method is based on
the tradition of participatory action research (PAR) and the core value of PAR is that
research is undertaken “with” instead of “on” the participants. Action is translated into
knowledge, and the knowledge comes into new actions, often described as a spiral (Reason
and Bradbury, 2009; Coghlan and Brannick, 2014). Knowledge creation in quality
improvement projects are presented as being driven by two mechanisms, methods and
psychology, and both are needed for success (Choo et al., 2007). EBCD is strongly influenced
by the design sector (Bate and Robert, 2006) and the method is intended to take the patient
participation another step further by involving the patient in the actual improvement project
together with the healthcare professionals, thereby the name co-design. The EBCD method
focusses on identifying certain key moments, so-called “touch points”, affecting the patients’
experience of healthcare. When changing a process one can use the understanding of these
key moments to improve the experience of receiving the service (Gage and Kolari, 2002; Bate
and Robert, 2007; Steen et al., 2011).
The EBCD method is structured into four steps, and each step is taken in an intimate
cooperation between the patients and the healthcare professionals (Bate and Robert, 2006,
2007). The four steps are: to capture the experience, to understand the experience, to
improve the experience and finally to follow-up that changes have led to improvement of the
experience (Bate and Robert, 2007) (Figure 2).
By working closely together in a structured way, the needs and expectations of both
groups can be understood and used when designing even better future experiences (Bate and
Robert, 2007; Steen et al., 2011). Patients are experts at the experience of receiving healthcare,
just as clinicians are experts in delivering healthcare. Together, they have unique possibilities
to improve the process. Many patients are interested in working in partnership with
healthcare professionals to improve health care services and supportive to the concept of
co-design (Maher et al., 2017).
Patients in
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2.4 What are the challenges of experience-based co-design?
There are challenges using the EBCD approach for improvement work. Motivating staff and
patients to devote time on a collaborative work can be hard (Iedema, et al., 2010; Greenhalgh
et al., 2010; Boyd et al., 2012). Reasons such as the staff being occupied giving care instead of
developing care and patients feeling that they do not have time due of working or living far
from hospital, or being too sick to contribute have been described (Iedema et al., 2010; Bowen
et al., 2013; Engstrom and Elg, 2015; Maher et al., 2017). It can also be difficult to keep the
momentum in groups containing both patients and staff during the whole project (Bak et al.,
2014; Maher et al., 2017). To secure and maintain patient engagement throughout co-design
projects, it is important to provide good communication throughout the project, offer
patients support, regular feedback on their contribution and making outcomes visible for
them (Maher et al., 2017). The EBCD method contains tools such as filming and interviewing
patients and staff, observational work and emotional mapping which can all be used during
the first phases of the project; however, there is very limited guidance and no specific tools
for the last two phases of the method (Bowen et al., 2013).
3. Methods
3.1 Setting
This paper describes experiences of the EBCD method on patients in the process of
stapedotomy (otosclerosis surgery) at the Department of Otorhinolaryngology (ear, nose and
Patients
Healthcare
professionals
To catch the experience
Individual
interviews
Individual
interviews
To understand the experience
Group
meeting
Group
meeting
To improve the experience
To follow up the experience
Joint group meeting
Figure 2.
The experience-based
co-design process
Joint group meeting
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throat or ENT) at Sahlgrenska University hospital, Sweden. The hospital is the only hospital
performing stapedotomy in the area with a population of about 785,000 inhabitants. The
surgery is performed by two consultants as an out-patient surgery. The surgeons operate
about 35 patients per year.
The reason why a person needs a stapedotomy is a disease called otosclerosis that leads
to hearing loss in one or two ears. For unknown reasons, new bone is formed in the area
around the stapes which eventually grows into the oval window. Sound vibrations from the
eardrum cannot reach sensory cells in the cochlea if the stapes is fixed, leading to symptoms
of decreased hearing. The disease usually presents itself in an adult age. The true incidence
of otosclerosis is not known, but one study has shown an incidence of 1.3 per cent (Hannula
et al., 2012). There are good opportunities to get a better hearing either through surgery or
by amplifying sound with hearing aids.
The EBCD method was chosen since the Department of ENT at Sahlgrenska University
Hospital wanted to test a new way of involving patients in the improvement of specific
care-processes. During the process, reflections by the participants of their experiences of
using EBCD were collected both orally and written as a base for a qualitative analysis.
Strengths and limitations were extracted from the recorded material and documents
written down during the project. A qualitative content analysis (Graneheim and Lundman,
2004) was done by the authors. In the analysis, units of meaning were captured and
categorized in strengths and limitations.
There are no earlier studies presented according to the use of EBCD and patients with
otosclerosis, a well-defined group of patients that moves through a distinct patient process.
3.2 Participants
There were 28 patients included who had completed stapedotomy between May 2012 and
June 2013 (number ¼ 40) and who were not already participating in a national study of
otosclerosis ( ¼ 12). The patients were sent a written invite to the EBCD study by mail.
Of the 28 patients, 6 accepted the invitation, of which 2 were men, and 4 females. The
patients’ ages ranged from 34 to 66, with a median of 49 years.
In order to include the patient’s full journey at the department, it was decided to find
professionals working at different units and departments for the project. One-to-one
meetings with the affected managers were being held by the project manager (first author)
where they were presented with an oral and written purpose of the study and the EBCD
method. These meetings provided the study with suggestions of which clinicians to
approach, as well as granting understanding from the managers. The healthcare
professionals were then approached and asked to participate in the study. A number of six
healthcare professionals were handed written information where the aim of the study was
presented together with a time schedule. The clinicians represented in the study included
two nurses at the out-patient clinic (one theatre nurse and one nurse on ward), a surgical
coordinator (nurse as well), an ENT surgeon and one clerk.
During the whole project, the first author had the role as the project leader.
3.3 Capturing experiences
The process began by mapping the patient’s journey from acceptance at the Department of
ENT to the discharge from the department after surgery. The mapping was being made
through direct observation and input from an advisory group (second and third authors).
Photographs were taken of the process to be used during the group meetings. As part of the
observational work, the first author attended patient-doctor consultations, followed patients
and clinicians during the out-patient surgery ward. The early observations provided some
key touch points in the process and aided the compilation of an interviewer’s guide.
Between May and August 2013, the patients’ (n ¼ 6) and the healthcare professionals’
(n ¼ 5) experience of receiving respectively giving otosclerosis care was captured in
one-to-one interviews by the main author. The date, time and location for the interviews
were arranged in agreement with the interviewee to not cause any inconvenience. The
interviews with the clinicians were conducted at their workplace. The patients were either
interviewed at the hospital, at their workplace or at home.
The interviews were recorded with the patient’s and clinician’s consent and started with
an open-ended question:
•
Could you tell us about your experience of the process from the first contact with our
department until now? Or:
•
Could you tell us about your experience of giving care to the patients with
otosclerosis from the first contact until your work with them is finished?
An interview guide was used to provide a rough chronology of events and aid questions but
was only used if the patient, or staff, got lost in her story. In this way, it was possible to let
them describe his or her story as naturalistically as possible.
The interviews were transcribed and analysed through a qualitative content analysis
(Graneheim and Lundman, 2004) aiming to explore the clinicians’ and patients’ “touch
points” – key events – which stand out as crucial to the experience of receiving or
delivering care (Bate and Robert, 2006, 2007). The analysis was made on all recorded
material by the project manager and a hospital development leader. When an emotion
was expressed, this was noted. It was also noted when during the process the touch
points arose. Sometimes, the patient, or clinician, verbalized the situations spontaneously,
and sometimes the interviewer made the interviewee verbalize specific situations
(e.g. notice of invitation, visit at out-patient clinic and arrival to day surgery) through
reflecting questions. There could be several emotions connected to one situation.
After this, the project manager made two different process maps where the two
groups’ experiences of care were plotted, mentioned as “emotional mapping” (Mckeever,
2004; Bowen et al., 2013).
3.4 Understanding experiences
After having captured the experiences and analysed the data from the staff and patient
interviews the next step was understanding and validating the experience. Two group
meetings were held, one with the patients and one with the healthcare professionals, each
lasting about 2 h. During these meetings, each group was presented with feedback in form
of the emotional map and pictures. They were given a chance to validate the findings, to
explain, add or correct any misunderstanding (Mckeever, 2004; Bate and Robert, 2007).
At the end of each group meeting, they agreed on a list of possible issues that they wished to
carry on working with together with the other half of the co-design group. After each
meeting, reflections were noted by the project manager.
3.5 Improving
In the third phase, there was a joint group meeting. This was the first time all the patients
and the staff met each other. The meeting took about 2.5 h.
During this meeting, a method called systemic meeting was used (Khan and Sarv, 2013).
The group of patients presented their experiences of receiving care with the help of their
process map. The staff then asked clarifying questions to the patients and reflected on the
stories, first, by themselves and then together with the patients. After this, touch point areas
possible to improve based from the patient’s experience were noted on a board. The focus
was then turned to the staff who presented their experiences of giving care to patients
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with otosclerosis. This was followed by clarifying questions from the patients, reflection and
possible touch point areas from the staff’s experience were also noted on the board.
All group members were then given three votes each to place optionally on one, two or
three of the improvement areas where they wanted to continue to work on. At the end of the
meeting, a plan was made about how the improvement work would continue from there on.
354
3.6 Follow-up
A systematic follow-up was then done with staff members and new stapedotomy patients,
both in written and verbal form. Questions related to the new pre- and post-op information
were – what they thought of the written information and if any improvements were needed.
The patient’s and staff’s experiences of the interviews, group meetings and co-design
group meetings, what could have made them better and what worked well was caught using
a written form sent out to each group member after the improvement meeting.
4. Practical results
4.1 Feedback from the patients of the otosclerosis process
In general, the patients were all very satisfied with both the psychological and physical
experience of their healthcare process. However, a few areas of improvement were noticed:
•
All of the patients had initial difficulties finding their way “into the system” to get
diagnosis and help at the hearing and deaf (HDV ) department.
•
The patients also noticed a lack of coordination between two departments dealing
with these patients, namely the HDV department who handles hearing disabilities in
general and the ENT department, responsible for the surgical treatment.
•
When the patients had met the ENT surgeon and a decision of surgery had been
made, the patients described uncertainties regarding preoperative preparation.
•
All patients, except one (who had previously worked at the hospital), described
difficulties finding their way to the hospital and/or to the out-patient surgery ward.
Practical issues regarding where to park the car and how to pay for parking outside
the hospital pre-operatively were other problems that recurred during the interviews.
•
Before discharge from the ward, the patients got both written and oral information
from the surgeon and a nurse at the ward. Despite this, the patients described
difficulties understanding and remembering the information they had been given.
4.2 Feedback from the staff of the otosclerosis process
The staff were, in general, very pleased with their experience of the process. During the
interviews, and group meetings, they struggled to focus on their own experience of giving
healthcare. Instead, they were caught reflecting on how they thought the patients
experienced the different parts of the process. One reflection from the staff at the out-patient
surgery was that they had noticed how worried patients often called them and had
questions about the normal postoperative passage of events. From the staff, three areas of
possible improvements were recognized:
(1) Time pressure on the doctor when explaining the surgical process, the out-patient
surgery concept, the expected outcomes and risks related to the surgery: the two
surgeons had already worked together to produce a written, standardized,
information sheet that they gave the patients at the first appointment. Despite this,
the planned time was not always adequate for information, leading to delays and
stress for the surgeon.
(2) The receptionist welcoming the patient on the day of surgery described a stress
factor in that the reception does not have a system for queuing. Sometimes, on busy
mornings, this leads to patients, and relatives, standing close to the counter to get
admitted. This, in turn, made the secretary uncomfortable with the situation and
how to handle the confidentiality.
(3) Before surgery the doctor usually examines the ear with a microscope in an adjacent
room to the operating theatre. The surgeon described recurrent problems with the
room being occupied by a physical therapist and that when he/she got to use it, it
was messy and had to be cleaned before it could be used.
4.3 Results from joint group meeting
From the areas of improvement identified by the two groups, the now joint group decided on
working with the following:
•
The three areas involved with patient information: to improve the written pre- and
postoperative information, to update and change the information on the hospital’s
homepage; and to include the long-term prognosis in all information; and
•
change routines for using the preoperative examination room.
Other areas of improvement left after the vote were noted by the project manager, and a
joint decision was made to leave these as time would not be enough to work on all of them.
4.4 Improvement work
The staff wanted to be responsible for improving how the preoperative examination room
was being used, but suggested that the patients themselves should help rewrite the current
patient information, both on the internet and on the written sheets. This division of tasks
was accepted by everyone, and it was decided that the patients would send their
suggestions to the second surgeon who would do the actual changes. Therefore, no joint
staff-patient improvement groups were established after the improvement phase.
The patients and the project manager met a few weeks after the joint meeting and
rewrote the pre- and post-operative information, which was then sent to the responsible
surgeon who made some further changes. Two months later, this was in clinical use. The
hospital’s ENT homepage was updated with more information according to the patients’
suggestions including a link to the information sheet.
4.5 Evaluation
It turned out to be impossible to find a time for a joint group follow-up meeting with
everyone involved in the project. Instead, as follow-up, it was decided that patients currently
going through the same surgery should be asked what they think about the written pre- and
post-op information the hospital provides.
Evaluation of current patients in the otosclerosis process shows that they are pleased, or
very pleased with the process. This specifically includes information about what is normal
after otosclerosis surgery (transient dizziness and taste reduction, changed perception of
tinnitus and itching) and what signs and symptoms they should pay attention to during the
first few weeks (pain not responding to over the counter medicine, high fever, purulent
discharge). Even if they get this information verbally before and after surgery, it seems that
written information decreases their anxiety.
The staff at the out-patient surgery have also described how they have noticed a lower
frequency of phone calls from worried patients after the project.
Improvements have been made to the preoperative examination room. The routines
changed within a couple of months, and the room is now only used by ENT surgeons.
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5. Analysis
In this chapter, the strengths and limitations of the EBCD methodology experienced by
participants in the presented project are presented.
5.1 Strengths
The participants experienced several strengths by the involvement of patients in the
improvement project as well as the use of the EBCD methodology. Five themes emerged
during the analysis, presented as follows:
(1) Make a difference – the patients thought that taking part in the project was a
positive experience leaving them with a sense of making a difference.
(2) A sense of togetherness – the patients appreciated meeting other patients with the
same disease, which they had not done before.
(3) Eye-opening – the staff experienced that the method made them aware about being
“blind” to parts of the patient’s experience. They realized that some of the patients’
worries were different from what they had imagined would be the case.
(4) A holistic view – the staff expressed gratitude for the chance the method gave them
to see the whole care process and how their own work related to everyone else’s.
(5) Engagement – the EBCD method lets the clinicians as well as patients become
directly involved in the quality improvement of their workplace and their
work situation.
5.2 Limitations
There were, however, some limitations that also occurred in the analysis. The limitations are
presented as:
(1) Nervousness in new role – patients mentioned being nervous about giving the
healthcare professionals feedback, especially about being personal and
expressing feelings.
(2) Difficulties to keep the focus – difficulties in getting staff to focus on their own
experience of giving healthcare during the interviews and the group meetings.
Mostly, they tended to speculate on what the patients might feel or think.
(3) Stuck in the stories – difficulties in getting the group to re-focus after the understanding
phase of the method and move on to the improvement part of the project.
(4) Not involving in the patents – difficulties getting the staff to let the patients be fully
involved in the improvements.
(5) Time consuming – difficulties to find times for meetings that suited everybody in
the project. The method in itself also takes time, which needs to be taken into
consideration in the planning of the project.
(6) Need for delimitation – the importance of identifying the beginning and the end of
the process to be improved. In this project, an improvement area was identified at
the junction of the HDV and the ENT Departments. This area could not be addressed
as no one from the HDV Department had been invited to become involved.
Strengths mentioned by patients were that their participation made a difference. The first
steps were found effective in giving an in-depth view of patients’ experiences, and the
staff got an increased understanding about specific patient needs. However, weaknesses
were found in the latter phases, those of improving and follow-up, health care staff
had difficulties to keep their focus on patients’ experiences and invite patients to be
involved. Patients’ participation decreased, and there was a lack of tools to support
the process.
6. Discussion
The EBCD method is often referred to as a successful approach to strengthen the patient’s
role in today’s healthcare (Tsianakas et al., 2012; Robert et al., 2015). In this study, the first
parts of the process were experienced as successful from the staff’s and the patients’
perspective. The staff expressed that the EBCD made them aware of being “blind” to parts
of the patients’ experiences of the care. In addition, the staff described the advantages of
patient involvement giving them a view of the whole care process. These mentioned benefits
of EBCD is also mentioned in earlier research (Steen et al., 2011; Gustavsson, 2014;
Gustavsson and Andersson, 2017). The patients who joined the otosclerosis project
experienced that their participation made a difference when improving the care process.
They appreciated meeting other patients with the same disease, and their overall experience
of the project was positive. The positive effect of patients meeting other patients and the joy
that brings is similar to findings presented by Engstrom and Elg (2015). The experiences
from our study is that the EBCD method worked well for capturing the patients’ experiences
of the care process and for getting health care professionals to understand the patients’
experiences, which constitutes the first two phases of EBCD. Staff are trained to listen to
patients, which could be a reason for the health care professionals to feel at ease during the
first parts of the EBCD method. They have no issues letting the patients take time and space
during these initial phases.
However, in contrast to the first two phases of EBCD, the joint group lost momentum in the
latter phases of the method. During the improvement phase, patients were used as consultants
for a specific part of the process, that of the pre- and post-operative information. Other parts of
the otosclerosis process that could possibly have involved patients and staff in joint
improvement groups were either not addressed at all or addressed only by the staff. Earlier
studies also mentioned difficulties to keep up the collaboration with patients in the latter parts
of EBCD (Iedema et al., 2010; Bowen et al., 2013; Bak et al., 2014; Maher et al., 2017). One cause
of decreased activity and cooperation between staff and patients in this project was that the
staff was keen to take care of the improvements themselves, possibly in addition to the
patients’ not ceasing the opportunity to get fully involved. This issue has been addressed
earlier and further research on the transformation of power relations between stakeholders is
needed as the collective ownership is central to the co-design process (Donetto et al., 2015).
Another cause of the decreased involvement of patients found in this study was the aspect of
limited time. It proved almost impossible to find time for the patients and the staff to meet.
The improvement work was supposed to be performed during office hours but, as the patients
worked elsewhere and the staff was not easily replaced at work by others, it proved to be hard
to find time for joint meetings. Improvement project takes a lot of time; to plan meetings, to
meet, to plan changes, to make changes, to evaluate changes and to implement new routines if
the changes were successful (Bergman and Klefsjo, 2010). The issue of cost vs benefit as well
as the challenge of time logistics during EBCD projects have been previously discussed
(Bowen et al., 2013; Bak et al., 2014), and needs to be further addressed in future research. This
paper found that by using “new” patients and the currently active staff during the follow-up
step of EBCD, we got a continuous evaluation of the pre-and post-operative information for
patients going through the otosclerosis process.
The findings in this paper also suggest that a structured approach for how to handle the
improvement phase of the method may support patient participation further. The
improvement and follow-up phases may have a need for quality tools such as PDSA-cycles,
root-cause analysis and fishbone diagram, for example (Batalden and Stoltz, 1993;
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Bergman and Klefsjo, 2010; Bergman et al., 2015). These tools could have helped the project
manager and the joint group to keep momentum, when the quality issues had been
identified, as a structured way to continue with the improvement efforts. If the latter parts of
the method could be strengthened, it may contribute to an increased patient involvement
during the whole process of quality improvement, and make patients interested in staying
involved for future healthcare improvement work.
In agreement with the model presented by Batalden and Davidoff (2007), the findings in
this paper increase the arguments for healthcare staff needing additional knowledge to their
professional one. Improvement projects can add acquaintance to above mentioned quality
tools, needed for structured and sustainable quality improvements. Working with different
concepts, tools and methods during a project like this is likely to improve the staff’s
experience and knowledge for future quality improvement projects (Choo et al., 2007). Choo
et al. (2007) also suggested that knowledge creation in quality improvement projects is being
driven by two mechanisms; methods and psychology, both needed for success. The EBCD
method focusses on the psychology of patients collaborating with healthcare staff, but the
method needs quality tools for problem solving to support the method.
Patient involvement in quality improvement needs to be further explored and developed
in the healthcare setting (Donaldson, 2008; Coulter et al., 2014; Maher et al., 2017). Swedish
healthcare is characterized as having weaker result in several important areas including
patients’ experiences of participation, information, accessibility and coordination of care
(The Commonwealth Fund, 2016). The findings in this paper can strengthen earlier research
in the area of patients collaborate with healthcare staff in quality improvements.
Specifically, the findings add information that can develop the EBCD method.
7. Conclusion
The aim of this paper is to illuminate strengths and limitations in quality improvement
work; when involving patients. Based on a case study and earlier research, EBCD is a
method shown to be valuable when improving quality of care (Steen et al., 2011; Tsianakas
et al., 2012; Robert et al., 2015; Gustavsson and Andersson, 2017; Maher et al., 2017). The
collaboration between patients and healthcare professionals in EBCD is one way of
strengthening the patients’ role in health care organizations. The method provides staff with
unique input and a share of workload that can be used when improving a process.
Strengths mentioned by patients were that they felt like their participation made a
difference and that they enjoyed the togetherness with other patients. The health care staff
got an increased holistic view and experienced the improvement work as an eye opener.
However, one limitation mentioned by patients was that the new role felt difficult and made
them anxious. The health care staff had difficulties to keep their focus on patients’
experiences and invite patients to be involved in the whole improvement process.
Healthcare professionals are interested in listening and identify improvement areas
when patients are sharing their experiences in collaborative improvement work. However,
when it comes to the improvement phase, healthcare professionals often exclude patients as
an involved partner. Based on the presented case in this paper and earlier research, a
suggestion is to support the improvement phase in EBCD with quality tools to support the
process and clearer involve the patients.
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About the authors
Åsa Robinson is MD at the Department of Otorhinolaryngology, Head and Neck Surgery, Lundby
Hospital, Gothenburg, Sweden.
Caterina Finizia is Professor, MD, at the Department of Otorhinolaryngology, Head and Neck
surgery, Sahlgrenska University Hospital, Gothenburg, Sweden. Finizia is also Development and
Research Director at område 5, Sahlgrenska University Hospital, Gothenburg, Sweden. Her research
field is randomised intervention studies in head and neck cancer patients with the goal to improve
function and health related quality of life (HRQL). The research field also includes evaluating
the benefit of surgery and hearing aid use respectively in otosclerosis in terms of objective and
subjective hearing improvement as well as HRQL.
Susanne Gustavsson is a registered nurse and midwife, with a PhD in Quality Sciences, and working as
Quality Director at Skaraborg Hospital, Sweden. She is also connected to the research platform Centre for
Healthcare Improvement (CHI) at Chalmers University of Technology. Gustavsson’s research interests focus
on quality management in healthcare, with a special interest in collaboration between patients and health
care professionals’ during improvement work. Susanne Gustavsson is the corresponding author and can be
contacted at: susanne.m.gustavsson@vgregion.se
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