1 © The Point of Care Foundation Putting patients at the heart of the system Council of Deans of Health Meeting Jocelyn Cornwell October 16 2014.

1©The Point of Care Foundation

Putting patients at the heart of the system

Council of Deans of Health Meeting

Jocelyn Cornwell

October 16 2014

Every system is perfectly designed to produce the results it gets

Starting point 1: systems thinking

Paul Batalden M.DDartmouth Institute for Health Policy and Practice

Starting point 2: design-thinking

(P)PERFORMANCE

How well it does the job, whether it’s fit for purpose.

Functionality

(E)ENGINEERING

Whether it is safe & reliable.Safety

(A)AESTHETICSHow it feels.

How it is experienced.Usability

Every product & every service has 3 distinct elements

THE AESTHETICS OF CARE - SMALL THINGS ARE BIG THINGS

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Example 1: a daughter’s story

Overall, my mother received the best care from staff who have treated and respected her as a person, rather than stereotyping her as an elderly person who’s not capable of thinking and doing things for herself.

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Example 1 (contd.)Throughout her time in hospital, staff continually called my mother by the wrong name. She has been called Harriet all her life but it is her middle name, so her first name is written on all her records. We drew this to the attention of staff on the ward; it was important especially as she was suffering from episodes of confusion, but it did not stop. Everyday someone from the family would visit her and wipe the wrong name off the whiteboard.

On one occasion, after tracking down a registrar responsible for her care, we explained the situation and he wrote “likes to be called Harriet” in big letters on the front of her notes but it still had little effect.

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Example 2 A grand daughter’s story

“My grandmother was moved twice in the first couple of days. The second move was carried out at 4 a.m. Agitated on being woken, she pulled out her feeding tube. Her dentures were lost in transit and could not be located despite us repeatedly going to ask staff at the ward she had come from. The lack of dentures left her unable to communicate and increased her difficulty with eating. She developed an aspiration pneumonia which could have been in part due to the lack of dentures. The pneumonia kept my grandmother in hospital for almost a month.”

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Example 1

• Relational care

• Process for listening to families/carers

• Patient’s records

• Team working

• Handover

Where the two examples lead

Example 2

• Relational care

• Management of patients’ belongings

• Decision-making authority

• Bed management

• Targets and priorities

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Relational care -

empathy

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Empathy keeps staff in touch with the patients’ feelings

1. Cognitive: the capacity to understand another person’s feelings

2. Affective: the capacity to respond appropriately to another person’s feelings

Our capacity for empathy has two distinct aspects

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11©The Point of Care Foundation Using patient experience to redesign healthcare services

Empathy is normally distributed in the population

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When empathy is switched off, we are in ‘I’ mode

• Tired, stressed or burned out

• Under pressure to do something else

• Interacting with a person who is ‘unpopular’ for

whatever reason

• Highly emotional - angry, frustrated, distressed or

frightened

• Working with digital equipment

We are more likely to switch off when we are:

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Effective methods for maximising empathy in individuals

1. Experience based co-design (EBCD)

2. Patient shadowing

3. Patients’ stories

4. Simulation

5. Participant observation

6. Analogous scenarios

Plus attention to self

7. Self-care, reflective practice, mindfulness

Methods to enhance cognitive and affective capacity

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Enabling conditions: management tasks

Cultural norms

Values in plain English; priorities in human terms

Reject language that objectifies patients; intolerance of rude and unkind acts

Involve patients in governance, improvement and training

Management /team working

Opportunities for reflection (Schwartz Rounds and others)

Train supervisors and hybrid managers to manage others

Systematic, frequent feedback from patients

Systems support

IT and patient records

Actively manage staff numbers and deployment

Relevance for education?

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Schwartz Centre Rounds

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Rounds themes

• The patient I’ll never forget

• Am I doing the right thing? Managing risk

• Human too – personal and professional overlap

• Trying to help in impossible circumstances

• Conflict – with patient; family; colleagues

• ‘Unrewarding patients’ – nasty; terrifying; intractable problems; ungrateful; uncooperative; families

• When things go wrong – whistle blowing

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Impacts of Rounds

US evaluations show that Rounds have a positive effect

•For individuals

•For teams

•For organisations

•This impact increases over time spent attending Rounds

Sanghavi DM (2006) What makes a compassionate patient-caregiver relationship? Joint Commission Journal on Quality and Patient Safety 32(5): 283-292.

Lown, BA, Manning, CF (2010) The Schwartz Center Rounds: Evaluation of an interdisciplinary approach to enhancing patient-centred communication, teamwork and provider support. Academic Medicine 85(6).

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Impact in the UK

Increase in:

•Staff confidence in handling sensitive issues

•Beliefs in the importance of empathy

•Actual empathy with patients as people

•Confidence in handling non-clinical aspects of care

•Openness to expressing thoughts, questions and feelings

A number of published studies report positive results

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The opportunities in education to transform relational care

1. Schwartz Rounds in education

2. Patients and carers –roles as teachers

3. Instruction in observations of care and patients shadowing

4. Mindfulness

5. Other?

Reflections?

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jocelyncornwell@pointofcare foundation.org.uk www.pointofcareoundation.org.uk

Twitter: @JocelynCornwell