This section describes the findings with respect to four aspects of the PExpI intervention implementation evaluation:
Acceptability & Adoption
The analysis of employee feedback around the content and experience with different training sessions indicated user-satisfaction [Table 4]. Specific posts were designed regarding trainings to facilitate eliciting feedback from the employees. For instance, videos of leadership training workshops with highlights were posted on the Facebook group. Participants felt the training session was apt and it helped them connect with the humanistic side of their profession. Some shared that the session helped them see things from the patient perspective and would now identify the patient with their name rather than bed number. With reference to the trainings, the participants also shared that their goals were now more tangible, achievable, and within reach. Some felt it led to their thoughts and plans being streamlined.
The feedback on the Facebook group suggested a strong intent expressed by the employees to apply the learning and find innovative strategies to improve patient care with several faculty physicians sharing their intent and ideas for QI projects. Also, during early implementation, a total of 178 application for different QI projects were received from the employees indicating their willingness to improve the service. Of these, 45 were presented by respective employees in 12 different individual-focused leadership sessions. The sessions were attended by 374 staff members. As a next step, 40 applications were shortlisted. 33 of these 40 had individual follow-up meetings with the leadership consultant. However, only 18 projects of these were part of final execution, which covered themes of compassion, communication, coordination, and competence (as identified from the qualitative analysis of patient feedback forms).
Degree and quality of execution across the intervention strategy for each of the four enablers was used to determine the fidelity of the PExpI intervention.
Purpose and vision: The new vision was communicated through workshops and on a shared platform-the Facebook group by the core group members. The attendance of employees for various leadership training workshops conducted between October 2017 to March 2018 is outlined in Table 5. A total of 10 sessions were conducted for leadership trainings. The leadership training workshops were designed to cover all staff of the SL and about 90% were covered (N=455). Performance on social media in the first 10 weeks indicated 97 posts and 1563 comments discussing the purpose and vision of the initiative with about 20-22% of the total posts by the core group members.
Engaging managers: The first set of trainings for middle managers was attended by 47 people with 50% of the physicians [Table 5]. Several practical ideas for execution were discussed online and as part of the workshops on the Facebook group but could not be systematically recorded. For the second set of trainings for the managers, a complete mentorship package with a standard protocol was created for nurses. A total of 680 man-hours were spent indicating the effort put into developing this package. Quality of the final package can be judged from the level of details to ensure implementation which included the supervision checklists operationalizing compassion for both nurses and their supervisors for objective ratings . Selected staff (N=33) with 52% nurses in supervisory roles completed the trainings. An outcome of quality of execution of these trainings was the ideas generated leading to subsequent QI projects, but data about the QIs that emerged could not be systematically maintained. Notable QI projects from the specific trainings for engaging managers were improving the experience of undergraduate students rotating in the service line  and designing wellness programme for trainee physicians . However, the mentorship package could not be rolled out for the frontline nursing staff during the course of the initiative.
Employee voice: The communication strategy utilizing social media (Facebook group) was found to be effective to engage the employees (90% active members). Several ideas were generated through the online discussions which culminated into QI projects. A detailed evaluation has been published earlier .
With regard to QI projects, an effort was made to ensure quality of project designs through regular dissemination about the use of ToC and conducting a one-day workshop to support feasible yet effective designs. Some of the QI projects managed to present a ToC and internal mechanisms to track progress as an indication of the quality of execution. Eight group meetings for execution were also conducted, attended by different cadres of employees (N=284) where progress of the projects was discussed, and feedback was provided. The quality of execution of the QI projects was determined by the coach's rating of them based on their progress shared in the individual meetings. According to the progress noted by the coach in the individual meetings for these projects (N=63), about 17% (N=11) showed ‘much progress’, 37% (N=23) showed some progress while the rest had no progress 41% (N=26). None of the projects was rated as showing excellent progress.
As indicators of degree and quality of execution, the following QI projects were implemented and sustained for at least one year: play-based psychosocial stimulation program , streamlining admission process , hands-off between intensive care unit and surgery operation theatres , improving medical students’ experience rotating in the service line , restructuring resident research program and “one physician model” (general pediatric service to be done by one admitting faculty at a time per week for better continuity of patient care). The sustained QI projects that tracked outcomes disseminated the results indicating benefits and quality of outcomes. The authors believe sustained execution is more attributable to individual factors as organizational emphasis on execution of QI projects was reduced in the post intervention period.
Integrity: In terms of quality of execution, data indicated that it took an average of 4.7 days for the coordinator to share patients’ feedback with the manager and an average of 3 more days to reach the employees. A total of 36% of the forms were meeting the SOP of appreciation being shared within 1 day. 72 appreciations were received which had named the physicians. 100% of these appreciations were emailed to respective physicians by the SLC with a personalized message in less than a day with 56 physicians responding to the email.
On the Facebook group, a total of 82 posts were uploaded for ‘person of the week’ appreciating employees for their compassionate practices towards their fellow colleagues and/or patients. This also gave an opportunity to acknowledge those not directly involved in patient care (e.g., security guards and housekeepers) but who were important in supporting those providing direct patient care. These nominations were given by peers and colleagues. These appreciation posts garnered most engagement as indexed by number of likes and comments .
Facilitators and barriers of implementing the PExpI intervention.
The following emerged as the main facilitators during the analysis: participation of leadership, effort towards creating value around the initiative, building strategic partnerships, an employee championing the intervention, transparency of communication, real time engagement platform, and attention given by leadership to resolve challenges [Table 6].
Leadership involvement: An important facilitator of the initiative was participation of hospital CEO and SLC in the initiative-related workshops, sessions, and meetings. Moreover, a continued visibility was demonstrated on the Facebook group through their posts and comments ensuring engagement and motivation of the employees. The posts entailed encouragement of the participants after attending their sessions, asking thought-provoking questions, and providing constructive feedback when needed.
Real-time feedback and encouragement: Leveraging the social media technology allowed for employees in different units to connect, provide feedback, and offer views on issues/challenges raised, while also encouraging them.
Alignment between leadership’s say-do: Another facilitator for implementation was keen interest from leadership in listening to employee challenges and acting promptly to resolve them. An example was the nursing pain point of excessive documentation which was noticed by the CEO on the Facebook conversations and immediate meetings were called with hospital business process re-engineering team. The team helped restructure and revise documentation forms in the subsequent few months.
Immediate recognition: The communication platform perhaps provided a much needed opportunity for employees to be appreciated and duly recognized in a prompt manner in the presence of hospital leadership. A post known as ‘Person of the Week’ was initiated in the first half of 2018. These posts had the highest engagement ratings.
Value creation: The team consciously made efforts to enhance the value of the initiative for the employees by showcasing the work internally and also inviting renowned celebrities to witness the activities in the wards. A 2-day visit for Dr. Patch Adams was arranged in April 2018 which included different activities for staff and patients. Thereafter was Dr. Karen Armstrong, who is a religious thinker, author, and the executive of Charter for Compassion, a global peace initiative. During her visit at the Aga Khan Centre in London in September 2018, she delivered the ‘Annual Pluralism Lecture’ in which she also spoke about her initiative: “Twelve steps to a compassionate life”, being implemented for a program in the pediatric SL to help the nurses and doctors develop a conducive relationship. She quoted the initiative as ‘compassion coming from the Muslim world’ . In 2019, national celebrities like Shehzad Roy and Mehwish Hayat also made individual visits to the Children’s Hospital [40, 41]. Employees with outstanding performances were given a chance to meet these celebrities, which not only boosted their morale, but also made them feel valued.
Assigned personnel: Sustainable implementation of the strategies was facilitated by personnel who designed and led the interventions and were responsible for the outcomes. The office of Director Patient Experience of Care was created, and the behavioral implementation scientist was appointed as the director patient experience of care. Other core member included an organizational psychologist (first not only in the service line but at AKUH too).
Strategic partnerships: The team was cognizant of the fact that a sustainable impact is achieved through strategic partnerships and therefore stakeholders with a shared vision were identified. One of them was Charter for Compassion (CfC) Pakistan who co-designed the employee mentorship package and organized celebrity visits through their contacts. Another was with a psychology department of a local university as implementers of play-based therapy which was one of the QI projects .
Timely dissemination: Regular dissemination to ‘spread the word’ both internally and externally (2 manuscripts, 11 conference abstracts, 3 online case studies, 2 inter-department talks, an online blog for an international patient experience institute, thesis of an international student) was another strategy the team felt, facilitated implementation. The dissemination activities acted as means of receiving peer feedback allowing for refinement of the idea and establishing credibility of the work, motivating the employees.
The barriers identified during individual meetings for project execution included variation in engagement of the employees leading them, additional responsibility (more than what employees would have expected), logistical challenges, and lack of time. Additional challenges realized were the QIs not being aligned with job description of the person leading it (e.g., admission QI), lack of project execution skills, and lack of appropriate incentives, especially for the senior managers.
Additional human resources required were a leadership coach for 6 months and a communication consultant for 3 months. Post intervention period, a team of patient experience was created including a director of patient experience (who had expertise in implementation of human experience projects), an organizational psychologist to support strategy design for employee engagement, and 2 RAs for data collection, management and analysis. Resources in terms of costs were incurred for training workshops and execution of the QIs but were not systematically maintained.