Step 1: Select a care experience

A care experience is defined from the patient’s or family’s point of view. It is their experience of a particular aspect of care, often centred on a particular clinical condition or presentation, for example, the care of people attending A&E with a hip fracture, or a child with asthma. It comprises what then happens to the patient and their family, regardless of the organisational boundaries. You can select broad or narrow care experiences, or segments of a long care experience, as long as you do not lose sight of the whole care experience, perhaps to be tackled by future projects.

PFCC is effective for any care experience – with two provisos. First, the care experience must be defined from patients’ and families’ points of view rather than from the organisation’s point of view (for example, the functioning of a particular ward or department). Pay particular attention to where and when the chosen experience begins and ends. For example, if a patient comes to hospital because of a foot injury, their journey might begin at the reception desk, or with a phone call to the hospital. Their care experience could include A&E, the medical assessment unit, radiology and care on the wards, including physiotherapy and occupational therapy. In some cases, it may also cross organisational boundaries within or between organisations.

Second, the care experience must be chosen for the right reasons. The selection must stem from a genuine desire to improve the health care of patients, their families and the experience of staff working with patients and families. It must take place in areas where the clinical teams have energy and enthusiasm to do this kind of work, rather than purely to try and solve difficulties such as a poorly functioning team. You will refine your care experience into specific aims in the later steps.

Every organisation will approach the selection of a care experience in a slightly different way. Royal United Hospital Bath worked on the end-of-life care experience.

Here they describe how and why they chose this particular experience:

Key points

• There is no fixed method for selecting the care experience you want to work on, but you might use meetings and workshops, as well as the methods detailed in the Tools section of this toolkit. Your organisation will have its own ways of determining priorities for quality improvement and decision-making, and the PFCC approach can fit in with those existing ways of working. The approach works best where the frontline team wants to do this work, and buys in to the vision and the process from the start.
• You may want to focus on a broad care experience, such as patients’ experience of attending A&E with a particular concern, for example, chest pain, or a more narrowly focused care experience, such as the discharge process for patients leaving hospital after a long stay. The experiences chosen by our care teams included children attending A&E with abdominal pain or acute asthma episodes, and hospital care of people at the end of life.
• If you have chosen a very complex experience – for example, one that covers a wide geographical area or more than one service across organisations, you may need to set boundaries initially. This is to ensure that the challenge is achievable. You may need to manage your scope by tackling some aspects of the experience now, as the initial project, with other aspects to be tackled as separate projects later.
• It is important to find a care experience as defined by the patients, not the organisation. This is important because it is often at the transition between the different parts of the health care system (such as transitions between departments) that problems arise.
• Make sure your care experience does not actually describe the functioning of a ward or a department. For example, the functioning of a pharmacy is not a care experience, though it might be part of one.
• Don’t use the approach to resolve issues that are unrelated to patients’ care experiences.
• Be sensible about your scope – include things that you actually can affect and have some control over.
• You might take as a starting point a list of organisational or national priorities where these relate to the experience and quality of patient care. One team chose to work on improving the experience for dementia patients because dementia was a national priority and a CQUIN. This was matched by their organisational priority to become more dementia-friendly. The PFCC project was an opportunity to put their strategic direction into practice.
• Another option is to draw on teams’ experiences. One team wanted to focus on their chosen area because a child whom they had treated had very poor outcomes. This experience had strongly affected them and motivated them to make changes.
• The care experience identifies your broad focus. Within that experience, you might focus on particular elements as you go through the later steps in the process. For example, two different hospital teams focused on the experience of children with asthma attending A&E. As a result of process mapping and shadowing exercises, one team focused on the process of coming into the system, while the other focused on the other end of the process: discharge back home.

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