There was a disturbing but not surprising article in the Guardian last week on how the ‘Silent majority’ of older people do not complain about substandard care. It reported that more than half of over-65s, who have faced problems did not complain as they feared it might impact treatment, ombudsman finds.
This is not just older people. When I was in hospital a few years ago, a volunteer came to my bed in the 6 bedded bay to see if he could ask me some questions about the quality of my care. As he pulled the chair next to my bed and got out his clipboard, I could see two nurses making the bed opposite mine, and the consultant was with the patient at the end of the bay.
“Did everyone introduce themselves to you?” he asked.
The answer was no. But I hesitated. Could the nurses hear me?
I speak at international conferences, have a PhD and yet it is hard to be powerful in your pajamas and say what you really think. It is hard to be honest when you don’t know what people can hear and what would happen if the answers were not favorable. So I completely understand why over half of older people do not complain.
We need to find other ways of helping people share what is not going well and how things need to change. One approach worth considering is Working Together for Change. This is a proactive way to routinely hear from patients or people receiving care, about what is working and not working from their perspective. Not only that, you co-produce the analysis and the actions with patients too. Here is an example of how one hospital, in Bispham, near Blackpool used it.
As part of their commitment to working in a more personalised and person-centred way Spiral Health introduced Working Together for Change and are using it every 6 months to inform their development. This means that the person responsible for quality asks every patient to share with her two things that were working well, and two things that could be improved, about a week into their hospital stay.
It often took persuasion to share something that was not working, for the same reason the article describes. What was different however, was that this information was collected from everyone, routinely, and no one could therefore be identified as a “troublemaker”. The other difference is that people were asked about what was working too. Some post hospital stay surveys may ask similar questions, but the difference here is that Cheryl, the quality lead, did something with the information immediately. This included sharing compliments with staff, as well as trying to directly address, wherever possible, whatever it was that was not working. Patients were also asked for two suggestions that they would like to see in the future in the hospital.
The information was aggregated on a six monthly basis with the information from all of the patients who had been on the ward during that period. Patients were also asked if they wanted to be involved in looking at the information, understanding and acting on it. It was not fed into a computer somewhere, it was analysed by patients, and staff, together.
I helped to facilitate the first time they used the Working Together for Change process. We brought together patients, therapy assistants, senior nurses and therapists, and managers for a day. As this was the first time we had used the process, we had data from 12 patients, but this was enough to start with (now it can be done with 100’s). We started by looking at all the ‘working’ information, and clustered it into themes. Three of the top ‘working well’ responses from patients at Bispham hospital were that the ‘staff were excellent’, that ‘the teamwork in the unit was good’ and that patients felt ‘calm and slept well during their stay’. The same process was used to find the top ‘not working’ and later, what was important in the future. The three top ‘not working’ responses were “I don’t like the food – it’s awful”, “I am hurried for meals and then have to wait” and “It took too long for someone to come for me”.
The comments about the food were not a surprise, however this time, the patients, staff and managers thought together about what the causes were, what success could look like, and what they were going to do next. As a result the unit’s menus were altered and the whole meal-time experience improved. There are 8 steps to the full process and you can read more about how it was used in a hospital here.
The same process has been used in a care home, hospice, home-care, schools, commissioners, and by national social care providers. Leonard Cheshire is using the process to inform their national strategy, and other leading social providers like Dimensions have been using the process for several years. Commissioners in Flintshire about starting to use it to gather information about care homes, and to inform their strategic planning.
To help patients and people share what is not working may need a different approach where we ask everyone, and build trust by showing that we do something with the information, and patients can be part of analyzing and acting on it if they want to be. This does not mean that people will not complain, but using something like Working Together for Change may mean that we can address issues before they become complaints and create more of a culture of continuously asking what is working and not working and acting on it together.