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CORRESPONDENCE
Response to: ‘A ‘work
smarter, not harder’
approach to improving
healthcare quality’ by
Hayes et al
Hayes et al1 highlight design-based
approaches to healthcare improvement as one means of achieving
patient-centred care, describing
them as involving ‘co-designing
care with patients that result in a
better fit with patients’ abilities and
needs’. They cite Experience-based
Co-design (EBCD) as one such
approach. They then go on to
argue that those leading improvement work in a healthcare organisation or system should adopt
similar approaches with their workforce and that, in doing so, they
would gain ‘a more explicit understanding of—and goal—to preserve
workforce capacity and reduce the
workload associated with change.’1
We wonder whether the authors
intended what could be read as an
apparent separation between, on
the one hand, ‘co-designing’ with
and for the benefit of patients
and, on the other, engaging with
staff to ease the perceived burden of
improvement work? If so, is such a
separation the most useful framing
when thinking about ‘smarter’ ways
of improving healthcare quality?
The article therefore opens up
questions relating to the most fundamental (and radical) tenet of
co-design, namely that ‘user and provider can work together to optimise
the content, form and delivery of services...[it] entails service development
driven by the equally respected
voices of users, providers and professionals’.2 In keeping with these sentiments, the original conceptualisation
of EBCD was as a ‘joint venture that
involves users and professionals
working together over a period and
throughout the change process as the
co-designers of a service’.3 In framing
the approach in such a way the intention was to give equal weight to
patient and staff experiences in the
quality improvement endeavour; not
only to seek to improve both but also
to shape behaviours and values for
the better. In this regard, Paul Bate—
the originator of the approach in
2005—always spoke of EBCD as a
‘Trojan horse’; behind the explicit
search for first order, incremental
quality improvements lay aspirations
of second-order, transformational
change (to the benefit of patients and
staff alike).
A decade on and our international
survey of 59 EBCD projects across six
countries reinforced the notion that
co-design work is at the very core of
the approach, underpinning service
change as well as broader impacts on
staff well-being and behaviours.4
However, a key finding of our
survey was that co-design is also, in
practice, the hardest aspect to
implement. Nonetheless, where
successfully implemented in practice,
the co-design stages of EBCD have
proved powerful. In projects carried
out in emergency departments in
New
South
Wales,
Australia,
co-design was reported to have
demonstrated a number of strengths,
including engaging service users in
‘deliberative’ processes that were
qualitatively different from traditional
forms of engagement and enabling
the service to implement solutions
that met the wishes, advice and
insights of patients and front-line
staff.5 Significantly in the context of
Hayes et al1 viewpoint article, the
approach also allowed project staff to
learn new skills and enabled frontline staff to better appreciate the
impact of healthcare practices and
environments on patients and carers.5
Despite this—and other examples
of successful incorporation of codesign into routine organisational
practices6—there remains a felt need
for illustrative and accessible resources
that would further clarify and bring
to life the ‘how’ and ‘why’ of
co-design in the healthcare context.4
In the same Australian project, where
preparation, recruitment of patients
and engagement of front-line staff
were not possible or not consistent,
co-design worked less well.7
As Iedema noted in his own
response to Hayes et al, while ‘we
expect frontline professionals to
somehow know how to co-design
practices, and know how to be smart
about what they do and what they
should do...their training has not
BMJ Qual Saf June 2015 Vol 24 No 6
skilled them in practice design’.8 To
help staff achieve this, we would
argue that they need to be encouraged to ‘step off the pavement’ and
work in a much closer joint endeavour with their patients (who will
bring their own unique insights to
such an enterprise in the form of that
specialised form of knowledge called
‘experience’). Closer collaborations
with service designers—with their
wide range of proven tools and
approaches (whether ‘gadget based’8
or not)—is another part of the
potential solution, albeit always with
an eye to the unique context of
healthcare organisations in which
this expertise is to be applied.
We have suggested elsewhere that
the adoption and implementation of
co-design in the healthcare sector
require critical approaches to both
organisational processes and the
application of design thinking.6 9
Digging a little deeper into the
detailed implementation of approaches such as EBCD undoubtedly
often reveals tensions between the
intended aims of co-design and its
actual forms in practice.9 Implicit in
co-design approaches is the aim to
alter power relations, but the
evidence as to whether or not they
do so in the healthcare setting is very
scant; certainly until now we know
little of the circumstances in which
they are successful in this regard.
As Hayes et al10 have already
commented, ‘there needs to be a
system-wide look at the capabilities
and investments required to create a
‘working smarter’ healthcare system’.
Asset-based or resource-based perspectives may help11 but crucial to
any such an assessment is closer
consideration of what both patients
and staff can bring, together, to
new co-designed ways of caring.
Perhaps harder work in the short
term but smarter in the long run?
Glenn Robert, Sara Donetto
National Nursing Research Unit, Florence
Nightingale Faculty of Nursing and Midwifery,
King’s College London, London, UK
Correspondence to Professor Glenn Robert,
National Nursing Research Unit, King’s College
London, James Clerk Maxwell Building, 57 Waterloo
Road, London SE1 8WA, UK; glenn.robert@kcl.ac.uk
Competing interests GR is one of the
original developers of EBCD and has
407
Downloaded from http://qualitysafety.bmj.com/ on July 7, 2015 - Published by group.bmj.com
Correspondence
been involved in the evolution and
adaptation of the approach since the
initial pilot project in 2005 which was
funded by the NHS Institute for
Innovation and Improvement. The Point
of Care Foundation in England provides
training in the EBCD approach and GR
contributes to this.
Provenance and peer review Not
commissioned; internally peer reviewed.
Open Access
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Open Access This is an Open Access
article distributed in accordance with the
Creative Commons Attribution
Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix,
adapt, build upon this work noncommercially, and license their derivative
works on different terms, provided the
original work is properly cited and the use
is non-commercial. See: http://
creativecommons.org/licenses/by-nc/4.0/
To cite Robert G, Donetto S. BMJ Qual Saf
2015;24:407–408.
Accepted 27 March 2015
Published Online First 23 April 2015
▸ http://dx.doi.org/10.1136/bmjqs-2014-003673
▸ http://dx.doi.org/10.1136/bmjqs-2015-004257
BMJ Qual Saf 2015;24:407–408.
doi:10.1136/bmjqs-2015-004240
REFERENCES
1 Hayes CW, Batalden PB, Goldmann D.
A ‘work smarter, not harder’ approach
to improving healthcare quality. BMJ
Qual Saf 2015;24:100–2.
2 Bradwell P, Marr S. Making the most of
collaboration. An international survey
of public service co-design. London:
DEMOS, 2008.
3 Bate P, Robert G. Experience-based
design: from redesigning the system
around the patient to co-designing
services with the patient. Qual Saf
Health Care 2006;15:307–10.
4 Donetto S, Tsianakas V, Robert G. Using
Experience-based Co-design to improve the
quality of healthcare: mapping where we
are now and establishing future directions.
London: King’s College London, 2014.
5 Iedema R, Merrick E, Piper D, et al.
Co-design as discursive practice in
emergency health services: the
architecture of deliberation. J Appl
Behav Sci 2010;46:73–91.
408
6 Robert G, Cornwell J, Locock L, et al.
Patients and staff as co-designers of health
care services. BMJ 2015;350:g7714.
7 Piper D, Iedema R, Gray J, et al.
Utilizing Experience-based Co-design to
improve the experience of patients
accessing emergency departments in
New South Wales public hospitals: an
evaluation study. Health Serv Manage
Res 2012;25:162–72.
8 Iedema R. Working smarter, not
harder. BMJ Qual Saf 2015;24:288–9.
9 Donetto S, Pierri P, Tsianakas V, et al.
Experience-based Co-design and
healthcare improvement: realising
participatory design in the public sector.
Des J 2015;18:227–48.
10 Hayes CW, Batalden PB, Goldmann D.
Response to: ‘working smarter, not
harder’ by Professor Iedema. BMJ Qual
Saf 2015;24:289–90.
11 Burton CR, Rycroft Malone J, Robert
G, et al. Investigating the organisational
impacts of quality improvement:
a protocol for a realist evaluation of
improvement approaches drawing on
the Resource Based View of the Firm.
BMJ Open 2014;4:e005650.
Reply to: ‘Harder but
smarter? Co-designing
together’ by Robert and
Donetto
We think that Drs Robert and
Donetto have touched upon an
important issue.1 First, we did not
intend to suggest that experiencebased co-design (EBCD) efforts be
separate activities—one set for
patients, one set for providers. The
evidence they point to and, I would
say, the lived experience of participants is that having care providers and
patients working together to design
care processes produces the best
value-based outcomes and experiences. We think this stems from the
primary drive of care providers—to
work with their patients to produce
better care and reduce suffering.
Having said that, we would argue
that there is separation occurring.
Examples exist in which EBCD
efforts have not adequately involved
care providers. For example, imagine
an initiative in which a hospital
quality department works with families to design an expanded visitor
hour strategy with the intent of
having no restrictions. The benefit of
this strategy is clear for families and
their inpatient loved ones. However,
if not designed with care providers,
the presence of families 24 h a day
could add significant workload to
providers which may result in the
presence of families being perceived
as a burden. If families and providers
designed together towards common
goals, one might imagine having
families sharing in their care of their
loved ones, increasing their sense of
involvement and offloading work
from providers.
We also imagine EBCD efforts that
do not necessarily need patient
involvement. An initiative to reorganise the medication preparation rooms
on inpatient wards would have direct
impact on nursing and pharmacy and
as such the principles of EBCD
should be applied. As with the application of LEAN methodologies and
the Model for Improvement, the
benefits of EBCD will be seen when
it is applied as intended. Again this
will require, as Drs Robert and
Donetto point out, an investment in
skill development of those seeking
change and those participating in the
production of best outcomes.
Christopher William Hayes
Correspondence to Dr Christopher Hayes,
Department of Medicine, St. Michael’s Hospital,
Institute for Health Policy, Management and Evaluation,
University of Toronto, Toronto, Ontario, Canada
Twitter Follow Chris Hayes at
@DrChrisHayes
Competing interests None declared.
Provenance and peer review Not
commissioned; internally peer reviewed.
To cite Hayes CW. BMJ Qual Saf 2015;24:408.
Accepted 31 March 2015
Published Online First 23 April 2015
▸ http://dx.doi.org/10.1136/bmjqs-2015-004240
BMJ Qual Saf 2015;24:408.
doi:10.1136/bmjqs-2015-004257
REFERENCE
1 Robert G, Donetto S. Harder but
smarter? Co-designing together. BMJ
Qual Saf 2015;24:407–8.
BMJ Qual Saf June 2015 Vol 24 No 6
Downloaded from http://qualitysafety.bmj.com/ on July 7, 2015 - Published by group.bmj.com
Response to: 'A 'work smarter, not harder'
approach to improving healthcare quality' by
Hayes et al
Glenn Robert and Sara Donetto
BMJ Qual Saf 2015 24: 407-408 originally published online April 23, 2015
doi: 10.1136/bmjqs-2015-004240
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