the 15 steps challenge for community services start off on the right foot -

© NHS Institute for Innovation and Improvement, 2011© NHS Institute for Innovation and Improvement, 2011

The 15 Steps Challenge for community services

Start off on the right foot - quality from a patient’s perspective

© NHS Institute for Innovation and Improvement, 2011

“I can tell what kind of care my daughter is going to get within 15 steps of walking on to a ward”

At a Productives workshop...

This comment sparked the 15 Steps Challenge


The 15 Step Challenge idea was born...

• First impressions count – they should inspire confidence and trust in your care.

• Thinking about the 15 Steps Challenge brings the patients view and voice into the process.

• Can we spot important clues indicating good quality patient experience?

• How could this be useful for staff, directors and patient representatives to help think through quality in their organisations?


Transferring the Challenge to a different setting: care in a patient’s home

• Is there a “15 Steps Challenge” for the community and what does this look like?

• Do community patients have the same feelings when someone comes to visit them at home as people do when they walk onto a ward?

• Can we still get a sense of the quality of care from first impressions?

• We asked these questions of staff and patients – they told us that the 15 Steps Challenge was important and they helped us to develop a version for care in patient’s homes


How was the Challenge developed?

• Literature and research review of what matters to patients

• Focus groups held to understand what “good” looks like to

patients and carers

• A co-designed approach that included staff, patient groups,

executive leads and other stakeholders

• Feedback received from Department of Health, Queen’s

Nursing Institute, Royal College of Nurses and Health

Professionals Council

• Cross referenced to and underpinned by the national Care

Quality Commission Essential Standards

• Testing of the Challenge tool with teams across the country


We asked what good looks like in the community

Patients and carers answered.........• Have appointments

• Choice of visits – planned, on time, contact patient if change needs to be made

• Be on time

• Maintain effective communication

• Clean, well presented

• Introductions – agree how to address each other

• Expectations – outlined at start of visit

• Discussions – explanations/reasons for visit/required treatment/investigations

• Skilled

• Methodical and organised

• Relaxed – friendly, interested in you,

• Reassuring – supporting, explains

• Safe – knowledgeable (underpinning of condition/ your individual needs)

• Involved – you have ownership of care

• Consent – seek informed consent

• Documentation – clear and no jargon

• Professional approach

• Comfortable – for patient and staff member

• Confidence – patient to be confident in roles and skills of staff

• Structured approach from the doorstep onwards

• Correct equipment available

• Clear treatment plan – goals set and communicated


The 15 Steps Challenge toolkit

A simple, easy to use document

Supports a range of national priorities and strategic links

Guidance on how to implement within organisations

Clear framework to help discussions with patients or carers about the of quality care across four categories


What it is.....

• A way of understanding patients first impressions more clearly

• Developing ways to build confidence in care from the outset

• A tool to hear the patient’s voice

• Supports continuous improvement

• A useful method to identify what works well and what could be improved –

supports sharing good practice and concentrating on patient experience

improvements

What it isn't....

• Performance management

• An audit (clinical, quality, safety or otherwise)


The 15 Steps Challenge – Community Version

Strategic Alignments


Key touch points around the 15 Step Challenge

Patient Experience

• Engaging patients

• Improved satisfaction

• Enhanced focus on Patient Surveys

Quality improvements(and QIPP)

• Service improvement initiatives

• Board engagement in quality

Support to regulatory and inspection frameworks and standards of practice

• CQC essential standards

National Priorities • NHS Outcomes Framework

• NHS Operating Framework

• RCN Principles of Good practice

• HPC


NHS Operating Framework

4 Key Themes:

• Putting patients at the centre of decision making• Completion of the last year of transition to the new system• Increasing the pace on delivery of the quality, innovation,

productivity and prevention (QIPP) challenge• Maintaining a strong grip on service and financial

performance

Strong focus on older people and dementia and other vulnerable patient groups

Direct alignment with NHS Outcomes Framework


The NHS Outcomes Framework 2012/13


Care Quality Commission

Evidence of patient engagementEvidence on meeting the outcomes

Supports the preparation for visits and inspections

Outcom

e

Standards

1 Respecting and involving services users

2 Consent to care and treatment

4 Personalised care and welfare of people who use the

service

8 Cleanliness and infection control

11 Safety, availability and suitability of equipment

16 Assessing and monitoring the quality of service provision


Supporting the sustainability of the Productive Community Services Programme

• Productive Community Services programme is a national QIPP workstream with the expectation that all NHS England trusts will be delivering the programme (or a similar initiative) by March 2013

• Useful for pre- and post-implementation of the Productive Community Services, ensuring good practice and progress is being maintained


The 15 Steps Challenge supports standards of practice

Royal College of Nursing Principles of Nursing Practice

Health Professionals Council – Standards of conduct, performance and ethics


Francis Inquiry – could this be happening in your community services?

18 recommendations

“It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm”.

Florence Nightingale (1859), Notes on Hospitals

Anthony Sumara’s five principles1. Creating a culture of caring; 2. Seeing zero harm as our target by keeping patients safe; 3. Listening, responding and acting to what our patients and

community are telling us; 4. Supporting our staff to become excellent. 5. Giving responsibility but holding to account as well; 6. Business and regulatory matters

One trust found that a patient had 120 visits from different health and social care professionals in an 18

month period!


Why Senior Leadership Engagement essential

• Make strategic alignments and carry the ‘bird’s eye view’

• Accountable for taking to the board in a coherent way

• Responsible for quality and connected to practice improvement

• Supports positive culture change

• Role modelling is one of the most important leadership practices

• Links board and frontline teams

The challenge needs to be driven with executive leadership


Quotes from test sites.......

•“We want to be able to deliver more personalised care and be really listening to our patients”Non Executive

Director

•“The challenge was manageable and required very little in additional resources from within the team” Health visitor

team lead

•“This tool helps to remind us of what we would want from care givers if we were on the receiving end.” Challenge co-

ordinator

•“This is so worth doing if it adds consistency and standards to the service we give” Member of

staff


The 15 Steps Challenge – Community Version

Getting Started


Stage 6Repeat the Challenge! See through the eyes of patients on a regular basis

Stage 5Action plans for improvement are developed with team and organisation sponsorQuick wins and longer action plansStage 4Feedback– the team, the sponsor, the BoardCelebrate and learn from what went well

Stage 3Choose teams and give out leaflets to new patientsUse the toolkit to guide your observationsStage 2Identify your Challenge teamInclude staff, executives, patient groups

How does the 15 Step Challenge work?

Stage 1Identify an organisational sponsor to support the challenge Champion of continuous improvement


Role of the Challenge Co-ordinator

• Liaise with executive sponsor

• Recruit and brief the 15 Steps Challenge team

• Co-ordinate challenge team to make phone calls/visit patients

• Co-ordinate logistics – time to phone/visit

• Collect and collate the feedback

• Co-ordinate feedback themes – highlighting these to the executive

sponsor and team lead

• Ensure appropriate action plans have been made and adhered to


Selecting the 15 Steps Challenge teamBoard members – ask your organisation sponsor to do this at

Executive and Board level. Focus on the strategic alignments. Non-executive board members see their roles as champions of quality this is a useful structure to explore. It is a format for Board members to connect with frontline activity.

Staff – it is good practice to use staff with different perspectives, non-clinical staff who bring a ‘fresh eyes’ approach and people form PALs team.

Patients/patient representatives/carers/relatives - there many places to recruit patient/carers to be part of the 15 Steps Challenge team. Start by asking your PALs and Patient Engagement teams within the organisation or find your Local Involvement Network (LINk) or Healthwatch group in your area – this voluntary group usually has members who are patient representatives


Briefing the 15 Steps teamClarity:• Go through the 15 Step Challenge document with the Challenge team• Ensure they are clear that they are exploring first impressions and the aim is to improve the

patient experience

Time commitment:• About 30 minutes for the initial briefing• About a half-day or a day at the trust (depending on number of patients being telephoned

or visited)

Responsibilities• Be honest• Be sensitive• Don't criticise, be a critical friend – help us learn• Tell us the good things – spot and share the good practice

Discuss what will happen after the Challenge:• Feedback to the board and team by Challenge Co-ordinator• Discuss if there will be a repeat of the 15 Steps Challenge to the same team.


Preparing teams

• It is good practice to let staff know that the Challenge is happening and ensure that they are clear about the aims of the Challenge;

See through fresh eyes Hear from patients what they care about the team Use the quote “I can tell within 15 steps onto a ward what

kind of care my daughter is going to receive” Share good practice quickly Address “quick wins”

• Explain that staff have to hand out the leaflets to all new patients in a given period of time

• This short, fun clip is a good way to highlight why we sometimes only see what we expect to see and the importance of fresh eyes

http://www.youtube.com/watch?v=IGQmdoK_ZfY

http://www.youtube.com/watch?v=IGQmdoK_ZfY


Patients ‘opt in’

• Explain that staff have to hand out leaflets to all new patients in a

given period of time

• Patients ‘opt in’ to taking part in the Challenge

• Staff need to deliver a positive message to encourage them to take

part

• Ensure contact details are clearly written on the leaflet

• Patients need to be given a time frame to return the leaflet


Leaflet to give to patients


Feedback methods for patientsIt is important to decide if your organisation wants to give a variety of options for following

up the responses to the Challenge.

• Telephone –patients may not always be available during office hours, so calls may need to be made in the evenings. Have a semi-structured script ready for use that you have agreed with your team in advance. This helps the caller to remember to cover and standardise some key points such as introductions, confidentiality and safeguarding.

• Home visits – it is worth considering if your organisation wants to offer this option as it may be time consuming. Consideration must be given to who is going to visit, and the organisation’s lone working or visiting policies, and CRB and identification requirements should be adhered to.

• E-mail – some patients may prefer answering questions via e-mail. The Challenge co-ordinator needs to be responsible for organising the sending and receiving of information in this manner.

• For all methods feedback, think about the timeframes for responding to patients. If too long is left between the leaflet being received by the Challenge team and getting in touch with the patient, the ability to recall first impressions may be lost.


There are four categories to discuss care....

Well organised

Safe and cared for

Involving

Communication


Before you start the Challenge

• Have appointments made to go and visit patients – remember lone

worker policy of the organisation/identification

• Have somewhere quiet that the team members can telephone

patients and speak to them at length if necessary

• Remember to take notes of the conversations you have with

patients

• Have the questions and points to consider available when talking to

patients• It is especially important to remind the Challenge team of

confidentiality and safeguarding issues. The conversations with patients need to protect their right to confidentiality unless there is a safeguarding concern


During the Challenge

• Use your senses – listen carefully to what the patient is saying to

you

• How does it make you feel? Gut feelings are important but try to

unpick why you have had this feeling – this is important for

constructive feedback

• Appear relaxed and allow patients time to get all their feelings and

thoughts over to you

• Probe the answers if necessary

• Record your comments on the template provided


What if I hear something that needs attention?

• E.g. Urgent safety/safeguarding issue of concern - Discuss with the Challenge Co-ordinator who will discuss with team leader

• E.g. Patient requesting attention – Alert a member of the frontline team, tell patient what you have done.


De-briefing after the Challenge

• Get everyone together for a discussion after speaking to a number of

patients – what specific details do you want to feedback to the team?

• Reflect on the conversations after they have all been completed – what

overall messages are there to feedback? What key themes are

emerging?

• The 15 Steps Challenge toolkit has a template to summarise comments.

• Ensure that the team leaders receive feedback as soon as possible after

the Challenge has taken place

• Ensure that the key themes and messages are discussed with

organisation sponsor


Feed back in a constructive way ...CRITICISMS• lack of interpersonal skills in the

criticiser• criticises behaviour • judgmental, i.e. making judgements

about the value of something• focuses on the person• criticiser is perceived as being harsh• criticiser ‘jumps in with both feet’ i.e.

hasn’t verified or checked out accuracy

• unstructured• problem-focused

SUPPORTIVE• enabling• positive, e.g. constructive and

planned• focuses on the behaviour• structured• considered response with

examples• solution focused• non-judgmental• action from positive outcomes• use the feedback sandwich –

Positive comment

Improvement comment

Positive comment


Key issues for action planning

The basics:• Identifying your objectives • Setting tasks which are achievable & measurable • Prioritising your tasks effectively• Identifying the steps needed to achieve your goals. • Work to a deadline.

Remember to think about:• Who owns the action? Ensure this is clear!• Where is the strategic alignment? • Are there additional uses of the data and the evidence of action? e.g.

evidence for CQC inspections• How will it be monitored and reported back?


For further information go to.....

NHS Institute for Innovation and ImprovementTel: 024 7647 5800

Website: www.institute.nhs.uk

To find out more about The Productive Series visit:www.institute.nhs.uk/productives

http://www.institute.nhs.uk/

http://www.institute.nhs.uk/productives

the 15 steps challenge for community services start off on the right foot -

Documents

steps challenge nhs

patients homes nhs institute

community patients

steps challenge toolkit

quality of care

line nhs institute

communicated nhs institute

country nhs institute