What patients do and their impact on implementation.

PURPOSE: The potential for including patients in implementation processes has received limited attention in the literature. The purpose of this paper is to explore the different roles adopted by 63 patients that emerged during and after four participatory quality improvement interventions, and the nature of their impact upon implementation processes and outcomes. DESIGN/METHODOLOGY/APPROACH: A cross-case ethnographic comparison of Experience-based Co-design in two clinical pathways in two UK NHS Trusts. FINDINGS: Two key themes emerge from the data. First, the authors found a range of different roles adopted by patients within and across the four projects; some were happy to share their experiences, others also helped to identify improvement priorities alongside staff whilst others were also involved in developing potential solutions with the staff who had cared for them. A few participants also helped implement those solutions and became "experts by experience" through engaging in the whole co-design process. Second, in terms of the impact of patient engagement with the co-design process whilst the changes championed by patients and carers were often small scale, as co-designers patients provided innovative ideas and solutions. Through their involvement and contributions they also acted as catalysts for broader change in the attitudes of staff by providing a motivation for wider organisational and attitudinal changes. RESEARCH LIMITATIONS/IMPLICATIONS: The research was conducted in two clinical pathways in two NHS trusts. However, the findings complement and add to the growing body of knowledge on experience based co-design. PRACTICAL IMPLICATIONS: Patient engagement is likely to require support and facilitation to ensure that patients can play a meaningful role as partners and co-designers in service improvement and implementation. Different roles suited particular individuals, with participants stepping in and out of the co-design process at various stages as suited their needs, capacities and (albeit sometimes perceptions re) skills. In this context, facilitation needs to be sensitive to individual needs and flexible to support involvement. SOCIAL IMPLICATIONS: Patients and carers can play active roles in service improvement, particularly where the approach facilitate active engagement as co-designers. ORIGINALITY/VALUE: Analysis of the role patients and carers in implementation and improvement.

A medical director's perspective on healthcare leadership.

Healthcare leadership needs doctors in particular to step forward, despite the pressures, lack of recognition and challenges to bring their talents to aid improvement for patients and staff. There is clear evidence worldwide of the power of clinical, particularly medical leadership and its benefits are currently underutilised in the UK; now is the opportunity for major change. Focusing on the patient first ('what matters to you?') will be a necessary change. Healthcare leadership needs to understand and drive 'value' despite the challenges. Taking the healthcare management and leadership path should be properly recognised as a strong career choice for doctors, not a move away from patient care. Healthcare leadership of the future needs to understand what motivates people, the important 'triumvirate' of medical managerial and nursing/allied health professional leadership, and how taking a quality improvement approach will give more sustainable patient-centred results.

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.

OBJECTIVES: To evaluate an accelerated form of experience-based co-design (EBCD), a type of participatory action research in which patients and staff work together to improve quality; to observe how acceleration affected the process and outcomes of the intervention. METHODS: An ethnographic process evaluation of an adapted form of EBCD was conducted, including observations, interviews, questionnaires and documentary analysis. Whilst retaining all components of EBCD, the adapted approach replaced local patient interviews with secondary analysis of a national archive of patient experience narratives to create national trigger films; shortened the timeframe; and employed local improvement facilitators. It was tested in intensive care and lung cancer in two English National Health Service (NHS) hospitals. A total of 96 clinical staff (primarily nursing and medical), and 63 patients and family members participated in co-design activities. RESULTS: The accelerated approach proved acceptable to staff and patients; using films of national rather than local narratives did not adversely affect local NHS staff engagement, and may have made the process less threatening or challenging. Local patients felt the national films generally reflected important themes although a minority felt they were more negative than their own experience. However, they served their purpose of 'triggering' discussion between patients and staff, and the resulting 48 co-design (improvement) activities across the four pathways were similar to those in EBCD, but achieved more quickly and at lower cost. CONCLUSIONS: Accelerated EBCD offers a rigorous and relatively cost-effective patient-centered quality improvement approach.

An evaluation of systemic inflammatory response syndrome signs in the Sepsis Occurrence In Acutely Ill Patients (SOAP) study.

OBJECTIVE: To define the frequency and prognostic implications of SIRS criteria in critically ill patients hospitalized in European ICUs. DESIGN AND SETTING: Cohort, multicentre, observational study of 198 ICUs in 24 European countries. PATIENTS AND INTERVENTIONS: All 3,147 new adult admissions to participating ICUs between 1 and 15 May 2002 were included. Data were collected prospectively, with common SIRS criteria. RESULTS: During the ICU stay 93% of patients had at least two SIRS criteria [respiratory rate (82%), heart rate (80%)]. The frequency of having three or four SIRS criteria vs. two was higher in infected than non-infected patients (p < 0.01). In non-infected patients having more than two SIRS criteria was associated with a higher risk of subsequent development of severe sepsis (odds ratio 2.6, p < 0.01) and septic shock (odds ratio 3.7, p < 0.01). Organ system failure and mortality increased as the number of SIRS criteria increased. CONCLUSIONS: Although common in the ICU, SIRS has prognostic importance in predicting infections, severity of disease, organ failure and outcome.

Systemic capillary leak syndrome after granulocyte colony-stimulating factor (G-CSF).

Capillary leak syndrome (CLS) commonly occurs in the intensive care setting. CLS is seen in conditions such as septic shock or may result from conditions such as multitrauma and pancreatitis, which result in the systemic inflammatory response syndrome (SIRS). We present two cases in which both patients suffered with CLS, which we believe was caused following administration of granulocyte colony-stimulating factor, to our knowledge not described in the intensive care patient previously. We discuss how these patients management differs from other intensive care unit patients with CLS and how it is important to diagnose this condition early in haematological oncology cases.