Small Steps – Big Changes

Gloucestershire Hospitals NHS Foundation Trust


Gloucestershire Hospitals NHS Foundation Trust consists of Gloucestershire Royal and Cheltenham General Hospitals. Our Trust employs more than 7,500 members of staff and sees in excess of 700,000 patients every year. These specialist hospitals provide emergency care, specialist inpatient care and outpatient appointments to our urban and rural communities within Gloucestershire and further afield.

General Summary

The problem with feedback data is staff taking ownership, as they often say ‘that’s not my data/problem. This project was innovative as staff took ownership of their data and led on multiple initiatives using quality improvement patient experience techniques. Ownership of feedback data has to be closest to the patient to make the biggest difference and anecdotal data is as important as official feedback data. The leadership journey began as a deficit-based model evolving into an appreciative enquiry model with co-design used at appropriate points. The project was effective in that all ward staff became engaged with the overall objective of improving their patients experience.

Initiatives failed and these were learned from, while successes were celebrated. The project started with a transactional leadership style and transitioned into transformational collective leadership. The philosophy became totally patient-focussed as the project progressed. The success of this project can be measured on how engaged the staff became. Their enthusiasm grew with their successes. The project will be sustained as the staff now take ownership of their feedback data and know how to respond with actions. The philosophy has already been transferred to other wards, with more wards keen to be involved.


The original project was one funded by NIHR whose aim was to understand how frontline staff used patient experience data, however it became clear that the staff did not have the time to analyse or understand what all the feedback was telling them. It was clear that the staff’s view of what the issues were, based on anecdotal evidence or what they were seeing very much mirrored what the data was reporting.

So, what if we encouraged the staff to act on this feedback in real time where improvements could be implemented quickly? The ward had a lot of vacancies and a history of violence and aggression from difficult long-term patients but it had an established Sister who had a desire to drive improvement. The Sister saw the project as a great opportunity to make a difference to both patients and staff and to positively influence patient care. However, it was very clear that it was going to be an uphill struggle unless we addressed the reservations of the staff first. The staff were wary of change and saw new initiatives as being led from above and not relevant ‘on the shop floor’ and so did not engage. This ward was showing concern in the staff stress survey as well as poor feedback scores, and we hoped to show that by improving the staff experience they in turn were able to improve the experience of their patients and to change the culture to one of continuous improvement.


A working party of ward staff members and a member of the Patient Experience Improvement Team was set up. We wanted to show the staff that we were listening to their improvement suggestions so we first asked them, via a flip chart and post-it note system, to suggest improvements to make their experience of working on the ward better. These suggestions were anonymous but we needed enough detail to be able to act on the suggestions so ‘Need more support’ had to be expanded with examples before we could action. (see photo) Every idea was implemented immediately by the Sister or passed to the relevant person who could deal with it. Where we were unable to action the suggestion, we reported why we couldn’t. Some examples of the changes suggested were to have senior nurse support on the evening shift and, by changing the rotas, this was possible. The consultants requested a white board that showed the name of the lead nurse for each bay so they knew who to speak to about a patient; this was implemented within a couple of days. As staff realised that we were serious about making things better, they came up with more suggestions. We spent a month concentrating purely on staff improvements. The staff were realistic and did not ask for things that we were obviously unable to change i.e. salaries or structural environmental changes. Following this we then asked the staff for suggestions on how we could improve the experience of the patients based on what they had observed on the ward or from suggestions made by patients during conversations. Again, this was via a post-it note but not necessarily anonymously. Suggestions were considered by the team with a view to supporting the staff to implement as many as possible unless there was good reason why not, even if the initiative only improved the experience of a couple of patients. Examples of this: (see photos)


  • Following a patient reporting that they did not feel that they had enough information about their condition, information boards were created for the three key conditions that were common on the ward, with racks beside them to hold information leaflets that patients and carers could take.
  • A patient suggested that flexible tool holders that are used in the garden shed would be ideal to hold walking sticks and so prevent them from constantly falling on the floor which increased the risk of the patient falling if he tried to retrieve. The patient also sourced this item and gave the nurse the details of where to get it from!


Initiatives were trialled in one bay and if successful, a business case was put forward to extend to other bays or to the whole Trust. The next stage was to also look at the data from other sources and again with support from the Patient Experience Team, the project team could identify concerning trends that we could put to the staff for suggestions on how to improve. A focus group consisting of patients who had been in the ward was arranged and staff learned a lot from them as to what it was like to be a patient on their ward and ideas of what would have made their experience better. We used a lot of visual props to encourage patients and carers to tell us what was important to them whilst they were on the ward. For example our What Matters to Me Tree (see photos) was put in place to capture the range of things that were important to patients, carers and staff as well as to demonstrate that the ward culture was one that was open to hearing about patient’s wishes and needs.



The biggest impact that this project made was that the ward staff became a ward team; they felt able to influence care and felt empowered to make small steps of change. They enjoy their work more and socialise whilst fundraising. They were able  , as a team, to write, direct and star in a training video on how to manage difficult patients. Something that was unthinkable prior to the project. This in turn, has led to improvements in the patient’s experience. We conducted a patient survey before the start of the project and repeated the survey after one year. There were improvements in most areas even though a lot of the initiatives that were introduced had not been fully embedded at the time of the 2nd survey. We will repeat the survey again in July 2018.

Questionnaire item: Change in results – Q8 When you had important questions to ask a doctor, did you get answers that you could understand?’ Yes, always increased from 50% to 56%;

Q11 Were you involved as much as you wanted to be in decisions about your care and treatment?’ yes definitely increased from 42% to 51%;

Q12 Did you have confidence in the decisions made about your condition or treatment? ‘Yes, always increased from 54% to 57%;

Q13 How much information about your condition or treatment was given to you? ‘The right amount increased from 62% to 78%;


Q21 Before-hand, (before operation or procedure), did a member of staff answer your questions about the operation or procedure in a way that you could understand? Yes, completely increased from 53% to 65%;

Q23 After the operation or procedure, did a member of staff explain how the operation or procedure had gone in a way that you could understand? ‘Yes, completely increased from 53% to 65%;

Q10 In your opinion, did the members of staff caring for you work well together? Yes always increased from 68% to 74%;

Q25 During your hospital stay, did you feel well looked after by hospital staff? ‘Yes always increased from 73% to 77%

We choose this method rather than measure each individual initiative that was put in place as we wanted the staff to ‘just do it’ and to acquire the habit of making small changes where they saw opportunities without having to adopt a formal improvement methodology. The ward staff were encouraged to attend the Trust run Gloucestershire Safety Quality Improvement Academy (GSQIA) day course where they were introduced to change methodologies so that they had a background to the theory of change.

Each new initiative was seen as a PDSA cycle in the project. Some worked better than others but those that were not successful were still included in our armoury to perhaps use in a different setting or at a different time. Some of the ideas that the ward put into place were so successful, that they were taken up by the whole Trust  these were often the simplest of ideas but which really made a big difference to the patient. For example, purple business card boxes (cost 13p each) were put in place to use as hearing aid boxes as a result of the staff awareness of the distressing effects for patients losing a hearing aid and thus not being able to communicate with the staff caring for them, as well as a wish to save the Trust the considerable cost of replacing them (£2k the previous year for that ward but during the term of the project, no aids were lost). Often the success of each initiative was judged by the patient and the verbal feedback that they gave to the staff.

Standing Out

This initiative was different because it sought to empower the staff to feel able to make changes where they saw that small changes could make a difference,  even if only to a few patients. We also demonstrated our commitment to the staff by working on making their experience of working on the ward better and then worked together to improve the patient’s experience. We used a full range of feedback sources including anecdotal feedback given during conversations between staff and patients. This was complimented by the staff awareness and knowledge of their ward and bowing to their expertise in what best care looked like for their patients.

Key Learning Points

  •  – If you intend to bring about a culture that is genuinely looking at patient experience, then you have to look at the staff experience too. All sources of feedback are important
  •  – No improvement idea is too small
  •  – There is no minimum number of beneficiaries of an improvement idea
  •  – Culture eats strategy for breakfast
  •  – Bottom Up!