Assessing patient experiences is now a vital part of ensuring quality care. One trust used electronic devices to track relatives’ experiences of the care they received
Johnette Brown, MSc, RN, is neonatal sister, neonatal unit, Homerton University Hospital Trust, London; Narendra Aladangady, PhD,FRCPCH, is consultant neonatologist and honorary senior lecturer in child health, Homerton University Hospital Foundation Trust and Barts and The London School of Medicine and Dentistry.
Brown J, Aladangady N (2010) Measuring the quality of care: using patient experience trackers in a neonatal unit. Nursing Times; 106: 7, early online publication.
Measuring patient experience is a crucial part of improving care. This article describes how a neonatal unit used patient experience trackers to measure and record relatives’ views on whether their needs were met. It outlines how the survey was undertaken, the obstacles encountered, and how the process could be improved.
Keywords Patient experience, Measurement, Relatives, Neonatal
- This article has been double-blind peer reviewed
Nurses wishing to carry out patient experience survey should consider the following issues:
- Overcoming resistance from some staff – it is important that the appropriate change management process is undertaken to ensure the majority of staff are consulted;
- Selecting the appropriate questions – we felt the original questions from the trust wide survey were too general for the neonatal unit.
- The positioning of patient experience tracker devices is important as they need to be visible to patients/relatives but they also need privacy to complete the survey.
There is growing interest in patient satisfaction as an indicator of healthcare outcome and quality of care. The NHS next stage review said quality would be judged using a range of measures including patient experience and patient reported outcome measures (PROMs) (Department of Health, 2008).
Department of Health (2009) guidance made clear that collecting and understanding patient satisfaction data and using it to improve care is a mark of best practice.
The neonatal unit
The neonatal unit at Homerton University Hospital is a typical example of a multidisciplinary teamwork setting. We deal with extremely sick and often unstable babies. Patients include babies born prematurely from 23 weeks’ gestation (17 weeks early), weighing as little as 500g, requiring full intensive care followed by prolonged periods of high dependency and special care. Some babies born at full term in poor health often require intensive care. This can be an extremely shocking and upsetting time for parents as they are unprepared for the situation, unlike parents of premature babies.
The unit also provides full palliative care support to babies and their families after withholding or withdrawing life sustaining treatment in babies’ best interests. The decision to withhold or withdraw treatment must be made with parents’ agreement (Nuffield Council on Bioethics, 2006; Royal College of Paediatrics and Child Health, 2004).
Babies can be admitted to the unit for a few hours for observations, or for several days for minor treatment such as nasogastric tube feeding, intravenous antibiotics or continuous positive airway pressure support. Medium to long term treatment may require them to stay in hospital for several weeks and sometimes months.
As part of our commitment to improving care for babies and their families, we were interested in new ways of assessing and evaluating their experience.
Patient experience tracker
The Dr Foster patient experience tracker (PET) device is a small wireless electronic handset used to gather information from patients (Dr Foster Intelligence, 2008).
The PET survey is both a quality improvement and performance management tool, and can be used to promote good practice by encouraging patients/relatives to be more actively engaged in healthcare delivery.
The PET device enables people to express their views on the service provided. This data provides feedback to identify potential improvements and review progress. The feedback, in the form of graphs and pie charts, is sent to all departmental clinical and non-clinical staff via email fortnightly. It is displayed on posters that are updated every month, giving the headline messages and scores.
The neonatal unit survey
The trust was already carrying out a PET survey in other wards when we decided to introduce it in the neonatal unit. We approached the trust PET lead, whose team gave us full support to start the project in September 2007.
A neonatal consultant, neonatal sister and the unit’s operational manager were involved at the start. We discussed the project with the senior medical and nursing teams, and then with junior nursing and medical staff, as well as other members of the multidisciplinary team. The neonatal staff unanimously agreed to adopt the PET survey, which was also approved by the PET lead and corporate team.
We prepared the first draft of questions before consulting with senior staff, and then prepared a second draft after consultation. We decided to have five similar questions in line with the rest of the hospital. The final draft was decided after consultation with all staff (Fig 1).
Positioning the PET device
Parents and relatives were informed about the PET device and survey by neonatal unit staff and the use of signs/poster displays.
However, we did not anticipate the difficulties involved in positioning the device in the unit. Initially it was placed in the parents’ waiting room, but uptake and entry was minimal, often with reports that no data was reaching the PET office or that the device was disabled.
We discovered it was sometimes switched off, on one occasion it was unplugged, or used for putting visitors’ coats on. We felt this might be happening because parents were unaware of its intended use. Staff were asked to tell parents about the device and how to use it, but this did not improve uptake.
The device was then placed in front of the nursing desk, where staff frequently gather, but uptake dropped further. We were concerned that parents might feel self conscious about answering questions in front of staff, so we moved the device further down the corridor. Initially this appeared to work, but quickly we were informed that data was not reaching the PET office. We discovered the device was not working due to an electrical fault.
After it was repaired, we decided the waiting room was the only place that was safe and could ensure parents’ privacy. An information poster was placed near the device with a caption “Help us to get better too”. This marginally improved the survey response rate.
Action to improve overall performance
The results showed that despite all our efforts there did not appear to be a significant improvement in our overall performance, and our score remained below the trust target of 95% satisfaction rate.
We made a number of changes to try to improve performance. Staff were reminded again about the importance of the trust’s objective of assessing patient satisfaction through the PET survey and achieving a 95% satisfaction rate. This was discussed regularly at medical and nursing handovers to ensure all staff were kept up to date on the neonatal unit’s results as well as planned changes to practice. Further discussions the uptake of the PET survey and its impact took place at the multidisciplinary neonatal unit meeting and the directorate meeting.
As these measures did not produce a noticeable change in uptake or results, we addressed this issue with our user group, that is, parents and families, and concluded that the survey was not asking the right questions. Two main issues emerged relating to staff introducing themselves or greeting parents.
Being able to identify clinical staff: the unit is very busy and divided into nurseries, so it is impractical to expect all staff to introduce themselves to parents on arrival as they may be dealing with an emergency or other task. The unit has a large multidisciplinary team of doctors, nurses and housekeepers who are often all wearing theatre blue gowns (as the general temperature is around 28°); this makes it difficult to distinguish clinical staff from support staff.
Entering the unit: staff who open the door to let parents into the unit often acknowledge them but carry on with whatever they were doing before. However, several members of our user group did not feel this was a greeting. This was partly due to parental anxiety when entering the unit. In light of these findings and following discussion with the multidisciplinary team, we modified the first two questions in Box 1 to:
1. Were you greeted by the nurse taking care of your baby?
2. Did the nurse or doctor taking care of your baby introduce themselves to you?
Changing the questions made a significant difference to the overall response - which increased from six and seven in the two weeks before the change to 30 and 35 in the two weeks after, and to the score, which increased from 31% to 92%.
Frontline staff can improve patients’ and relatives’ experiences by understanding how people cope with stress. This can only be achieved by actively listening to their experiences and acting promptly on both positive and negative aspects to ensure appropriate care.
It is essential that all staff take responsibility and ownership of patient experience surveys to achieve overall success. However, good uptake and accurate responses depend on the clarity of information provided to patients and relatives. The questions should be appropriate to each department; generic questions “muddy” the issues and confuse clients.
Staff should not feel defensive about the findings but should be prepared to respond to them to improve patient satisfaction and therefore patient care.
- In a highly stressful environment such as the neonatal unit, which is often a frightening place with new equipment, it is important that babies, parents and family members experience positive psychological outcomes.
- Peabody (1927) argued that “the secret of the care of the patient is in the caring of the patient”. This is especially important in this unit, where staff must also take into account parents’ and families’ needs.
- When faced with uncertainty about their baby’s survival and outcome, parents often experience responses and feelings associated with grief reaction (Fowlie and HcHaffie, 2004).
We would like to thank trust PET lead Jennie Negus, neonatal unit operational manager Jenny Frost, and the neonatal unit staff, Homerton University Hospital Trust, for their support.
Department of Health (2009) Understanding What Matters: A Guide to Using Patient Feedback to Transform Services. London: DH.
Department of Health (2008) High Quality Care for All: NHS Next Stage Review Final Report. London: DH.
Dr Foster Intelligence (2008) Patient Insight: Harnessing the Power of Public Opinion. London: Dr Foster Intelligence.
Fowlie PW, McHaffie H (2004) ABC of preterm birth – supporting parents in the neonatal unit. British Medical Journal; 329: 7478, 1336.
Nuffield Council on Bioethics (2006) Critical Care Decisions in Fetal and Neonatal Medicine: Ethical Issues. London: Nuffield Council on Bioethics.
Peabody FW (1927) A medical classic: the care of the patient. Journal of the American Medical Association; 88: 877.
Royal College of Paediatrics and Child Health (2004) Withholding or Withdrawing Life Sustaining Treatment in Children: A Framework for Practice. London: RCPCH.