Project start-up

Case for change

It is important to be clear why Kōrero mai should be put in place.

Sites have found it useful to present hospital decision makers with international evidence on patient escalation, to help them understand the idea of Kōrero mai. The evidence shows having a patient, family and whānau escalation pathway does not result in an increase in calls but is a necessary escalation pathway for deterioration.[1]

Later, you will be able to add your own evidence on why Kōrero mai is important. You may already have examples that show why a patient, family and whānau escalation pathway is needed. You can read Rasik’s story and read Geoff and Angela’s story.

Project sponsorship and clinical governance

Having a project sponsor is important for making connections in your organisation and releasing staff to work on the project. Project sponsors also help deal with challenges throughout the project.

Kōrero mai projects are an important part of a hospital’s recognition and response system. Projects need to be linked with the pre-existing patient deterioration clinical governance group. Make sure your project has a representative or reporting line to this group. Strong clinical governance is essential to the success and sustainability of Kōrero mai projects.

Honouring te Tiriti o Waitangi

Kāwanatanga – partnering and shared decision-making Informed and shaped equally by tangata whenua and tangata Te Tiriti worldviews and perspectives.	Tino rangatiratanga – recognising Māori authority Recognising the importance of tangata whenua authority and autonomy. Supporting tangata whenua led processes, actions and decision-making, through shared power and resources.
Ōritetanga – equity Undertaking specific actions to ensure equitable outcomes for tangata whenua and recognising that these actions can also support equitable outcomes for other groups.	Wairuatanga – upholding values, belief systems and worldviews Tangata whenua worldviews, values and belief systems are prioritised.

 

The four articles of te Tiriti o Waitangi (shown in the diagram) underpin the relationship between health services and Māori, and line up well with the idea of co-design.

The Commission has contracted an evaluation company to evaluate the patient deterioration programme, including the Kōrero mai workstream. Their evaluation report on key insights from the implementation of cohort one in four DHBs emphasises the early engagement of Kōrero mai teams with their hospitals’ Māori health directorates.

Kōrero mai teams have used several approaches to honour te Tiriti o Waitangi partnerships, including:

• using a co-design approach between the Māori team (Pae Ora) and Kōrero mai team, which led to Kōrero mai becoming part of the existing Mahi Tahi programme in MidCentral DHB
• having a haumoana (navigator) in the Kōrero mai project team who engages with whānau and community to give feedback on their experiences with escalating care
• having a separate Kōrero mai workstream for Māori

In Waitematā DHB, the Māori Health Team helped host two hui for Māori to share their experiences of dealing with the hospital. Whānau were recruited through networks within the Māori Health and Patient Experience teams. However, the Māori Health Team found that applying a cultural lens to co-designing an escalation pathway required time and resources they did not have. The project team presented a paper about their experience to the DHB Board, to continue the work further.

• actively seeking out Māori consumer representatives for the Kōrero mai co-design process.

[Side note] DHBs with support and involvement from DHB Māori advisors enabled the working group to understand the experiences and views of Māori patients and whānau better. Māori advisors on working groups are actively providing insights into how to engage with Māori to create a successful escalation process. (Synergia 2019)

Identifying a project area

The best place to start your project is to find an inpatient area where you want to understand a problem or the opportunities for improvement. Carry out a stocktake of current DHB processes and projects and integrate your Kōrero Mai project into these. For example, at MidCentral DHB, the focus of Mahi Tahi is on family and whānau being part of the care team, with the opportunity to be included in all planning of care.

Kōrero mai has been used in many different areas, for example, paediatrics, acute stroke, rehabilitation and in a kaupapa Māori ward. These areas are often identified through:

• an escalation of care incident
• staff interest and capability
• reviewing organisational data to identify concerns about escalation of care, for example, complaints and incident forms. 

Think about how easy it will be to share the findings from your Kōrero mai project area across wider hospital services.

Once you have identified the project area you can set up a team to co-design your Kōrero mai process.

Creating a project team

You can use existing networks to create a Kōrero mai project team. Make sure people on the Kōrero mai project team are linked to related hospital projects or processes.

Teams often have around seven to nine members, and two or three need to be consumers. Previous Kōrero mai project leaders have asked the following people to be involved:

• medical staff
• charge nurses
• disability advocates
• others involved with patient deterioration work
• members of Māori, Pacific and Asian health groups
• staff from Consumer Engagement, Patient Experience, Quality, Safety and Complaints.

[Side note] The two consumer representatives who worked with us as core members of the project team had a lot of expertise to offer. This included one of them being involved in the first workstream of the patient deterioration programme and the second consumer having an existing relationship with the CDHB through their involvement in the Child Health Advisory Council (CHAC) – a consumer group supported by our organisation to provide input into the health services children/families/whānau receive. [Canterbury DHB]

Teams have found it is important to have:

• consumers involved from the start
• team members who are committed to the project and who can maintain momentum. 

Projects benefit from having:

• a structure with clear reporting lines and responsibilities
• a leader with experience in project management and quality improvement
• more than one consumer on the team, so they can support each other
• a consumer team member who has experience working with hospital teams. 

It is also helpful to think about the following questions when planning your Kōrero mai project.

• Is the team representative of the work you are planning to do?
• Are there consumers working at project team level?
• How will you be culturally responsive to different groups?
• What roles do people have on the team?
• How much time can people commit to the project?
• How much time is needed to maintain momentum?
• How will the team meet and work with each other?
• Who else could help (for example, data analysts, administrative support and communications staff)?

[Side note] For us it was useful to identify 2 to 3 people to do most of the background work, with everything else being achieved within the project meetings, as most people do not have time outside this. [MidCentral DHB]

First team meeting

Use the first team meeting to:

• introduce everyone
• sort out the roles and expectations of members
• build a shared understanding of the background and aim of Kōrero mai. 

This helps group members to understand the rationale for the programme.

The first meeting is also the time to talk about ethics and confidentiality and to deal with paperwork for consumer members of the team (for example, reimbursement of expenses and payment).

[Side note] It is important that consumer members of the project team have their contribution recognised. Your organisation may have a policy that supports consumers’ participation. If not, we recommend they are paid in line with the Commission’s policy for paying consumers. This policy follows whole-day contributions. Use it as a guide to calculate an appropriate payment amount.

Writing a problem and aim statement

Problem and aim statements are often used in quality-improvement work. The statement is a clear summary of the problem and what the team hopes to achieve in a specified time. The statement sets out what success looks like.

Teams have found that defining an aim for their Kōrero mai project focuses their thinking about what they want to achieve. Don’t leap to a solution at this early stage.

[Side note] Using a co-design methodology our aim is to identify and understand the barriers and concerns patients/family/whānau have regarding escalation of care at CCDHB. This approach will inform a design process that complements patient/family/whānau escalation of care with our existing clinical escalation pathway. It is our aim to have testing completed by May 2019. (Capital & Coast DHB)

Collecting baseline data helps team members to understand the problem or opportunity from different perspectives. This involves gathering routinely collected organisational data on escalation (for example, RiskPro data) plus the experiences of consumers and staff. This data will help when developing the project problem and aim statement. Teams should also revisit the aim statement at the start of the ‘Improve’ stage.

In Canterbury DHB’s Kōrero mai project, baseline data was gathered by reviewing the consumer feedback collated for 2016–17.

‘This was done to define the problem and aim statement for the project, as well as establishing one of many future metrics around the success of a patient/family/whānau escalation system. Formal complaint data was scanned for key words within the descriptors, to identify those that possibly met one or more of the following criteria:

• multiple presentations and/or communication of progressive symptoms but no action taken
• an adverse event or outcome following multiple attempts to raise concern
• the complaint explicitly mentioned they felt they were not listened to concerning the patient/family/whānau member’s condition.

Those meeting the criteria led to the full original complaint being reviewed. These were then summarised, to extract both the cause and effect story and associated emotions expressed by the complainants. Additionally, we reviewed informal complaint data and compliments for the same period, to identify comments stories that exemplified a positive and timely response to a deteriorating patient and/or behaviours and attributes described by families indicating they felt listened too or opportunities to improve).

Learning point: As part of our baseline data collection, we explored if any systems were currently in place to communicate or encourage families to escalate concerns around care their loved one was receiving.’ [Canterbury DHB]

Developing elevator pitches

An elevator pitch is a short description of the project to help promote it or ask people to take part. Kōrero mai teams developed slightly different elevator pitches for consumers and staff. These were changed during co-design to reflect a deeper understanding of the challenges involved with the project.

It is useful to develop the elevator pitch in the start-up phase, to prepare for the next ‘Engage’ phase.

Managing capacity and time

The co-design process is important for developing effective Kōrero mai projects. But this process needs plenty of time. One cycle of testing and improvement generally takes between eight and 12 months. This depends on when the December and January holiday and busy hospital winter period fall in the overall timeframe. It also depends on the project’s scope, how many team members are involved and how much time each one has to spend on the project.

The biggest challenge for project teams is having enough time to progress the work. It is essential from the start that plenty of time is given to the project. Kōrero mai teams that had a dedicated project lead, with protected Kōrero mai project resources, were able to keep their project moving.

It can be challenging for staff to know how many hours they may have available each week. It is helpful to have two or three people who can continue working on the project between meetings, to keep the momentum going.

To make the most of the time available, record people’s availability and the allocation and completion of tasks. Keep this record up to date. You can use a Gantt chart (available as a template in Excel) to manage this. Think about:

• how frequently you can meet
• how often you need to meet
• how each person can contribute to the project. 

Make sure all meetings have a specific purpose, start promptly, run to time and that everyone attending leaves with actions and a timeframe.

Ethics

People involved in Kōrero mai projects need to be told about the purpose, methods and possible uses of any information they provide.

Data must be collected only for the stated purpose of the Kōrero mai project and include only that which you need to answer your co-design objectives.

Everyone must formally agree to the use of any information they provide, including attribution of quotes.

Be clear with consumers that if they choose not to take part, their decision will not affect their routine care and treatment in any way. If consumers agree to take part, check with them frequently that they are still comfortable with their choice.

All people sharing their experience take part on a strictly voluntary basis and can withdraw at any time without need for explanation.

People’s privacy and the confidentiality of what they tell you must be respected.

Appoint a staff member in the project team as the contact person for queries and complaints about the Kōrero mai project.

Any improvement activity must be done in an ethical manner. In general, quality assurance and quality improvement work, such as Kōrero mai, does not need ethical approval, provided it meets certain criteria. Teams should check with their local Ethics leads.

For more information, look at pages 216–223 of the National ethical standards for health and disability research and quality improvement.

Keeping data secure

Make sure patient confidentiality is kept at all times when Kōrero mai patient experience data is gathered and used.

Data must be kept secure and be accessible only to authorised people. Anonymise the data and remove identifying information such as name, contact details, date of birth and National Health Index numbers. Store data in locked filing cabinets, password protected electronic files or on a secure, restricted-access server. Always password protect flash drives.

Destroy completed surveys and notes, once your project is finished. Make sure your DHB’s quality and safety department has a copy of your results to allow comparison with any re-audit that may be done in the future.