So first, Anne, can you please just explain a little about how the Happy App works in healthcare and the ideas behind its creation?
Anne: “About five or six years ago I, and a colleague of mine and surgeon at UH Bristol, Andrew Hollowood, started working on patient flow in healthcare. We were looking at the way patients moved through hospitals. What barriers there where. And what was happening on the ground that stopped people moving from one place in the hospital to another, or between teams, smoothly and effectively.
“We knew there were lots of people, working in different areas of healthcare, with lots of really good ideas. Particularly about what worked and what didn’t. But, we also knew that there were a lot of ‘work arounds’ in place. In other words, instead of saying ‘this does not work, we need to fix this’ staff had learnt to work around the problem. This was primarily because of barriers to change. Both perceived and real.”
How did you start about addressing this problem?
Anne: “We ran some weeks called ‘breaking the cycle weeks’. In these we asked employees to tell us everything that was good/bad and put each issue in a ‘fix it box’. We then tried to fix these issues. Some of them were really minor. For instance, ‘the printer doesn’t work, and I have to walk half way round the hospital to use it’. In contrast, some issues were quite major and needed to be sorted. We soon realised that these issues needed to be sorted not in a single week once a year, but continuously.”
Anne: “In addition, we were quite interested in change management and culture change. In particular how people actually felt about it and what effects these changes have. Even if you do a really good job and get a good level of engagement, there will always be people that you haven’t been able to engage with. Or that you haven’t included enough. We wanted to work out how these changes affected these people on a daily basis.”
Where did you start your enquiries?
Anne: “We started in a couple of areas. Predominantly in the children’s emergency department (where I work) and one of the surgical areas where Andy works. Initially we just set up something that was really simple, in the form of an excel spreadsheet. The only question on the form was ‘how are you feeling?’. To answer you selected one of the three emoji style faces (unhappy, neutral or happy) and left a free-text comment.
“This was quite laborious as we had to go in every single day and download all the comments. We then had to cut and paste them into a word document. From this we could say:
– These are all the things that you told us about.
– This is how you felt.
– This is what we have done about it.
Or, in some cases ‘actually we couldn’t fix this, but this is why’. Then we were able to give an explanation as to why we were unable to fix the issue.”
Can you tell us a little bit about CLAHRC?
Anne: “We did quite a lot of work with the CLAHRC, who are a research organisation affiliated to the NHS. They interviewed lots of staff for us and evaluated our outputs. We also held workshops with staff and came up with some key findings:
First- Feedback had to be anonymous.
Second- The tool had to be really quick, easy and intuitive to use. Not difficult or time consuming.
Third- Porter, cleaner or consultant, it had to be accessible to everybody.
“Fourth- Most importantly you had to provide acknowledgement of feedback given. People didn’t automatically expect everything to be fixed overnight. But they did expect to have some acknowledgement that they had left a comment. To see that people had listened to and cared about what was said, even if it was unfixable, was key.
“But, as I said earlier, this system at that time was very laborious and not scalable. As a result, we got it developed, initially as a web-based application. Now it as a fully mobile app.”
What did this allow you to do?
A) Scale it. So you/we don’t have to download all the information every day.
B) Allowed us to theme things. To look across the organisation better and to understand what the common themes were that were coming out of different areas.
C) It acted as a smoke detector for the hospital, staff feelings and moods. We know that, over long periods of time, most areas benchmark fairly similarly. Lots of areas will have days where staff are unhappy/happy. But, over time, if you start to see areas where the feedback is always very negative, this gives you an indication that something is going on. And that the issue is not a normal variation. This allows you to go into an in-depth analysis of that area and get HR involved sooner. We saw it as a kind of smoke detector, as a warning really for what was going on in the trust.”
A metaphorical smoke detector to highlight issues early is fantastic. But why is this technology so important, and what does it really mean for healthcare?
Anne: “Well, it provides information on three levels.
“First. On a local and personal level it helps with engagement. In that, by providing my feedback, I feel more engaged with what I am doing. On a personal level, you put something in and you actually get something back out of it. So that is quite positive.
“Second, From a team level it helps teams define themselves and encourages local leadership. We were quite keen that everything was locally owned and that we could empower local teams and local leaders to make changes. By keeping it local you didn’t/don’t have to push everything up the NHS hierarchy. Which is quite significant. Instead, you could just get on with things and people felt that they owned their own issues and problems. In addition, teams bonded over and celebrated their successes. We got lots of comments about good teamwork.
“Third. From an organisational point of view, you have benefits in terms of HR type stuff. So in recruitment retention you start seeing improvements.”
Did any findings surprise you?
Anne: “In some places we visited we got lots of comments back about work life balance. In most areas you sort of assume that people in healthcare are asking for loads more of this and loads more of that. When, actually, when we dug down into the comments, that was not the case. What they wanted were things that were quite deliverable. Aspects such as rotas to be out on time, or to have good notice about being able to attend a wedding, were key. These organisational issues were paramount, yet not being sorted.
“And that I think is quite useful for an organisation because you can do something about these issues. There is often a perception that everything needs to cost more money. But, in actuality, there are lots of improvements that can be made that don’t need to cost a lot. We need to find ways to work smarter and better and asking staff for those ideas is by far the most cost effective and constructive way of doing it.”
It is marvellous that you can pinpoint these issues so swiftly. While, yes, we do need more money and staff, there are so many other factors that don’t cost the earth and, if fixed, could make our healthcare system so much better.
In 2016 you and your team actually won an award for staff engagement at the HSJ awards. That’s quite an accomplishment. Two years on where do you see the app developing?
Anne: “Well, when we won the HSJ awards we were still with a limited number of trusts and, at that point, we didn’t have it as a mobile app. In the last couple of years, we have:
- Made it mobile, so it is much more accessible to lots of different staff groups. When we started it was very much tailored towards the key trusts. Now we can see benefits in community trusts and are starting to think about using it in ambulance services. So, in terms of usability, having it mobile makes it much more flexible.
- The other thing that we recognise is we can start to dig down into the data allot more and get a lot more insight. That is what we have been working with Pansensic on. We look at the word or text analysis of the data in much more detail. We are starting to get large volumes of information coming through. Which means we are able to provide a local dashboard. But we can also provide something that is much more intuitive and useful at board level. So, not only do local teams see the benefits, but the trust boards and those at organisational level are also benefiting. It is exciting developing this and making that part of the package.”
How could this technology help outside of healthcare?
- We are also keen to start using and looking at it in other areas such as in education. We see great benefits for it in terms of providing feedback on either higher education or secondary school level, to acquire and analyse information from both pupils and teachers potentially.
- Overall, we are now at a point where we are getting more information out of it at a board level, as well as at a local team level, and its triangulating that with other data sources so you start to get a really rounded picture. Regardless of what sector or organisation you are using it in, we think that it will provide an exciting new way of looking at engagement.”
What a multifaceted tool. Thank you for demonstrating just how insightful the Happy App can be.
To read more about the Happy App and how it works click here!
We look forward to seeing where and how it progresses into the future of healthcare and more.
(This interview has been lightly edited for the purpose of clarity)
Image Credit: CLAHRCBITE