Stage 1 – Assessing the context

Outcome

By completing step 1.1 you will have a written statement of the problem(s) you think the selected PREM can help your organisation to solve, and why it is a suitable method for solving the problem. You are making an argument for why you will use the selected PREM and not a different patient experience survey, and this could be used as part of your business case.

Things to consider

This section lists the items that need to be considered in Step 1.1 to specify why and how you want to use the selected PREM in your organisation.

Audit of current activity

It could be helpful to start with an audit of your organisation’s current activities in collecting patient feedback. 

• How do these existing activities currently feed into your work on, for example, quality improvement, patient-centred care, accreditation? How would the PREM fit into this picture? What gaps can it fill and what processes or reports can it inform? How can it complement or feed into other activities?
• If you already use a patient experience survey, what aspects of patients’ experiences do you currently measure, and how do these compare to the selected PREM’s concepts? Will the PREM be used as a replacement for existing tools or as an add-on module?

The context for PREM implementation

Organisations implementing a new PREM may or may not have existing survey programs and may or may not have control over whether the selected PREM is administered to their patients. This affects the type of rationale you develop for using the PREM in your organisation.

Three example scenarios, and how these might affect your business case for adopting the selected PREM, are considered below.

• If you have been told you must implement the PREM in your organisation, or that the PREM will be administered to your patients by another organisation or authority
  • note the rationale given to you for choosing the PREM by your head office or regional authority and think about what else you can get out of the implementation for your own organisation’s benefit, so that the resulting data does not just disappear ‘up the line’ without you making meaningful use of it locally
• If you are already using a patient experience survey in your organisation and switching to a new PREM or adding the PREM to your existing survey
  • consider the implications of the change (cost, concepts measured, change in mode of administration, change in presentation of results)
  • consider how this will affect current reporting of patient experience and what changes will flow through from ‘board to ward’
  • consider how you could use this opportunity to improve how your organisation engages with consumers and collects and uses patient experience information. What benefits or features does the PREM have compared to your old survey and how can you take advantage of these? 
• If you do not have an existing patient survey
  • consider how the results of the PREM could fill gaps in your organisation’s knowledge about the quality and person-centeredness of its care, and how the PREM might complement other types of information your organisation collects to monitor and improve quality and safety.

Outcome

By completing step 1.2 you will have a written statement of what a successful implementation of the PREM would look like. You could divide this into the ultimate outcomes you want to see, and how you will know you are on the right track to achieving the ultimate outcomes (intermediate outcomes). This step is very important to informing any later evaluation you may conduct.

Things to consider

This section lists the items that need to be considered in Step 1.2 to define what success will look like in your organisation.

Ultimate outcomes

When defining the ultimate outcomes you want the PREM to have, you might consider how these can align with and contribute to current policy, operational and strategic objectives. Think about your organisation’s short- and long-term priorities and plans, areas that have previously been identified for improvement, and the priorities of other organisations whose policies affect you (such as governments and head offices).

Note that it is very unlikely that the PREM alone can create all these outcomes – a more comprehensive approach to monitoring patient perspectives and viewing this in the context of other safety and quality information is necessary. However, there is evidence that improved patient experience is associated with many of these outcomes.

Outcomes you choose to monitor the impact of the PREM might include:

• Positive trends in PREM results over time
• Early identification of concerning patterns in patient safety near misses, unsafe practices and adverse events
• Improvement in other types of quality and safety outcomes including clinical outcomes
• Increasing public and patient trust in your organisation (and its reputation)
• Positive accreditation outcomes for actions related to person-centred care
• Increased focus by decision-makers on improving the aspects of experience that are important to patients
• Increased consumer involvement in decision-making at all levels of the organisation
• Improved disclosure and communication of adverse safety events to patients.

Mechanisms to achieve the outcomes

How will you know that you are on the right track to achieving the ultimate outcomes? Monitoring the intermediate outcomes – the mechanisms your organisation puts in place to trigger the ultimate outcomes – will give you a good indication of progress.

Potential mechanisms that might help achieve the desired outcomes in your organisation include:

• Regularly reporting results and trends to executive, board, staff and consumers
• Integrating PREM results into executive and board decision-making processes
• Creating an automatic trigger for action when PREM results fall below a certain level or when specific red flags are raised by the results
• Integrating PREMs into routine quality improvement processes and Plan-Do-Study-Act (PDSA) cycles
• Reporting and comparing PREM results across wards or services
• Using PREM results to regularly update staff
• Celebrating PREM results in high-performing or improving parts of the service
• Establishing consumer focus groups to dig deeper into the results.

Outcome

By completing step 1.3 you will have a map of the likely contextual influences (constraining and enabling) on PREM implementation – including political, stakeholder and logistics considerations. You could use this to inform a risk management plan to show how you will work with or mitigate the constraining factors and harness the enabling factors to ensure success.

Things to consider

This section lists the items that need to be considered in Step 1.3 to assess constraints and enablers in your organisation.

Constraints

There may be a range of constraints on the routine collection and use of patient experience information in your organisation. These constraints may affect how the selected PREM is implemented, when it is done and who is involved.

It is important that you identify these constraints early in the process so that you can take them into account in planning your PREM implementation.

Potential constraints include:

• Existing patient experience measurement activity – you will need to see what your organisation does now, to see how the PREM can complement this activity without ‘reinventing the wheel’
• Human and financial resources constraints – it may be necessary to think creatively about how the additional work will be done and who will do it. Can the PREM be rolled into an existing process? Will external resources be required? Can resources be shared with other organisations?
• Cultural constraints – there may be resistance in parts of the organisation to the idea of measuring patient experience and/or using this to improve care; these kinds of issues can be addressed with careful consideration of how to gain buy-in and engagement among different stakeholder groups
• Legislative and contractual requirements (for example, Department of Veterans Affairs or jurisdictional requirements) – see how the PREM fits in with your existing obligations
• Reporting cycles – make sure timing of PREM collection and reporting fits well with existing reporting cycles (for example, if reports to the board are quarterly, you may wish to use the PREM in the month before the reports, so that the results can be included)
• Other events and priorities – you may have other events to consider, such as staff training schedules or consumer forum meetings; you will also have to see where patient feedback fits in your organisation’s priorities.

Enablers

Enablers are resources or situations that will help to ensure the success of your implementation. Identifying existing resources will enable you to effectively draw on them when implementing the PREM.

Potential enablers include:

• Executive sponsors
• Clinical champions
• Staff training forums
• A person-centred care strategy
• Consumer committees and forums
• Information on consumer preferences and needs
• Changes to models of care.

Outcome

By completing step 1.4 you will have the beginnings of a stakeholder engagement and management strategy for both internal and external stakeholders. This can include analysis of stakeholder needs and preferences, mechanisms for stakeholder engagement in implementation, and mechanisms for stakeholder engagement in the ongoing and routine use of the PREM results.

Things to consider

This section lists the items that need to be considered in Step 1.4 to decide how you will engage with stakeholders.

Stakeholder needs analysis

A stakeholder needs analysis will identify the stakeholder groups to involve in the implementation and use of the PREM, and explore their expectations, needs and concerns. You can consider this among selected hospital staff, or conduct a consultation with stakeholder groups.

‘Marketing’ the PREM

You may need to ‘market’ the PREM to stakeholders, especially during the initial stages of implementation. The marketing should raise awareness among different groups, encourage acceptance of both the process and the use of PREM information, and manage stakeholder expectations of what the PREM can and can’t do.

Marketing activities and resources may include:

• Materials (posters, brochures, web and intranet information)
• Events (awareness-raising events, forums, presentations at staff meetings)
• Staff education or training 
• Champions (both senior leadership and clinician champions can help to cement the role of the PREM in the organisation).

Long-term engagement

Usually, the PREM will be implemented in a whole organisation as part of overall strategic planning. However, if the implementation is initiated below senior management level, it is essential that you seek executive or management approval so that the PREM can contribute to broader goals and strategies and work within existing processes (if possible).

To ensure meaningful use of the PREM to achieve your ultimate outcomes over the longer term, you can consider what engagement processes and regular events you need to put in place. For example:

• Posting results throughout the organisation (through staff reports or ‘how we are doing boards’)
• Posting results publicly (through the website or media liaison)
• Holding friendly competitions between wards, units or departments
• Establishing a consumer and health professional panel to routinely scrutinise results and recommend and track actions
• Asking consumers to make presentations to staff on issues highlighted by the PREM.

• Black N, Varaganum M, Hutchings A. Relationship between patient reported experience (PREMs) and patient reported outcomes (PROMs) in elective surgery. BMJ Quality and Safety 2014;23(7):534–42.
• Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. American Journal of Managed Care 2011;17(1):41–8. 
• Canadian Foundation for Healthcare Improvement. Patient engagement resource hub. Ottawa: Canadian Foundation for Healthcare Improvement; 2018.
• Cornwell J. Reframing the work on patient experience Improvement. Patient Experience Journal 2015;2(1):11–4.
• Dimopoulos-Bick T, Dawda P, Maher L, Verma R, Palmer V. Experience-based co-design: tackling common challenges. Journal of Health Design 2018;3(1):86–93.
• Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open 2013;3(1):e001570. 
• Fereday S, Rezel, K. Patient and public involvement in quality improvement. London: Healthcare Quality Improvement Partnership; 2017.
• Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: executive summary. London: The Stationery Office; 2013.
• Geissler KH, Friedberg MW, SteelFisher GK, Schneider EC. Motivators and barriers to using patient experience reports for performance improvement. Medical Care Research and Review 2013;70(6):621–35.
• Sheard L, Marsh C, O'Hara J, Armitage G, Wright J, Lawton R. The Patient Feedback Response Framework – Understanding why UK hospital staff find it difficult to make improvements based on patient feedback: a qualitative study. Social Science & Medicine 2017;178:19–27.
• The Health Foundation. A framework for measuring and monitoring safety: a practical guide to using a new framework for measuring and monitoring safety in the NHS. London: Health Foundation; 2018.
• The Point of Care Foundation. Why use patient experience data? London: The Point of Care Foundation; 2018.