Lancashire Care NHS Foundation Trust are proud to be part of the national Always Event (AE) pilot which was funded as part of the Compassion in Practice Strategy by NHS England working in partnership with Picker (Europe) and the Institute for Healthcare Improvement (IHI) – Always Events® is registered trademark and ‘owned’ by IHI.

AEs are defined as those aspects of the care experience that should always occur when people and family members interact with healthcare professionals and the health care delivery system.

IHI’s AEs framework provides a strategy to help health care providers identify, develop, and achieve reliability in a person- and family-centered approach to improve individual’s experiences of care.

An AE is a clear, action-oriented, and pervasive practice or set of behaviours that:

• Provides a foundation for partnering with people and their families

• Ensures optimal experience and improved outcomes

• Provides a common platform for all that demonstrates a continuing commitment to person and family centred care

The opportunity to be part of the national pilot was timely for our Trust and an Adult Learning Disability Team volunteered to participate. Together the AE was co-designed with people who use services and their carers, to understand what matters to them and identify our AE:

• I will always be supported in moving on in care (transitions in care) Ideas were generated which would enable the AE, including:

• The development of a contact card on discharge

• Notification of proposed staff changes / transfers by letter, with photographs of new staff • A monthly “pop-in and chat” support session

These ideas have been developed and tested using Plan, Do, Study, Act improvement methodology.

Co-design has been fundamental to the development of our AE with people who use our services and their carers involved throughout, developing an AE in their own words, co-designing the evaluation questions and presenting their story. Between July 2015 and early Jan 2016 26 people were discharged following the new procedure (new letter, contact card, pop in and chat invitation). A follow up contact call was made 2 weeks later by support worker and cases were discussed at the team weekly discharge meeting.

The evaluation has been completed by Picker Europe and the findings show a positive difference to the experiences of care for those who use services and staff.

Feedback from people using services has included:

“I keep the card on the fridge with a magnet – so I see it all the time”

“My idea was chosen….I feel good”

Feedback from staff members:

‘‘Co-design made the implementation feel real and right the way target driven things aren’t’’

“I was worried that it was going to be difficult to do but it’s not at all. It’s a small investment of time to have a big impact”

The next steps are to continue develop our AE with the team. A roll out plan is in place to spread the AE to other Learning Disability teams and across the organisation.

For more information about Always Events please see the links to websites below:




About the Author:

As Head of Quality Improvement and Experience at Lancashire Care NHS Foundation Trust I lead the quality improvement and experience team and the implementation of Always Events throughout the Trust. This includes the participation in the national Always Event pilot, working with NHS England, the Institute for Healthcare Improvement and Picker Europe. I am a qualified nurse with experience of working in both acute and community settings. I am passionate about people being at the heart of everything we do, co-design and quality improvement. I am also a founding cohort member of Q, a UK-wide initiative led by the Health Foundation and supported and co-funded by NHS Improvement.

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