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Gaining a patient’s view of acute care

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A trust involved in piloting the 15 Step Challenge to improve its understanding of patients’ experiences found it a useful method of obtaining positive feedback


Kerry Bloodworth is assistant director of nursing, Nottingham University Hospitals Trust


Bloodworth K (2013) Gaining a patient’s view of acute care. Nursing Times; 109, Online issue.

Nottingham University Hospitals Trust (NUH) was one of the trusts that tested the 15 Steps Challenge and is the first in the country to have implemented it in all 80 wards at its two sites (Queen’s Medical Centre and Nottingham City Hospital).

  • This article has been double-blind peer reviewed
  • Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page


5 key points

  1. The 15 Steps Challenge draws on first impressions to gain an insight into how patients and visitors feel
  2. The process is aligned to Care Quality Commission standards
  3. The challenge gives a snapshot of a trust, as all wards receive a surprise visit on the same day
  4. The exercise highlights where improvements can be made and allows good practice to be identified and shared
  5. Staff must only visit unfamiliar wards and should use buzzers not their access cards to gain entry to wards as this is what patients and visitors do

The 15 Steps Challenge was developed by the NHS Institute for Innovation and Improvement, with input from patients, carers and staff, to enable frontline hospital staff to see their wards and clinical areas through the eyes of a patient or visitor. It is named after a comment by a parent of a patient, who said she could tell what kind of care her daughter was going to get within 15 steps of walking into a ward.

The challenge is about making first impressions count. It helps staff to gain an understanding of how patients feel about the care they receive and how improvements can be made.

Early days

Nottingham was keen to test the 15 Steps Challenge while it was still in draft form as it appeared it would give a “snapshot” of the organisation in a single day.

The process is aligned to the Care Quality Commission’s quality standards, and, since the trust was expecting a visit from the CQC over the autumn, it would give an insight to the care we were delivering.

Once the trust at an executive level had agreed to take on the 15 Steps Challenge, we gained the support of the directors of nursing and human resources. Ward sisters and senior nurses were keen to be involved as it appeared that the challenge would enable then to network and share knowledge and skills in each others’ wards.

We set up a small working party consisting of ward sisters and lay members, and both assistant directors of nursing and quality - who were the joint leads for the project. The working party was responsible for the planning, training, and preparation of the 15 Steps Challenge day and recruitment of the challenge teams.

After a successful pilot in July across eight wards, the trust decided to implement the challenge in all 80 wards on the same day, covering two sites and three shifts (morning, afternoon and evening). This was intended to identify key aspects of care that wards were doing well, so that good practice could be celebrated and shared quickly; at the same time, it would highlight areas for improvement.

Experience from the pilot visits had shown clearly that the hospital changes throughout the day, with frantically busy mornings, visitors being welcomed in the afternoon and peaceful evenings when the hospital quietens down for the night.

We agreed that each challenge walk-around team would include a board member or senior trust leader, matron, ward sister and lay member volunteer.

We needed 14 teams to enable every inpatient area to be visited on a single day, and needed to recruit more lay people to contribute to the teams. We emailed all non-staff foundation members (a group brought together for our foundation trust application) asking for volunteers and, over the course of the following few weeks, had over 40 enquiries.

We invited volunteers to the hospital and gave them more information about the 15 Steps Challenge so they could decide whether they still wanted to volunteer.

Our volunteers came from all walks of life, backgrounds, ages, ethnic backgrounds and were representative of our local community. All underwent Criminal Records Bureau checks and received training on infection control, health and safety, information governance and fire safety before entering the wards. The training was conducted both in and out of office hours to accommodate the volunteers who were in employment.

We also needed to recruit NUH staff members, so we organised several briefing events and invited senior leaders, matrons and ward sisters to them. This group of volunteers gave us enough staff members to complete the walk-around teams. Hospital staff did not go to their own areas of practice but were allocated to wards of which they had no previous knowledge. This also enabled a great deal of networking and sharing of ideas between the ward sisters.

All ward sisters were informed that the 15 Steps Challenge would take place in September, but were not told when, or who would be visiting their ward. All wards had received a copy of the 15 Steps Challenge booklet.

The day itself

On the day of the ward visits, a short briefing was held for all walk-around teams to ensure they were clear about what was happening and what their role was in exploring the quality of care.

“I was impressed by the buzz in the room before we all set off. I was also impressed by the professionalism and dedication of the staff on the wards we visited; even in a small time I could tell they liked their work and were keen to help their patients.” Richard Eade, lay volunteer

The teams were asked to walk into wards’ public spaces and get a feel of how the ward operated. Hospital staff were reminded not to use their access cards to enter wards, but to use the buzzer system, as this is what patients and relatives would do.

The 15 Steps Challenge booklet encouraged teams to use their senses to build a first impression of the ward, then look in greater depth to identify some of the detail of what they experienced. For example, they asked themselves: How does this ward make me feel? Is there a welcoming reception area? Do patients have access to call bells, drinks, side tables and walking aids?

During the walk-arounds, teams spoke to staff and patients on the ward, and were encouraged to note their experiences and observations.

“It is crucial to see things through the patients’ eyes. Very often, when you’re involved in the running of a trust, you don’t see that. You walk onto a ward, you use your swipe card to get in, you’re focused on a particular issue and you don’t actually give time to the first impression you get on a ward. The 15 Steps Challenge helps us do that; it’s all about first impressions.”

Peter Barrett, NUH chairman

By the time evening came, the walk-around teams were expecting wards to be waiting for their visit, but there was still an element of surprise when they arrived.

All wards received their feedback either on the day or the following day. Verbal feedback was reinforced by written feedback on a sheet of A4.

Following feedback from the ward walk-arounds, the trust has ensured that action is taken. We identified key points to feed back to wards, including positive practices that needed to be shared and celebrated trust-wide, as well as areas where improvements could be made.

“We know by listening to our patients, visitors and staff that there’s a rich reservoir of great ideas, most of which are either low cost or no cost. Harvesting that tremendous reservoir of great ideas and fantastic good will from patients, visitors and staff is what we’re determined to do.” Peter Homa, chief executive officer

Reflections following the day

We held a debriefing event several weeks later to review the challenge day and to look at what improvements we needed to implement before our next challenge day in the new year.

The day was a rewarding experience; many team members have fed back their experiences, from visiting the wards in a different capacity from their “day job”. The response to the event has been so positive that many staff members have already volunteered for our next challenge day.

“I hope the general experience was as positive as mine. I feel passionate about the NHS, both as a former employee, and as a current and future user. My small involvement in the 15 Steps Challenge has left me feeling pleased that NUH is my ‘local’ NHS trust.”

Sheila Markham, lay volunteer

All wards received feedback from the walk-around team. Its delivery varied -some received an email from their matron, some received feedback from the challenge team the following day, and some received their feedback after the visit on the day. This aspect needs clarification and standardisation before we undertake our next challenge.

This was a mammoth exercise to plan and execute. It was possibly also quite courageous to visit the whole hospital in a single day. Organising 14 walk-around teams across two campuses and ensuring all wards were visited required a lot of cross checking.

With such a large number of staff involved, it was also challenging to ensure that the date remained confidential and all wards received an unannounced visit, so the walk-around teams could get a true feel of the ward on that day.

Each team visited six wards. For our next challenge day, we will reduce this to four or five so that wards can receive their feedback on the day.

Feedback received by trusts is often negative, and is frequently around a failure to meet a trust or government target. The 15 Steps Challenge enabled us to look through the eyes of our patients and relatives and enable wards to receive positive feedback for all their hard work and the excellent care they deliver to patients (Box 1).

NUH is planning to use the information to feed into quality improvement plans at board and ward levels and to provide evidence to the CQC around how patients and staff are driving these plans. We plan to hold another 15 Steps Challenge day in April 2013.

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