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A toolkit to assess first impressions of healthcare

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First impressions can affect patients’ perceptions of their whole care journey. A toolkit was developed to assess how care settings are perceived within 15 steps of first entry


Focus groups with patients, service users and their families, conducted by the NHS Institute for Innovations and Improvement, revealed the importance of first impressions when entering care settings. These can affect perceptions of the whole care journey. Toolkits were developed for different settings to enable healthcare providers to test these first impressions by using “walk-around” teams. This article describes the assessment process and how some trusts have used the 15 Steps Challenge.

Citation: Williams A (2013) A toolkit to assess first impressions of healthcare. Nursing Times; 109: online issue.

Author: Alice Williams is associate at the NHS Institute for Innovation and Improvement, focusing on patient experience and engagement.


Have you ever walked into a shop or a restaurant and thought “I don’t like the look of this place”, and made a snap decision to walk out? First impressions count and in healthcare can influence the way patients and their families perceive their whole experience.

The 15 Steps Challenge is a way of thinking about our first impressions of healthcare. In 2010-11 the NHS Institute for Innovation and Improvement held a series of focus groups with patients and relatives, which included people from diverse ethnic backgrounds, older people, and parents to give as wide and representative a range of views as possible. Several focus groups also included staff from different teams and service areas in the NHS. The groups discussed the following:

  • What does good care look like to patients?
  • Do first impressions count and why?
  • What is it that staff do that makes patients feel confident and valued?

A mother in one of the groups, who often had to take her daughter onto a hospital ward, said: “I can tell what kind of care my daughter is going to get within 15 steps of walking onto a ward.” This sparked the development of the 15 Steps Challenge toolkits.

While this mother’s statement described her acute hospital experience, it became clear that many service users and relatives believed the principle was also true for mental health inpatient settings and community care. As a result, toolkits were produced for acute services, mental health inpatient care and community services.

The 15 Steps Challenge toolkits

Each toolkit has been co-produced with patients, service users, carers and staff from each specialist area. They provide a series of questions and prompts to guide users through their first impressions of a care setting to help staff, patients, service users and others work together to identify improvements that can enhance patient or service user experience. They provide a way of understanding patients’ and service users’ first impressions more clearly and a method for creating positive improvements and dialogue about the quality of care.

The aim of the challenge is to improve patient and service user experience by:

  • Involving service users and carers in service developments;
  • Giving service users and carers a voice regarding their experience of the service;
  • Gaining real time feedback and quick action regarding the issues raised during 15 steps challenge visits;
  • Assisting in the sustainability and progression of other initiatives, such as the Productive Mental Health Ward and Essence of Care;
  • Raising the profile of the importance of first impressions and experiences of the service.

The toolkits also help organisations to understand and identify the key components of high-quality care that are important to patients. They help to highlight what we can learn about quality from our first impressions. Both the acute and mental health toolkits are based on simple ward walk-arounds, where a challenge team consisting of a patient/service user, a member of staff and a board member explores inpatient care settings. Using the toolkit observation guides, team members try to understand what aspects of the ward bring comfort and confidence to patients using the service. The observation guides are short and straightforward to use, but are also underpinned by several Care Quality Commission essential standards and the international evidence on what matters to patients. Challenge team members ask themselves some key questions:

  • How does this ward make me feel welcome?
  • What can I tell about a safety culture on this ward?
  • Will people here care for me and involve me?
  • Is this ward well-organised and calm?

The 15 Steps Challenge is not an audit or a performance management tool but a framework to help organisations to gain a better understanding of the quality of care being delivered and identify areas needing improvement. Once good practice has been identified it can be shared rapidly across the organisation and improvements can be made.

What difference is it making for patients?

The case studies below demonstrate how the 15 Steps Challenge is being used by a range of trusts, and its effects on services.

Nottinghamshire Healthcare Trust

The trust got involved with the 15 Steps Challenge for mental health inpatient care during the testing stage. Since then it has created a schedule of visits for its forensic division that will see all wards visited twice a year initially.

The Trust has a pool of people who will play a part in the challenge team, including nurse consultants, matrons, executive team members, governor members, service users and carer representatives. The response to the challenge has been positive across the division. Raising the profile of first impressions has already empowered staff members to review and make changes to their environment and it is already assisting the sustainability of the work the trust is currently undertaking on The Productive Series.

Royal Surrey County Hospital Foundation Trust

This was one of the first trusts to get involved in the 15 Steps Challenge. Jo Embleton, head of nursing explains some of the benefits:

“In doing the challenge we arrived at the paediatric and maternity wards as if we were patients or relatives. We waited to be buzzed in rather than using our swipe cards. We suddenly understood that ward entrance doors are prime sites to set a positive welcoming tone to visitors, and a great place for important information. As a result we are thinking about a standard and coordinated corporate approach to ward entrances so that visitors feel welcome and informed.”

Staff involved in the challenge enjoyed the experience. The visits gave them an opportunity to see how other wards were operating and some good ideas to take back to their own areas.

West Hertfordshire Hospitals Trust

This trust took part in piloting and testing of the 15 Steps Challenge. Amanda Johnson (interim matron for surgery and anaesthetics) and Jane Roberts (Productive Ward lead) decided to test the toolkit at a clinical leaders day for matrons and ward sisters. Staff were placed into teams, briefed about the challenge and assigned to an unfamiliar area for 30 minutes to explore using the 15 steps approach.

Once all the teams had carried out their walk-arounds and reassembled, they shared some of the common themes they had identified. “There was a huge buzz of interest in the room,” Ms Johnson explains. “Initially we agreed feedback would be anonymous but by the refreshment break everyone wanted to know about their own areas and wanted to share what they had seen.”

Key themes identified included some quick-win changes, improvements that cost little but could make a big difference to how patients and their families perceive areas. The trust is now planning to repeat the 15 Steps Challenge quarterly with patient representatives and non-executive directors.

University Hospital Southampton Foundation Trust

The Southampton trust is using the 15 Steps Challenge as an integral part of a process they have developed for clinical ward accreditation. The trust uses a clinical dashboard for each ward that focuses on safety and quality and every year there is a performance review. The Trust wanted to bring a much stronger and qualitative patient perspective into this process and asked its patient reference group to work with the accreditation team on the 15 Steps Challenge. Feedback has been extremely positive. Patients liked the 15 Steps Challenge because they were able to structure their thoughts and observations, while staff valued it because the feedback they were getting focused on different aspects of care.

The trust also plans to use the 15 Steps Challenge approach to review their acute services for people with learning disabilities and are already involving patients, families and carers in using the 15 steps model to determine what a learning disabilities “friendly” ward should include.

Benefits for staff

One of the key benefits of the 15 Steps Challenge for staff is the opportunity to network and share best practice. So often frontline teams are confined to their own care environment and rarely take time to visit other areas to see what is working well and what learning they can take back to their teams. The 15 Steps Challenge overcomes this and makes sharing best practice a priority to help deliver a better patient experience.

Getting started

To start using the 15 Steps Challenge, organisations in NHS England can download the toolkits and resources for free at The National Archives, where they will find step-by-step guidance on how to get started for their particular care setting. This takes them through from identifying their challenge teams to feeding back their findings and sharing good practice across the organisation. A range of resources, such as briefing notes to help patients and staff prepare for the challenge, templates to help structure feedback gained from patients and presentation slides are also available, making it simple and quick for organisations to use.

Key points

  • First impressions of healthcare settings can affect the way patients and their families perceive their whole patient journey
  • A toolkit was developed to assess impressions of care settings within 15 steps of first entry
  • Patients and service users and their families, and healthcare staff, were involved in developing the tool
  • The toolkits include prompts that are used to guide assessors on their first impressions
  • The toolkits give staff an opportunity to visit other areas to see what is working well and what learning they can take back to their teams
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