Inpatient Stroke Service, Dudley Group NHS Foundation Trust

Clinical challenge
Papers by NHS England cite that we should ensure people have a positive experience of care and that ‘experience’ is one of 3 key components of quality and needs to be given equal emphasis along with safety and effectiveness.
 
As a Stroke Service we acknowledged the importance of achieving the SSNAP performance targets but equally we felt quality should include patient experience and this is not captured by SSNAP. Having a patient user group was considered to be a way that we could change that focus and ensure we viewed our performance more holistically.

Solution
We decided to facilitate a patient and carer ‘Listening Into Action’ (LiA) event. We identified core members of the Stroke Service to take this forward ensuring the whole Multi Disciplinary Team (MDT) was represented, including the voluntary sector. Our mission statement was ‘To make the experience of stroke patients the best it can possibly be when they stay in our hospital’.
 
Rationale for inclusion was simple, it could be anyone who had stayed on the Stroke Unit within the last 12 months. We also included those who had raised previous concerns thereby giving them an opportunity to be involved and ensuring a broad range of views.  The event was facilitated by the Chief Nurse.
 
A combined total of 24 patients and carers attended the event. The conversations from patients and carers were an inspiration. It was at times an incredibly moving experience; sometimes difficult to hear. As well as the catharsis this offered, we heard about what mattered to our patients loud and clear, perhaps for the first time properly and in a way that resonated with them.

Impact
As well as the obvious platform this gave us from which to make changes, the patients and carers themselves found it hugely valuable. Most importantly though, they reported that they felt listened too and valued and this is reflected in the scores below regarding the evaluation of the event:

• 93% felt the event was very good to excellent
• 96% felt that the event was a good use of their time
• 92% felt that their feedback will help us improve patient care

 Some of the positive comments raised during the LiA were:

• Supportive team
• Therapy team were excellent
• Speech and Language Therapists very helpful from the beginning
• Nursing care excellent, nothing too much trouble even after 12 hour shift
• Good choice at mealtimes
• Dudley Stroke Association provide an incredible service, very supportive and informative

 The feedback and comments relating to issues we needed to address and improve were categorised into 5 main themes:

• Staffing
• Care
• Communication
• Behaviours
• Service 

A summary of the event evaluation and themes and associated comments from the feedback were given to staff. The positive comments were tabled separately so easier to identify and enable staff to recognise what they were doing well and indeed to boost morale. The comments which required action were fedback and each service lead from the LiA working group was responsible for sharing and discussing this in detail but more importantly, obtaining staff views regarding how these could be tackled constructively. This was a pivotal part of the process to facilitate staff engagement and ultimately share ownership of the eventual action plan going forwards. This could not be an initiative owned by the working group, to be successful it had to be a collaborative approach with everyone signing up to the vision of making a difference. So, the action plan was devised based upon all of this feedback.
 
A summary of some of the actions already achieved are outlined below:

• MDT have increased the amount of joint clinical sessions
• Extensive review of MDT meetings including format, process and documentation with the aim of improving communication and patient care
• Discharge Facilitator now based specifically on Stroke Unit and is actively involved in the discharge planning process and a key role is to ensure all information is discussed with patients and their carers accordingly
• Promotion of members of the Stroke MDT to patients and carers so that they are easily identifiable and key information shared regarding their roles
• Processes and systems in place to facilitate the timely dispensing of medication at discharge
• A pilot is underway to introduce 4 family meeting slots per week which MDT will attend and which will be led by the Doctor – this is in addition to the current rehab reviews and case conferences and is specifically aimed at providing designated time for patients and carers to raise any issues they wish to discuss/clarify
• Information booklets/resources obtained to enable better communication, support and information sharing with children of Stroke patients
• Development of profession specific information leaflets that can be used to support therapy as appropriate
• Currently working collaboratively with the voluntary sector (Dudley Stroke Association) to introduce relative and carer ‘drop in’ sessions twice weekly to offer general advice including benefits, etc
• ‘You said/we did’ feedback actively promoted on the ward via designated notice board
• Extensive work undertaken by Stroke CNS to raise awareness and improve knowledge and skills of stroke/FAST with staff in A+E and Urgent Care
• Review of stroke Psychology Service and new ways of working identified and trialled to optimise the resource available to best support patients
• Standard Operating Procedure (SOP) completed to support the protection of a thrombectomy and non thrombectomy bed on the stroke unit. This has helped to improve patient flow to the Stroke Unit and helps to ensure the best care pathway for stroke patients is achieved.
• Processes effectively reviewed to ensure the consistent effective and efficient repatriation of stroke patients to ensure patient needs are met and resources  optimised
• Extensive audit undertaken and report submitted including options appraisal regarding the impact of lack of Speech and Language Therapy service provision at weekends.
• New visiting times introduced in response to patient and carer feedback

Reflection
The LiA working group continues to meet on a monthly basis to review progress, identify barriers and potential solutions to ensure we remain on track to deliver the targets set out in the action plan. Progress is reported to staff to maintain their engagement and ensure it remains a collaborative priority.
 
Regular reports are submitted to the Trust ‘Patient Experience and Improvement Group’ to whom we are accountable.
 
A further LiA follow up event has been completed and the same patients and carers invited back to have an update on the actions taken and to gain feedback on whether they believe we are fulfilling the promises we set 6 months earlier. The evaluation of this event was equally positive:

• 97% felt that the event was very good to excellent
• 91% felt the event was a good use of their time
• 94% felt that their feedback will help improve patient care

 Additional comments were all positive:

• Encouraged that you are listening to peoples’ concerns and doing your utmost to improve the care and alleviate problems
• Things are going in the right direction – great!
• Issues are being addressed which is a big positive
• Being listened too and having the opportunity to raise points that need to be acted upon
• Positive, grateful for all that you do!

 Although the focus of this case study is upon using patient experience to improve care, the actions that have been taken as a direct result of the feedback are often intrinsically linked to SSNAP targets and performance. Improving patient experience often improves performance against SSNAP targets. We believe that both are equally important as ultimately it enables us to gain a better holistic view of our performance.
 
Dudley Stroke Service continues to be committed to driving forwards the actions needed to deliver the best patient experience and the best patient care. The patients and carers have put their trust in us and that is a privilege – we owe it to each one of them to make that difference!