BackgroundMeasuring, understanding and improving patients’ experiences is of central importance to health care systems, but there is debate about the best methods for gathering and understanding patient experiences and how to then use them to improve care. Experience-based co-design (EBCD) has been evaluated as a successful approach to quality improvement in health care, drawing on video narrative interviews with local patients and involving them as equal partners in co-designing quality improvements. However, the time and cost involved have been reported as a barrier to adoption. The Health Experiences Research Group at the University of Oxford collects and analyses video and audio-recorded interviews with people about their experiences of illness. It now has a national archive of around 3000 interviews, covering around 75 different conditions or topics. Selected extracts from these interviews are disseminated for a lay audience onwww.healthtalkonline.org. In this study, we set out to investigate whether or not this archive of interviews could replace the need for discovery interviews with local patients.ObjectivesTo use a national video and audio archive of patient experience narratives to develop, test and evaluate a rapid patient-centred service improvement approach (‘accelerated experience-based co-design’ or AEBCD). By using national rather than local patient interviews, we aimed to halve the overall cycle from 12 to 6 months, allowing for EBCD to be conducted in two clinical pathways rather than one. We observed how this affected the process and outcomes of the intervention.DesignThe intervention was an adapted form of EBCD, a participatory action research approach in which patients and staff work together to identify and implement quality improvements. The intervention retained all six components of EBCD, but used national trigger films, shortened the time frame and employed local service improvement facilitators. An ethnographic process evaluation was conducted, including observations, interviews, questionnaires, cost and documentary analysis including previous EBCD evaluation reports.SettingIntensive care and lung cancer services in two English NHS hospital trusts (Royal Berkshire and Royal Brompton and Harefield).ParticipantsNinety-six clinical staff (primarily nursing and medical) and 63 patients and family members.InterventionFor this accelerated intervention, the trigger film was derived from pre-existing national patient experience interviews. Local facilitators conducted staff discovery interviews. Thereafter, the process followed the usual EBCD pattern: the film was shown to local patients in a workshop meeting, and staff had a separate meeting to discuss the results of their feedback. Staff and patients then came together in a further workshop to view the film, agree priorities for improvement and set up co-design working groups to take these priorities forward.ResultsThe accelerated approach proved readily acceptable to staff and patients; using films of national rather than local narratives did not adversely affect local NHS staff engagement, and may in some cases have made the process less threatening or challenging. Local patients felt that the national films generally reflected important themes, although a minority felt that they were more negative than their own personal experience. However, they served their purpose as a ‘trigger’ to discussion, and the resulting 48 co-design activities across the four pathways were similar in nature to those in EBCD but achieved at reduced cost. AEBCD was nearly half the cost of EBCD. However, where a trigger film already exists, pathways can be implemented for as little as 40% of the cost of traditional EBCD. It was not necessary to do additional work locally to supplement the national interviews. The intervention carried a ‘cost’ in terms of heavy workload and intensive activity for the local facilitators, but also brought benefits in terms of staff development/capacity-building. Furthermore, as in previous EBCDs, the approach was subsequently adopted in other clinical pathways in the trusts.ConclusionsAccelerated experience-based co-design delivered an accelerated version of EBCD, generating a comparable set of improvement activities. The national film acted as an effective trigger to the co-design process. Based on the results of the evaluation, AEBCD offers a rigorous and effective patient-centred quality improvement approach. We aim to develop further trigger films from the archived material as resources permit, and to investigate different ways of conducting the analysis (e.g. involving patients in doing the analysis).FundingThe National Institute for Health Research Health Services and Delivery Research programme.
Accelerated EBCD offers a rigorous and relatively cost-effective patient-centered quality improvement approach.
Action research has been characterised as systematic enquiry into practice, undertaken by those involved, with the aim changing and improving that practice: an approach designed to have impact. Whilst much has been written about the process and practice of 'researching', historically 'impact' has been somewhat taken for granted. In recent years, however, the impact of all forms of research has become the focus of interest with many funding bodies now demanding that researchers not only articulate the prospective impact of their work, but what kinds of evidence will be proffered to demonstrate that impact. This has raised questions for action researchers, not about whether their work has an impact, but what form that impact takes, how it is recognised and by whom. This paper focuses on difficulties researchers find in both articulating the impact of participatory research and demonstrating links between such forms of research and impact. We draw on discussions about the notion of impact with authors that have self-reported and published their work as participatory. These discussions revealed that not only were there difficulties in clarifying the participatory dimension of their research but that whilst authors were able to discuss particular impacts of their work, articulating and evidencing that impact was often absent from their published papers. This paper offers insights into some of issues and barriers those who undertake participatory research face in explicating, for the external audience (and indeed sometimes for ourselves), the impact of this action-based form of enquiry.
Purpose – The potential for including patients in implementation processes has received limited attention in the literature. The purpose of this paper is to explore the different roles adopted by 63 patients that emerged during and after four participatory quality improvement interventions, and the nature of their impact upon implementation processes and outcomes. Design/methodology/approach – A cross-case ethnographic comparison of Experience-based Co-design in two clinical pathways in two UK NHS Trusts. Findings – Two key themes emerge from the data. First, the authors found a range of different roles adopted by patients within and across the four projects; some were happy to share their experiences, others also helped to identify improvement priorities alongside staff whilst others were also involved in developing potential solutions with the staff who had cared for them. A few participants also helped implement those solutions and became “experts by experience” through engaging in the whole co-design process. Second, in terms of the impact of patient engagement with the co-design process whilst the changes championed by patients and carers were often small scale, as co-designers patients provided innovative ideas and solutions. Through their involvement and contributions they also acted as catalysts for broader change in the attitudes of staff by providing a motivation for wider organisational and attitudinal changes. Research limitations/implications – The research was conducted in two clinical pathways in two NHS trusts. However, the findings complement and add to the growing body of knowledge on experience based co-design. Practical implications – Patient engagement is likely to require support and facilitation to ensure that patients can play a meaningful role as partners and co-designers in service improvement and implementation. Different roles suited particular individuals, with participants stepping in and out of the co-design process at various stages as suited their needs, capacities and (albeit sometimes perceptions re) skills. In this context, facilitation needs to be sensitive to individual needs and flexible to support involvement. Social implications – Patients and carers can play active roles in service improvement, particularly where the approach facilitate active engagement as co-designers. Originality/value – Analysis of the role patients and carers in implementation and improvement.
This paper discusses the link between community music improvisation and the integration of refugees, asylum seekers and local residents, and proposes a new way of thinking about priority-setting in refugee integration and rehabilitation support schemes. Drawing on observations and interviews with an integrated music group in Wales, we explore the effect of participating in structured musical activities and improvisation in weekly meetings, as well as at public performances in community arts events. We observed that embedding improvisation led to four outcomes. It (i) encouraged individual unscripted performances, instilling confidence in solo performance, (ii) gave individuals who had experienced displacement and marginalisation a chance to lead in a safe, performative space, (iii) gave other participants a chance to follow and accompany this piece instrumentally or vocally, drawing on their own cultural traditions and thus creating innovative cross-cultural pieces; and (iv) provided participants and audience members with a unique and unrepeated, uplifting experience that triggered their imaginations, and prompted questions and further discussion between participants. These findings suggest that the combination of structured musical activity and improvisation may help to foster a sense of wellbeing and social inclusion, shift power dynamics, and create a space for cross-cultural dialogue. These unique outcomes highlight how music can create a community of people from seemingly completely different locations or situations. Furthermore, the well-established Welsh choral traditions and local community arts provided a receptive environment for this diverse group of performers. Therefore, it was not just the musical activities but their connection to the wider local community arts scene that delivered these individual, collective and wider societal benefits.
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