Improving Healthcare Services: Coproduction, Codesign and Operations 3030364976, 9783030364977

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Improving Healthcare Services Coproduction, Codesign and Operations

Sharon J. Williams Lynne Caley

Improving Healthcare Services “This manuscript provides a valuable contribution in exploring two mechanisms – co-production and quality improvement – that have largely been developed independently but synergistically can offer more to improving healthcare systems. The authors consider the varying terminology and definitions for both approaches and discuss the benefits and challenges of developing an integrated approach. Interesting case studies are provided as illustrative examples of patient and family involvement in quality improvement. Conceptual integrated models are provided which integrated key principles of co-production with two popular approaches used in healthcare: Lean thinking and Model for Improvement. The reflective (what’s missing) sections consider the lessons learnt from undertaking this research and/or the learning for healthcare organisations. This then allows academics to benefit from the agenda provided for future research. Healthcare professionals and managers looking to co-produce healthcare improvements will also find this text invaluable.” —Professor Zoe Radnor, Vice President, Strategy and Planning; Equality, Diversity and Inclusion, City, University of London

Sharon J. Williams • Lynne Caley

Improving Healthcare Services Coproduction, Codesign and Operations

Sharon J. Williams College of Human & Health Sciences Swansea University Swansea, UK

Lynne Caley Consolidated Caley Ltd Peterborough, UK

ISBN 978-3-030-36497-7    ISBN 978-3-030-36498-4 (eBook) https://doi.org/10.1007/978-3-030-36498-4 © The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Cover Pattern © Melisa Hasan This Palgrave Pivot imprint is published by the registered company Springer Nature Switzerland AG. The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

Victor Fuchs (1968) opens his early book on the “emerging service economy” with the acknowledgement that in contrast to making a product, there are always two parties involved in making a service. I interviewed him to explore how he came to that (Fuch 2015). He said, “it’s obvious.” I pressed him for more. He related the story of the time when one of his children cut his hand. Fuchs’ wife wanted to develop a plan for the problem, was uncertain about the need for a suture and called the doctor. Together they discussed the indications for a suture, where to get it and what to do if it wasn’t needed. “So,” he said, “it took two parties to make the service—you see, it’s obvious.”I wonder if it’s so obvious today. We live in a world where the logic of making a product – one party “makes” it, another party(s) buys it – seems to be the dominant view of how everything is made…even services! The authors of this book offer a refreshing contrast as they invite us to consider how services are actually made and improved. They build on the assumption that innovation and improvement become possible when there is a deep knowledge of the way things are “made” – hence, the link between service operations, improvement and coproduction. For example, the coproduction of a service to achieve, preserve or improve someone’s health involves a relationship and some action (Batalden 2018). They are held together in the shared work of patient and professional by knowledge, skill, habit, and some shared power. In addition, the work involves a willingness to be vulnerable in order to create, benefit from authentic relationships. The creation of a healthcare service is driven by several “streams” of knowledge: a.)the lived reality of the person – sometimes known as “beneficiary” or “client”; b.)the “as is” system v

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and its navigation by those seeking benefit; c.)  “science-informed practice”; and d.) the lived reality of the person – sometimes known as “professional.” This multiple knowledge-driven dyadic work of two parties is not “free-standing.” (Batalden et al. 2016). It occurs in settings that enable a sense of “agency” by those involved, an experienced sense of “support” for the shared work, an ongoing curiosity for “design,” and encouragement for “integrative thinking” across a variety of knowledge domains (Riel and Martin 2017). Opening the logic of making a service invites clarity about “ownership” of the desired outcome and an accountability for the contribution that a service makes to that end. For example, despite many hopes, suggestions and efforts to try, it is actually very difficult to outsource one’s own health or learning to another person, even a related “professional.” Further, “service coproduction” invites measurement of the contributions that each party brings to the task, whether the intended aim was realized, and the degree to which the setting helped make it easier or more difficult. These invitations for “service-making” offer new opportunities for design, for human and system development, for value creation, for innovation and for ongoing improvement. This volume offers its readers a reflective place to begin. Savour it. The Dartmouth Institute for Health Policy and Clinical Practice Geisel Medical School at Dartmouth Hanover, NH, USA August 2019

Professor Paul Batalden

References Fuchs, V. (1968). The service economy. New  York: National Bureau of Economic Research. Fuchs, V. (2015, October 2). Personal conversation with author. Palo Alto. Batalden, P. (2018). Getting more health from healthcare: Quality improvement must acknowledge patient coproduction. BMJ, 362, k3617. https://doi. org/10.1136/bmj.k3617. (Published 6 September, 2018). Batalden, M., Batalden, P., Margolis, P., et al. (2016). The coproduction of healthcare service. BMJ Quality Safety, 25, 509–517. Riel, J., & Martin, R. (2017). Creating great choices: A leader’s guide to integrative thinking. Boston: Harvard Business Press.

Preface

Involving service users in the design and delivery of healthcare has become a popular concept for practitioners, managers, policymakers, academics and patients and their families. Various approaches to how this might be achieved are being introduced alongside the various models and frameworks used to improve the quality of healthcare systems. We explore the opportunity to integrate models used for co-design and co-production with those of quality improvement. Drawing on service operations management, this study develops the thinking around the involvement of services users in improving healthcare services. We use two case studies which focus on two long-term chronic conditions and five published cases to illustrate an insightful explanation of how quality improvement can be integrated to co-production. We provide a research agenda that supports further development and understanding of what we have termed person-­ centred improvement. This study will be of interest to healthcare professionals, managers, researchers, educators and advanced students in public service operations and health service management. Swansea, UK Peterborough, UK

Sharon J. Williams Lynne Caley

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Acknowledgements

The authors would like to thank all the patients, relatives, healthcare professionals and managers that contributed to the case research included in this text. The authors would also like to thank Jessica Harrison who commissioned this work and the publishing team who provided guidance and support when bringing together the final manuscript. Special thanks are extended to Professor Zoe Radnor who has acted as an academic mentor to Professor Sharon Williams during her academic career and encouraged her to write this and her first pivot entitled Improving Healthcare Operations. The authors would also like to express their thanks to Professor Paul Batalden for his foreword and for Professor Radnor for her endorsement of this text.

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Contents

1 Introduction to Public Service Management and Service Operations  1 2 Quality Improvement in Healthcare: Where Are We Now and Where Next? 15 3 Citizen Involvement: What Does It Mean? 25 4 Defining Co-production 39 5 Quality Improvement and Co-production and Co-design Models and Approaches 55 6 Case Study: Improving a Pulmonary Rehabilitation Programme – A Co-produced Approach 69 7 Case Study: Improving a Community Based Huntington’s Disease Service – A Family-­Centred Approach 81 8 Co-producing Quality Improvement: Cases from the Published Literature 91

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9 The Role of Co-design and Co-production in Improving Healthcare Services: Conclusion and Future Research Agenda103 Index119

Abbreviations

COPD EBCD HD MfI OPD PAM PDSA PPI or PI PR QFD QI SOM

Chronic Obstructive Pulmonary Disease Experience based co-design Huntington’s Disease Model for Improvement Outpatient Department Public Administration and Management Plan Do Study Act Patient and Public Involvement or Patient Involvement Pulmonary Rehabilitation Quality Function Deployment Quality Improvement Service Operations Management

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List of Figures

Fig. 1.1 Fig. 4.1 Fig. 4.2 Fig. 6.1 Fig. 6.2 Fig. 7.1 Fig. 9.1

Theoretical framework. (Source: Authors) 8 Ladder of participation. (Source: Adapted from the New Economic Foundation (2013, p. 10)) 45 From consultation to co-production. (Source: Compiled by the authors)46 Stages of Pulmonary rehabilitation improvement programme. (Source: Compiled by authors) 71 PDSA cycles of change to improve flow. (Source: Compiled by authors)72 Knowledge and Activities of person-centred approach used by the HD team. (Source: Compiled by authors) 86 Revised theoretical framework. (Source: Compiled by the authors)107

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List of Tables

Table 6.1 Table 6.2 Table 7.1 Table 9.1 Table 9.2

Summary of the PR improvement and co-production activity 74 EBCD and the PR Case study 76 Summary of the HD improvement and co-production activity 85 Integrating lean thinking and principles of co-design and co-production108 Questions for future research 112

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CHAPTER 1

Introduction to Public Service Management and Service Operations

Abstract  This chapter introduces the concept of service operations and the need for continuous improvement. We offer three interacting approaches by which public sector design and delivery may be assessed. We introduce the concepts of co-production and co-design, which have been popularised in healthcare in terms of both practice and research. We highlight the work done to promote quality improvement in healthcare. Finally, we emphasise the need to bring together these three approaches and consider how this might work in practice. Keywords  Service operations management • Public services • Co-design • Co-production • Service-dominant logic • Healthcare

Introduction In this chapter, we briefly consider the trajectory of service operations management and the role of citizens/customers/users, which includes the emergence of service dominance logic within public-sector management. Our discussion extends from the public sector to public services and discuss why involving users in improving the management and operation of the public sector is essential to the design and provision of public services. Specifically we link our discussion to healthcare which is the public service that is the main feature of this text. However, we feel much of what we are

© The Author(s) 2020 S. J. Williams, L. Caley, Improving Healthcare Services, https://doi.org/10.1007/978-3-030-36498-4_1

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proposing is applicable to other public services and private healthcare systems with some adjustment for context.

Service Operations Management “Service” at one time only implied face-to-face interactions between two people, that is the service provider and the person receiving the service (service user) (Glushko and Tabas 2009). Today the design and delivery of services is much more complex (Glushko 2010); services can involve different person-to-person encounters, modes of delivery (e.g. self-­service, online), multi-channels of distribution, multi devices from various locations in different contexts. Many of these interactions (also known as moments of truth) will be information intensive and perhaps to a lesser extent will be designed to deliver a bespoke service to the user, what might be called a person or citizen-centred approach. The ‘service concept’, a termed coined by Sasser et al. (1978), has been described as playing a key role in service design and development. It explains the “how and what” of service design, what Sasser et al. (1978) defined as the total bundle of goods and services sold to the customer. The service concept helps mediate between what customers identify they actually want and need, and the organisation’s strategic intent and ability to deliver and meet these needs (Meyer Goldstein et al. 2002). Harvey’s (1990) research in social services explains how relationships in professional services influence process design and consequently service outcomes. The balance of power in professional service organizations can also influence the relationships among professionals, service users and managers. In subsequent research, Harvey (1992) recognized that the knowledge gap between the professional and the customer requires attention if services are to be improved. All of this discussion around the interaction between service providers and users relies on the ability to identify the target market (e.g. the right customer). Many organisations segment their potential customers based on common attributes and characteristics (e.g. demographics). In service operations management, customers tend to be segmented based on operational attributions (e.g. amount of customer contact and/or level of customisation) (Chase et al. 1998; Schmenner 1986, 1995; Chase and Tansik 1983; Chase 1981). Customer segmentation is an important area that seems under-researched within public services and specifically healthcare, yet is crucial to service (re)design and the co-production agenda.

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Returning to the service concept, Roth and Menor (2003) suggest that one of the first steps in designing a new service or assessing its effectiveness is to consider all the elements of the service from the perspective of the consumer and the provider. Usually, this will include a combination of tangible and intangible elements. We suggest a similar process needs to happen when redesigning services. When reviewing a service often the assessment is limited to defined parts of the process rather than all elements. Early studies on service management considered the interaction between service users and service providers (e.g. organisations) in the process of providing services (Fuchs 1968). More recently, service operations management has focused on service design (as well as management), particularly the interaction between the professional (e.g. front-line staff) actually delivering the service and the customer or service user. Radnor and Bateman (2016) refer to service operations management as being concerned with both the output (outcome) of the services (e.g. customer service) and the service organisation – in terms of how it is configured and managed to provide (value-adding) services to its customers. This presents two perspectives of the service: 1. From an operation’s point of view, -in terms of the service provided; and 2. From a service user’s viewpoint in terms of how the service is received. The traditional input-process-output model is central to (service) operations management. Each service operation (e.g. hospital) will manage and use input resources (e.g. Medicines, scanners, IT, beds etc.). One significant point to highlight (different to managing product operations) is that the service user who is receiving the service/treatment or the member of staff who requires support from IT are seen as important inputs. Typically service organisations provide many services (e.g. surgery, outpatient clinics, A&E, diagnostic services, reception, catering) which process the inputs to hopefully provide the desired outputs (outcomes such as good quality of care, more knowledgeable staff, availability of information). The service provided is the service process which involves the service user – therefore services are co-created or co-produced with the service user  – and outputs are produced (e.g. patient outcome  – better health; personalised care; organisational outcomes – good use of theatres, number of operations performed). The service received is the experience of the service provided – the service user’s interpretation of and response to their

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journey. The interaction between the service provider and the service user is the opportunity to create value (Johnston and Kong 2011; Johnston et al. 2012).

Public Service Operations Management Radnor and Bateman (2016) recently called for the development of (service) operations management thinking and theory to be applied to public sector organisations and public services in general  – which they termed public service operations management. The focus of this new discipline is for OM scholars to adapt traditional frameworks and concepts originally developed with manufacturing and private service organisations to the context and workings of public services (e.g. healthcare, emergency services, local government, third sector and voluntary organisations). Within each service, there will be high levels of variation when delivering local services. Key areas of (service) operations management such as development of an operations strategy, managing capacity and demand are typically not well understood or practiced in public services. Recently, improving operations has featured more prominently in public services; this is largely due to the need for efficiency gains, a reduction in budgets and the recognition of involving citizens and users in the design and delivery of services (Radnor and Bateman 2016). It is important to note the point made about the adaption (not adoption) of operations management strategies and methods to public services. Scholars (e.g. Osborne and Brown 2011) highlight the ‘fatal flaw’ of viewing public services as manufacturing rather than as service processes. In other words, the majority of public goods (whether delivered by government, non-profit and third sector or private sector) are not public products but public services that are part of people’s lives. Public services are often intangible and service-driven. Radnor et al. (2014), among others, have argued for public services to move away from this product-dominant logic, where production and consumption are separated as discrete processes. To a (public) services-dominant logic where the service experience is placed at the centre of public services delivery, (Osborne et al. 2015; Virtanen and Stenvall 2014), and where citizens are seen as co-producers of public services rather than solely the client or receiver of services (Radnor and Bateman 2016). This work has been extended to explore the benefits of public service-dominant logic to lean improvement methodologies in healthcare (Radnor and Osborne 2013).

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Interactions in healthcare are often complex and may involve multiple providers, with differing skills, roles and competences. Value is likely to differ across the different providers which may cause confusion for patients and a reluctance to participate in co-production activity (Fyrberg Yngfalk 2013; Hardyman et al. 2015).

Healthcare Operations Management In recent times, all healthcare systems have been facing a number of challenges such as ageing populations, shrinking budgets and higher expectations for effective and efficient treatments. Therefore, improving and managing healthcare operations is fundamental to the performance of individual healthcare organisations and the wider healthcare system. The problems arising in healthcare operations management are described as being similar to the problems in (service) operations management including strategic planning problems (e.g. design of services), design of healthcare supply chains, facility planning and design (e.g. layout of hospitals) demand and capacity management and scheduling and workforce planning (Brandeau et al. 2004). Although similar problems arise, healthcare systems and processes are reported as being more complicated (Guven-Uslu et al. 2014). It is the uncertainty around patient demand, clinicians’ time, availability of equipment, and usage of medicine that beset decision-making and operational performance. Mis-aligned incentives and targets are also defined as being a barrier to implementing operations management and improvement practices in healthcare organisations (McKone-Sweet et al. 2005). Despite these challenges, for some time now, we have seen improvement approaches being used to improve the delivery of healthcare. The results have been mixed with some organisations continuing to struggle to make and/or sustain improvements. We feel there is a need for a more integrated approach to improvement. A similar call has been made by Baim-Lance et  al. (2019) after reviewing patients participation in the delivery of healthcare. They refer to everyday and unavoidable co-­ production and recommend that co-delivery is intentionally integrated with design and improvement planning. Currently, however, it is unclear how different co-production and improvement approaches are aligned or integrated to ensure that improvement efforts are maximised and the possibility of sub-optimising parts of the healthcare system is avoided. With a recent surge of interest in engaging service users/patients in the design

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and delivery of healthcare services, we explore how concepts such as co-­ production and co-design might be linked with popular quality improvement approaches such as Lean thinking and the Model for Improvement.

Co-production and Public Services Within the context of public services, much has already been written about co-design, co-production and co-creation but often from a limited viewpoint of the philosophical and theoretical aspects of producing and delivering public services (Virtanen and Stenvall 2014). Ovretveit (2005) draws comparisons between customers of private industry and public services, with the role and nature of the latter being quite distinctive, where there are many customers, most of whom are not purchasers with a less predictable link between inputs, processes and outcomes. Virtanen and Stenvall (2014, p. 102) describe public services as “arenas for interaction, co-operation, and co-creation, orchestrated by networks of the organisations providing services”. They point out that the role of the service user has changed over time and is now recognised as a key element in the modern rationale of public services. As previously noted, our reliance on product-dominant thinking (i.e. viewing healthcare as a product) within public services has been questioned, particularly by those seeking to reform and improve public services. Many of the improvement models and approaches used in services originate from industry and as Batalden (2018) acknowledges sometimes these fit well, but at other times, the fit is awkward; it then becomes necessary to include a service model, that considers both the user and the provider. Increasing citizen participation is sometimes seen as a way to increase the efficacy of regulation, improve the provision of public goods and services, and bolster outcomes in areas such as health and education that straddle the boundaries between public and private, social and individual. If young people continue to demand greater engagement with the institutions that affect them and digital technologies continue to make information more accessible, we can expect both the demand for avenues of co-production and the potential of its contributions to increase (Fung 2015). More recently, Harvey (2016) re-examined the professional-service user relationship and provided a model that recognizes the complexity of the interactions and how both the professionals’ training and their mental model can affect their behaviour. Service users often lack adequate knowledge, capability and willingness in which to engage and interact

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with professionals. To help address these limitations, Harvey proposed that professionals could work more closely with existing and potential service users by offering guidance and education programmes (e.g. expert patient programmes). In this context, service users appear to be treated more like employees, where they are trained by professionals, who define their roles, demonstrate their required tasks and explain the risks of failure to play their roles – which some may argue has the potential for bias and manipulation. However, Harvey acknowledges that professionals have no formal authority to enforce compliance since service users are usually paying directly (or indirectly in the form of taxation) for them. In this text, we first examine the two key concepts of quality improvement and co-design/co-production separately to understand the trajectory of each concept and the current debates and applications. This will enable us to find the similarities, differences and potential areas for integration. In what follows, we briefly review the academic literature for each concept, which will inform the future research agenda we propose in the concluding chapter.

Outline of the Study The overall aim of this study is to examine how two concepts, co-­ production and quality improvement might be brought together to improve the design and delivery of healthcare services. Quality improvement in healthcare has embraced several models and frameworks. We have selected two of the most popular, Lean thinking (Womack and Jones 1996) and the Model for Improvement (Langley et al. 2009) on which to base our analysis. Similarly, for co-production, we have selected a conceptual co-production framework proposed by Batalden et al. (2016) and the Experience-based Co-design approach (Bate and Robert 2007) both of which are gaining traction in the sector. We examine the trajectory of QI and co-production both in terms of meaning and application. We recognise the two concepts have been developed in parallel rather than in tandem. Therefore we draw on empirical (UK-based) and published cases to illustrate application and opportunities for integration. Given our discussion around [public] service operations, quality improvement and co-production, we have theoretically framed our approach within the context of three different lenses: service operations; quality improvement and co-production (see Fig. 1.1). For the remainder of this text we use these lenses to contextualise our research and relevant

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[Public] Service Operations Management

Personcentred improvement

Quality Improvement

Co-production and Co-design

Fig. 1.1  Theoretical framework. (Source: Authors)

cases published by others. Given the holistic approach associated with these three lenses we see there are potential synergies that we will explore later within the text.

Key Definitions We present brief definitions to provide clarity around some of the key terms used within this text. In some cases, terms are used interchangeably and these are also explained below. • Operations Management (OM)  – is a set of activities that creates goods and services by transforming inputs (e.g. skills, materials, equipment, technology, customers) into outputs (products, benefits, intentions, emotions). OM activity focuses on improving ­product/ service performance, managing quality and delivery time, enhancing customer service and creating operational flexibility. • Service Operations Management – broadly entails providing services and value, to customers or [service] users, ensuring they get the right experiences and the desired outcomes. It involves understanding the

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needs of the customers, designing and managing the service processes, meeting the organisational objectives and continually improving the service operations and processes (Johnston et al. 2012, p. 17). • Quality improvement (QI) – a simple definition refers to a systematic and sustainable approach that uses specific techniques to improve quality. In terms of healthcare, “improving quality is about making healthcare safe, effective, patient-centred, timely, efficient and equitable” (The Health Foundation 2013). QI can be discussed in relation to specific approaches such as Lean and Six Sigma, which both originate from manufacturing, or with reference to models that have largely been associated with healthcare (e.g. Model for Improvement). Other terms such as process improvement, continuous improvement, improvement science, and improvement studies are used interchangeably with QI. • Co-design and Co-production – as will become evident within this text, are terms that are widely used and typically not well defined. As chapters are assigned specifically to help with the task of defining these concepts we start here with some simple definitions: Co-design: in healthcare involves the equal partnership of individuals who work within the system (healthcare staff) and individuals who have lived experience of using the system (patients and their families/carers) working together to (re) design a system/service making full use of each other’s knowledge, resources and contributions, to achieve better outcomes or improved efficiency (Bovaird and Loeffler 2012). Co-production: is based on the sharing of information and on shared decision making between the service users and providers (Bettencourt et  al. 2002; Realpe and Wallace 2010). It generally involves producing a product or service together and comes after the co-design phase (Vennick et al. 2016) and co-creation which usually refers to combining co-design and co-production together (Alsem et al. 2017). As we have prepared this text, we have noticed an array of terms for service user which are used interchangeably. When referring to published literature it is difficult to streamline this terminology as it varies depending on the academic discipline and perspective from which it is written. Given the healthcare context, where possible we aim to use patients as a proxy for customer, citizen, person and service user.

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Conclusion This chapter has provided an overview of service operations and the importance of quality improvement. We have introduced the concept of co-production, which has been popularised in healthcare both in terms of practice and research. We highlight the timely need to bring together these theoretical approaches to consider how this might work in practice. The desire to include patients and the public in the (re)design of healthcare services is growing. Hence, there is a need to assess how this motivation can be used effectively integrated with quality improvement.

Structure of the Publication The structure of this publication is as follows: Chap. 2 provides an overview of some of the key approaches to quality improvement and their application in healthcare. Chapter 3 introduces the concept of patient and public involvement and the growing interest around co-production in healthcare. Chapter 4 reports on the varying definitions used for co-­ production and the challenges around its use in practice. In Chap. 5, we review the more popular QI and co-production and co-design models and frameworks used in healthcare. In Chaps. 6 and 7 we use two empirical cases to review how QI and co-design and co-production approaches are employed and reflect on potential links between the two. Lessons learnt from these analyses are shared. Chapter 8 reviews examples of patient involvement in five QI related published cases. In the final chapter we consider the implications of this research for academics and practitioners, and we provide a future research agenda to that will help to promote and integrate the important role co-production can play in improving the quality of healthcare.

References Alsem, M., van Meeteren, K., Verhoef, M., Schmitz, M., Jongmans, J., Meily-­ Visser, M., & Ketelaar, M. (2017). Co-creation of a digital tool for the empowerment of parents of children with physical disabilities. Research Involvement and Engagement, 3, 26. https://doi.org/10.1186/s40900-017-0079-6. Baim-Lance, A., Tietz, D., Lever, H., Swart, M., & Agins, B. (2019). Everyday and unavoidable coproduction: Exploring patient participation in the delivery of healthcare services. Sociology of Health & Illness, 41(1), 128–142.

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Batalden, P. (2018). Getting more health from healthcare: Quality improvement must acknowledge patient co-production – An essay by Paul Batalden. BMJ, 362, K3617. Batalden, M., Batalden, P., Margolis, P., Seid, M., Armstrong, G., Opipari-Arrigan, L., & Hartung, H. (2016). Coproduction of healthcare service. BMJ Quality & Safety, 25, 509–517. Bate, P., & Robert, G. (2007). Bringing user experience to health care improvement: The concepts, methods and practices of experience-based co-design. Oxford: Radcliffe Publishing. Bettencourt, L., Ostrom, A., Brown, S., & Roundtree, R. (2002). Client coproduction in knowledge-intensive business services. California Management Review, 44, 100–128. Bovaird, T., & Loeffler, E. (2012). From engagement to co-production: How users and communities contribute to public services. In T.  Brandsen & V.  Pestoff (Eds.), New public governance, the third sector and co-production. London: Routledge. Brandeau, M., Sainfort, F., & Pierskalla, W. P. (Eds.). (2004). Operations research and health care. Boston: Kluwer Academic Publishers. Chase, R. B. (1981). The customer contact approach to services: Theoretical bases and practical extensions. Operations Research, 29(4), 698–706. Chase, R., & Tansik, D. (1983). The customer contact model for organization design. Management Science, 29(9), 1037–1050. Chase, R., Aquilano, N., & Jacobs, R. (1998). Operations management for competitive advantage. Boston: McGraw-Hill Irwin. Fuchs, V. (1968). The service economy. New  York: National Bureau of Economic Research. Fung, A. (2015). Putting the public back into governance: The challenges of citizen participation and its future. Public Administration Review, 75(4), 513–522. Fyrberg Yngfalk, A. (2013). ‘It’s not us, it’s them!’ – Rethinking value co-creation among multiple actors. Journal of Marketing Management, 29(9–10), 163–1181. Glushko, R. (2010). Severn contexts for service system design. In P. Maglio, et al., (Eds.), Handbook for service science: Research and innovations in the service economy (pp.  219–248). Available at http://sistemas-humano-computacionais. wdfiles.com/local%2D%2Dfiles/capitulo%3Asistemas-de-ser vico/ SevenContexts.pdf Glushko, R., & Tabas, L. (2009). Document engineering: Analysing and designing documents for business informatics and web services. Cambridge, MA: The MIT Press. Guven-Uslu, P., Chan, H., Ijaz, S., Bak, O., Whitlow, B., & Kumar, V. (2014). In-depth study of ‘decoupling point’ as a reference model: An application for health service supply chain. Production Planning & Control, 25(13–14), 1107–1117.

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Hardyman, W., Daunt, K., & Kitchener, M. (2015). Value co-creation through patient engagement in health care: A micro level approach and research agenda. Public Management Review, 17, 90–107. Harvey, J. (1990). Operations management in professional service organisations: A typology. International Journal of Operations & Production Management, 10(4), 5–15. Harvey, J. (1992). The operations management challenge in the delivery of complex human services. International Journal of Operations & Production Management, 12(4), 100–107. Harvey, J. (2016). Professional service supply chains. Journal of Operations Management, 42, 52–61. Johnston, R., & Kong, X. (2011). The customer experience: A road-map for improvement. Managing Service Quality, 21(1), 5–24. Johnston, R., Clark, G., & Shulver, M. (2012). Service operations management: Improving service delivery (4th ed.). Harlow: Pearson Education Ltd. Langley, G., Moen, R., Nolan, K., Nolan, T., Norman, C., & Provost, L. (2009). The improvement guide: A practical approach to enhancing organisational performance (2nd ed.). San Francisco: Jossey-Bass. McKone-Sweet, K. E., Hamilton, P., & Willis, S. B. (2005). The ailing healthcare supply chain: A prescription for change. Journal of Supply Chain Management, 41(1), 4–17. Meyer Goldstein, S., Johnston, R., Duffy, J., & Rao, J. (2002). The service concept: The missing link in service design research? Journal of Operations Management, 20(2), 121–134. Osborne, S., & Brown, L. (2011). Innovation, public policy and public services: The word that would be king? Public Administration, 89(4), 1335–1350. Osborne, S., Radnor, Z., Kinder, T., & Vidal, I. (2015). The SERVICE framework: A public-service-dominant approach to sustainable public services. British Journal of Management, 00, 1–15. https://doi.org/10.1111/1467-8551.12094. Ovretveit, J. (2005). Public service quality improvement. In E. Ferlie et al. (Eds.), The Oxford handbook of public management (pp.  51–71). Oxford: Oxford University Press. Radnor, Z., & Bateman, N. (2016). The role and substance of public service operations. In Z.  Radnor, Z.  Bateman, A.  Esain, M.  Kumar, S.  Williams, & D. Upton (Eds.), Public service operations management: A research handbook. Abingdon: Routledge. Radnor, Z., & Osborne, S. (2013). Lean: A failed theory for public services? Public Management Review, 15(2), 265–287. Radnor, Z., Osborne, S., Kinder, T., & Mutton, J. (2014). Operationalising co-­ production in public services delivery: The contribution of service blue-­ printing. Public Management Review, 16, 13–20.

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Realpe, A., & Wallace, L. (2010). What is co-production? London: The Health Foundation. Available at https://personcentredcare.health.org.uk/sites/ default/files/resources/what_is_co-production.pdf. Accessed 27 July 2019. Roth, A., & Menor, L. (2003). Insights into service operations management: A research agenda. Production and Operations Management, 12(2), 145–164. Sasser, W., Olsen, R., & Wyckoff, D. (1978). Management of service operations. Boston: Allyn and Bacon. Schmenner, R. (1986). How can service businesses survive and prosper? Sloan Management Review, 27(3), 21–32. Schmenner, R. (1995). Service operations management. Englewood Clifffs: Prentice Hall. The Health Foundation. (2013). Quality improvement made simple: What everyone should know about health care quality improvement. London: The Health Foundation. Vennick, F., van de Bovenkamp, H., Putters, K., & Crit, K. (2016). Co-production in healthcare: Rhetoric and practice. International Review of Administrative Sciences, 82(1), 150–168. Virtanen, P., & Stenvall, J. (2014). The evolution of public services from co-­ production to co-creation and beyond: New public management’s unfinished trajectory? The International Journal of Leadership in Public Services, 10(2), 91–107. Womack, J., & Jones, D. (1996). Lean thinking: Banish waste and create wealth in your corporation. New York: Simon Schuster.

CHAPTER 2

Quality Improvement in Healthcare: Where Are We Now and Where Next?

Abstract  We examine the emergence and degree of adoption of concepts associated with quality improvement in healthcare, much of which developed within other sectors of industry. At the same time, ideas of patient involvement and participation have gained ground, but it is noticeable that the two trajectories have emerged, developed and spread in parallel rather than together. Yet they have much in common and much to contribute to the wellbeing of service users. In this chapter we focus on the literature dating from emergence of ideas about improvement that appeared a decade ago but which have not maintained initial enthusiasm, We ask why this is the case and why the two trajectories have developed in parallel rather than in concert. Keywords  Quality improvement (QI) • Model for Improvement • Lean • Healthcare • Co-production

Introduction In this chapter, we draw on published works on quality improvement focusing on models and approaches in relation to their applicability to healthcare and where possible co-production. To try to capture the wider application and learning from QI our analysis of the key literature straddles management and healthcare related publications.

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Over the last two decades, we have seen a steady increase in the use of quality improvement techniques in healthcare (Burgess and Radnor 2012, 2013). Arguably, this has largely been in response to recognised performance issues, operational defects and attempts to improve patient outcomes. Many organisations have adapted and used methods from other industries such as Lean thinking (Womack and Jones 1996), along with frameworks modelled more for healthcare (e.g. The Model for Improvement developed by the Institute for Healthcare Improvement – Langley et al. 2009) for use in their local environments. Despite the widespread promotion of QI, the evidence that it produces positive changes and sustainable results in healthcare has been mixed (Dixon-Woods and Martin 2016). It is clear we still have much to learn particularly how we research, implement and sustain QI. To try to understand the mixed success of the implementation of QI in healthcare we draw on key messages from some of the published reviews on this topic. We then examine the literature to see how co-production has been linked with QI if at all. It is our belief that writings on these two important areas have developed separately and have largely remained discrete in their application. Yet, we believe there are key benefits that can be achieved if the approaches are integrated.

Quality Improvement in Healthcare: An Overview Quality improvement (QI) in healthcare can be defined as “the combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development learning)” (Batalden and Davidoff 2007, p. 2). Berwick (1989) states that real change can only be achieved by changing the system and by this he means the system can range from a large hospital to a small GP practice. To achieve change the system requires quality improvement to be an intrinsic part of everyone’s daily work (Batalden and Davidoff 2007). Since the early 2000s there has been a noticeable spread of awareness and use of QI across the healthcare sector, particularly in hospitals (Burgess and Radnor 2012, 2013) and more recently in primary care (Brennan et al. 2012, 2013). An early review of the literature found the key determinants for successful implementation of QI in healthcare were participa-

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tion of clinicians and a supporting organisational culture. The determinants that led to failure were described as clinical areas where implementation was problematic (e.g. COPD), disagreement with national guidelines on best practice and vague feedback (Shortell et al. 1998). Interestingly, the determinants of failure are mainly related to the infrastructure required to support QI rather than the approach itself (Grol et al. 2013). Another example that helps us to understand how the public sector has been improving its operations is a review of the literature focusing on the use of business process improvement methodologies (BPIM) in public services (Radnor 2010). This review examined what BPIM methodologies were being implemented in the public sector and what impact these were having and if these methodologies were being sustained. The results of the study found that 51% of publications focused on lean, 35% of these studies were associated with health services. The impact of BPIM was mixed depending on the level of implementation – with process and department level being more successful than organisational level. In terms of sustainability the need to move away from using BPIM as a short term fix to a long-term strategy where tools and techniques needed to be adapted rather than adopted to public services. Interestingly, at that time co-­production and co-design were not approaches that were prominent in BPIM. A more recent rapid narrative review of QI literature combined with an analysis of evaluation reports of [The Health Foundation] programmes identified ten key challenges to implementing and securing improvement in healthcare (Dixon-Woods et  al. 2012). The challenges cover three broad areas: (1) Design and planning of improvement programmes; (2) Organisational and institutional contexts and (3) sustainability and spread beyond the initial intervention period. The desire to limit healthcare improvement to tools and techniques has been one of the main criticisms of quality improvement endeavours. We have seen a considerable growth in the use of process mapping, check lists, trigger tools, run charts, and driver diagrams which have produced some effective change. However, to isolate training and education to these areas without considering the environmental and social context within which healthcare is delivered may be limiting ambition and desire for whole system and sustainable change.

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Implementing Lean Thinking in Healthcare It is estimated Lean thinking was first introduced to Healthcare in the early 2000s (2001 in the UK and 2002 in the USA – Radnor and Osborne 2013). Since then, Lean has become one of the most prominent approaches in reforming healthcare services. This popularity is confirmed by Brandao de Souza’s (2009) review of 90 academic writings in ten different countries. In 2015 this had increased to 243 articles (D’Andreamatteoa et al. 2015) and the analysis showed Lean is mostly seen as a means to increase productivity, with acute settings (hospitals) being the most prominent in the literature. The theoretical focus has been mainly on barriers, challenges and success factors. Sustainability, measurement and critical appraisal, along with system wide studies were underrepresented. No reference was made to patient involvement or co-production within this review. The key focus was on patient safety and patient satisfaction. Typically Lean has been embraced as a ‘one-size-fits-all’ solution and rarely considered within the context of how it might integrate with other approaches and methods used to improve healthcare. A recent conceptual study illustrates how Lean might be linked with integrated care pathways (Williams and Radnor 2018). Several steps within this new model refer to engaging with patients and staff. So far, no empirical studies have been reported on how this might work in practice. Holden et  al.’s (2015) study conducted in three Swedish hospitals examined two important areas: first the role of context and how it shapes Lean and second healthcare workers’ perceptions of Lean methodologies. Their mixed methods study reported perceptions of Lean varied according to hospital context, unit acuteness and professional role. They called for the field to move beyond confirming the success of Lean implementation to explaining, predicting and replicating success. In other words for studies to go beyond saying it was successful to explaining how and why it worked, lessons learned and what can be transferred elsewhere. They recommended this required careful theory building, hypothesis testing and attention to both patient and worker outcomes. Evidence that these recommendations have been put in place is limited, despite several calls for the development of programme theory (Davidoff et al. 2014; Reed et al. 2014). A more recent systematic review of lean interventions conducted by Moraros et al. (2016) identified 22 articles. The study found that Lean interventions have no statistically significant association with patient satisfaction and health outcomes, a negative association with financial costs

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and worker satisfaction and inconsistent benefits on process outcomes like patient flow and safety. No reference was made to patient engagement or co-production or co-design.

What Does the Literature Tell us? In the light of recent reviews of QI in healthcare, one might judge that Lean thinking remains a popular approach to improving health services. Interestingly, Woodnutt’s (2018) review, assessing whether Lean is sustainable in today’s NHS hospitals, notes there are divergent methods of defining and implementing Lean across the studies reviewed. The most prominent method employed was value stream/process-mapping. He emphasises the difficulties associated with defining value in healthcare – which is the first and key principle in Lean thinking. Woodnutt believes ambiguity in definition and implementation has hampered a system-wide approach to Lean being adopted by the NHS.  Looking wider than Woodnutt’s study one might argue that these ambiguities are not confined specifically to Lean thinking – other approaches lifted and used from elsewhere (e.g. Six Sigma, Theory of Constraints, Total Quality Management) – whether theoretical, or practical from other sectors – tend to be understood superficially and therefore likely to fail. Woodnutt’s (2018) mapping of the literature over a timeline indicates an evolution from pragmatic (quasi-scientific and experiential) research to more academic and scientific designs. But he highlights robust methodological studies are limited. The call for better-designed improvement studies in healthcare also comes from Dixon-woods and Martin (2016). They identify key challenges as fidelity in the application of QI methods is mixed, projects are often small-scale and time limited, little attention paid to evaluation and sharing of successes and failures. McIntosh et al.’s (2014) review of over 100 articles associated with Lean and other business process improvement methods in healthcare highlights the challenges of introducing concepts from manufacturing to healthcare. They argue that a cultural change unheralded in the NHS’s history is required, supported by key enablers such as capable leadership, behaviour monitoring and stakeholder engagement. It is unclear as to whether patients and relatives are included in this engagement activity and when and for what reason engagement would occur. Reference is made to the difficulties in defining value in services because staff deliver important intangible benefits (e.g. trust) alongside the tangible benefits (improved health).

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Quality Improvement and Co-production To help us understand how much has already been published focusing on quality improvement and co-production as a shared activity we undertook a scoping review of the literature. Key management and healthcare databases (e.g. CINAHL, Medline, Scopus) were used. Search terms included Review, Quality Improvement, Co-production (Coproduction), Co-design (Codesign), Participatory design, Experience based design, Co-creation. Our search revealed very few literature review papers. One such paper by Kohler et al. (2017) reviewed close to 30 articles. Using a literature review and a jurisdictional scan the team found that despite the importance of patient engagement it was unclear how it was measured or indeed if it improves health outcomes for patients and families. Gallican et al.’s (2012) scoping review identified 15 different terms with which to refer to patient engagement, including participation, involvement, patient centred care, consumer engagement, and public engagement. Co-production and co-design were not included in these definitions and terminology. Expanding our search terms to include patient involvement uncovered a realist literature review which examined how patient involvement works in healthcare quality improvement (Bergerum et al. 2019). The authors classified the 18 papers included in the review according to the patient involvement approach used  – co-design (n  =  10); patient engagement (n = 4); co-production (n = 2) co-creation (n = 1); patient-centred care (n = 1). Three theories are provided to support active patient involvement in QI efforts are: • Tailoring patient involvement to each QI effort may result in interaction and partnership within the system/area of improvement • Supporting interactions and partnerships within the area of improvement may result in behavioural change • Supporting the behavioural change that results for the QI effort by involving patients at all level of the organisation. Tailoring patient involvement to each QI effort may result in interaction and partnership within the system/area of improvement. The authors acknowledge the impact of patient involvement in quality improvement is poorly understood both in practice and theory and therefore call for empirical studies to test their proposed theories. Other articles

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from our review are discussed in chapter eight where we use five published cases to examine how patients have been involved in quality improvement. Writings have shown that there is a general lack of consensus and understanding about terminology (Bergerum et al. 2019). Unclear goals and expectations and roles and responsibilities of stakeholders are major barriers to achieving meaningful and successful patient engagement. Unsurprisingly, healthcare systems continue to struggle with a tokenistic approach when engaging patients and families (Ocloo and Matthews 2016). Kohler et  al. (2017) argue that until healthcare organisations and systems are able to create a safe place where the voices of patients and families are valued, we will never properly engage patients and families. Much of this discussion is around ensuring patients and their family members become more involved in decisions about their care, rather than the (re)design of services and/or quality improvement programmes. Co-production and improvement rarely feature within the same paper or search criteria, and given the results of our search, it would seem that there is limited attempt to link the two concepts. Reflecting on the use of co-production within quality improvement programmes seems obvious given the narrative around understanding value and the needs of patients and more broadly citizens/communities. Yet, you would surmise that efforts to engage and involve patients in decisions around the design and delivery of their care is somewhat overdue given that quality improvement has been around in healthcare for the past two decades. Traditionally QI has been largely based on perspectives from staff. Given the move towards co-production being placed at the heart of a quality healthcare system in that it needs to be co-produced by patients, families and healthcare professionals, who work interdependently to co-­ create and co-deliver care (Sabadosa and Batalden, 2014), one would expect to see more examples of patient involvement in QI activity.

Conclusion We have examined the emergence and degree of adoption of the concepts associated with quality improvement in healthcare, much of which developed within other sectors of industry. Awareness of QI methodology across the healthcare sector can be traced back at least a decade and early enthusiasm resulted in many initiatives to trial and embed Lean ideas and practices at workplace levels. For a number of reasons early energy has not been sustained. This may be a result of unique pressures in healthcare but

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equally it may be the result of lack of significant research and evolution within the field. The literature tells us that confusion and uncertainty inhibits adoption of many sound new practices, but that generalisability is hampered primarily by lack of clear measures of success. At the same time, ideas of patient involvement and participation have gained ground, but it is noticeable that the two trajectories have emerged, developed and spread in parallel rather than together. Yet they have much in common and much to contribute to the wellbeing of service users. Questions that we suggest from examination of both methodological approaches include . Why is sustainability of improvement so difficult to achieve? 1 2. Who’s voice is heard at the point of change in design/delivery? 3. Is it the ideas or the vocabulary used that prevents collaboration? 4. Is it possible to establish stronger links between QI and Co-­production to enable (where appropriate) person-centred improvement?

References Batalden, P., & Davidoff, F. (2007). What is “quality improvement” and how can it transform healthcare? Quality and Safety in Health Care, 16(1), 2–3. Bergerum, C., Thor, J., Josefsson, K., & Wolmesjo, M. (2019). How might patient involvement in healthcare quality improvement efforts work – A realistic literature review. Health Expectations. https://doi.org/10.1111/hex.12900. Berwick, D. (1989). Continuous improvement as an ideal in health care. New England Journal of Medicine, 320, 53–56. Brandao de Souza, L. (2009). Trends and approaches in lean healthcare. Leadership in Health Services, 22(2), 121–139. Brennan, S., Bosch, M., Buchan, H., & Green, S. (2012). Measuring organisational and individual factors thought to influence the success of quality improvement in primary care@ a systematic review of instruments. Implementation Science, 7, 121. Brennan, S., Bosch, M., Buchan, H., & Green, S. (2013). Measuring team factors thought to influence the success of quality improvement in primary care@ a systematic review of instruments. Implementation Science, 8, 20. Burgess, N., & Radnor, Z. (2012). Service improvement in the English National Health Service: Complexities and tensions. Journal of Management and Organisation, 18(5), 594–607.

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Burgess, N., & Radnor, Z. (2013). Evaluating lean in healthcare. International Journal of Health Care Quality Assurance, 26(3), 220–235. D’Andreamatteoa, A., FedericoLegab, L., & Sargiacomoa, M. (2015). Lean in healthcare: A comprehensive review. Health Policy, 119, 1197–1209. Davidoff, F., Dixon-Woods, M., Leviton, L., & Michie, S. (2014). Demystifying theory and its use in improvement. BMJ Quality and Safety, 24(3), 228–238. Dixon-Woods, M., & Martin, G. (2016). Does quality improvement improve quality? Future Hospital Journal, 3(3), 191–194. Dixon-Woods, M., McNichol, S., & Martin, G. (2012). Ten challenges in improving quality in healthcare: Lessons from the Health Foundation’s programme evaluations and relevant literature. BMJ Quality and Safety, 21, 876–884. Gallican, J., Burns, K., Bellows, M., & Eigenseher, C. (2012). The many faces of patient engagement. Society for Participatory Medicine, 26(4), 32. Grol, R., Wensing, M., Bosch, M., Hulscher, M., & Eccles, M. (2013). Theories on implementation of change in healthcare. In R. Chapter in Grol, M. Wensing, M. Eccles, & D. Davis (Eds.), Improving patient care: The implementation of change in health care (2nd ed.). Chichester: Wiley. Holden, R., Eriksson, A., Andreasson, J., Williamsson, A., & Dellve, L. (2015). Healthcare workers’ perceptions of lean: A context-sensitive, mixed methods study in three Swedish hospitals. Applied Ergonomics, 47, 181–192. Kohler, G., Sampalli, T., Ryer, A., Porter, J., Wood, L., Bedford, L., et al. (2017). Bringing value-based perspectives to care: Including patient and family members in decision-making processes. International Journal of Health Policy and Management, 6(11), 661–668. Langley, G., Moen, R., Nolan, K., Nolan, T., Norman, C., & Provost, L. (2009). The improvement guide: A practical approach to enhancing organisational performance (2nd ed.). San Francisco: Jossey-Bass. McIntosh, B., Sheppy, B., & Cohen, I. (2014). Illusion or delusion – Lean management in the health sector. International Journal of Health Care Quality Assurance, 27(6), 482–492. Moraros, J., Lemstra, M., & Nwankwo, C. (2016). Lean interventions in healthcare: Do they actually work? A systematic literature review. International Journal of Quality in Health Care, 28(2), 150–165. Ocloo, J., & Matthews, R. (2016). From tokenism to empowerment: Progressing patient and public involvement in healthcare improvement. BMJ Quality and Safety, 2, 626–632. Radnor, Z. (2010). Review of business process improvement methodologies in public services. London: Advanced Institute of Management Research. Radnor, Z., & Osborne, S. (2013). Lean: A failed theory for public services? Public Management Review, 15(2), 265–287.

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Reed, J., McNicholas, C., Woodcock, T., Issen, L., & Bell, D. (2014). Designing quality improvement initiatives: The action effect method, a structured approach to identifying and articulating programme theory. BMJ Quality and Safety, 23, 1040–1048. Sabadosa, K., & Batalden, P. (2014). The interdependent roles of patients, families and professionals in cystic fibrosis: A system for the co-production of healthcare and its improvement. BMJ Quality and Safety, 23, i90–i94. Shortell, S., Bennett, C., & Byrk, G. (1998). Assessing the impact of continuous quality improvement on clinical practice: What it will take to accelerate progress. Milbank Quarterly, 76, 593–624. Williams, S., & Radnor, Z. (2018). An integrative approach to improving patient care pathways. International Journal of Health Care Quality Assurance, 31(7), 810–821. Womack, J., & Jones, D. (1996). Lean thinking: Banish waste and create wealth in your corporation. New York: Simon and Schuster. Woodnutt, S. (2018). Is lean sustainable in today’s NHS hospitals? A systematic literature review using the meta-narrative and integrative methods. International Journal for Quality in Health Care, 30(8), 578–586. https://doi.org/10.1093/ intqhc/mzy070.

CHAPTER 3

Citizen Involvement: What Does It Mean?

Abstract  In this chapter we address issues around patient and service user involvement asking why it has become best practice to widen the body of those involved with the design and delivery of healthcare. In particular, we reflect on the manner in which the individual seems to have taken precedence over the community, and why this has led to the growth of citizen involvement in the management of health and well-being. We recognise that organisations have a role to play in facilitating citizen involvement. We suggest that there are challenges in taking this approach as well as opportunity costs, and we query whether the benefits outweigh these costs. Keywords  Person-centred • Citizen-centred • Co-production • Patient and Public Involvement (PPI) • Healthcare • Citizen Science • Shared decision-making • Human factors

Introduction In this chapter, we highlight the general confusion surrounding the term “co-production”. We address the rhetoric around person-centred and citizen-centred services and patient/citizen involvement. We critique the trajectory of the literature from what seems to have started with patient-­ centred care (mental health services) and has progressed to a wider application of public service involvement, where the term co-production is © The Author(s) 2020 S. J. Williams, L. Caley, Improving Healthcare Services, https://doi.org/10.1007/978-3-030-36498-4_3

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freely used within the rhetoric of mainstream management (Clarke et al. 2017). We draw from the literature associated with co-production in the public sector and healthcare more specifically in relation to quality improvement.

Person-Centred Care The interest in person-centred care (also referred to as patient-directed, person-focused, user-centred, patient-centred) (which is different to co-­ production) has gathered momentum, particularly in relation to quality improvement and the design of healthcare services. Person-centred care can be defined as a way of improving healthcare safety, quality and coordination and is assumed to expand and shift a traditional healthcare model from one which the healthcare professional or other provider holds the primary decision-making role to one that supports individual (service user) choice and autonomy in healthcare decisions. In the UK, the NHS’s Five Year Forward View (NHS England 2014) included personalised care as part of the plans to develop new models of service delivery. Person-­ centred care focuses on enabling people to live healthier lives through prevention, empowerment, shared decision-making and self-management support (Mullen 2017). Person-centred care is not about a specific role or situation or seniority. It requires the right skills in the right place to enable effective and impactful conversations between practitioners and service users, wherever the interaction takes place. The complexity lies in practitioners of all levels being able to combine many behaviours, decisions and interactions between communities, organisations, colleagues, people, families and carers (Mullen 2017). The Skills for Health, Health Education England and Skills for Care’s Framework (2017) was developed to promote and support person-­centred approaches for the health and social care workforce. The Framework encourages shared decision making where all possible options are outlined and information is personalised, accessible and useful.

Patient and Public Involvement (PPI) Patient and Public involvement (PPI) has become a widely used term in healthcare and mainly refers to professionals and the public working together as equal partners, to ensure high quality research and service

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provision (Harries et al. 2019). Often PPI is also referred to as service user and carer involvement (Pandya-Wood et  al. 2019). It was the World Health Organization declaration of Alma-Ata of 1978, which stated that ‘people have the rights and the duty to participate individually and collectively in their health care’ (World Health Organization 1978, p. 1) which led to the involvement of people in health issues. In the United Kingdom (UK), the principle of PPI is embedded within the National Health Service (NHS). For example, the latest version of the Handbook to the UK NHS Constitution (Department of Health 2019, p.  16) stresses that “the patient will be at the heart of everything the NHS does”. PPI is not limited to the design and delivery of healthcare; involvement has been extended to health services research in the UK. The Department of Health in England has made PPI a fundamental part of its research strategy since it set up the NHS Research and Development Programme in 1992. In 1996, the National Institute for Health Research (NIHR) introduced INVOLVE, the national advisory group funded to support active public involvement in the NHS, public health and social care research (INVOLVE 2012). They define patient and public involvement in research as ‘research being carried out with or by members of the public rather than to, about or for them’ (INVOLVE 2019). They have also recently published guidance on how to co-produce research (INVOLVE 2018). Organisations are instrumental in fostering a culture that enables and supports PPI. A recent study by Renedo et al. (2015) identified four key elements of organisational culture that can facilitate PPI. 1. Non-hierarchical, multi-disciplinary collaboration between and among healthcare professionals and patients. 2. Ability to recognise desired improvement and to show mutual recognition and respect for all stakeholders 3. Commitment to rapid improvement 4. Commitment to continuous improvement and to act on learning.

Citizen Science In the mid-1990s, the term citizen science was coined by Bonney (in the US) and Urwin (in the UK) (Riesch and Potter 2013). There are several definitions and approaches associated with citizen science. For example, scientists and scientific institutions might take a “top-down” initiative to

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engage members of the public in education to increase awareness and enthusiasm for science. Another example is enlisting volunteers in the collection and reporting of data on factors in their surrounding environments. This latter example contributes empirical observations for analysis by professional researchers. Under this interpretation, citizen science projects have included bird migration patterns, ecological trends and the identification of food security factors (Gura 2013). This “top-down” approach is located in the public engagement category. By contrast, a “bottom up” approach to citizen science is more policy directed and fits the public involvement category (Irwin 2015). Community-based urban planning and environmental science projects would fit this category. Such projects are responsive to the needs of the community and typically involve lay people in the conduct and governance of the research. In some circumstances, lay people have used ‘crowdfunding’ and other techniques to conduct their own research projects outside of the traditional science community altogether (Woolley et al. 2016). There is a growing interest in the use of citizen science in healthcare. Recently the THIS Institute published a useful report entitled “citizen science: crowdfunding for research” (Lichten et  al. 2018). It provides examples of how crowdfunding is employed in scientific research along with the benefits and challenges of doing so. Den Broeder et al. (2018) provide a review of how citizen science may be used within the arena of public health. Although the challenges are recognised by the authors they argue that Citizen Science or similar approaches such as participatory action research and ‘popular epidemiology’ may yield better knowledge, empowered communities, and improved community health. A conceptual framework to enable evaluation of Citizen Science in practice is provided, which includes a typology of different types of Citizen Science and a causal framework that shows how Citizen Science in public health might benefit both the knowledge produced as well as the ‘Citizen Scientists’ as active participants. (Den Broeder et al. 2018).

What Is Co-production? Not infrequently the word co-production is used without a transparent definition of what is meant by the term. Osborne et al. (2016) start from the premise that co-production is a ‘woolly word’, which often leads to the term being misused or misunderstood and then runs the risk of it becoming denuded of meaning (Clarke et al. 2017).

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Such ambiguity leads us to questions such as – does co-production have to involve a patient? And how superficial can the involvement of the patient be? For example, does a survey to garner patient voices constitute co-production? If a team from one ward meets and develops a new methodology for a technique from which they both benefit, is this co-­ production? If members of one specialist team co-operate with members of another specialist team, is this co-production? Does co-production necessarily involve shared activity, or can it involve just opinion gathering? What follows is a number of scenarios; the question is – how many of these rather common situations constitute co-production? 1. A clinical team wish to make physical changes to the layout of their clinic in the expectation that this will improve the patient experience. They invite one of a number of the Trust’s Patient Representatives to join their planning meetings and provide his/her views on planned changes. 2. Another team believe that there are better ways of informing patients than those currently in use. They undertake a survey of regular users to check whether their understanding of patient confusion is correct. 3. A clinical team wish to make changes to the way that patients are informed of their options when it comes to treatment for a long term condition. They invite one of their longest standing patients with the particular condition to join their steering group which is tasked with agreeing the form and manner in which patients are informed. 4. A long standing contract for provision of a peripheral service is due for renewal and there are a number of potential providers in the frame. A group of staff and patients are convened and tasked with writing the new contract’s terms and conditions; selection of the team members is made from those who are most likely to use the service  – staff and patients  – and is made by senior managers at the Trust. 5. It has long been recognised that waiting lists for an OPD clinic are lengthy requiring many patients to wait inordinately for appointments. It is assumed that a more efficient system can be devised and so a group of staff request permission to undertake a small improvement project to identify causes and make suggestions for improvements. A small group of regular users of the service are invited to join the improvement team.

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6. A new digital technology has been introduced in one area of the Trust and has been operating for a year; informally the results are seen as patchy. Senior managers have to decide whether to continue to roll out the technology across the Trust and have charged a small group, including some users, with reviewing, reporting, and making recommendations for next steps. 7. A new hospital is planned with a 5 year development schedule; it will radically alter the way that healthcare is delivered in the region. Architects and planners wish to ensure that there is sufficient patient involvement in planning so they advertise locally for volunteers to join a focus group scheduled to meet regularly to comment on plans as they evolve. 8. There has been an increase in the number of near misses on a ward for the elderly and concern has been raised by a small group of relatives about standards of safety. Managers wish to reassure relatives and they invite representatives to join clinical meetings on a regular basis where such issues are discussed. If, as might be argued, all of these examples model service user involvement and thus PPI, this begs questions about balance, power and motivation. There are opportunity costs involved in listening to, and incorporating, service user perspectives in planned changes, whether that be at the design or the delivery phase, and this requires that the benefits outweigh the costs. But whose benefit counts most?

Co-production from the Perspective of the Citizen Repeatedly calls have been made to engage and involve patients and the public in their healthcare and particularly for them to be central to these discussions (Ocloo and Matthews 2016). Patient and Public Involvement (PPI) is now a key part of healthcare reforms across Western economies (Tritter 2009; Wait and Nolte 2006), with claims that patients and the public can make important contributions to most stages of healthcare planning and delivery (Coulter and Ellins 2006). Before the turn of this century, many of the ethical principles followed in medical practice reflected a paternalistic approach to healthcare and its delivery. The traditional practice of medicine involved the patient seeing

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the doctor; the doctor telling the patient what to do, and the patient complying (more or less!). There was little public knowledge of medicine and medical science, and a patient’s respect for doctors was based – in part at least  – on the fact that they were, literally, placing their life in the doctor’s hands. There was blind trust and faith in the doctor’s greater knowledge and ability, and much of professional ethics was designed to underpin the massive responsibility that fell on the shoulders of doctors and other healthcare professionals as a result. We have since seen a dramatic shift towards the existence of a more informed, articulate, and questioning public, who have greater rights and remedies. They rightly expect to be informed and involved in decisions, which affect them, and it is this mutual respect for the rights and opinions of the other that has shifted the balance of professional ethics – in some respects at least – in recent years. In the context of the movement towards co-production, we have to ask why this change has arisen and if the resultant altered relationship between clinician and citizen is wholly beneficial for both sides. Vennick et  al. (2016, p.  157) define co-production as “introducing user-generated knowledge in public service delivery by involving individual citizens and groups”. This definition does not explore which citizens are involved and it begs questions about the choice of participant(s) given how crucial to success the outlook, knowledge and attitude of the citizen participant will be. It does not question the role of the participant and the extent to which all parties (citizens and professionals) are equal partners. There is likely to be a gap between rhetoric and reality, for example the capacity of citizens to both speak up and to give informed views, with a tendency to default to easy choices. Potential challenges include inter alia: • Not everybody will join in and there will be diversity of commitment • The group may take a direction not welcomed by professionals bringing into focus issues of power and responsibility • The pendulum of power can swing (perhaps) too far between professional and citizen • The model challenges standardisation which is the cornerstone of efficient delivery of healthcare

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• There is likely to be a resistant healthcare culture deeply embedded that will defy attempts to change All of these issues will be explored in following chapters. From the professional perspective, Nutbrown et al. (2015) draw attention to questions about why service and/or professionals would invest time and energy in coproduction, given that the practice is undoubtedly time consuming, the opportunity costs are high, and the outcomes unpredictable. Early work on coproduction in the US in the field of town planning and reported by Arnstein (quoted in Nutbrown et  al. 2015) asked what professionals were aiming to achieve. A number of covert outcomes were perceived including manipulation (of public perceptions); therapy (coating the pill of change); placating (quietening angry voices); delegating (sharing any potential blame); partnership (“we’re all in this together”).

Why Is Co-production Becoming Dominant? Why has the paternalistic medical model been side-lined and why is it now considered important for the patient/citizen voice to be heard? Why do professionals deem it worth the time and effort to invest in working alongside recipients of healthcare to design, co-ordinate and deliver safe and effective care? We should first acknowledge the way that society has changed and the manner in which individuals now believe that they can and should control and manage their own destiny, be that healthcare or personal data. Since the 1980s there has been a shift away from a model of community and hierarchy into that of individual choice and life development, with fracturing along gender, family and community lines. The individual has become the central unit of social life, meaning that an individual’s identity is becoming less bound by collective identity (i.e. social norms and values), and that individuals no longer see their fate as being directly shared with other group members. Instead, individuals are increasingly defining their life as a reflexive or self-steered phenomenon. Individualisation theorists have linked individualisation with modernization, globalization and capitalism. All of this mirrors the needs and voice of the individual in decision-­ making and thus the growth of patient participation and the choice theories that have underpinned policymaking in the last decade.

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Shared Decision-Making Shared decision-making encourages people to take personal responsibility for their health status. Studies link increased patient involvement to improved treatment adherence, disease coping, and quality of life, whereas lack of patient involvement correlates with lower adherence to treatment, patient satisfaction, and health outcomes (Drolet and White 2012). The advantages of shared decision making are clear: maximizing the likelihood that both patient and clinician will be respected, satisfied, and invested in the outcome. The concept of shared decisions is premised on an assumption of equality which might be challenged. Weber (1964) defined power as being: “the ability of an individual or group to achieve their own goals or aims when others are trying to prevent them from realising them”. Arguably then, the approach of sharing information, knowledge and goals should enhance the outcome for all parties. But the reality is that equality is not always present in such social situations, and an approximation can only be achieved if all parties recognise and work towards this goal. Success or otherwise is difficult to measure.

Human Factors We have seen changes in demography (we are living longer) and also in wellbeing brought about by life-style changes and by technology-driven innovation in treatments. Although there is some way to go, we have conquered many of the life-threatening diseases that shortened the lives of previous generations. The result is that more people are living longer and are managing long term conditions, sometimes for decades. Inevitably they become expert in the physiology and the management of their condition. They have a unique perspective in that they witness the entire patient journey. It seems only sensible to encourage their view to be heard. The value of human centred design in healthcare becomes increasingly clear as demographics and developments in treating diseases and conditions makes it possible for extended lifespans and changed focus to the management of ill health rather than curative models. Human focused design extends not just to the manner in which healthcare devices are imagined but also to who the likely first user will be and how this might shape diagnosis.

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At the same time, the idea of community is dormant if not dead, but in a modified form reflecting the concept of shared understanding. Theories propounded by Dewey (1969) on learning from each other; by Vygotsky (1978) on proximity and the value to be gained from experience; and Polanyi (1967) on tacit (hidden) knowledge all play into the move towards involving citizens in the design and delivery of safe healthcare. The work of Wenger (1998) draws from early models of apprenticeship whereby the master and apprentice were in close communication 24/7 and development was holistic – the master learned from the experience of the apprentice as well as vice versa. Flat hierarchies, shared voices and shared responsibilities; all for the greater good.

Citizens, Expectations, Rights and Responsibilities The manner in which we conduct our daily lives, our expectations of that life – length, wellness, opportunities – is reflected in the extent to which we, the citizen, are prepared and equipped to become actively involved in our own healthcare. As technology enables early diagnosis and cure of the majority of life threatening conditions, at the same time it allows us to monitor and influence our own health trajectory. There is an expectation that we will proactively manage our own health, which brings with it a concomitant expectation that PPI will be the norm. No longer are we passive recipients of professional services; we need to be active contributors to the service from which we and others benefit.

Conclusion It has become accepted that the modern way of managing healthcare is to involve the individual and that this leads to better outcomes for both the patient and for the clinical professionals trying to maximise efficiency and effectiveness. However, this approach belies a number of assumptions that have been given limited if any testing. It assumes that the time and energy required to involve citizens will be outweighed by the benefits. It assumes that issues of power and hierarchy can be managed, and it assumes that the motives of all participants are overt and positive. Despite the increasing rhetoric and support for patient involvement in healthcare, improvements to practice remain slow and variable (Ward et al. 2011; Ward and Armitage 2012; Ocloo and Fulop 2012;

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Hor et  al. 2013). According to Beresford (2013) and Ocloo and Matthews (2016) the key barriers to patient involvement can be summarised as: • Not valuing or listening to what people say • Asking for involvement but not taking it seriously or enabling it to be effective • Discouraging involvement on bases of identity • Making people believe they do not have much to contribute • Lack of information about getting involved • Gatekeepers/individuals who block involvement • Not paying people for their involvement Similarly, the key enablers to patient involvement can be summarised as (Beresford 2013; Ocloo and Matthews 2016): • People are able to access organisations and their decision-making structures to enable their involvement • Offer support to build confidence and skills for meaningful involvement • Reach out to those traditionally identified as ‘hard to reach’ groups • Develop innovative ways to encourage involvement  – including enjoyable supportive and safe environments • Use tools to support patient empowerment – shared decision making, expert patient programmes, person budgets • Good practice regarding health literacy In relation to patient involvement and the wider co-production agenda there are a number of challenges to be addressed and these will form the basis of following chapters. Questions to be addressed: . Whose voice gets heard – how are participants selected? 1 2. How much influence does each participant (citizen/profes sional) have? 3. What is the motive of each participant? 4. How do you reconcile cultural barriers to change?

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References Beresford, P. (2013). Beyond the usual suspects. London: Shaping Our Lives. Clarke, D., Jones, F., Harris, R., & Robert, G. (2017). What outcomes are associated with developing and implementing co-produced interventions in acute healthcare settings? A rapid evidence synthesis. BMJ Open, 7, e014650. Coulter, A., & Ellins, J. (2006). Patient focused interventions: A review of the evidence. London: The Health Foundation. Den Broeder, L., Van Oers, H., Schuit, A., & Wagemakers, A. (2018). Citizen science for public health. Health Promotion International, 33, 505–514. Department of Health. (2019). The NHS Constitution 2019. Available at: https:// assets.publishing.service.gov.uk/government/uploads/system/uploads/ attachment_data/file/770675/The_Handbook_to_the_NHS_ Constitution_-_2019.pdf. Accessed 18 Jan 2019. Dewey, J. (1969). Experience and education. London: Collier-Macmillan. Drolet, B.  C., & White, C.  L. (2012). Selective Paternalism. AMA Journal of Ethics, 84(3), 582–588. Gura, T. (2013). Citizen science: Amateur experts. Nature, 496(744), 259–261. Harries, P., Barron, D., & Ballinger, C. (2019). Developments in public involvement and co-production in research: Embracing our values and those of our service users and carers. British Journal of Occupational Therapy, First Published May 27, 2019 Editorial. Available at: https://doi.org/10.1177/0308022619844143. Accessed 28 July 2019. Health Education England, Skills for Health, Skills for Care. (2017). New framework to promote person-centred approaches in healthcare. Available at http:// tinyurl.com/y89gvzzr. Accessed 5 Aug 2019. Hor, S., Godbold, N., Collier, A., & Iedema, I. (2013). Finding the patient in safety. Health (London, England), 17(6), 567–583. INVOLVE. (2012). Briefing notes for researchers: Public involvement in NHS, public health and social care research. Available at: www.invo.org.uk/wp-content/ uploads/2014/11/9938_INVOLVE_Briefing_Notes_WEB.pdf. Accessed 17 July 2019. INVOLVE. (2018). Guidance on co-producing a research project. Available at: www.invo.org.uk/wp-content/uploads/2018/03/Copro_Guidance_Mar18. pdf. Accessed 17 July 2019. INVOLVE. (2019). Welcome to INVOLVE. Available at: www.invo.org.uk/. Accessed 19 July 2019. Irwin, A. (2015). Science, public engagement. In J. Wright (Ed.), International encyclopedia of the social and behavioural sciences (pp. 255–260). Oxford: Elsevier. Lichten, C., Ioppolo, R.  D., Angelo, C., Simmons, R., & Morgan Jones, M. (2018). Citizen science: Crowdsourcing for research. Cambridge: The Health Improvement Studies Institute. Available at https://www.thisinstitute.cam.

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ac.uk/wp-content/uploads/2018/05/THIS-Institute-Crowdsourcing-forresearch-978-1-9996539-0-3.pdf. Accessed 5 Aug 2019. Mullen, C. (2017). Person-centred care – A 2017 framework. British Journal of Healthcare Assistants, 11(12), 597–601. NHS England. (2014). NHS five year forward view. Available at www.england. nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf. Accessed 5 Aug 2019. Nutbrown, C., Bishop, J., & Wheeler, H. (2015). Co-production of family literacy projects to enhance early literary development. Journal of Children’s Services, 10(3), 265–279. Ocloo, J., & Fulop, N. (2012). Developing a critical approach to patient and public involvement in patient safety in the NHS: Learning lessons from other parts of the public sector? Health Expectations, 15(4), 424–432. Ocloo, J., & Matthews, R. (2016). From tokenism to empowerment: Progressing patient and public involvement in healthcare improvement. BMJ Quality and Safety, 2, 626–632. Osborne, S., Radnor, Z., & Strokosch, K. (2016). Co-production and the co-­ creation of value in public services: A suitable case for treatment? Public Management Review, 18, 639–653. Pandya-Wood, R., Elliott, J., & Barron, D. S. (2019). Service user and lay involvement in healthcare. In C. Llewellyn (Ed.), Cambridge handbook of psychology, health and medicine (3rd ed., pp.  347–352). Cambridge: Cambridge University Press. Polanyi, M. (1967). The tacit dimension. London: Tavistock. Renedo, A., Marston, C., Spyridonidis, D., & Barlow, J. (2015). Patient and public involvement in healthcare quality improvement: How organisations can help patients and professionals to collaborative. Public Management Review, 17(1), 17–34. Riesch, H., & Potter, C. (2013). Citizen science as seen by scientists: Methodological, epistemological and ethical dimensions. Public Understanding Science, 23(1), 107–120. Tritter, J. (2009). Revolution or evolution: The challenges of conceptualising patient and public involvement in a consumerist world. Health Expectations, 12, 275–287. Vennick, F., van de Bovenkamp, H., Putters, K., & Crit, K. (2016). Co-production in healthcare: Rhetoric and practice. International Review of Administrative Sciences, 82(1), 150–168. Vygotsky, L. (1978). Mind in society. Cambridge, MA: Harvard Business Press. Wait, S., & Nolte, E. (2006). Public involvement policies in health: Exploring their conceptual basis. Health Economic Policy Law, 1(2), 149–162. Ward, J. K., & Armitage, G. (2012). Can patients report patient safety incidents in a hospital setting? A systematic review. BMJ Quality and Safety, 21(8), 685–699.

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Ward, J. K., McEachan, R. R. C., Lawton, R., Armitage, G., Watt, I., Wright, J., & The Yorkshire Quality Safety Research Group. (2011). Patient involvement in patient safety: Protocol for developing an intervention using patient reports of organisational safety and patient incident reporting. BMC Health Services Research, 11, 130 Available online at: http://www.biomedcentral. com/1472-6963/11/130 Weber, M. (1964). The theory of social and economic organisation (trans: Henderson, A. M., & Parsons, T.). New York: Free Press. Wenger, E. (1998). Communities of practice: Learning as a social system. Available at http://www.co-i-l.com/coil/knowledge-garden/cop/lss.shtml. Accessed 4 Aug 2019. Woolley, J., McGowan, M., Teare, H., Coathup, V., Fishman, J., Settersten, R., Sterckx, S., Kaye, J., & Juengst, E. (2016). Citizen science or scientific citizenship? Disentangling the uses of public engagement rhetoric in national research initiatives. BMC Medical Ethics, 17, 33–50. World Health Organization. (1978). Declaration of Alma-Ata, International Conference on Primary Health Care, Alma-Ata, USSR, 6–12, September. Available at: www.who.int/publications/almaata_declaration_en.pdf. Accessed 22 July 2019.

CHAPTER 4

Defining Co-production

Abstract  This chapter has two distinct foci. We begin by looking at the wide variety of meanings associated with the term “co-production”, which has led to confusion and uncertainty about when, why, who and what is involved in this form of healthcare delivery. We provide a graphic showing a range of interactions that infer a deepening relationship between providers and users of services, with suggestions about where consultation ends and co-production starts. Following this we draw attention to the issues and challenges involved in managing co-production from the perspective of providers and users. Keywords  Co-production • Consultation • Collaboration • User involvement

Introduction Co-production is becoming an increasingly popular term in healthcare, with evidence of its use by policymakers, practitioners and academics (Filipe et al. 2017). This suggests there has been a shift from the traditional consultation model with patients and service users to a more proactive and shared form of healthcare design and delivery. However it is not always clear what is being co-produced, for whom, nor what are the ­outcomes of such collaborative efforts. Although we are particularly interested in how we might link co-production to quality improvement, it is © The Author(s) 2020 S. J. Williams, L. Caley, Improving Healthcare Services, https://doi.org/10.1007/978-3-030-36498-4_4

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important first for us to try to establish and agree what co-production means. This chapter therefore first examines the defining principles and models associated with co-production across various public services. It then studies the general criticisms of co-production/co-design and some of the challenges that need to be considered.

Terminology: Defining Co-production It is widely acknowledged that use of the term “co-production” is surrounded by confusion (Orr and Bennett 2012) and conceptual debate (Kaehne et al. 2018). Vennick et al. (2016, p. 56) define co-production as introducing user-generated knowledge in public service delivery by involving individual citizens and groups

But they further say the ‘co’ in co-production refers thus to an action that is designed mutually by regular producers and patients, but not necessarily (our emphasis) through direct interactions of their efforts

This suggests that co-production is concerned with a partnership arrangement at design stage but not at the point of delivery. But evidence suggests that not infrequently co-production begins after project design has been carried out and delivery is the focus of co-productive efforts. Steen et al. (2016) say that co-production is collaboration between public service agents and citizen- users for delivery of public services.

They cite service planning, delivery, monitoring and evaluation as activities that benefit from a co-productive approach; clearly much wider that Vennick et  al.’s (2016) suggestion of drawing on the knowledge of end-users. Similarly, Smith and Ward (2015) promote co-production as bridging the ‘translation gap’ between research and practice, where diverse stakeholders (decision-makers, professionals, service users) play an active role in problem definition, methodological design, data collection and analysis and the application of evidence into practice.

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The Scottish Borders Community Planning Partnership (2019, p.  5) provide a description of co-production that supports the practical application of co-produced activity by stating, co-production is an approach that combines our mutual strengths and capacities so that we can work with one another on an equal basis to achieve positive change.

Huxham and Vangen (2005) use the term “collaborative advantage” to explain a relationship that offers the possibility of widened resource and expertise sharing for mutual benefit. Kaehen et al. (2018) suggest there is some agreement on the dynamic and highly contingent characteristic of co-production, which is dependent on the multiple factors within a complex organisational and systemic landscape of health and social care. If we look closely at these definitions it is apparent that many of the words used are ill-defined and fuzzy. What do we mean by “involving” or “designing an action” or “collaboration” or “delivery”; and what is meant by Vennick et al.’s (2016) “not necessarily”? In reality, the interpretation of all of these terms will vary, and thus the impact of their deployment will vary also. Again, the manner in which such actions are performed will vary, with impact on outcomes. Currie et al. (2016) describe three case studies of “public involvement” where in each circumstance the same model of engagement was employed, but with differing outcomes, interpreted by Currie et al. (2016) as related to the varying managerial approaches used by professional staff. Osborne et al. (2016, p. 640) provide a useful and broad definition of co-production as the voluntary or involuntary involvement of public service users in any of the design, management and delivery and/or evaluation of public services.

This is helpful in that it recognises that involvement might be involuntary at times, but what involvement might include is perhaps left to the designer or orchestrator of the improvement activity. Therefore, it remains unclear how “co-production” relates to other nebulous terms such as Patient and Public Involvement; or User Involvement; Shared Decision Making; or patient choice; or the “expert patient”? Is it just a matter of vocabulary or are they different things altogether? The real issue of trying

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to capture patient population needs with the reality of involving individual service users is a difficult one to reconcile. Looking at the origins of co-production, Osborne and Strokosch (2013) identify two, often unconnected, areas of work – one from public administration and management (PAM) and the other from service management theory. Elinor Ostrom’s (1972) seminal work is ceded as the originator of co-production from a PAM perspective. She described it as the process through which inputs used to produce a good or service are contributed by individuals who are not “in” the same organisation. (Ostrom 1972, p. 46)

She suggested public service organisations were as much dependent on the community for policy implementation and service delivery as the community was dependent on them. From the perspective of service management scholars the nature and role of co-production in service delivery is quite different (Osborne et al. 2016). Here the concern is not about how co-production is ‘added in’ when delivering a service. Co-production is viewed as an essential and compulsory part of (public) service delivery. Osborne et al. (2016) go as far as to say that it is impossible to deliver public services without co-­ production. They note that quality and performance of a service is shaped primarily by the expectations of the user, their active or passive role in the service delivery process and their subsequent experience of the process. The point at which user expectations meet with experience of the service (known as the ‘moment of truth’) determines the level of satisfaction with the service delivery, performance and outcomes (Magnusson 2003; Venetis and Ghauri 2004). Boyle and Harris (2009, p.  6) suggest that co-production has been conceived as an innovative approach of public service provision, which moves citizens from their traditional ‘dependency culture’ typically produced by the welfare state. Yet, Alford (1998) claims that co-production is beneficial both to citizens and public service organisations and both should have a vested interest in pursuing such an approach. For citizens, co-produced services are more likely to be valued due to their engagement in the design and the process of value creation. For public service organisations co-production enables them to deliver more effective and efficient services. Parks et al. (1981, p. 146) describe

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the mix of activities that both public service agents and citizens contribute to the provision of public service. The former are involved as professionals or “regular producers” while “citizen production” is based on voluntary efforts by individuals and groups to enhance the quality and/or quantity of the services they use

Service co-production is said to activate the dormant assets (e.g. service users) addressing them at the creation of public value. This is where citizens are seen as partners in public service delivery, rather than mere consumers of public goods (Palumbo 2016). Brandsen and Honingh (2016) point out the problematic nature of the terms • “voluntary efforts” (payment is not unknown but the value of contribution is probably not fully recognised) • “professionals” (the meaning of this term has altered over the last few decades) • “in the same organisation” (drawing attention to those “in” and those “out” of an organisation). In order to clarify some of these potential confusions Brandsen and Honingh (2016)  propose a typology of co-production comprising four elements • Activities that comprise implementation only compared with those that are involved with both design and implementation • Activities that support the core values of the organisation concerned compared with those that are incidental to the core values. More recently, Hanson (2018) proposes that when a healthcare system is truly co-produced it requires senior managers to make their decisions within the context of ongoing, proactive engagement with staff, patients, and community groups. They refer to the importance of information sharing and feedback mechanisms and democratic representation – including key stakeholders who engage with members of the public (e.g. counsellors, community groups). They provide a co-production diagram which represents the interaction between these various stakeholders and includes the external forces such as regulations, funding, legislation and standards which may impact on such activity.

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Co-production as a methodological approach is not alone in suffering from variation in vocabulary and understanding of key terms. Terminology has been a bugbear in the field of innovation and improvement in the delivery of safe and effective healthcare for as long as the need to improve has been recognised. If we look back two decades we can trace the evolution of ideas and imperatives (systems improvement; clinical micro-­ systems; quality improvement; patient safety; human factors, etc.). The terms are used freely amongst managers and clinicians but there is lack of clarity about how/if they relate to each other, and where the boundaries of their influence begin and end. Too often colleagues assume that they have a shared understanding without testing this assumption. We believe co-production has taken a similar and perhaps shorter path in that terminology is emerging and being used freely by managers and clinicians but with limited knowledge of each other’s understanding and experience of application. Dadau et al. (2019) note the evolving nature of co-­production and the co-paradigm more generally and our evolving understanding of it contributes to the issues around definition and terminology.

Implementing Co-production: From Consultation to Co-production Kaehne et al. (2018) helpfully refer to a scale/spectrum when referring to co-production. At one end of the spectrum, there is an assumption that service users are able to describe accurately the specific issues that matter to them personally, without necessarily considering the wider needs of the population. This approach resembles consultation, which is different to co-production. At the other end of the spectrum is the model of co-­ production, which advocates full accountability and involvement of patients and users in the decision-making process, ideally from (pre-) design of concept through to delivery and evaluation. Movement across the spectrum from consultation to co-production becomes increasing reliant on the assumption that individuals can reflect population needs, wholly or partially. Other issues such as accountability and power sharing between service users and providers need to be considered. The policy drive towards ‘services designed for patient by patients’ presents many challenges and has been criticised for its idealism (Osborne and Strokosch 2013; Lwembe et al. 2017; Van Eijk and Steen 2016). We explore these challenges further within this chapter. Figure 4.1 is helpful to identify the different levels of participation and the steps and activities that might be needed to move to co-designing and co-producing quality improvements.

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Engaging

Codesigning

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Coproducing

Consulting Informing

Doing with

Educating Coercing

Doing for Doing to

Fig. 4.1  Ladder of participation. (Source: Adapted from the New Economic Foundation (2013, p. 10))

Terminology associated with co-production is wide and varied. For example, Voorberg, et al. (2015) refer to co-creation as a ‘magic concept’, to justify both its popular appeal and the ability to pin it down, define, describe, or explain it. The concept of a scale/spectrum is helpful to delineate terms and provide some clarity around use. Here we offer a visual (see Fig.  4.2) compiled from various sources, which we have found helpful to position some of the terms that might be used interchangeably by scholars. However, more importantly, it has helped us to articulate to our readers where within this scale/spectrum we feel some integration between quality improvement and co-production approaches might be helpful. We propose the level of engagement can be linked to the focus of improvement. For example, consultation and involvement we see has been somewhat limited and therefore improvements are largely driven internally by those within the service. As we progress along the continuum the level of patient involvement moves improvement to be more person-centred and ­eventually co-produced. Similarly, the first two to three boxes (consultation to user-centredness) might be viewed as addressing individual need whereas the co-design, co-creation and co-production are concerned with a group/community of service users.

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Service-led improvement

User consultation

Person-centred improvement

User involvement/ participation

Usercentredness

Co-designed, co-created or co-produced improvement

Co-design

Coproduction

Co-creation

Service–user Involvement

Group/community –user Involvement

Fig. 4.2  From consultation to co-production. (Source: Compiled by the authors)

Challenges of Implementing Co-production Defining co-production has been challenging given the term is widely used in various sectors including healthcare. Given this ambiguity in meaning it is not surprising there are some challenges and issues that need to be considered when planning, implementing and managing co-designed and co-produced activity. Here we discuss the issues we have found when reviewing the literature. We do not suggest this list is exhaustive or prescriptive and is likely to differ depending on context and aims of the activity.

Rhetoric and Reality We assume that co-production is pursued because it is deemed to empower communities, improve service design and delivery, enhance service decisions, provide democratic accountability and contribute to higher quality services. But much existing research suggests that, while there is strong policy support, any potential contribution is stymied by contested terminology, limitations in the underpinning evidence base, different attitudes to co-production, and variable attempts at its implementation. As we have already alluded to there are issues relating to accountability, power sharing and representation among others.

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As previously noted, the literature emphasises the role of inclusivity and meaningful partnerships between all stakeholders (e.g. Rycroft-Malone et al. 2016; Cooke et al. 2017). Usefully, Clarke et al. (2019) identify two issues associated with inclusion within the context of translational research. The first issue is that much of the focus is placed on establishing and setting up co-production initiatives; these are not always followed over time in order to understand how inclusivity is sustained over the period of the project. The second issue is the extent to which interactions between stakeholders are localised to support and facilitate the inclusivity of diverse stakeholder groups.

Managing Aims Every quality improvement initiative embodies a set of objectives that underpin the direction and perceived benefit of its undertaking. One can argue that there are formal aims (those cited in proposals and documentation). For example, managers may aim to arrive at efficient and effective delivery of services and perceive co-production as a suitable means of achieving this. But there are also likely to be informal aims, some of which may not be articulated. Early work on co-production in the US in the field of town planning by Arnstein (quoted in Nutbrown et al. 2015) found that managers’ informal aims included: • Manipulation - of service users views and perceptions; • Therapy  – helping service users come to terms with unwelcome changes; • Informing – ensuring that service users achieve accurate information; • Consultation – finding out what service users desire; • Placation – soothing anxious users of services in times of change; • Partnership – whilst acknowledging that service users are important stakeholders; • Delegated power  – spreading the load of responsibility across the stakeholder community; • Citizen control – following a communitarian agenda. Equally, service users will embody formal and informal aims for being involved in co-production. This involvement may include wishing to ensure efficiency of delivery but also an aim to influence and direct developments; an intention to gain early knowledge and keep a step ahead of

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innovations, or a simple aim to have a say in how health and social care is locally managed. There may be an altruistic motive for involvement amongst those who believe they have experience to share, or there may be a personal drive to gain early benefit from involvement. Some of these aims will be apparent but many will be tacit, and remain unacknowledged. Not infrequently, there is a working assumption from those involved (service providers and users) in improvement initiatives that aims are shared and agreed, until at a late stage of the initiative when disagreements uncover misperceptions that might have been better explored at an earlier stage. Although some approaches to improvement might allude to this exploration of understanding assumptions and values (e.g. Lean thinking), it would appear this is often overlooked completely or not performed well.

Grappling with Advantage and Inertia If there is a general assumption that collaboration brings advantage, it is not always clear to those most closely involved. Too often actions and activities become protracted, and inertia can set in; managing the process foregrounds and inhibits managing the project. This may stem from confusion and disagreement about aims leading to lack of trust and a feeling of being pulled in many directions. Power may lie elsewhere and outside of the partnership actors and this may result in problems, hurdles and dilemmas that cannot be satisfied. Inertia may be a deliberate strategy or it may be an inadvertent consequence of the way that the project has been devised. Fleddermus (2015) reminds us that It’s not co-production as such but the way co-production is organised and managed that determines ultimate outcomes

Chei et al. (2011) highlight the importance of partner match, partner expertise and affective commitment for successful outcomes.

Negotiating Purpose As with so many initiatives, time spent planning and defining the purpose/aims in the early stages of a project can never be time wasted. One is reminded of Bruce Tuckman’s (1965  – also see Tuckman and Jensen

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1977) imperative about norming and storming, which too often is rushed or overlooked. But in the case of co-production where a range of experience and background may be present, purpose setting becomes of overarching necessity and agreed clarity of purpose is essential. In a situation of pressure and anxiety, encouraging honesty and trust can be difficult especially at the earliest stages of a relationship, and how this is handled will reflect on the entire length of the project and beyond.

Membership Structure and Dynamics Managers and clinicians may be required to take part in co-productive efforts, whereas citizens are volunteers. This of itself will shape the way that relationships and voices are heard. Who gets chosen, who gets heard, and how power dynamics influence outcomes is an important element of co-production and these issues tend to be ignored in the first flush of a relationship, or down the line when things are becoming heated. As Currie et al. (2016) demonstrated, differing personalities can result in differing outcomes, even when the same approaches are used.

Coping with Trust Fleddermus (2015), in a review of a public sector initiative in the Netherlands, found that trust and motivation at an individual level decreased over six months both amongst service providers and more generally, particularly if there were perceived to be free riders amongst the group. He stressed the need to look at intrinsic and extrinsic motivation and at organisational support as measures of the degree of trust inherent in a project. Huxham and Vangen (2005) remind us of the cyclical nature of trust, with peaks and troughs over the life of a project.

Using Power Usually unspoken but always present, power dynamics are crucial to any co-productive effort, and denying its existence can be damaging and fruitless. The seat of power can be surprising, and it will exist at macro (policy) level as well as micro (implementation) level. Power need not always be a negative force; if used wisely then the exercise of power and influence can negate inertia and lack of trust.

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Capability A recent qualitative study conducted in Wales in the UK examining how coproduction was viewed by clinicians and the members of the public found capability to be both a barrier and a facilitator (Holland-Hart et  al. 2019). Participants of the study recognised the capability of citizens to participate in coproduced activities varied. Capability was linked to physical health including mental health and psychological factors such as knowledge and health literacy, empowerment, self-efficacy and communication skills.

Dark Side of Co-production Some scholars have raised questions around the use of co-production (mainly in a research context) and the risks and costs involved, and managing the varying (and possibly competing) interests of the different stakeholders (Oliver et al. 2019). Rarely are the costs and risks included in the literature or mechanisms to help manage these. Oliver et al. (2019) advocate a cautious approach to co-production which includes evaluating the outcomes and exploring the costs and benefits. Palumbo and Manna (2018) refer to the importance of individual and organisational health literacy and the implementation of co-production. In situations where health literacy is low patients are unable to establish a fair and comfortable relationship with healthcare providers. The bigger the gap is between the individual and organisational literacy, the higher the risk of individuals (patients) not participating. Poor organisational literacy compels healthcare professionals to embrace a ‘medical model’ of healthcare which results in the patient becoming a recipient of care rather than being involved in creating high value care. Bovaird et al. (2019) also raise the importance of this emerging literature on the dark-side of co-production. Although they refer more widely to public services the issues they raise are applicable to healthcare. First is the risk of not meeting citizen/patient expectations which may lead to disillusionment and withdrawal. They also highlight the need for careful management of the outcomes of co-designed activity to ensure any potential risks identified by some stakeholders are heard and taken into account. If these are overlooked again this could result in withdrawal or limited support for subsequent withdrawal.

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Co-destruction and Co-contamination Williams et  al. (2016) propose an interesting concept of value co-­ destruction. They refer to the fact that positive value is co-created at the interaction between service providers and users who apply and integrate their own resources to their benefit. They also suggest it is possible resources can be used in an adverse manner so that value co-destruction results. If value is defined as “an improvement in system well-being” (Vargo et al. 2008, p. 149), then the misuse of resources and the ensuing negative consequences is contingent upon at least one of the system’s perspective about the ‘appropriate’ or ‘expected’ manner in which the resources should be applied and integrated (Ple and Cáceres 2010, p. 432). Regardless of which system or entity initiates the misuse of resources, value deconstruction is a mutual result stemming from the interaction between the two different systems.

Conclusion In this chapter, we have explored the many ways in which co-production has been defined, and the difficulty of arriving at a shared view of what is meant by the term. Uncertainty surrounds the breadth and depth of involvement and the scope of citizen participation. We have provided a visual to help to delineate some of the terminology often used interchangeably by scholars and professionals. However, even once such challenges are addressed, there are further considerations that cannot be ignored, such as the accountability and relationship issues when staff and citizens, with varying levels of expertise and worldview, are brought together to work as a team and how these views are then reconciled with the wider views and needs of the wider population. For improvement activity, we believe key issues that need attention include: • Representation – who is involved? Do the users represent the wider population/community? • How much autonomy has the improvement team? • Relationship management • Reconciling local (service user) views with (wider) population needs.

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Huxham, C., & Vangen, S. (2005). Managing to collaborate: The theory and practice of collaborative advantage. New York: Routledge. Kaehne, A., Beacham, A., & Feather, J. (2018). Co-production in integrated health and social care programmes: A pragmatic model. Journal of Integrated Care, 26(1), 87–96. Lwembe, S., Green, S., Chigwende, J., Ojwang, T., & Dennis, R. (2017). Co-production as an approach to developing stakeholder partnerships to reduce mental health inequalities: An evaluation of a pilot service. Primary Health Care Research and Development, 18(1), 14–23. Magnusson, P. (2003). Benefits of involving users in service innovation. European Journal of Innovation Management, 6(4), 228–238. New Economics Foundation. (2013). Co-production in mental health: A literature review. London: New Economics Foundation. Available at https://neweconomics.org/uploads/files/ca0975b7cd88125c3e_ywm6bp3l1.pdf. Accessed 20 July 2019. Nutbrown, C., Bishop, J., & Wheeler, H. (2015). Co-production of family literacy projects to enhance early literacy development. Journal of Childrens’ Services, 10(3), XXXX. Oliver, K., Kothari, A., & Mays, N. (2019). The dark side of coproduction: Do the costs outweigh the benefits for health research? Health Research Policy and Systems, 17(33). https://doi.org/10.1186/s12961-019-0432-3. Orr, K., & Bennett, M. (2012). Public administration scholarship and the politics of co-producing academic-practitioner research. Public Administration Review, 72(4), 487–495. Osborne, S., & Strokosch, K. (2013). It takes two to tango? Understanding the co-production of public services by integrating the services management and public administration perspectives. British Journal of Management, 24, S31–S47. Osborne, S., Radnor, Z., & Strokosch, K. (2016). Co-production and the co-­ creation of value in public services: A suitable case for treatment? Public Management Review, 18, 639–653. Ostrom, E. (1972). Metropolitan reform: Propositions derived from two traditions. Social Science Quarterly, 53, 474–493. Palumbo, R. (2016). Contextualizing co-production of health care: A systematic literature review. International Journal of Public Sector Management, 29(1), 72–90. Palumbo, R., & Manna, R. (2018). What if things go wrong in co-producing health services? Exploring the implementation problems of health care co-­ production. Policy and Society, 37(3), 368–385. Parks, R., Baker, P., Kiser, L., Oakerson, R., Ostrom, E., Ostrom, V., Percy, S., Vandivort, M., Whitaker, G., & Wilson, R. (1981). Consumers as coproducers of public series: Some economic and institutional considerations. Policy Studies Journal, 9(7), 1001–1011.

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CHAPTER 5

Quality Improvement and Co-production and Co-design Models and Approaches

Abstract  In this chapter we start to bring together some of the popular models and approaches used within quality improvement and co-design and co-production. First, we provide a brief overview of Lean thinking and the Model for Improvement, two most commonly used approaches to quality improvement in healthcare. We then do a similar exercise for co-­ design and co-production using the Experience-based co-design toolkit and a conceptual model for co-production. We conclude this chapter by suggesting ways that co-production might be combined with quality improvement. Keywords  Quality Improvement (QI) • Lean thinking • Model for Improvement • Co-production • Experience based co-design (EBDC) • Co-design • Plan-Do-Study-Act (PDSA)

Introduction The urge to improve the quality of healthcare delivery has been high on the agenda of managers and policy makers for some years. Quality Improvement (QI) requires that initiatives are planned in a systematic way, informed by the best possible research evidence, and are based on rigorous observational, and sometimes experimental, data. Such activities aim to produce learning that others can reflect upon, and replicate or adapt.

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QI does not stop at merely finding what works; it focuses on developing and testing methodologies for improvement of the delivery of health services and then researching how best to implement these in practice to improve the safety, value and quality of care. Its goal is to ensure that quality improvement efforts are based as much on evidence as the best practices they seek to implement. Improvement work builds on multi-disciplinary research and practice including but not limited to operations management, industrial engineering, management science, psychology and sociology. QI approaches have been present within healthcare during the last two decades and have been increasingly applied after being sponsored by US and UK health think tanks. QI is a broad concept and it has two distinct elements; that of systematically studying what makes improvements effective and widely implemented; but also finding ways of narrowing the gap between research and practice and ensuring that evidence based findings are rolled out and sustained into routine care. More recently there has been a call for QI approaches to ensure the voices of patients and the public are heard in the (re)design of healthcare services (Ham et  al. 2016). There is some evidence that co-producing quality improvement makes a difference. For example, the results of a project commissioned by the NHS England Patient Experience Team in 2015, found that co-production results in increased attention to the experience of care, alongside clinical effectiveness and safety, and NHS organizations are more likely to act on patient and carer feedback to improve experience of care (McNally et al. 2015). Similarly a study in five Dutch hospitals found that: “The process of coproduction stimulated hospitals’ thinking about how to realize quality improvements…seeing patients and hearing their experiences created a sense of urgency among staff to act on the improvement issues raised. Moreover, the experiences served to legitimatize improvements to higher management bodies” (Vennik et al. 2015). What an integrated approach of QI and co-production and co-design looks like and how it is implemented is not clear. What we attempt to do in this text is to provide some examples of how this might work. The first part of this chapter introduces two dominant QI approaches used in healthcare  – Lean Thinking and the Model for Improvement  – along with two models for co-design and co-production – the well-known experience-based co-design approach and a recently published conceptual co-production model (Batalden et al. 2016). We recognise there are other

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QI and co-production approaches that we could have included in this chapter and acknowledged many of these in this or previous chapters. The latter part of the chapter then provides an example of how these QI and co-design and co-production models can be brought together. This case is for illustrative purposes only. Further cases drawn from the published literature and our own empirical work are provided in Chap. 6, 7 and 8.

Quality Improvement Models and Approaches In the last two decades there has been a huge increase in moves towards improving the delivery of healthcare, to increase efficiency, focus on safer care, and reduce harm. Involving citizens/users in the many projects that have proliferated has been encouraged; so much so, that funders often make it a requirement of their support that there is public and patient involvement. At the same time, there are a number of approaches to improving quality in healthcare that have become known and followed (e.g. Lean, Six Sigma, Model for Improvement). There is no clear evidence that one approach is better than others. Rather, success lies in the process of having a systematic, consistent and evidence-based approach to improvement (Ross and Nayor 2017). Here we have selected Lean thinking (Womack and Jones 1996) and The Model for Improvement (Langley et al. 2009) based on their popularity in healthcare. Lean Thinking Lean originates from manufacturing and the Toyota Production System and over the past two decades there have been many studies that have reported on how Lean has been implemented within healthcare (e.g. Aherne and Whelton 2010; Burgess and Radnor 2013). A lean organization understands customer value and designs its key processes to seamlessly deliver and continuously increase this. The ultimate goal is to provide perfect value to the customer through a value creation process that aims to reduce or remove non-value adding (waste) activity. There are five basic principles of lean thinking (Womack and Jones 1996): 1. Understanding and Identifying Value Lean teams constantly review their service from the perspective of the customer. How does the service best serve customer need? Why and when

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do they need it? How are we behaving that fulfils that need? To ensure activities are value-adding it is important for organisations to continually seek what customers’ value from their products or services. To do this effectively, it is important that organisations continually engage with a cross-section of their customers. Any improvements undertaken by the organisation should be taken from what is considered to be value-adding from the customers’ viewpoint. It is imperative therefore that customers are central to improvement activity. 2. Mapping the Value Stream Once value has been identified (what’s offered, why, and for whom), those involved can evaluate each process that leads toward the end goal, moving into the next of the 5 principles of Lean: Mapping the Value Stream, enabling the team to understand how value flows through the organisation - and more importantly, where it gets stuck. The result is a physical ‘map’ of the value streams being improved, which details the key steps of the process within the value stream. For healthcare, we might refer to value streams as patient journey or patient pathways (Williams 2017). These are different to, but may encompass clinical pathways, and can include activities such as referral; diagnosis; treatment; handover; after care. The main type of map employed within healthcare are process activity maps. 3. Creating Flow With the process or value stream map in hand, the third of the five Lean principles is addressed: to create flow by analysing each step in the process, finding ways to maximize efficiencies, and reduce waste. The [improvement] team aims to optimize flow in all aspects of the service. Following every process/value stream to the customer, the team evaluates the steps to determine if each is necessary and, if so, where there are areas to reduce errors, friction, inefficiencies, or delays in the flow of the value to the customer. 4. Establishing Pull In the fourth of the five principles, the teams consider the customer’s perspective on the final service. When does the customer actually need each element of the service? The idea of the customer being able to ‘pull’

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the value as needed is what truly revolutionized thinking about delivery of a service. Instead of investing in materials and then storage to be ready for a customer’s order, teams can time each stage to precisely meet the customers need exactly when required, minimising empty beds and operating theatres. This ‘just-in-time’ principle has been more difficult to translate to healthcare settings. Some scholars have referred to patients ‘pulling’ resources and expertise as and when required. 5. Seeking Perfection Finally, the areas of improvement are identified and meaningful and manageable changes are implemented, seeking the most efficient processes to bring the greatest value to the customer. In practice, these key Lean principles are cyclical in continuous pursuit of improvement. Each process is constantly analysed to continually increase value (reduced cost, time, resources used, space, etc.). The focus is on the elements that add value and eliminate those that do not. Improvements are made to the flow and the delivery of value as defined by customer needs. Ultimately, the goal is not perfection (which is unattainable), but rather, the pursuit of it  – a concept otherwise known as continuous improvement. Model for Improvement/PDSA The Model for Improvement has evolved from industry but has been adapted by US researchers (Langley et al. 2009) and arguably more closely takes account of healthcare environments. It provides a framework for developing, testing and implementing changes to lead to the optimal improvement. It takes a systematic approach, trying to avoid the conventional practice of moving to solution before carefully identifying cause. Stress is placed on data gathering to ensure that the correct diagnosis of the problem is made; thereafter a process of evidence based small improvements is planned, made and evaluated (the PDSA cycle) to test out changes, building on the learning from these test cycles in a structured manner before wholesale implementation. This gives stakeholders the opportunity to see if the proposed change will succeed and is a powerful tool for learning from ideas that do and don’t work. This way, the process of change is safer and less disruptive for patients and staff. The framework includes three key questions that need to be addressed first, before any small change has been initiated.

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Key questions . What are we trying to accomplish? (The aim statement). 1 2. How will we know if the change is an improvement? What measures of success will we use? 3. What changes can we make that will result in improvement? (The change concepts to be tested) The approach has been unusual in healthcare because traditionally, action based staff are inclined to introduce new ideas without sufficient testing. The four stages of the PDSA cycle are: • Plan – the change to be tested or implemented • Do – carry out the test or change • Study  – based on the measurable outcomes agreed before starting out, collect data before and after the change and reflect on the impact of the change and what was learned • Act – plan the next change cycle or full implementation. Not infrequently, projects designed to improve healthcare and which are promoted as co-productive efforts employ one of these models. However projects vary in the manner in which they are designed and implemented, and comparisons are therefore difficult to achieve. Wilson et al. (2003) surveyed collaborative improvement projects in seven countries to ascertain their common components and identify variations in the ways these components are implemented. Their study identified seven features of collaboratives that the leaders interviewed thought were critical determinants of how effective the collaboratives were: sponsorship, topic, ideas for improvements, participants, senior leadership support, preliminary work and learning, and strategies for learning about and making improvements.

Co-design and Co-production Models and Approaches Co-design and co-production approaches used in healthcare acknowledge that people with ‘lived experience’ of a particular condition are often best placed to advise on what support and services will make a positive difference to them and often their families/carers. Over the last decade we have

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seen a growing interest in various approaches to involving patients in their care e.g. patient consultation, engagement, involvement and participation. As a result various models (e.g. Citizen-participation roadmap (Farmer et  al. 2017); Experience-based co-design  (EBCD) (Bate and Robert 2007); National model for Co-production  – England (Marshall et  al. 2019) Co-producing services  – Co-creating health (1000 Lives Improvement Service 2013) and networks (e.g. Scottish Co-production Network; Co-production network for Wales) have appeared to help support implementation. Similar to the QI section we have selected two prominent models to feature as part of our integration exploration. We have chosen Batalden et  al’s. (2016)  Co-production model due to its wider applicability to communities and EBCD due to its popularity. We use these two approaches to review the role of co-production in our two empirical cases presented in Chaps. 6 and 7. Co-production Model Batalden et  al. (2016) provide a useful conceptual model of healthcare service co-production which considers the interaction of professionals and patients, both of which are considered within the context of the healthcare system and the wider society. They recognise that, as participants within the healthcare system, it is possible for them to shape the system. Relationships within and between groups of patients and professionals are important along with blurring of roles and the boundaries of the healthcare system. The model recognises different levels of co-creative relationships e.g. basic level requiring respectful interaction and effective communication. Shared planning requires a deeper understanding of expertise and values. Shared execution required a deeper trust, cultivation of shared goals and mutuality in responsibility and accountability for performance. Later in this text, we revisit this conceptual model to assess the level of coproduced activity within our health care case research. Experience-Based Co-design Experience-based Co-design (EBCD) was first developed in 2005 by staff within a Head & Neck Cancer Service in England and is arguably one of the most well-known (and practiced) approaches to co-design in the UK. The aim of this approach is to improve healthcare services through a combination of participatory and user experience design tools. It requires

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staff, patients and carers to reflect on their experiences of a service and by working together to identify improvement priorities along with implementing changes. These changes are then jointly reviewed by staff and patients (Bate and Robert 2007; Donetto et al. 2014). The approach has been informed by the following theoretical and methodological thinking (Robert 2013): • participatory action research; • user-centred design; • learning theory; and • narrative-based approaches to change. Experience-based co-design (EBCD) was developed in direct response to how those leading early projects were paying insufficient attention to the co-design phase and relying instead on traditional, narrower approaches to implementing improvements to services (Donetto et  al. 2014), which one might argue were driven largely from only engaging with staff. In contrast, and as first conceived, the ‘co’ in co-design refers emphatically to partnership and shared leadership between patients and professionals. And co-design means more than just being responsive to patients and listening to their needs; patients need not just be active partners ‘having a say’ in their care but directly contributing to the design and delivery of that care: “In its complete sense, users may be involved in every step of the design process from diagnosis and need analysis, through envisioning and model building, to prototyping and testing, implementing and evaluating. And in this process, they do not just say things, they do things as well; and they do them in person, not through some third party” (Bate and Robert 2007, p. 30). Donetto et al.’s (2014) report notes that EBCD has been implemented in a variety of clinical areas (including emergency medicine, drug & alcohol services, a range of cancer services, paediatrics, diabetes care and mental health services) and projects took between 6 and 12  months to complete. Less than a half of those who lead EBCD projects received training. The main challenge associated with EBCD projects was the time they took to complete. The main benefit was the level of engagement with patients. The key stages of the EBCD approach are (Bate and Robert 2007; Donetto et al. 2014):

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. EBCD project set up 1 2. Engaging with staff and conducting experience-based interviews/ workshops/observations 3. Engaging with patients/relatives and conducting experience-based interviews/workshops/observations & video record 12–15 narrative based interviews 4. Arranging and conducting co-design meeting with staff and patients/relatives and identify and prioritise changes 5. Forming small co-design groups to address the changes prioritised 6. Celebrating and reviewing event/changes Since the inception of EBCD, there have been a growing number of conference papers, reports and published articles, which have included EBCD studies to improve mental health services (Larkin et al. 2015), cancer services (e.g. Tsianakas et al. 2012; Santin et al. 2019), palliative care (e.g. Borgstrom and Barclay 2019) and emergency departments (e.g. Piper et al. 2012). In addition, there are now a number of tool kits and websites to assist those interested and undertaking EBCD activity (see for example The Point of Care Foundation (2019), NHS Institute for Innovation and Improvement (2011)).

Implementing Quality Improvement in a Co-produced Environment Here we suggest how Lean and the Model for Improvement might apply in a co-productive environment. In Chap. 3 we suggested a number of scenarios that might be described as co-productive. For example: It has long been recognised that waiting lists for an OPD clinic are lengthy requiring many patients to wait inordinately for appointments. It is assumed that a more efficient system can be devised and so a group of staff request permission to undertake a small improvement project to identify causes and make suggestions for improvements. A small group of regular users of the service are invited to join the improvement team.

We use this as our illustration to start to unpack how QI might be implemented in a co-produced environment.

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How Might Lean Be Used for this Project? • Identify Value – the purpose of this stage is to find out precisely what service users need from the service under scrutiny and so a process of data gathering should be undertaken. Staff may assume that citizens are unhappy with the wait, but this needs to be ­verified – it has been found, for example, that occasionally a wait can be beneficial when bad news needs to be assimilated. • Map the Value Stream – to establish precisely who is involved in each stage of the process, where their responsibilities lie and how each step of the process fits together. This information will be held by a number of people, and it is unlikely that any one person is fully informed. Value Stream Mapping generally takes place in a workshop environment and can take several attempts before everyone is in agreement about the accuracy of the “map”. In this case the compilation of a waiting list will involve a number of staff who may not be in direct contact with each other – bringing them together in a workshop can be revealing. The experience of the service user can be crucial and needs to be captured at this stage to ensure breadth and accuracy of information and to understand ‘exactly what happens’ rather than what is expected to happen. Walking and observing the process and interviewing those involved in the process/value stream can add context and more detail to the map. More frequently we are now seeing service users (patients and carers) join healthcare practitioners to undertake these mapping activities. • Create Flow  – once the map is agreed the team will then discuss delays, duplications and weaknesses and look for efficiencies that can be made. Occasionally replications in activity are found; sometimes indirect routes are taken; gaps and errors are revealed. Suggestions for how weaknesses can be rectified will be discussed. • Establish Pull – plans to make changes need to be examined by all parties including service users, to ensure overall that the revised ­process meets expectations. Once this is agreed then the change can be implemented and monitored. • Seek Perfection – recognising that it is unlikely that changes will result in a perfect system first time around, ongoing discussion and monitoring should be done to confirm that service user needs are met. It may well be the case that several attempts are needed and the cyclical nature of the undertaking is clear.

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How Might the Model for Improvement Be Used for this Project? This model is also based on discussion, bringing together all of those involved in the process and enabling shared understanding of the issues to be addressed. Recognition of the problem is the starting point, and this may surprise those involved as perceptions will vary. Once fully aired and agreed, the focus of the improvement is identified. In the case of lengthy waiting lists it may be a communication issue, or rostoring, or a lack of resources. The service user can offer a valuable perspective on this. The emphasis with this model is on ensuring that the full extent of the problem is known before any change is made, so data are gathered to provide a picture of the starting point (base line) – what is the current position regarding waiting list length – does it vary daily/monthly/seasonally etc. Such information is needed as a comparator for post-project comparison. Only once this information is fully known can a small change be made, studied and compared for benefits. This approach emphasises the difference of small changes and it stresses that a number of repeats of the PDSA cycle should be made, studied and improved. As in the case of the Lean approach, the assumption is that improvement is a continual process.

Conclusion In this chapter we have moved from defining co-production to looking at the manner in which it takes place. We assume that service users are involved in efforts to improve the service of which they are recipients, and that their view and experience of the value (stream) chain of the delivery of care offers a unique perspective. We briefly describe the two most commonly used methods of undertaking improvement projects and we speculate on how they might be used in the commonly found situation of long waiting lists. Questions that we address in later chapters cover the extent to which staff and citizens/service users can agree on: • the accuracy of their mental model of the process • where changes can best be made • at what point a further cyclical change is needed

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References 1000 Lives Improvement Service. (2013). Co-producing services – Co-creating health. Available at http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/T4I%20%288%29%20Co-production.pdf. Accessed 10 Aug 2019. Aherne, J., & Whelton, J. (Eds.). (2010). Applying lean in healthcare: A collection of international case studies. New York: Productivity Press. Batalden, M., Batalden, P., Margolis, P., Seid, M., Armstrong, G., Opipari-Arrigan, L., & Hartung, H. (2016). Coproduction of healthcare service. BMJ Quality and Safety, 25, 509–517. Bate, S. P., & Robert, G. (2007). Bringing user experience to healthcare improvement: The concepts, methods and practices of experience-based design. Oxford: Radcliffe Publishing. Borgstrom, E., & Barclay, S. (2019). Experience-based design, co-design and experience-based co-design in palliative and end-of-life care. BMJ Supportive & Palliative Care, 9(1), 60–66. Burgess, N., & Radnor, Z. (2013). Evaluating lean in healthcare. International Journal of Health Care Quality Assurance, 26(3), 220–235. Donetto, S., Tsianakas, V., & Robert, G. (2014). 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. Farmer, J., Taylor, J., Stewart, E., & Kenny, A. (2017). Citizen participation in health services coproduction: A roadmap for navigating participation types and outcomes. Australian Journal of Primary Health, 23, 509–515. Ham, C., Berwick, D., & Dixon. J. (2016). Improving quality in the English NHS: A strategy for action. London: The King’s Fund. Available at: https://www. kingsfund.org.uk/sites/default/files/field/field_publication_file/Improvingquality-Kings-Fund-February-2016.pdf. Accessed 10 Aug 2019. Langley, G., Moen, R., Nolan, K., Nolan, T., Norman, C., & Provost, L. (2009). The improvement guide: A practical approach to enhancing organisational performance (2nd ed.). San Francisco: Jossey-Bass. Larkin, M., Boden, Z., & Newton, E. (2015). On the brink of genuinely collaborative care: Experience-based co-design in mental health. Qualitative Health Research, 25(11), 1463–1476. Marshall, C., Zambeaux, A., Ainley, E., McNally, D. K., Wolfenden, L., & Lee, H. (2019). NHS England Always Events® program: Developing a national model for co-production. Patient Experience Journal, 6(1), 154–165. McNally, D., Sharples, S., Criag, G., & Goraya, A. (2015). Patient leadership: Taking patient experience to the next level? Patient Experience Journal, 15(2), 7–15.

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NHS Institute for Innovation and Improvement. (2011). The EBD approach: Experience Based Destin  – Using patient and staff experience to design better healthcare services. Available at https://improvement.nhs.uk/resources/theexperience-based-design-approach/. Accessed 10 Aug 2019. Piper, D., Iedema, R., Gray, J., Verna, R., Holmes, L., & Manning, N. (2012). Utilizing experience-based co-design to improve the experience of patients accessing emergency departments in New South Wales public hospitals: An evaluation study. Health Services Management Research, 25, 162–172. Robert, G. (2013). Participatory action research: Using experience-based co-­ design (EBCD) to improve healthcare services. In S.  Ziebland, J.  Calabrese, A. Coulter, & L. Locock (Eds.), Understanding and using experiences of health and illness. Oxford: Oxford University Press. Ross, S., & Nayor, C. (2017). Quality improvement in mental health. London: The King’s Fund. Available at https://www.kingsfund.org.uk/publications/ quality-improvement-mental-health. Accessed 10 Aug 2019. Santin, O., McShane, T., Hudson, P., & Prue, G. (2019). Using a six-step co-­ design model to develop and test a peer-led we-based resources (PLWR) to support information carers of cancer patients. Journal of the Psychological, Social and Behavioral Dimensions of Cancer, 28(3), 518–524. The Point of Care Foundation. (2019). EBCD: Experience-based co-design toolkit. Available at https://www.pointofcarefoundation.org.uk/resource/experiencebased-co-design-ebcd-toolkit/. Accessed 8 July 2019. Tsianakas, V., Robert, G., Maben, J., Richardson, A., Dale, C., & Wiseman, T. (2012). Implementing patient-centred cancer care: Using experience-based co-­ design to improve patient experience in breast and lung cancer services. Supportive Care in Cancer, 20, 2639–2647. Vennik, F., Van de Bovenkamp, H., Putters, K., & Grit, K. (2015). Co-production in healthcare: Rhetoric and practice. International Review of Administrative Sciences, 82(1), 150–168. Williams, S.  J. (2017). Improving healthcare operations: The application of lean, agile and leagility in care pathway design. Cham: Palgrave. Wilson, T. M., Berwick, D. M., & Cleary, P. D. (2003). What do collaborative improvement projects do? Experiences from seven countries. Joint Commission Journal on Quality and Safety, 29(2), 85–93. Womack, J., & Jones, D. (1996). Lean thinking: Banish waste and create wealth in your corporation. New York: Simon and Schuster.

CHAPTER 6

Case Study: Improving a Pulmonary Rehabilitation Programme – A Co-produced Approach

Abstract  This chapter provides a case study of research undertaken in the UK which examines improving the provision of a pulmonary rehabilitation programme by engaging with patients. From undertaking experience-­ based interviews with staff, patient and relative participants and patient-led workshops and mapping activities it was possible to implement a number of Plan-do-study-act cycles of change. Drawing on the principles of Experienced-based co-design and a conceptual co-production model we illustrate the wider learning for co-producing improvement activity from this case. Keywords  Pulmonary Rehabilitation (PR) • Co-design • Co-production • Experience-based Co-design (EBCD) • Plan-Do-­Study-Act (PDSA) • Lean thinking • Quality Improvement

Introduction This chapter presents a case study which draws on the redesign activity for a long-term respiratory condition, chronic obstructive pulmonary disease (COPD) pathway. The improvement activity of this pathway has been reported elsewhere (Williams 2017; Williams et  al. 2019). Here we are interested in a specific part of the pathway, the Pulmonary Rehabilitation (PR) programme and how patients have been involved in making improvements to the service. © The Author(s) 2020 S. J. Williams, L. Caley, Improving Healthcare Services, https://doi.org/10.1007/978-3-030-36498-4_6

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The involvement of patients and the public in improvement projects can be beneficial but requires careful management if its full potential is to be realized (Armstrong et al. 2013). Justifications for involving patients in improvement projects are broadly similar to those for involvement in healthcare more generally. They include framing patients as the users and funders who have a legitimate stake in health services and are entitled to influence the (re)design of services (Bate and Robert 2007). This case research was conducted in one hospital based in the UK. From conducting redesign workshops with patients and semi-structured interviews with healthcare professionals, patients and relatives, our analysis provides details of the co-produced improvement activities. The aims of this chapter are: • To describe the co-designed improvement activities undertaken with patients to improve the design and delivery of a PR programme. • To review these activities in relation to models and approaches used in co-design and coproduction.

Background to the Case Study This case was undertaken within a hospital setting within the UK.  The primary focus was services for respiratory patients, in particular those with Chronic Obstructive Pulmonary Disease (COPD). This is the name for a group of progressive lung diseases which includes emphysema and chronic bronchitis. Having mapped the COPD pathway (defined as patient journey from diagnosis to post diagnosis, to post-diagnosis including care management in the community) as part of a wider improvement project (see Williams 2017) key transition points in the pathway were identified where patients might (un)willingly exit from receiving care. Pulmonary Rehabilitation (PR) was one of these junctions that required further attention. Pulmonary rehabilitation (PR), a specialised programme of exercise and education, is reported to be an effective intervention for some respiratory patients. In the UK PR classes often have long waiting lists with referrals coming from several sources including respiratory consultants, GPs and specialist nurses. Dropout rates and patients not attending are often issues for those managing and running the classes (Healthcare Quality Improvement Partnership 2018). Therefore there is a need to understand the problem of poor patient participation (Nici and ZuWallack 2012).

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Patient engagement is seen as being fundamental to the participation and completion of PR programmes (Efraimsson et al. 2011).

Quality Improvement Activities This case study broadly followed the design of a Lean improvement programme (see Fig. 6.1) which included a series of small cycles of change using the Plan-Do-Study-Act methodology (also used in the Model for Improvement (Langley et al. 2009) (see Fig. 6.2). The starting point for the PR improvement project was defining the problem which reflected the UK national picture for PR services: long waiting times and the need to reduce non-attendance and drop-out rates. The team gathered baseline data to help quantify and evidence these issues. From conducting experience-based interviews with staff and patients it was possible to create a high level map of a typical patient journey (value stream) from referral through to completion of the PR programme to moving on to maintenance classes in the community. This map helped the team to identify the source of the non-value adding activities such as delays and long waiting times. Although PR was viewed positively by many patients who had completed the programme, the data showed there were as many patients who were referred and never attended or completed the programme. A number of small cycles of change using the PDSA methodology were introduced (see Fig.  6.2). These included the introduction of patient Value • Experiencebased interviews with patients and staff • Problem statement – e.g. long waits for PR programme and poor patient engagement

Value stream (pathway) • High level maps of Respiratory pathway and Pulmonary Rehabilitation Programme • Identified transition points in the PR pathway where lose patients • Collected base line data -

Flow • PDSA cycles to improve access to and information about the PR programme • See Figure 6.2 for details

Pull

Perfection • Involvement of patients and volunteers in the improvement project • E.g. patient volunteers & re-design of patient information sheets

• Sustained involvement of volunteers • Possible roll out to other programmes within the area

Fig. 6.1  Stages of Pulmonary rehabilitation improvement programme. (Source: Compiled by authors)

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Plan Act

Do

Introduction of patient volunteers to one PR class • Evaluating outcome of intervention

Study

Plan Act

Do

Introduction of patient volunteers to one maintenance (community-based) class

Study

Plan Act

Do

Introduction of patient volunteers to one in-patient respiratory ward in the hospital

Do

Patient-led redesign of PR information leaflet

Do

Patient-led design and development of PR website

Study Plan Act Study

Plan Act Study

Fig. 6.2  PDSA cycles of change to improve flow. (Source: Compiled by authors)

volunteers to the PR programme. It was evident from the interviews with patients that key transition points in the pathway such as attending the first PR class or transferring to maintenance classes in the community were difficult for some patients. Members of the PR team along with patients discussed various options that might help with these transition points. A number of PDSA change projects were introduced including the ­introduction of patient volunteers at the PR class, wards and community maintenance classes.

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Co-design and Co-production Activities From the experience-based interviews with patients it was apparent that many of their frustrations were around the availability and sources of information. It was evident that some patients did not feel sufficiently informed about the potential benefits of attending a PR programme, the reasons why they had been referred or what they might expect. Three design workshops were undertaken with nine PR patients who volunteered to review the design of the existing patient information leaflets given to patients with COPD. The patients worked in small groups and reviewed the text and visuals. Suggested modifications were shared across the three groups. Initial changes were agreed by the group and revised patient leaflets were drafted for review at the second workshop. Further changes were proposed and the changes were approved by the group during the third workshop. In total three leaflets were redesigned by the patients. The new leaflets were presented at the monthly staff meeting for review. A few minor amendments were made – mainly for accuracy – and then sent to senior managers/clinicians for final approval. Patients were also involved in designing a pulmonary rehabilitation website. This again involved writing and reviewing text and contributing to patient videos. A similar review and approval process was undertaken with the patients and staff. The PR team was able to show an increase in patient satisfaction and once patients joined the programme more of them were completing the programme.

Implications and Learning for Co-producing Improvement It is intented to follow up with further focus groups on an annual basis to enable the team to ensure the information on the PR programme continues to meet the needs of its patients. The team will continue to monitor and evaluate the volunteer programme with the possibility of extending to other therapies and services. The experience-based approach used in this case tries to ensure the patient voice is captured and is central to the redesign of the service (Bate and Robert 2006, 2007). This study has highlighted the critical points in the patient PR journey where specific interventions may assist in ensuring continuity of service when patients and information crossing organisational or functional

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boundaries. In Table 6.1 we have summarised the approaches to QI and patient involvement used in the PR programme along with the strengths and weaknesses of each of the PDSA improvement cycles. To further Table 6.1  Summary of the PR improvement and co-production activity Case study project

Aims of the project

Pulmonary Improve the rehabilitation quality of (PR) project care and outcomes for COPD patients Improve attendance and completion rates for the PR programme

Source: Compiled by authors

QI Methods

Involvement model

Critical factors/ learning/outcomes

Process mapping of COPD pathway and PR programme PDSA cycles of change (see Fig. 6.2) Redesign of information materials Introduction of patient volunteers at critical transition points in the pathway e.g. inpatient ward, PR programme and maintenance classes in the community

Involvement of PR patients in redesign workshops Introduction of patient volunteers to the PR programme Patient experience interviews and patient focus groups

Patient focus groups and design workshops identified ways to improve communication and identified further areas of improvement. Active and ongoing of patients involvement was feasible and beneficial – Especially the volunteers. Earlier involvement of patients would have identified the design of the project Further engagement with wider PR staff team to gain buy-in to support proposed changes Interactions between patients and professionals increased the persuasive power of those advocating improvement. Need to ensure recruitment of volunteers/patients considers diversity of (local) patient population

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explore the learning from this case we use two co-production models to assess the level of involvement within this Lean improvement activity. PR Case and Batalden et al.’s Co-production Model The first model is that of Batalden et  al.’s (2016) conceptual framework which we found helpful to think about where, in the different stages associated with co-production, the activity sits and to what extent, in terms of engagement, the case has addressed issues around public and patient involvement. This is helpful to consider in the design of the rollout and spread of the co-produced activity and the extent of engagement that is needed. We considered the outcomes and level of involvement within the case study using Batalden et al.’s (2016) conceptual co-production model. As this was an existing programme it was not possible for patients to be involved in the original design and planning of the programme or the information. All the activity focused on the redesign of the information sources that had been previously designed by the clinical team. The co-­ production model does recognise that patient participants are members of the wider community and the need to ensure those participating in the workshops were representative of these groups. The selection of the group was based on volunteers from the PR programme which may have provided a limited view of perspectives and experiences. The model is helpful to expand the level of involvement to pre-programme and the wider community (e.g. outside of those participants who have experienced PR. PR Case and the Experience-Based Co-design Approach From reviewing this case study it would seem that an adapted approach to experience-based co-production has been taken, which the Point of Care Foundation (2019) recognises might be needed when resources and time is limited. It is important however, to evaluate and assess the reasons for and the extent of departure from the prescribed approach. We draw these comparisons in Table 6.2. The Point of Care Foundation (2019) emphasises the importance of a steering group which is to meet at critical stages in the EDCD process (e.g. before the start, before feedback events, after the first co-design group and after the celebration). A steering group was not appointed for the case study due to limited funds and time. Reaching out to a wider group may have been helpful in managing the challenges of engaging with

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Table 6.2  EBCD and the PR Case study EBCD stages

PR case study

Observe clinical areas – gain an understanding of what is happening on a daily basis Observation of COPD pathway undertaken by researcher Process map completed to visual pathway

Observation of COPD pathway undertaken by researcher Process map completed to visual pathway Experience-based interviews undertaken with staff, patients and relatives about experiences of pathway – niggles and good practice (audio-recorded) Interviews transcribed and analysed and some data used to annotate process map

Experience-based interviews undertaken with staff, patients and relatives about experiences of pathway – niggles and good practice (audio-recorded) Interviews transcribed and analysed and some data used to annotate process map Feedback sessions held with some members of the team to identify areas for improvement Held focus group with patients and asked for volunteers to assist in redesign activity Held 3 design workshops over 6 month period Held feedback workshops with patient groups in the community

Feedback sessions held with some members of the team to identify areas for improvement Held focus group with patients and asked for volunteers to assist in redesign activity Held 3 design workshops over 6 month period Held feedback workshops with patient groups in the community

Adapted from The Point of Care Foundation (2019)

the wider staff groups and communicating the benefits of the project and the potential of spreading the learning from the case to other PR programmes, therapy services and patient volunteer programmes. Other key points of the EBCD approach that are useful for us to reflect upon are: 1. The need to focus on patient and staff experiences and emotions rather than attitudes. In this case we tried to capture experiences and emotions using experience-based interviews and using a process map to illustrate patient, information and emotion flows. 2. Use of storytelling to identify opportunities for improvement and focus on the usability of the service for patients and families. Storytelling was not a method employed within this case. Although experiences were captured during the interviews and for the web-

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site. The process map was the main source used to identify areas for improvement. 3. It empowers staff and patients to make changes. Improvements were made to the patient leaflets which were led by patient groups and endorsed by staff. 4. EBCD is a qualitative approach which provides rich insights into the experience of patients. The experience based interviews used for the case study provided rich insights to design and operation of the existing COPD pathway and the PR programme. Areas for improvement were also identified. 5. EBCD is reported as an adaptable approach which can be tailored for different situations (e.g. budget). The approach taken for the case does not follow all the stages associated with EBCD or the accelerated version. Experiences were audio-recorded rather than by video. Using film is reported to provide users/patients with a voice. Other studies have used stock videos instead of filming their own services users, which has produced positive results (The Point of Care Foundation 2019). The PR case study has taken an adapted approach to EBCD.  It has combined the use of process mapping and identification of small cycles of change (e.g. PDSA) with experience-based interviews and patient-led redesign workshops. The use of videos to capture patient and staff experiences was not used. Although resource intensive such narratives could be useful for the spread of improvement activity and wider engagement of patients, staff and members of the community.

What’s Missing? In this case, patient involvement largely relies on volunteers which were relatively easy to recruit from those attending current and existing programmes. It is difficult to assess whether these volunteers are representative of the COPD patients within the community the programme serves. It would be helpful to provide details of the strategies used and what else might be needed if recruitment is an issue. It is anticipated with any rollout of a volunteer programme of this kind that careful planning and monitoring will be required to ensure diversity, engagement and sustainability of the volunteer model.

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It is evident that not all of the stages of the EBCD cycle were included in the case. An evaluation study of EBCD reports the evolution and adaption of the approach over the time to take account of local organisational context and processes – but the authors stress the need to retain the central tenants of the approach (Donetto et al. 2014). The activities reported to be most used were patient and staff co-design meetings, small co-design groups to work on improvement activities, staff interviews, patient interviews and the celebration event. In the PR case the filming of patient interviews (used for website rather than identifying areas of improvement) and the celebration event were omitted. Both of these activities would have been helpful to engage and inform the senior management team and wider PR team who were not directly involved in the improvement activities. Efforts were made to collect baseline performance data on waiting times, non-attendance and completion rates. It was difficult to ascertain the quality of these data. Similarly, it is difficult to evaluate the cost and benefits of including patients within this improvement activity. Measurement and evaluation are areas that clearly require attention within any integrated co-produced quality improvement approach.

Conclusions We have provided examples of how the PR team engaged with patients in order to improve the design and delivery of the PR programme. We offer this case study to illustrate how a co-design activity might be undertaken and how improvement tools such as value stream and/or process mapping can be helpful to identify small cycles of change where patient involvement is crucial. We highlight areas where patient involvement could have been greater. Many of the issues we have raised in this text around representation, evaluation and sustainability of co-design and co-production are present within the case and therefore require careful planning and monitoring in future activity.

References Armstrong, N., Herbert, G., Aveling, E., Dixon-Woods, M., & Martin, G. (2013). Optimizing patient involvement in quality improvement. Health Expectations, 16(3), 36–47.

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Batalden, M., Batalden, P., Margolis, P., Seid, M., Armstrong, G., Opipari-Arrigan, L., & Hartung, H. (2016). Coproduction of healthcare service. BMJ Quality and Safety, 25, 509–517. Bate, P., & Robert, G. (2006). Experience-based design: From redesigning the system around the patient to co-designing services with the patient. Quality and Safety in Health Care, 15(5), 307–310. Bate, P., & Robert, G. (2007). Bringing user experience to healthcare improvement: The concepts, methods and practices of experience-based design. Abingdon: Radcliffe Publishing Ltd. Donetto, S., Tsianakas, V., & Robert, G. (2014). Using experience-based co-design (EBCD) to improve the quality of healthcare: Mapping where we are now and establishing future directions. London: King’s College London. Efraimsson, E. O., Fossum, B., Ehrenberg, A., Larsson, K., & Klang, B. (2011). Use of motivational interviewing in smoking cessation at nurse-led chronic obstructive pulmonary disease clinics. Journal of Advanced Nursing, 68, 767–782. Healthcare Quality Improvement Partnership. (2018, April). National COPD Audit Programme Pulmonary rehabilitation: An exercise in improvement National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme: Clinical and organisational audits of pulmonary rehabilitation services in England and Wales 2017 National report. Available at https://www.hqip.org. uk/wp-content/uploads/2018/04/COPD-National-repor t-2018Pulmonary-rehabilitation-an-exercise-in-improvement.pdf. Accessed 20 Oct 2019. Langley, G., Moen, R., Nolan, K., Nolan, T., Norman, C., & Provost, L. (2009). The improvement guide: A practical approach to enhancing organisational performance (2nd ed.). San Francisco: Jossey-Bass. Nici, L., & ZuWallack, R. (2012). An official American Thoracic Society workshop report: The integrated care of the COPD patient. Proceedings of the American Thoracic Society, 9, 9–18. The Point of Care Foundation. (2019). What is experience-based co-design? Available at https://www.pointofcarefoundation.org.uk/resource/experience-based-co-design-ebcd-toolkit/step-by-step-guide/1-experience-basedco-design/. Accessed 4 Aug 2019. Williams, S.  J. (2017). Improving healthcare operations: The application of lean, agile and leagility in care pathway design. London: Palgrave Pivot. Williams, S. J., Beadle, H., & Turner, A. (2019). Experience-based co-design as a means to improve a pulmonary rehabilitation programme: A UK case study. International Journal of Health Care Quality Assurance, 32(5), 778–787.

CHAPTER 7

Case Study: Improving a Community Based Huntington’s Disease Service – A Family-­ Centred Approach

Abstract  This chapter provides a case study of research undertaken in the UK, to examine the improvement activities of a community-based Huntington’s Disease specialist multi-disciplinary team. From undertaking experience based interviews with staff, patients and relatives and observing relative and patient group meetings it was possible to map a generic patient journey. Using the principles of person-centred care and a conceptual co-production model, we discuss the wider learning for co-­producing improvement activity from this case. We recognise the provision of Huntington’s Disease services will differ across the UK and therefore the involvement models illustrated here may not be fully applicable to all service models for this complex long-term condition. Keywords  Co-production • Huntington’s Disease (HD) • Person-­centred • Family-centred • Multi-disciplinary • Patient and public involvement (PPI) • Plan-Do-Study-Act (PDSA) • Model for Improvement

Introduction This chapter reports on a case study, which draws on the co-produced redesign activities of a community-based Huntington’s Disease (HD) team. The redesign of this HD service using Lean thinking and architecture of supply chains has been reported elsewhere (Williams 2017). © The Author(s) 2020 S. J. Williams, L. Caley, Improving Healthcare Services, https://doi.org/10.1007/978-3-030-36498-4_7

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Here we are interested in the family-centred activities that the team introduced and how staff, patients and relatives have been involved in making improvements to the service. We use Batalden et  al.’s (2016) co-production framework to help analyse the extent of the co-production activity. The case research was conducted with a multi-professional, community-­ based service delivered in one region of the UK.  From interviewing healthcare professionals, patients and relatives our analysis provides details of the family-centred improvement activities. The aims of this chapter are: • To describe the role of person-centred care within a complex patient pathway such as HD. • To describe the family-centred activities undertaken with patients and relatives to improve the design and delivery of an HD service. • To review these activities in relation to models and approaches used in person-centred care and coproduction.

Background to the Case Study This case was undertaken within a community care setting within the UK. The HD pathway was mapped as part of a wider project (for further details see Williams 2017). In this case we provide further details of the person-centred and co-production activity which we believe are central to the design and delivery of this HD service. Huntington’s disease (HD) is a genetic neurodegenerative disease and is characterised by motor disorder, emotional changes and cognitive decline. Unfortunately, at present, there is no treatment available to slow or prevent the progression of the disease, but several potential disease-­ modifying treatments are under development (Tabrizi et  al. 2013). Previous HD research has largely focused on clinical and educational interventions. Little research examines the design of service models or the HD patient care pathway. People with HD have multiple complex needs, and therefore require multifaceted care that is complex to deliver (Mestre and Shannon 2017). Intuitively, the complexity of the care in HD calls for the participation of different healthcare professions. Mestre and Shannon’s (2017) multidisci-

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plinary model of HD care draws on medical specialists (e.g. neurologists, psychiatrists, psychologists), specialised nurses and allied health professionals (e.g. physiotherapists, occupational therapists, dieticians). Arguably there is a need for recognition of the importance of a patient-centred approach and caregiver support and guidance. In some areas of the UK, services involve multi-disciplinary teams whereas in other areas the service is reliant on one specialist nurse who makes referrals into other services. Many HD patients are highly dependent on family members, who may also be at risk of inheriting the disease and/or have children/siblings who are at risk of HD (Vamos et al. 2007). A recent study evaluated an intervention designed to assist carers of HD patients in developing their knowledge-base and methods for coping with the symptoms of HD (Dale et  al. 2014). In addition to the reported increase in knowledge of, and confidence in their ability to care for HD sufferers, the carers identified three areas thought to be beneficial from the intervention. First, they valued the practical advice received and the information on coping strategies. Second, were the benefits of spending time with other carers, and third was the value of group discussions that were included in this improvement activity.

Quality Improvement Activities This case study broadly follows the design of the Model for Improvement (Langley et al. 2009) which included creating a high-level map of the HD pathway detailing the patient journey from referral (including self-referral) to HD clinic and specialist nurse to (in this case) the support from a specialist multi-disciplinary team based in the community  – see Williams (2017) for further detail. The aim of this multi-disciplinary HD team was to deliver a co-­produced family-centred service, by providing an enabling model of care, which helped patients and families to navigate a complex system in order to optimise their quality of life and functioning throughout their lifespan. Discussions (partly instigated from a patient/family survey) focused on the need to extend the service to include family-centred interventions as well as patient-centred interventions. The completion of a high-level ­process map helped to identify the key stages within a ‘generic’ HD patient journey. After the initial stage of diagnosis, the progression of the disease

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and the type of interventions (e.g. mental health, cognitive/emotional and motor symptoms (HDA 2016) required varies for each patient  – therefore the service needs to be proactive, flexible and ‘customised’ according to need. This is not to say there is an unlimited offering of interventions, but these are initiated by the team as and when required. Each patient has a designated member of the team to coordinate their care. From weekly multi-disciplinary team meetings current and future needs of the HD client and family are considered and interventions planned. The team also manages external referrals to clinicians and services outside of the team’s skill set e.g. dieticians, mental health professionals, palliative care services, community dentists. The team recognised that increasingly their work was supporting not only patients but also family members to access services outside of the healthcare system (e.g. housing, welfare, education) by working closely with statutory agencies and accessing Support Workers and the Voluntary sector services. The multi-disciplinary nature of the team enables it to support one another to hold difficult situations, assess and manage risk and continually review the needs of the HD families. The team wanted to extend their service to include some family-centred interventions.

Person-Centred and Co-produced Activities Data were collected by undertaking experience-based interviews with healthcare professionals (HD team members), patients and relatives/carers to understand the current design of the service model and patient care pathway and observations of the interventions. The team also administered a patient and family satisfaction survey which provided baseline data. In response to feedback from the families and patients, the team introduced two interventions as PDSA cycles of change: 1. Monthly Family Group Meetings, which provided relatives with the opportunity to share experiences with other relatives in a safe and supportive environment, and patients, participated in task-focused activities including food tasting, gaming etc. 2. A Walking Group which was open to both patients and relatives. In addition to these activities, some of the family members set up a Facebook site, which enabled them to continue their communication and support to one another outside of the team-led activities.

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Implications and Learning for Co-producing Improvement It is the team’s intention to continue to work with families to identify other interventions. Similarly, the team will continue to collaborate with other services to support the proactive and flexible service they strive to provide for their patients and families. In Table 7.1 we have summarised the approaches the QI and patient/ family involvement used by the HD team along with the strengths and Table 7.1  Summary of the HD improvement and co-production activity Case study project

Aims of the project

QI Methods

Involvement model

Critical factors/ learning/ outcomes

Huntington’s disease (HD) project

Improve the quality of care and outcomes for HD patients and their families Introduce family-centred interventions

Process mapping of HD pathway Model for improvement – PDSA cycles of change Introduction of family-centred interventions – Family group meetings & walking groups

Involvement of families in the design of the monthly group meetings Patient and family experience interviews Family-led interventions – Facebook page

Active and ongoing patient and family involvement was feasible and beneficial. Earlier involvement of families would have helped to identify other interventions. Interactions between families and professionals increased the persuasive power of those advocating improvement. Need to ensure recruitment of volunteers/ patients considers diversity of (local) patient population

Source: Compiled by the authors

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weaknesses of the improvement cycles. To explore further the learning from this case we use two models to assess the level of involvement within this improvement activity.

From Person-Centred Care to Family-Centred Co-produced Care Multi-disciplinary working enables the team to offer a flexible, accessible and responsive service that is personalised to the needs of the patient and their family. Working more closely with families through the monthly support sessions enables the team to better understand the wider support required from other services. The team has developed its knowledge of local and regional services so they are able to signpost or assist their patients and families to access these if needed. Figure 7.1 summarises the knowledge and activities of person-centred approaches that the team has enabled through the person-centred care Framework. The knowledge supporting the person-centred approach advocated by the team was their awareness and knowledge of services and resources available to their patients and families. Much of this was  established through developing good relations with local councils, health services and charities. The team viewed patients and families as assets – in that they had

Activities • • Awareness of local services The core of • and resources Person- • Asset based approach centred • Quality improvement • care Looking beyond traditional health and social solutions •

Knowledge • • • •

Shared decision making Care coordination Care & support planning Signposting Managing risk Integration of services across sectors Working in partnership at individual and service level

Fig. 7.1  Knowledge and Activities of person-centred approach used by the HD team. (Source: Compiled by authors)

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experience and knowledge of HD that was valuable to the running of their service. The team were keen to continue to develop and redesign their service and explore ideas and opportunities to improve, which included looking beyond the usual clinical interventions to include the family and possibly the wider community. The types of activities the team premised their person-centred approach on were: • Shared decision-making within the team and with patients and their families; • Care co-ordination – each patient allocated a member of the team to coordinate their care; • Weekly team meetings to support planning and monitoring of care; • Signposting to other services within and outside of the region; • Multi-disciplinary nature of the team enabled them to manage risk more appropriately, • Integrated working promoted across disciplines and organisations; and • Partnership working with charities, local councils and other organisations to meet individual patient needs as well as organisational synergies and benefits. As HD is a genetic disorder it is possible that family members have already cared for and may have lost relatives to the disease, hence, some participants describing the need for care to be family-centred, rather than patient-centred in order to accommodate the wider social issues of HD. The staff participants spoke about how it was necessary to work with members of the family as well as the patient. The wellbeing of carers was of particular importance to both the team as well as the patient.

Co-producing HD Family-Centred Services This case goes beyond patient consultation and engagement to a service model, which positively engages the wider social system (Realpe and Wallace 2010). Considering Batalden et al.’s (2016) model we describe how the HD service model links to co-production and identifies where the team and the families could continue to strengthen the co-production elements of the service.

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Thinking more broadly about the interactions across various services there are clear links between the specialist HD team and other services within health and social care along with other services such as housing, education and third sector organisations (e.g. counselling services). In the first instance, communication is likely to be via members of the HD team. For example, there are interactions and interventions (e.g. family group meetings and walking groups) between the team, patients and families. Initially these were instigated by the HD team based on feedback from families, but more recently the interventions have been developed and led by patients and their families (e.g. Facebook page and communication outside of the group meetings). To enhance the family-centred approach of this service model further other community groups and third sector organisations could be approached to develop interactions and interventions that would benefit the HD patients and families. Revisiting the high-­ level process map pathway might help the team and families to identify and prioritise areas of co-designed improvements to provide better value and family-centred activities. Batalden et al.’s (2016) model indicates three levels of co-production are central to producing high value co-produced healthcare services. The three levels can be found within the HD case and act as a good foundation in which to build further activity. 1. Co-planning – after the initial meeting families were involved in the planning of the monthly family meetings and walking groups 2. Co-execution – the families became central to setting the topics for discussion at the family meetings 3. Civil discourse – was central to the initiation and continued support of the family-centred interventions. Batalden et  al.’s (2016) model encourages a systems view of co-­ production expanding outside of healthcare to include other services and community groups. This case has started to explore family-centred interventions which engage with other services. The families involved are also developing their own interventions which link to a wider community group of other family members and friends. Batalden et  al. (2016) suggest a combination of these activities leads to high value co-produced health services.

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What’s Missing? This case study is limited to one service in the UK.  The service is community-­based and has a dedicated multi-professional team. It is likely that services elsewhere in the UK and further afield will be structured differently both in terms of the profile and location of the team. In some instances there may not be a dedicated team or this may be limited to a specialised role. In this case engagement with, and reliance on families, may be greater; their role in redesign and improvement activity would also be of significance. As with other patient-led or in this case family-led activity, the reliance on volunteers is apparent. Representation within these groups is important in that it reflects the needs of the wider population of patients and their families. What is not evident in this case, but perhaps implied is the flat hierarchy and a movement away from the traditional medical model where the clinician knows best. Other important issues we raised earlier in this text around shared voices and shared responsibilities are again relevant to this case but not necessarily explicit for others to emulate. The involvement of family members is pertinent to this HD case study. We recognise that this might not be the case for other conditions. Much of the co-production literature to-date refers to engagement with patients. However as we demonstrate, some conditions require the inclusion of the wider family network. The literature refers largely to person-centred care. Little reference is made to family-centred care, particularly for complex conditions such as Huntington’s disease. It would be helpful to understand whether there are additional enabling and inhibiting factors to be considered and what the benefits to families are.

Conclusions We have provided examples of how the HD team has adopted a family-­ centred approach which sits at the heart of their multi-disciplinary model of care. Using process mapping we were able to understand how the pathway operates and what elements of care need to be personalised to the patients and their families. Using existing frameworks we have illustrated the extent of the person-centred and co-produced activity.

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References Batalden, M., Batalden, P., Margolis, P., Seid, M., Armstrong, G., Opipari-Arrigan, L., & Hartung, H. (2016). Coproduction of healthcare service. BMJ Quality and Safety, 25, 509–517. Dale, M., Freire-Patino, D., & Matthews, H. (2014). Caring with confidence for Huntington’s disease. Social Care and Neurodisability, 5(4), 191–200. Huntington’s Disease Association. (2016). Huntington’s Disease Association. (2012). Available at http://hda.org.uk/hd. Accessed 16 June 2019. Langley, G., Moen, R., Nolan, K., Nolan, T., Norman, C., & Provost, L. (2009). The improvement guide: A practical approach to enhancing organisational performance (2nd ed.). San Francisco: Jossey-Bass. Mestre, T., & Shannon, K. (2017). Huntington disease care: From the past to the present, to the future. Parkinsonism and Related Disorders, 44, 114–118. Realpe, A., & Wallace, L. M. (2010). What is co-production? London: The Health Foundation. Tabrizi, S., Scahill, R., Owen, G., Durr, A., Leavitt, B., Roos, R., et al. (2013). Predictors of phenotypic progression and disease onset in premanifest and early-stage Huntington’s disease in the TRACK-HD study: Analysis of 36-month observational data. The Lancet Neurology, 12(7), 637–649. Vamos, M., Hambridge, J., Edwards, M., & Conaghan, J. (2007). The impact of Huntington’s disease on family life. Psychosomatics, 48(5), 400–404. Williams, S.  J. (2017). Improving healthcare operations: The application of lean, agile and leagility in care pathway design. Palgrave Pivot, London: Palgrave Publishers.

CHAPTER 8

Co-producing Quality Improvement: Cases from the Published Literature

Abstract  From a sparse literature we selected five contrasting papers concerned with patient and public involvement, co-design, co-production and quality improvement, with the intention of gaining understanding of how these approaches are viewed and applied in the development of safe healthcare delivery practices. We were particularly interested in a number of areas of confusion and debate and have reported on the case studies using this lens. Keywords  Quality improvement • Patient and public involvement • Co-production • Co-design

Introduction In this chapter we review five published case studies on patient involvement/co-production and quality improvement. We wished to understand a number of things such as: 1. The way that public and patient involvement and co-production were defined in the literature; 2. The extent to which the involvement of patients and service users was prevalent in research and quality improvement work; 3. Questions about who, why and how in improvement activity; and

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4. Whether there were similar challenges recognised and addressed in varying contexts. Time precluded us from undertaking a systematic review of the literature, and in the event it proved difficult to find examples that combined the two approaches. We are not alone in finding this the case; Armstrong et al. (2013) also note that there is limited published work examining the role of patient involvement in quality improvement. Similarly, Ocloo and Matthews (2016, p.  26) outline various reasons why achieving genuine patient involvement presents challenges, before concluding that current involvement practices at a national and local level often involve a narrow group of individuals….

While they mainly refer to the lack of diversity of patient involvement in healthcare improvement, they also cite concern about the representativeness of patients within the research arena that seeks to provide evidence to underpin wider involvement. Some of the most vulnerable patients are often excluded from research exploring the involvement of patients in patient safety. Patient and public involvement in quality improvement activity is often limited and may not reflect the reality for some of the most vulnerable patients and their families (Ocloo and Matthews 2016). Our choice of case studies reflects the range to be found in journals and other sources. We accessed search engines using search terms “public and patient involvement”, “Co-production” and “quality improvement” and from the few available selected what we believe to be a representative range. Note that they are all recent publications, reflecting the increased interest in this area. In each section we describe the reported case and then critique the report with reference to the approaches described, the manner in which success was judged, the degree of generalisability/transferability of each case, and the way that issues and challenges were dealt with.

Case 1: Patient Involvement in Quality Improvement Armstrong et al. (2013) provide three case studies, which illustrate contrasting approaches to involving patients in quality improvement projects. In addition, they identify the strengths and weaknesses of each of the approaches. They remind us that public and patient involvement (PPI) in

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quality improvement projects raises specific challenges when trying to improve and/or redesign services, particularly to achieve the changes that they might seek (Dixon-Woods et al. 2012). PPI does not follow a “one-­ size-­does –not fit all” approach as indicated by the different involvement models and QI methods used within the three case studies. The paper draws on a funded evaluation of three projects of a larger programme of improvement initiatives; PPI was mandated as part of the contract. Each articulated a different rationale for involving patients, and there were variations in perception about who should be involved in terms of representativeness and how to ensure that PPI is not side-lined or subverted due to lack of familiarity with the system and power differentials. Armstrong et al. (2013) suggest that PPI can sometimes be perceived as more about legitimising managerial and professional decisions that have been made anyway. So ambiguity about the value of involving patients in QI exists. The paper proposed a number of key features that are likely to increase the value of PPI for a QI project: 1. Involve the patient representative early, for example at protocol design phase which will ensure that the patient voice is heard at the planning stage and will enable a more rapid understanding of the challenges to be gained by the patient rep(s); 2. Have effective communications channels – both formal and informal – this helps with flexibility, understanding and more rapid decisions to be made; and 3. Give the patient rep(s) clearly defined roles taking time and effort to establish. The paper concluded that patients can make distinctive contributions as persuaders providing a means of influencing opinion and debate from differing perspectives and by acting as advocates across groups. Patients can also act as knowledge brokers, building links across and between groups and acting as mediators when required. There were some key generic messages drawn from across the three cases: • Level of involvement is contingent on the condition and what the project is trying to achieve; • Appreciate the time needed to achieve meaningful involvement;

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• Consider and clarify roles and expected contributions from patient involvement; • Ensure patients are prepared and trained for their expected level of involvement; • Develop effective and appropriate communication channels – both formal and informal – about the value of involving in QI; • Create a non-hierarchical structure to support PPI activity and engagement with all team members.

What’s Missing? Comparisons were made between the manner in which the selection of patients was made recognising that context and the nature of the clinical condition can affect the degree of involvement. There were some imaginative methods of involving patients but some that were less imaginative or effective. It would have been useful to have been provided with some quantification of the benefit and value of PPI but the paper noted that measures of involvement in PPI are not routinely found in audits. Focusing on the PPI element of each project precluded much debate about the precise nature of the QI project so it was not possible to judge the minutiae of involvement; it appeared that patients were engaged in committee and overview debates rather than any “hands-on” so no QI approaches were assessed. Some useful ideas around best practice in involvement were given. The paper usefully touches on issues of power differentials and this is an area that could usefully have been explored further.

Case 2: Co-production and Designing New Programmes Lwembe et al. (2017) evaluate the role of co-production in the development of new community mental health services for black and minority ethic services users. The cross-sector initiative brought together agencies including public health, a community organisation, mental health practitioners and patients to co-design and co-deliver, a Department of Health initiative “Improving Access to Psychological Therapies” (IAPT). This collaboration was based on co-production principles and the ethos of service users being ‘active asset-holders rather than passive consumers’, therefore promoting collaboration rather than paternalistic relationships between staff and service users (Lwembe et al., 2017, p. 16). The focus of

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the initiative was on the delivery of outcomes rather than the delivery of services. The overall aim was to recruit local residents to train as Mental Health Champions along with other activities (see Lwembe et al. 2017 for further details). The co-production framework included: • A defined role for each partner; • Operational decisions to be agreed by all; • Evaluation led by Public Health; • Project hosted by community group – which included training and engaging with local residents champions and outreach workers; • Patients encouraged to self-refer; • Referrals from GPs, from the IAPT or local resident; • Project delivered in the community supported by practitioner and expert patient. The evaluation study reports on the participation in the co-production process, which was first met by patients with suspicion. After conducting one-to-one sessions and conveying more details of the co-production process patient attitudes changed. Assessments from other agencies were positive towards the co-production process and regarded it as one of the key factors in gaining successful participation within the project. Patient participants reported feeling empowered and positive towards the opportunity to play an active role in the delivery of the service. The enabling factors of the co-production process included the engagement of an expert patient from the local community to co-facilitate the sessions, joint decision making by all stakeholders, cultural competency of the practitioners and the delivery of the intervention within the community setting. For this study, co-production was reported to offer a way to break down historical, systemic and socio-cultural barriers and to better target services to those most in need (Lwembe et al. 2017). The authors highlight the importance of adopting the co-production process from the start to ensure improved engagement and outcomes can be achieved.

What’s Missing? This case study provides valuable insight to the issues around engagement and participation in mental health services. What is less clear from this evaluation is the actual mechanisms, methods and perhaps framework used to guide this project. It is clear that co-production principles can be

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used to help design and deliver new services, as well as improve existing services. For this project (we accept this may not be the role of an evaluation) it would be helpful to clearly define source and details of the co-­ production principles used and provide further information on how these were operationalised in conjunction with the design and delivery activity. Given that many of us are still trying to operationalise co-production within healthcare more details are required on the ‘how’.

Case 3: Co-production of Knowledge for Practice Our third case study is drawn from a knowledge translation project which focused on developing a computer simulation model of an emergency pathway for acute ischaemic stroke with a view to minimising the time between the onset and treatment of the condition (Heaton et al. 2016). The paper addressed the question of what the theory of co-production adds to understanding of processes of knowledge creation and translation at one of 9 CLAHRCS (Collaborations for Leadership in Allied Health Research and Care). Earlier evaluation work done by the authors had identified 9 mechanisms associated with close collaboration; the paper reported on work undertaken to find whether there was a close fit between these mechanisms and recognised principles of co-production. Whether the mechanisms were active or not in the individual projects reflected subtle but important differences in the ways in which the partners collaborated on the projects. This paper uses the 9 mechanisms as a lens to examine the stroke case study. The principles examined: 1. Active agents – the end-user is King! Primacy is given to the needs and views of end –users – in this case clinicians; 2. Equality of partners – local end-user driven; 3. Reciprocity and mutuality – learn from each other – improves working relationships; 4. Transformative  – convincing through structures and processes  – credibility acceptability – pooled and utilised each other’s local and specialised knowledge resources and connections; 5. Facilitated – structures procedures that support collaboration. The pathway redesign was deemed to have been successful by end users.

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What’s Missing? This paper draws attention to differing views of what constitutes co-­ production and the who, why and how of its operation. The project team were seen as collaborators and this begs questions about whether collaboration is different from co-production. The team was made up exclusively of clinicians and researchers with no PPI involvement reported, although it appears that patients were part of allied project teams. The paper gives no indication of how success was measured apart from subjective feedback from clinician end-user partners in the project, which may be an oversight on the part of the authors.

Case 4: Patient Involvement in Improving Rheumatology Outpatients The paper by de Souza et al. (2016) reports on efforts made in a London hospital Rheumatology Department to involve patients with long term conditions in the running of the department with the aim of improving the service provided. The project was given the name GRIIP (Group Rheumatology Initiative Involving Patients) and had a finite life beginning 2013/2014. The paper reports that feedback from patients has been positive and concludes that patients can effectively contribute to service improvement provided they are supported, respected as equals and the organisation is willing to undergo a cultural change. Initial aims were to form an independent patient group (IPG); to initiate patient education evenings; and to develop a mobile app. In the case of the IPG, selection of participants was made by clinicians from their lists; diversity appears to have been a significant indicator but questions of representativeness seem to have ended here. Meetings were regularly scheduled but attendance appears to have been confined to patients only; the paper reports that minutes were taken, approved and then sent on to clinicians and managers. It might be argued that this would ensure openness and transparency of discussion but the model is one of psychological distance. Patient Education Evenings began with low takeup but improved over the period of time that they ran, which suggests that they were valued by patients, who were encouraged to propose topics for discussion. The paper describes a model of passive engagement with speakers drawn from clinical staff.

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The third element of the initiative was the design and development of a mobile app to inform and retain patient interest in their care. Patients were involved in the design to the extent that their views were sought and a “wish list” drawn up; clinical views were also sought although it sounds as though this was done separately.

What’s Missing? In terms of accepted principles concerning patient involvement, this initiative appears to be very weak. The authors conclude that patients can effectively contribute to service improvement, if supported and respected and equals in an environment of culture change. But the paper provides very little to convince that this is an exemplar of such an approach. 1. Evidence of “support” apart from the provision of rooms, timetables and contact details is not apparent. The model as described is one of distance and “us and them” rather than equal and transparent. 2. Equality as a relational approach is hard to identify from the description given; indeed it sounds like a conventional power disparity model. Communication as described is very formal and unidirectional. 3. Suggestions of culture shift are provided in the way that clinicians and managers receive and supposedly act on the minutes of the IPG, and the wish list for the mobile app, but there is clearly a way to go. Engagement between the patient group and the professional group sounds distant and “managed”. The paper does not claim to describe co-production and it has to be recognised that thinking has evolved over the last decade about who, how, and why patients should be involved in the shape of the services for which they are end-users. Nevertheless it would have been helpful to have been given some idea of the manner in which initiatives were chosen, progressed, and measured and why patients were seen as no more than information providers. Systematic quality improvements have been common for a decade and the issues that form the context for GRIIP make themselves ideally placed for QI model approaches, with a co-productive ­element embedded. But the paper does not explore the manner in which projects were designed, delivered, not what outcomes were anticipated. Some evidence of evaluation of effectiveness would have been helpful.

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Case 5: A Survey of Paediatricians Regarding PPI and Service Improvement Winch et  al. (2018) reported on a survey undertaken across the entire membership of the Royal Collage of Paediatrics and Child Health (RCPCH), designed to find out if Paediatricians felt that their organisation supported and encouraged public and patient involvement (PPI) in research activities and clinical improvement work. They were asked for their views about prevalence but also about what challenges they felt obstructed such involvement, and how the professional body, the RCPCH, could address the challenges. The context for such a survey lies in the extent to which PPI is now appropriately regarded as an important part of a research ethics submission and a funding application. Thus, PPI is not just good practice, but a crucial aspect of research conduct. The professional body has done much to encourage and support PPI over the last 10 years, but questions remain about the extent to which this is known and utilised by its membership. The online survey (n  =  4333) attracted a 44.4% response rate. Only 29.1% said that in their organisation PPI was central to research; 27% said that they were not sure; 26.5% said involvement was tokenistic; while 14.4% said that they believed that there was little or no PPI involvement in research undertaken in their organisation. When asked about PPI involvement in service improvement work 36% said PPI was central to this activity; 35.1% said that involvement was tokenistic; and 14.5% said that there was little or no PPI in service improvement. It is notable that the figures are closely aligned, suggesting that those organisations that encourage PPI in one element of improvement are the same organisations that encourage it in other elements. Challenges identified by respondents included lack of clinical time to enable PPI incorporation in research and service improvement, cited by 34.8% of respondents. Other challenges centred around problems of engagement, such as ensuring that views put forward by patient representatives were valid; lack of patient and parent time; difficulties of communicating research to patients and parents. Survey respondents also cited lack of support from their organisation as a challenge, including the non-availability of funding to support PPI activity.

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Winch et al. concluded that the majority of Paediatricians reported that they thought PPI was not central to their organisation with regard to either research or service improvement.

What’s Missing? From the publication date, 2018, we can conclude that views expressed are current in this fast changing environment of policy and practical evolution in the delivery of safe healthcare. Whilst recognising that the paper reports on the reality of just one specialty, paediatrics, we can conclude that the situation is broadly similar in most other specialties. A large survey conducted by the professional body attracted a low response rate and of those who did respond, only a minority reported positively to questions about PPI in two important and relevant areas of activity in healthcare delivery. It is notable that the professional body believes that they are promoting and supporting good practice but that this is not perceived and utilised “on the ground” which suggests that there are some communication difficulties that might be overcome. Although the challenges reported are real ones, it is arguable that they too might quickly be overcome given recognition of the benefits of involving patients and parents in research and improvement.

Conclusions From a sparse literature we selected five contrasting papers concerned with PPI and quality improvement, with the intention of gaining understanding of how these approaches are viewed and applied in the development of safe healthcare delivery practices. We were particularly interested in a number of areas of confusion and debate and have reported on the case studies using this lens. In the introduction to this chapter we posed a number of questions that we hoped the literature would address. In summary we can say that 1. the way that public and patient involvement and co-production was defined in the literature From the papers it is apparent that there remains some confusion about how terms are defined and the relationships between each of them. PPI may arguably be different from co-production in the extent to which the

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patient/service user role is perceived, with PPI being perhaps more advisory whereas the co-producer being more actively engaged in design and delivery. Collaboration is taken to mean a professional to professional link. This categorisation has emerged from the limited number of papers that we have surveyed and may benefit from wider testing. 2. the extent to which the involvement of patients and service users was prevalent in research and quality improvement work Given the small number of papers that we found it can be concluded that this practice is not widespread, and the paper by Winch et al. (2018) supports this conclusion. Even when claimed it is apparent that the extent of involvement can be quite low, such as that reported in the paper by de Souza et al. (2016). It might be argued that interest in the approach of involving patients and service users in improvement work is fairly immature and that there is a lag between activity and its reporting. It is notable that all of the papers selected here are recent publications and that we may look forward to many more in the years ahead. 3. questions about who, why and how in improvement activity Our sample of papers illustrates the variety of ways in which patient/ service users are selected to take part as representatives. The context and circumstances of each project will clearly influence who is chosen and who can make a forceful and relevant contribution to the team. But there is undoubtedly a feeling of opportunism in many selection choices. In response to the “why” question it is clear that funders are instrumental in requiring patient representation in much improvement activity, which then begs questions about the extent to which lip service is paid to the inclusion of patients and service users. How representatives are included, their clarity of role and responsibility, and the power differentials that exist in improvement teams, is variable and covertly reported in our selection of papers. 4. whether there were similar challenges recognised and addressed in varying contexts. One can argue that the challenges are more similar than many would admit, and that solutions are not as perplexing as could be surmised from the papers. The paper by Armstrong et al. (2013) is very helpful here in

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outlining principles for co-production and generic messages designed to enhance success. In conclusion we can say that the literature confirms the view that the field of co-production in quality improvement is in its earliest stages and would benefit from work to clarify and share experiences towards the enhancement of understanding amongst all stakeholders.

References Armstrong, N., Herbert, G., Avelin, E., Dixon-woods, M., & Martin, G. (2013). Optimizing patient involvement in quality improvement. Health Expectations, 16, e36–e47. De Souza, S., Galloway, J., Simpson, C., Chura, R., Dobson, J., Gullick, N., Steer, S., & Lempp, H. (2016). Patient involvement in rheumatology outpatient service design and delivery: A case study. Health Expectations, 20(3), 508–518. Dixon-Woods, M., McNichol, S., & Martin, G. (2012). Ten challenges in improving quality in healthcare lessons from the Health Foundation’s evaluations and relevant literature. BMJ Quality and Safety, 21, 876–884. Heaton, J., Day, J., & Britten, N. (2016). Collaborative research and the co-­ production of knowledge for practice: An illustrative case study. Implementation Science, 11(20). https://doi.org/10.1186/s13012-016-0383-9. Lwembe, S., Green, S., Chigwende, J., Ojwang, T., & Dennis, R. (2017). Co-production as an approach to developing stakeholder partnerships to reduce mental health inequalities: An evaluation of a pilot service. Primary Health Care Research & Development, 18, 14–23. Ocloo, J., & Matthews, R. (2016). From tokenism to empowerment: Progressing patient and public involvement in healthcare improvement. BMJ Quality and Safety, 25, 626–632. Winch, R., McColgan, M., Sparrow, E., Modi, N., & Greenough, A. (2018). Public and patient involvement in Child Health Research and Service Improvements: A survey of hospital doctors. BMJ Paediatrics Open, 2, e000206. https://doi.org/10.1136/bmjpo-2017-000206.

CHAPTER 9

The Role of Co-design and Co-production in Improving Healthcare Services: Conclusion and Future Research Agenda

Abstract  This chapter presents a short summary of the key findings from this study which explores how two concepts, co-design/co-production and quality improvement can be brought together to improve the design and delivery of healthcare services. In light of the results, we revisit the theoretical framework introduced in Chap. 1 and offer a conceptual model, which provides an integrated approach to co-producing quality improvement using Lean thinking. We consider what implications the study has for healthcare organisations and the key messages for practitioners and academics. The chapter culminates with a number of research propositions to act as a proposal for future research for scholars interested in integrating healthcare/service operations management, quality improvement and co-design/co-production to improve healthcare services. Keywords  Co-production • Co-design • Quality improvement • Model for Improvement • PDSA • Lean

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Introduction This final chapter brings together the various strands of research discussed within this text. In particular, it considers the learning from the theoretical lenses we introduced in Chap. 1 – service operations, quality improvement and co-design and co-production. This study is novel in that it looks for ways in which to integrate dominant QI approaches with popular co-­ design and co-production methods. To date it would seem that co-­ production and co-design and quality improvement have developed in parallel. We propose there is benefit in more closely aligning these activities as we see there is real opportunity in which to improve our efforts in both approaches. We recognise there are a number of practical implications that need attention when bringing these activities together. The final part of the chapter offers a research agenda in the form of a series of research propositions and some concluding reflections on this study.

Implications for Theory The interest in co-design and co-production and quality improvement in healthcare has certainly gathered pace but it seems that these two concepts have largely developed independently yet we believe there are synergistic benefits of an integrated approach. Nevertheless, we recognise there are challenges in operationalising this proposal particularly when we still have more to learn about the use of each of these in practice. We summarise our key findings in relation to the three theoretical lenses, which were used to frame our study: 1. Service Operations Management Service operations management provides a simple but useful model to view the interaction between the service provider and the service receiver and all that this entails (inputs, processes and outputs) (e.g. Johnston and Kong 2011; Johnston et  al. 2012). Providing healthcare is a complex business that requires careful planning, managing and monitoring of many processes and interactions between various stakeholders. The focus of this text has been on healthcare rather than other public services. Nevertheless, it is evident from our cases and the published literature that public services need to carefully review the implementation of QI approaches that have historically evolved from dominant product-based logic.

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­ iewing healthcare improvement through a services operation manV agement lens will encourage adaptation and adjustment for local context. A service dominant logic approach will enable service users (patients) to be seen as co-producers rather than receivers of services (care). Fuchs (1968) several decades ago pointed out that it takes two parties to make a service. Paul Batalden reminds us of this work at the start of this text. Both scholars state that this is obvious given the exchanges between patients/carers and practitioners. Therefore we need to support opportunities in which to learn about and effectively deliver person-centred or family-centred care. 2. Quality Improvement in healthcare Our focus in this text was on two popular quality improvement approaches in healthcare  – Lean thinking and the Model for Improvement. Although both models have been used in practice for at least a decade there is still much to learn about their application in healthcare. In this text we offer some suggestions for how QI can be more closely integrated with co-design and co-production thinking. In line with service dominant logic, this approach may help to encompass patient/service user views early in the improvement process as advocated by Lean thinking and other approaches to improvement. Often the patient voice is lost until mapping activity is underway. The empirical cases we have examined here relied on the use of high level process maps. Service blueprinting (for example see Radnor et al. 2014) is an alternative that will help to visualise the interactions between patients and service providers and identify opportunities for improvement. Similarly, the inclusion of tools such as the Kano model, SERVQUAL and Quality function deployment (QFD) will help to define value and integrate the patient’s voice into the service redesign process (see for example Materla et al. 2019). . Co-design and Co-production in healthcare 3 We have engaged with the literature and some of the practical activity undertaken within this growing sphere of co-design and co-­ production. Throughout this text, we have grappled with providing a recognisable definition for co-production (and associated derivatives). The term is used loosely and may already be in danger of losing meaning, as it moves more into mainstream management discourse and practice (Clark et al. 2017). It is important to appreciate the ‘messiness’ of co-production and encourage continual reflection

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throughout the improvement activity (Miles et al. 2018). Issues of power, power relations and questions of representation/inclusivity in co-production and co-design approaches still need to be addressed, along with questions around whether such activity fosters inclusion or reinstates existing social exclusions (Palmer et al. 2018). We have mentioned in previous chapters the issues of representation and inclusivity in co-production. For research, there may well be restrictions that make ethical sense insofar as patients cannot provide informed consent, but they skew the existing empirical literature by excluding the very patients that are central to the area of research (Ocloo and Matthews 2016). Those patients, relatives, citizens involved in quality improvement may not reflect the reality for some of the most vulnerable patients and their families, limiting generalisability of results and limiting the likelihood that interventions or approaches will lead to meaningful or lasting impact on service. More effort is needed in how we engage with those groups that are ‘hard to reach’. Seeking innovative ways in which to reach out to these groups is imperative if a co-production approach in improvement is to be successful. As advocated in EBCD there is a need to formally integrate the use of story-telling in improvement approaches, alongside the more popular methods such as observations and interviews. Consideration needs to be given to how narratives are used to ensure improvements are not based on one or two illuminating and emotive stories. Emotional mapping (see Johnston et al. 2012) is one method that can be used to enable these stories to be meaningfully included in the improvement activity. Our findings have enabled us to revise our theoretical framework and provide additional detail in terms of how this might be operationalised (see Fig. 9.1).

Implications for Practice Using cases from our research and those from published sources, we provide examples of how this integrated approach might be achieved. Interestingly, none of the cases formally recognised an integrated approach to guide their implementation. Nevertheless, from retrospectively reviewing the cases it was possible to determine links between the two approaches

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• Understanding value from user’s perspective • Use of Service blueprinting, Kano model, SERVQUAL, Quality Function Deployment

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Input-process-output model Service-dominant logic Service user as coproducer of service

[Public] Service Operations Management

Personcentred improvement

Quality Improvement

Co-production and Co-design

Flexible and reflective approach Representation, Power relations Story telling Emotional mapping

Fig. 9.1  Revised theoretical framework. (Source: Compiled by the authors)

and to identify where opportunities for integration might exist. Using the Lean thinking (Womack and Jones 1996)  and the Model for Improvement (Langley et al. 2009) we propose two conceptual models for consideration. 1. Integrating Lean thinking and principles of co-design and co-production This integrated model (see Table 9.1) uses the five Lean principles as its overarching framework. The principles provide a systematic road map where key steps of co-design and co-production models can be included to support a co-produced approach to QI. 2. Integrating the Model for Improvement and principles of co-­ design and co-production

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Table 9.1 Integrating lean thinking and principles of co-design and co-production 1. Understanding value (from patient perspective)  Define area for improvement  Invite patients participants – might need to visit local groups or third sector organisations  Patients to attend QI training if appropriate/needed  Using key principles of co-production  Workshops with patients and relatives to define value – include Kano model to understand expectations  Workshops with staff to define value and expectations 2. Mapping the value stream (pathway) (understanding the context)  Study the evidence (what does good look like?)  Service blueprinting (to identify interactions with patients and ‘moments of truth’) and mapping – current state and ideal state  Walk and observe process/pathway  Record information flows  Experience based interviews with staff, patients and relatives to record patient flows and emotional flows (if appropriate to project and resources allow film patient/staff stories)  Establish baseline measures 3. Flow  Analysis of patient stories, films and experience based interviews to understand interruptions of flow, quality issues, areas of good practice  Identify areas of the pathway suitable for standardisation or require a person-centred approach  Review against measures 4. Pull resources as needed by the patient/empower staff  Using model for improvement design PDSA small cycles of change – include patients and relatives  Implement PDSA small cycles of change to reduce delays, remove duplication and improve flow  Review against measures 5. Work towards perfection  Continually review progress of small cycles of change  Sustaining change/feedback loops  Update current state and ideal state maps/service blueprints  Review against measures to sustain improvements Source: Compiled by the authors

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To integrate the key principles of co-design and co-production with the Model for Improvement (Langley et al. 2009) we have included specific areas that need to be considered to co-produce improvement activity. 1. Definition of problem – what trying to achieve • Identify community groups and mechanisms for engagement and any training needs E.g. health literacy, basic QI & evaluation skills, EBCD • Define participation plan – to include representation and selection roles & responsibilities Environment, resources & communication • Patient/relatives involved in defining the scope and aim of the improvement activity Managing relationships 2. Knowing the change is an improvement • Tailor patient involvement to QI activity: Patients involved in experience-based co-design activity, process mapping and data collection • Patients involved in evaluating improvements 3. Defining the changes • Patients involved in testing small cycles of change These proposals to more closely integrate improvement and coproduction approaches are based on our review of literature and case analyses. Our proposals need to be empirically tested and evaluated in practice.

Implications of the Research The implications of this research are threefold: 1. Academics This research has spanned three subject areas – service operations management, quality improvement and co-design and co-­ production. Although we have demonstrated there is synergy across these subjects it has been challenging to manage the complexities of multi-disciplinary research and be able to convey the results to

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s­everal audiences in a meaningful way. The challenges were mainly associated with the varying definitions and terminology used across and within disciplines. A full systematic review of the literature was beyond the scope of this text, therefore we had to be selective in terms of the models and approaches we have chosen to use. We recognise our analysis could have included other road maps, tools and techniques but our aim was to demonstrate how integration of QI and co-design and co-production might be achieved. We have provided some conceptual ideas that now need empirically testing. . Health organisations and practitioners 2 There are several key messages for healthcare practitioners and managers involved in co-producing improvements in healthcare.

(a) There is an opportunity to integrate models of improvement and co-production to ensure patient involvement is central to design, implementation and evaluation of improvement activity. We have provided some conceptual ideas of how this might be achieved.



(b) Patient involvement has been criticised for being tokenistic. Careful attention needs to be paid to recruitment, representation and managing relationships.



(c) Patient participants require training in basic QI and co-design/ co-­production methods to make a meaningful contribution.



(d) Adequate resources need to be available to ensure patient involvement is sustained throughout the improvement activity.

Limitations of the Study This study has its limitations, some of which will inform our proposals for future research. As previously noted, we have not conducted a full systematic review of the literature associated with quality improvement and co-­ design and co-production. Where possible we have signposted to models and frameworks, which have been outside our discussion. Chapter 8 included a review of five cases published in the literature. Although

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research is limited, we could have included some other cases if space would have allowed. The five we selected provided variety in context and learning. It was difficult to find cases that were deliberately testing an integrated approach to co-produced improvement. Most of the cases were centred on quality improvement and the involvement of patients and families. Our retrospective analysis is not ideal but we have been able to extract lessons for future activity and provide some conceptual thinking and approaches. We recognise the importance of moving away from a product-­dominant logic. Our dichotomy is that the models and theories we have used to frame our conceptual thinking are derived from management and industry. This reinforces the importance of service-dominant logic and the need to see service-users as co-producers of services. The adaptation (to context) not adoption is also key to our proposals.

Future Research Agenda and Research Propositions We have posed a number of key questions as we have compiled this text (see Table  9.2). Although we have attempted to address some of these within the text, each of these deserves further attention. We have categorised the questions into four key areas: Co-producing improvement; selection; participation; and relationship management.

Research Agenda and Research Propositions Throughout this text we have recognised the issues relating to defining and operationalising quality improvement and co-production activity. What we have tried to do is to think about how such activity might be closely linked. We often see  that there is a clear divide between co-­ production and improvement, and where clear opportunities exist to engage with the public and patients these are often missed. It is welcoming to see the development of co-production models, roadmaps and toolkits which are available to practitioners. What is less obvious is how to integrate these within improvement. The EBCD approach is probably the closest to bringing these two activities together. We present our suggestions for further research in the form of seven research propositions. We believe that further research is required to examine how integration can take place. Currently we believe empirical examples that can provide a blueprint for future projects are limited. There are co-design and co-­

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Table 9.2  Questions for future research Key questions Co-producing improvement  Why is sustainability of improvement so difficult to achieve?  How much autonomy has the improvement team?  Where changes can best be made?  At what point is a further cyclical change needed? Selection and representation  Representation – who is involved?  Do the users represent the wider population/community?  Whose voice gets heard – How are participants selected?  Whose voice is heard at the point of change in design/delivery?  What is the motive of each participant? Participation  Is it the ideas or the vocabulary used that prevents collaboration?  How do you reconcile cultural barriers to change?  How accurate are mental model of the process?  Can we reconcile local (service user) views with (wider) population needs? Relationship management  How much influence does each participant (citizen/professional) have? Source: Compiled by the authors

Patient involvement Will patient involvement help to achieve sustainable improvement? Will patient involvement increase the autonomy given to teams? Will patient involvement help to prioritise the changes to be implemented? Will patient involvement help teams to maintain focus and momentum What mechanisms are used to locate and invite patients to join the initiative? How are group meetings managed and what training has been undertaken by all participants? – Need to manage power differentials

What training have patients received? Have all forms of communication been checked by lay member of group? Need to manage power differentials

Work to flatten any hierarchy Manage power differentials

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production models and approaches emerging which we have not covered that empirical research needs to consider e.g. ‘slow co-production (Miles et al. 2018); Accelerated experience-based co-design (Locock et al. 2014). 1. Empirical research to develop and test the integration of quality improvement and principles of co-design and co-production in healthcare. Health services by nature are co-produced services (Fuchs 1968; Batalden 2018; Palumbo 2016). Therefore, co-production should be seen as an integral part of any efforts to improve or innovate health care services, but at the same time should not be considered a panacea where there is one approach that fits all situations. Here we have tried to illustrate how different models/ thinking associated with co-production might fit with QI approaches. We also note that some adaptation and flexibility will be needed in light of the context within which these are being implemented. This was highlighted by all the cases we have examined within this text. Bovaird et al. (2019) emphasise much the same thing and caution managers that a single approach to co-production is unlikely to work in all circumstances. They also highlight the need for appropriate organisational arrangements to be made to support coproduction – e.g. set up co-production offices, seek knowledge sharing opportunities and collaborative activities. In healthcare, however, we need to acknowledge the prevailing use and loyalty to the traditional bio-medical model of care (which is being challenged and alternative sought as noted in this text), healthcare professionals often overlook the value-adding contribution that patients can bring and/or the courage to involve patients in the provision of their care. Often these challenges are heightened by the lack of organisational structures, systems and capabilities to empower patients. The QI research agenda has called for sound evaluations to help develop an evidence base to provide a better understanding of what works, for who and when (Dixon-Woods 2019). We make a similar call for co-production research and its integration with QI. 2. Research is required to identify the organisational enabling and inhibiting factors that may influence the introduction and use of co-production in improving the quality of healthcare services. Building on the notion of the prevailing bio-medical model. Previous studies have raised the need for a cultural shift to support the involvement of patients in the design and delivery of their care. Patient empowerment,

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patient engagement, patient involvement and patient-centred care are all terms that are widely used. As noted in this text, there is a growing n ­ umber of approaches and models available to assist with the implementation of co-production activity. What is not widely understood is the cultural differences and perspectives of healthcare professionals and patients (and relatives) in relation to co-producing health care services. 3. Exploration of cultural differences and perceptions of healthcare professionals and patients involved in co-producing and co-designing health care services. In addition to understanding the conditions and perceptions required to support co-production. Currently, what is not clear are the skills and competencies needed by both patients and healthcare professionals to enable co-production activity to be performed well, particularly within the context of improvement. For healthcare professionals, lack of time and lack of competencies are often noted as the reasons to limit involvement with patients (Palumbo 2016). We have raised issues around selection, recruitment, diversity and equality along with the issue of managing power differentials. These are all areas that need to be included in the development of key competencies and skills for practitioners to enable them to initiate and develop co-produced healthcare and improvement activity. 4. Empirical research to establish the key competencies and skills required by healthcare professionals and patients (relatives) to support coproduction in improvement. In this text, we have started to explore how approaches to co-­production and quality improvement may be integrated. We have proposed a number of recommendations and approaches in terms of how this might be achieved. Further research is now needed to understand the practical challenges and benefits of integrating these approaches and ultimately recording the outputs, particularly in relation to patient outcomes. 5. Empirical research is required to understand the implications of integrating co-production activity with quality improvement models, frameworks and approaches.

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As with any intervention, the biggest challenge is spread and sustainability. With quality improvement, the ability to undertake activity on a small scale can be tested and set as an experiment of change. The challenge starts when attempting to replicate and/or spread the pilot activity to other parts of the system or other, often similar contexts. Little is known about co-design and co-production to do this effectively. Much of the research provides examples of single case studies. More research is required that encompasses other research designs to enable a robust evidence base to be developed and one that clearly tests and examines the role co-production plays in the spread and sustainability of improvement activity. 6. Practitioners and scholars to share examples of how co-production has been employed to spread and sustain improvement in service redesign and delivery. The costs and benefits of co-production and quality improvement activities are generally not well documented. Although evaluation models exist these are not well integrated into improvement and often not instigated until the latter part of improvement activity. We have identified the challenges of undertaking co-design and co-production in a meaningful way. To overcome some of these issues requires resources (e.g. education/ training, travel expenses, venues, equipment) that may not be readily available. Similarly having good measurement of such activity will also be valuable not only to spreading good practice but to documenting the scale of the changes made and to contributing to the evidence base that is still needed for both QI and co-production. 7. Empirical research to demonstrate the important role of evaluation and measurement in the co-production of healthcare improvements.

Concluding Remarks In this text we have combined three theoretical concepts in which to view how a person-centred approach to improvement might be delivered – this includes service operations management, quality improvement and co-­ design and co-production. All three terms are well-versed in the literature but not necessarily well-enacted or evidenced in practice. As we move to

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an integrated health and social care system it will be interesting to see how these concepts develop in this arena. We have emphasised the importance of taking a service-dominant stance within the management and (re) design of healthcare operations. There is now a growing recognition that health services by nature are co-produced services which enable patients and their relatives to be acutely involved in the activities, which concern their health and wellbeing. Therefore, as Fuchs (1968) stated it is ‘obvious’ that the health care system should be seen as a co-producing service where patients and healthcare professionals are thoroughly and equally involved in a co-creating partnership (Palumbo 2016). We need to appreciate the ‘messiness’ and complexity of implementing person-centred improvement and be respectful of the issues we have raised within the text around representation, inclusivity and power differentials. We have provided a number of recommendations for further research in particular there is a need to provide an evidence base of research including illustrative cases of co-producing complex conditions that need to access an array of services. Like the co-production of good care, the co-production of good improvement requires attention to readiness, curiosity, reframing of challenges into opportunities, listening and learning, and participation (Sabadosa and Batalden 2014, p. i94).

References Batalden, P. (2018). Getting more health from healthcare: quality improvement must acknowledge patient coproduction. British Medical Journal, 362, k3617. https://doi.org/10.1136/bmj.k3617. Bovaird, T., Flemig, S., Loeffler, E., & Osborne, S. (2019). How far have we come with co-production  – And what’s next? Public Money & Management, 39(4), 229–232. Clark, D., Jones, F., Harris, R., & Robert, G. (2017). What outcomes are associated with developing and implementing co-produced interventions in acute healthcare settings? A rapid evidence synthesis. BMJ Open, 7, e014650. https:// doi.org/10.1136/bmjopne-2016-014650. Dixon-woods, M. (2019). How to improve healthcare improvement—An essay by Mary Dixon-Woods. BMJ, 367. https://doi.org/10.1136/bmj.l5514. (Published 01 October 2019). Fuchs, V. (1968). The service economy. New  York: National Bureau of Economic Research.

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Johnston, R., & Kong, X. (2011). The customer experience: A road-map for improvement. Managing Service Quality, 21(1), 5–24. Johnston, R., Clark, G., & Shulver, M. (2012). Service operations management: Improving service delivery (4th ed.). Harlow: Pearson Education Ltd. Langley, G., Moen, R., Nolan, K., Nolan, T., Norman, C., & Provost, L. (2009). The improvement guide: A practical approach to enhancing organisational performance (2nd ed.). San Francisco: Jossey-Bass. Locock, L., Robert, G., & Boaz, A. (2014). Using a national archive of patient experience narratives to promote local patient-centered quality improvement: An ethnographic process evaluation of ‘accelerated’ experience-based co-­ design. Journal of Health Services Research & Policy, 19(4). https://doi. org/10.1177/1355819614531565. Materla, T., Cudney, E., & Antony, J. (2019). The application of Kano model in the healthcare industry: A systematic literature review. Total Quality Management & Business Excellence, 30(5–6), 660–681. Miles, S., Renedo, A., & Marston, C. (2018). ‘Slow co-production’ for deeper patient involvement in health care. The Journal of Health Design, 3(1), 57–62. Ocloo, J., & Matthews, R. (2016). From tokenism to empowerment: Progressing patient and public involvement in healthcare improvement. BMJ Quality and Safety, 2, 626–632. Palmer, V., Weavell, W., Callander, R., Piper, D., Richard, L., Maher, L., Boyd, H., Herrman, H., Furler, J., Gunn, J., Iedema, R., & Robert, G. (2018). The participatory zeitgeist: An explanatory theoretical model of change in an era of coproduction and codesign in healthcare improvement. Journal of Medical Humanities. Available at https://doi.org/10.1136/medhum-2017-011398 Palumbo, R. (2016). Contextualizing co-production of health care: A systematic literature review. International Journal of Public Sector Management, 29(1), 72–90. Radnor, Z., Osborne, S., Kinder, T., & Mutton, J. (2014). Operationalising co-­ production in public services delivery: The contribution of service blueprinting. Public Management Review, 16, 402–423. Sabadosa, K., & Batalden, P.  B. (2014). The interdependent roles of patients, families and professionals in cystic fibrosis: A system for the coproduction of healthcare and its improvement. BMJ Quality and Safety, 23, i90–i94. Womack, J., & Jones, D. (1996). Lean thinking: Banish waste and create wealth in your corporation. New York: Simon and Schuster.

Index

B Business Process Improvement Methodologies (BPIM), 17

E Experience-based co-design (EBCD), 7, 56, 61, 75–77, 113

C Case study, vii, 41, 69–78, 81–89, 91–93, 95, 96, 100, 115 Chronic Obstructive Pulmonary Disease (COPD), 17, 69, 70, 73, 77 Citizen science, 27–28 Co-creation, 6, 9, 20, 45 Co-design, definition, 9 Competencies, 5, 95, 114 Co-production dark side, 50 definition, 9, 10, 20, 28, 31, 39–51, 65, 91, 100, 105, 111 framework, 7, 10, 82, 95 model, 10, 44, 55–65, 70, 75, 82, 87, 107, 110, 111, 113 in research, 10, 50, 111, 113, 115 Crowdfunding, 28

H Human factors, 33–34, 44 Huntington’s Disease (HD), 81–89 K Kano model, 105, 108 L Ladder of participation, 45 Lean thinking, 6, 7, 16, 18–19, 48, 56–59, 81, 105, 107–108 M Model for improvement, 6, 7, 9, 16, 56, 57, 59–60, 63, 65, 71, 83, 105, 107–109

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119

120 

INDEX

Moments of truth, 2, 108 Multi-disciplinary, 27, 56, 83, 84, 86, 87, 89, 109 Multi-professional, 82, 89 P Patient and Public Involvement (PPI), 10, 26–27, 30, 34, 92–94, 97, 99–101 Patient-centred care, 20, 25 Person-centred care, 26, 82, 86–87, 89 Person-centred improvement, vii, 22, 116 Plan do study act (PDSA), 59–60, 65, 71, 72, 74, 77, 84, 108 Process mapping, 17, 19, 77, 78, 89, 109 Product-dominant logic, 4, 111 Public health, 27, 28, 94, 95 Public services, vii, 1–10, 17, 25, 31, 40–43, 50, 104 Q Quality Function Deployment (QFD), 105

R Research agenda, vii, 7, 10, 104–116 Research proposition, 104, 111–115 Respiratory, 69, 70 S Service blueprinting, 105, 108 Service-dominant logic, 4, 105, 111 Service operations, v, vii, 1–10, 104 Skills, v, 5, 8, 26, 35, 50, 84, 109, 114 T Theoretical framework, 8, 106, 107 U User-centred care, 26 W Wellbeing, 22, 33, 51, 87, 116