The 15 Steps Challenge for community services Start off on the right foot -

1. The 15 Steps Challenge for community services Start off on the right foot - quality from a patient’s perspective

2. At a Productives workshop... “I can tell what kind of care my daughter is going to get within 15 steps of walking on to a ward” This comment sparked the 15 Steps Challenge

3. 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?

4. 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

5. 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

6. 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

7. 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

8. 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)

9. The 15 Steps Challenge – Community Version Strategic Alignments

10. Patient Experience • Engaging patients • Improved satisfaction • Enhanced focus on Patient Surveys • National Priorities • NHS Outcomes Framework • NHS Operating Framework • RCN Principles of Good practice • HPC Key touch points around the 15 Step Challenge • Support to regulatory and inspection frameworks and standards of practice • CQC essential standards • Quality improvements • (and QIPP) • Service improvement initiatives • Board engagement in quality

11. 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

12. The NHS Outcomes Framework 2012/13

13. Supports the preparation for visits and inspections Care Quality Commission • Evidence of patient engagement • Evidence on meeting the outcomes

14. 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

15. 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

16. 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 principles • Creating a culture of caring; • Seeing zero harm as our target by keeping patients safe; • Listening, responding and acting to what our patients and community are telling us; • Supporting our staff to become excellent. • Giving responsibility but holding to account as well; • 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!

17. Why Senior Leadership Engagement essential The challenge needs to be driven with executive leadership • 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

18. Quotes from test sites.......

19. The 15 Steps Challenge – Community Version Getting Started

20. How does the 15 Step Challenge work? Stage 6 Repeat the Challenge! See through the eyes of patients on a regular basis Stage 5 Action plans for improvement are developed with team and organisation sponsor Quick wins and longer action plans Stage 4 Feedback– the team, the sponsor, the Board Celebrate and learn from what went well Stage 3 Choose teams and give out leaflets to new patients Use the toolkit to guide your observations Stage 2 Identify your Challenge team Include staff, executives, patient groups Stage 1 Identify an organisational sponsor to support the challenge Champion of continuous improvement

21. 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

22. Selecting the 15 Steps Challenge team Board 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

23. Briefing the 15 Steps team Clarity: • 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.

24. 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

25. 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

26. Leaflet to give to patients

27. Feedback methods for patients It 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.

28. There are four categories to discuss care....

29. 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

30. 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

31. 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.

32. 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

33. Feed back in a constructive way ... • 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 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

34. 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?

36. For further information go to..... NHS Institute for Innovation and Improvement Tel: 024 7647 5800 Website: www.institute.nhs.uk To find out more about The Productive Series visit: www.institute.nhs.uk/productives