research article

Co-Designing Health Care Solutions with Patient Representatives and Clinicians in a Large Acute Hospital Setting: Process and Engagement

Martin Bollard1*, Alison Dowling2, Lynne Westwood3, Ann-Marie Cannaby4

1 Head of Nursing Faculty of Health and Wellbeing University of Wolverhampton, UK

2 Head of Patient Experience and Involvement Royal Wolverhampton NHS Trust, UK

3 Learning Disability Pathway Lead Faculty of Health and Wellbeing University of Wolverhampton, UK

4 Group Chief Nursing Officer/Deputy Chief Executive The Royal Wolverhampton NHS Trust and Walsall Healthcare NHS Trust. Deputy Chief Executive Walsall Healthcare NHS Trust, UK

*Corresponding author: Martin Bollard, Head of Nursing University of Wolverhampton, UK

Received Date: 19 December, 2022

Accepted Date: 05 January, 2023

Published Date: 10 January, 2023

Citation: Bollard M, Dowling A, Westwood L, Cannaby AM (2023) Co-Designing Health Care Solutions with Patient Representatives and Clinicians in a Large Acute Hospital Setting: Process and Engagement. Int J Nurs Health Care Res 6: 1382. DOI: https://doi.org/10.29011/2688-9501.101382

Abstract

The benefits of involving patients and wider members of the public as partners in care are being increasingly recognised internationally. Co-design is one of the methods reported to promote patient-based health service improvements and offers a participatory approach to engage patients and citizens in solving health care challenges. However, current limitations are levelled at this corpus of work, indicating a lack of sustainability and substantive evidence of any known associated processes that can yield sustainable longer-term patient benefit. This service improvement project was underpinned by a Human Centred Design (HCD) methodology incorporating the Design Council’s process Discover, Define, Develop and Deliver [1]. This assisted in providing a participatory framework of co-produced work over a twelve-month period with three clinical pathway teams, Stroke, Children and Young People (CYP) and Learning and Developmental Disabilities (LD.) Meeting specific project objectives, patient- based projects were developed using a toolkit and Collaborative Action Plans that steered involvement throughout. Evaluative results elicited three themes, generating a product idea together, acknowledging the contribution of all, barriers and challenges. Within this, the clinicians and patient representatives reported the value of having a safe space to carry out experienced based work with their respective patient representatives. Additionally, they reported the chosen HCD framework guided the process of engagement determining co-produced health care solutions to patient derived challenges. Conclusions are drawn that suggest further work and research is required to testbed the ‘how to’ processes associated with successful co-design in health and social care. This could provide an empirical basis for the value and process associated with sustainable human centred design required at both a micro and macro level of healthcare.

Keywords: Co-designed health improvements Human Centred Design patient-based health solutions, Acute care

Introduction

There is increasing recognition of the benefits of involving patients, carers, and wider members of the public as partners in their care design and delivery [2,3]. The process to achieve this within Health and Social Care practice, policy and research has been widely enacted through Co-production and co-existing terms such as Co-design and Co-creation. These processes have become associated with bringing patients and communities together, with the ambition of developing equal partnerships to influence care pathways [4]. Traditionally, healthcare decisions have been made with little to no involvement of the people who will be most affected by those decisions [5]. Whilst complex modern healthcare practice has strived to move beyond this paternalistic model, the inevitable hierarchy and professional structuring within Health and Social can still internationally present a challenge to the ambition of bringing clinicians and patient representatives together to solve service challenges [5]. Co-production aims to challenge this tacit imbalance of power held within groups of individuals, who make important decisions about other’s lives, livelihoods and bodies, particularly at the point of illness and vulnerability. Moreover, Co-design is based on long-standing practices such as community engagement and public participation [6]. Co-design therefore seeks to change this imbalance of power, through methodologically building new relationships, capability and capacity for clinicians and patient representatives through the process of co-created solutions [7]. Robert et al. (2015) [8] state that applying a Codesign approach in the healthcare context represents a radical reconceptualization of the role of patients and a structured process for involving them throughout all stages of quality improvement, with user experience at the centre. However, reported the clustered terms associated with Co-design and Co-production were still at the point of evolving and this adds uncertainty to their applicability in practice settings and also for the purposes of research.

The service improvement project reported in this paper adopted a Co-design method to work with three pathway teams in a large Acute and Community Provider in the West Midlands, United Kingdom (UK) - Stroke, Children and Young People (CYP) and Learning Disability (LD). The Nursing Hospital Executives and the teams at the outset widely accepted that involving patients in their clinical decisions and the way in which services redesign, is the right thing to do [9]. Furthermore, emerging evidence of quality improvement initiatives points to how collective thinking and sharing of experiences between patients and health professionals are essential for achieving better usage of health resources [10], particularly when supported by national standards [11].

HCD is a leading approach, which sets out to promote experience-based work. HCD is based on the use of techniques, which communicate, interact, understands and stimulate the people involved, obtaining an understanding of their needs, desires, and experiences [12]. Several fields of study have seen the incorporation of more participatory methods, such as HCD and the evolution has occurred as the design approach has been adopted more widely across different disciplines-built environment and social sciences, [13]. Increasingly, the influence of HCD approaches is growing in health systems research internationally [14]. As a ‘practice framework’, HCD integrates a three-part cyclical process of helping stakeholders derive inspiration (understanding the experiences, needs and challenges of users of community resources), produce ideation (creating ideas and solutions) and conduct, the implementation of community health strategies [15]. HCD seeks to elicit empathy for users to understand how different sets of people experience health, and address challenges and solutions within their context. It does so through adopting diverse and collaborative teams, working on action-oriented rapid prototyping based on user-derived insights, rather than from topdown approaches (Roberts et al., 2016).

The project reported here adopted a HCD approach alongside the Design Council’s method Discover, Define, Develop, Deliver [1], as a framework to complement and enhance engagement with the project participants across the three pathway teams.

Despite the volume of work in Co-design across the health and social care interface both in the UK and internationally [16], an understanding of the process that may pinpoint essential prerequisites to achieving effective participation between patients and clinicians, has yet to emerge. The aim of this paper is to suggest that effective participation in Co-design work can be achieved, if the process of engagement in-patient led initiatives for health professionals and patients is clear from the outset and is facilitated by a human centred approach that supports experiencebased solutions. The authors advocate the deliberate process of engagement and time taken to develop partnerships with the three pathway teams reported here goes some way to demonstrate this. The project objectives included:

1. To facilitate Co-production workshop(s) with key organizational personnel and their associated work stream communities.

2. To support the development of products underpinned by Coproduction methods, inclusive of tangible products such as toolkits.

3. To identify the learning map that pinpoints the ‘how to’ of RWT’s Co-production associated with the selected pathway teams.

Process

Initial Engagement

During spring 2021, several meetings were held between members of Nursing Executive Team, the Head of Patient Experience and Engagement at Royal Wolverhampton Hospital (RWT) and Senior Academics from the Faculty of Health & Wellbeing, University of Wolverhampton. Following this consultation, a proposal of work was agreed with a small academic team led by MB. The executive team were able to secure monies from the Charities Board to support the projects milestones. The acute hospital provider sought to instigate co-production principles with its staff group via three selected service pathways. Distilling from a variety of metric data sources, such as Patient Feedback data, Friends and Family Tests, Complaints and the Care Quality Commission National Surveys, the Deputy Chief Executive and Acting Chief Nurse were keen to improve health inequalities for their patient populations, LD, Stroke and Children and Young People’s. For this organisation the 3 service pathways (Table 1) were made up of teams acted as pilot areas for further experience-based design work.

Learning Disability Pathway

Specialist Nurses x 3

Key worker from

Dudley Voices Advocacy Organisation

Patient Representatives x 2

RWT Patient Engagement Team x 1

Stroke Pathway

Senior Nurses x2

Physiotherapist

Nurses x 1 plus 2 Patient Representatives

RWT Patient Engagement Team x 1

Children and Young People

Pathway

Speech and Language Manager

Clinical nurse specialist x 2

Patient Representative x 1

RWT Patient Engagement Team x 1

Table 1: Composition of Pathway Teams.

Pre-Engagement Workshops

Two pre-engagement workshops were provided to the pathway teams, one in July and September 2021. Following Covid 19 protocols, the LD workshop was provided off site (away from hospital and working environment), as it was decided engagement would be more effective than in a virtual space for the patient representatives with a learning disability. The children’s and stroke pathway joined a facilitated virtual session, which was aimed at identifying the team’s definitions and understanding of Co-production/Co-design. This initiated the process of engagement with the pathway teams and identified how they wished to structure the involvement process. Communication adjustments and alignments to form a set of co-planning principles from the outset were discussed. In essence, the workshops allowed the pathways time to discover how they (the clinicians and patients) understood their Co-production starting point and principles. It also enabled an open conversation with the challenges they currently faced within their service areas. This facilitated the opportunity to consider what solution, or product might be developed to overcome the challenges raised and how the patient voice would be ‘front and centre’ in this process. This began the application of the Discover stage of the model, which underpinned the project (Table 2).

 

Table 2: Discover stage of the model.

Different definitions of Co-production/Co-Design were shared during this workshop to help clarify the co-existing and interchangeable terminology, which exists on this topic area. After further discussion, the following explanation was offered to enable the team member’s clarity on how they would be taking part in the project. The following phrase acted as a statement of intent for the project:

We will be acting as Co-creators, following Co-design methodology underpinned by Co-production principles.

The project facilitators were then able to re-message this within the face-face workshops held in the middle of September 2021 and revisit the statement throughout the duration of the project.

Face to face Workshops

Building on the pre-engagement activities, the 2 day offsite (away from hospital setting) workshops put the patients and clinicians service pathways through a series of Co-creation exercises together, for example establishing team co-production principles (Figure 1) and a team narrative building exercise. Building on this in the second day, enabled the teams to place the lived experience of their patient representatives at the heart of their work through the development of Collaborative Action Plans (CAP). In this way, the project Co-creators were moving through the process of mutually Defining (Design Council 2013) [1] the challenges and problems they face in their clinical pathway to identifying and making suggestions to Develop (Design Council 2013) [1] a solution focused product. This process was evidenced in the production of the CAP produced by the end of the second off-site workshop. In principle a collaborative goal focused action plan with how the patient representatives wished to be involved throughout the project, were grounded in the principles of a HCD approach [12].

Figure 1 : Learning Disability Team Co-Production Principles.

• We want an inclusive approach that meets individual needs.

• We want an understanding that what may work for one may not work for another and that means being adaptable.

• We want a person-centred approach.

• We want to be able to give feedback and have the patient’s voice heard.

• We want improved communication and information sharing.

• We want people to get to know us by spending time to get to know us.

• At this point each service pathway was asked to secure ‘buy in’ from their wider multi-disciplinary team and begin the process of developing their products-Develop.

Check -in sessions

The project team were keen to maintain the momentum of the project outside of the workshop delivery days and offer further support as the teams developed their patient focused products. A member of the project team LW worked closely with the LD pathway and off-site face to face check ins were arranged responsive to the patent reps and team’s needs over the remainder of the project. Virtual check-ins were held for the CYP and Stroke teams in November and March 2022. The project lead MB was able to assess product progress and again check in with how the pathway teams felt they were able to follow their agreed principles of Co-production.

Product Outputs

One of the project objectives was for each pathway to develop a patient-based product arising from the pathway’s Co-created service challenge. The pathway maps developed in the second workshops depicted the patient experience within each service area. From this the three pathways agreed on the specific challenge they wished to focus on and from this, a product they wished to develop (Figure 2).