Quality in healthcare services has been a contentious subject over the past decade. Recent reports have highlighted previously unacceptable poor practice in failing NHS Trusts (Francis, 2013; Kirkup, 2015), and as a result, service users' expectations are high. The fundamental element in quality of care in the NHS is the experience of the service user (Granville, 2006; Care Quality Commission (CQC), 2016; Crowe and Sharma, 2017). Maternity care relies on the experiences of women and their families to improve services and recognise problems (Wenzel and Jabbal, 2016). Some service users have become experts in how healthcare should be delivered (Blunt, 2014) and have even influenced and redesigned local, regional and national policy through their persistence on social media (Newburn, 2017).
Better Births (National Maternity Review, 2016) outlined how maternity services were required to change the organisation and running of services to provide more personalised, safer care with continuity of carer. The report concluded that using technological innovations sourced from a variety of fields could add a richness of ideas and practical solutions, leading to improvements (National Maternity Review, 2016). Co-designing services with service users and healthcare providers should be the norm and has been encouraged for more than a decade (Granville, 2006).
Changes to the quality of care in maternity services not only enhance user experiences but may, in the long term, reduce NHS costs (Blunt, 2014). The challenge is to engage other health professionals involved with maternity services to use innovative ideas to improve quality. Without collaboration from other disciplines, it becomes more difficult to ensure personalisation of care in practice. A multidisciplinary group of health professionals and service users is required for creative quality improvement in the culture of transformational leadership (Granville, 2006). In the long term, these changes may improve productivity and increase staff satisfaction in the workplace, which in turn may result in lower levels of absenteeism, a reduction in negligence claims and more positive outcomes (Blunt, 2014).
What is crowdsourcing?
The term ‘crowdsourcing’ was originally used by Jeff Howe in 2006 to describe how problems could be solved by using ideas collated from a large group of people (Howe, 2006). Crowdsourcing has been applied in many disciplines and can be tailored to solve myriad problems, for example asking consumers to design new flavours of crisps or to contribute new ideas for Lego products (Corney et al, 2010).
By using a large public audience, typically online, solutions can be found quickly and relatively cheaply (Swan, 2012). Problem-solving can also be achieved in organised workshops, mixing top-down and bottom-up approaches, where innovation and efficiency are the objectives. Sharing knowledge with peers allows for creativity and otherwise unknown expertise to be used and implemented in the workplace (Ye and Kankanhalli, 2017).
Crowdsourcing as a concept is based on the social exchange theory, where human interactions are said to be dependent on a reward or punishments system (Garcia Martinez, 2017; Ye and Kankanhalli, 2017). Individuals who participate in crowdsourcing have been shown to tailor their ideas to solve identified problems depending on whether there is a reward for engagement, which implies that there is an underlying agenda to participation in crowdsourcing and knowledge-sharing behaviours (Ye and Kankanhalli, 2017). The social exchange theory establishes that sharing knowledge is welcomed and rewarded, and that problem-solvers contribute collectively. Crowdsourcing is particularly useful when a problem appears ambiguous or requires substantial creative input to solve, as it allows a direct connection and communication with service users (Edwards, 2011) and can be used to address problems in practice.
In healthcare, collecting different perspectives from staff, patients and the wider public can illustrate the need for change, provide solutions and improve services (Granville, 2006). Blunt (2014) suggested that to improve user experience in healthcare, it would be prudent to assess and use strategies from other areas of business. The use of crowdsourcing in maternity services has yet to be fully established.
Using crowdsourcing to improve maternity experience
In 2014, a grassroots social media campaign known as #MatExp (short for ‘Maternity Experience’) emerged, with the aim of improving maternity care experiences (Box 1). #MatExp is founded on a transformation tool, ‘Whose Shoes?’, that promotes creativity and choice in healthcare, and challenges the attitudes and assumptions of health professionals and service users alike.
Whose Shoes? (Wilcock, 2016) is a bespoke game that is played in a structured workshop setting with a variety of health professionals and service users, who are considered as a ‘crowdsourcing collective’ (Figure 1). Participants can be anyone involved in the topic for improvement, including health professionals, volunteers, heads of department, NHS England employees or service users. Service users are recruited through social media or a phone call from organisers, maybe word of mouth when a specific memorable case has been discussed, or from a risk case. Maternity Voice Partnerships are also useful to engage service users. Discussions are tailored to fit with each workshop criteria, and participants, who have many different perspectives on the topic, are encouraged to bring real experiences to the table. Participants generate various possible improvements to areas of maternity care laid out in the Whose Shoes? game (Figure 2). The philosophy of Whose Shoes? is that person-centred practice, with crowdsourcing as a means to produce creative and sometimes radical changes, will improve the quality of care.
#MatExp uses a specifically designed version of the Whose Shoes? board game, in which the cards and poems that make up the game have been adapted to spark discussion and change, based on crowdsourced material from blogs, Facebook, Twitter, networking, Friends and Family comments, charities and Maternity Voice Partnerships. Participants commit to a change related to a specific aspect of care, however small, with an action plan that is followed up by workshop leaders to ensure that ideas become reality. For health professionals, this could as simple as changing the wording used in patient letters following feedback from patients, allowing partners into theatre for third-degree tear repairs, or ensuring that mothers in intensive care have their babies with them. Service users may pledge to start up a group for fathers-to-be, or make suggestions to improve care.
Literature review
Methods
A preliminary review of the literature related to the use of crowdsourcing in maternity services was undertaken as part of a Masters degree. By entering the term ‘crowdsourcing’ into a general search, a total of 351 articles were found across many disciplines such as medicine, health, psychology, agriculture, finance and information technology. Many of these articles were focused in east Asia, where industries such as finance and IT use crowdsourcing, mostly online, to solve problems effectively (Corney et al, 2010).
A more detailed search of literature published in English within the past 10 years was conducted using CINAHL and Science Direct, with keywords such as: ‘crowdsourcing’, ‘crowdsourcing and midwives’, ‘crowdsourcing and maternity’ and ‘crowdsourcing and improvement’. This yielded limited results, and produced articles mainly related to crowdsourcing outside healthcare. A hand search of journals, including the Royal College of Midwifery (RCM) publication Midwives, The Practising Midwife and MIDIRS, offered no primary research on crowdsourcing in maternity care. Searching for ‘crowdsourcing and midwives’ resulted in one article (Adams, 2011) that appeared across many databases.
From this search, nine articles were selected due to their focus of crowdsourcing as a quality improvement tool. These were categorised into two groups:
Four general issues emerged from the discussions in these articles:
In the absence of primary research, these themes were relevant to the discussion of the uses of crowdsourcing and how it could be translated into providing high-quality maternity care.
Results
Crowdsourcing definitions
Howe (2006) acknowledged that most technological advances stemmed from people with a new idea (particularly amateurs). McCartney (2013) noted that crowdsourcing was fuelled by information technology and highlighted that healthcare categorised crowdsourcing as a medical subject for collecting feedback. Adams (2011) defined crowdsourcing as a reporting tool for policy reform, quality improvement and product development.
Crowdsourcing and patient experience
The NHS favours the use of tools such as the Friends and Family questionnaire to gather real-time feedback from patients regarding their care. Although this is useful to improve services, in maternity care, this type of feedback may lead women and their families to provide positive comments, as the questionnaire is often completed on leaving hospital with a new baby. Other countries such as the Netherlands and the US encourage patients to review their care and publicise their experiences online, although bias can still be introduced (Shoenberg, 2012; Weiner, 2014). Adams (2011) studied data from six international websites that asked patients to share their experiences of care. The author concluded that the voice of the user was vital in shaping care, and noted that certain quality control tasks that were previously performed internally later relied on crowdsourcing.
Blurring of boundaries
Several sources have acknowledged the potential benefits of using crowdsourcing in healthcare, but have also argued that there is an obvious difference between doctor and patient. Choo et al (2015) argued that crowdsourcing through social media can be a way for health professionals to share their knowledge and engage with service users, medical students and other colleagues to seek solutions to problems; while others (Showalter, 2012; Shoenberg, 2012; Weiner, 2014) suggested that the boundaries between health professionals and service users are blurred, as patients are now able to access information on the internet with which to challenge health professionals (Sinclair, 2014). McCartney (2013) suggests that clearly defined roles are needed for crowdsourcing to be successful: as the crowd is ‘employed’ for a specific task, its members must have the knowledge to participate.
Crowdsourcing as technological innovation
The literature included in the review favoured the concept of crowdsourcing to improve care, working conditions for staff, and an overall general positivity towards healthcare. Sinclair (2014:39) noted that technology provided a ‘platform for shared learning’ on a global level that must be used effectively and consistently in order for midwives to provide excellent care, while commentaries from The King's Fund (2017) have alluded to crowdsourcing as the future of the NHS. The reach of the online community enables larger scale interactions to take place, and Brabham et al (2014: 179) emphasised the value of online crowdsourcing as ‘a highly structured process from the organization's side, drawing on the creativity and intelligence of an online community in an open, but controlled, way.’ Brabham et al (2014) also suggested that it provides a flexible approach with has a shared top-down and bottom-up process, in which the intended audience's involvement leads to relevant solutions. As a result, health professionals have an ideal and unique opportunity to channel the latest innovations in technology (Choo et al, 2015).
Although there appears to be limited primary evidence into the impact of crowdsourcing in maternity care, Whose Shoes? has illustrated how it could be used (Fowler and Patterson, 2013). Better Births (National Maternity Review, 2016) provides another example of how crowdsourcing—in the form of an online survey for staff, women and families—was used to rate and suggest improvements in maternity care.
From the limited literature identified for a preliminary review, it appears that the potential of crowdsourcing is acknowledged, but it is not used creatively, and a more in-depth evaluation and study of crowdsourcing is needed. As more innovative solutions to solve problems in maternity care are required, service providers will need to consider the use of face-to-face crowdsourcing opportunities in addition to the virtual environment.
Conclusion
This article has introduced the concept of crowdsourcing as a means to offer creative solutions to everyday challenges in maternity care. Although the use of crowdsourcing as part of existing transformation tools such as Whose Shoes? has been illustrated, there appears to be an absence of primary research on the effectiveness of crowdsourcing and the involvement of midwives. The literature appears to show that the use of online crowdsourcing, although popular with other industries, it is somewhat disconnected in maternity from where solutions are required. Therefore, it is crucial to emphasise the advantage of using tools such as Whose Shoes? where face-to-face discussions around improvements to the maternity experience may be a more creative and powerful way of discussing issues and generating solutions. Crowdsourcing using a workshop scenario, in which creative face-to-face discussions take place, may elicit solutions that are meaningful and realistic. Part 2 (to follow in a future issue) will present the findings of a service evaluation which explored midwives views of participating in a crowdsourcing activity.