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Archive for November, 2014

Patient empowerment

13 Nov, 14 | by BMJ Quality

Dr Paul Shannon is a practising NHS consultant anaesthetist with an extensive clinical leadership record in the NHS at local, regional and national level. He is a member of the new Yorkshire and Humber Clinical Senate Assembly. His passion is to improve patient care.

Dr Paul Shannon is a practising NHS consultant anaesthetist with an extensive clinical leadership record in the NHS at local, regional and national level. He is a member of the new Yorkshire and Humber Clinical Senate Assembly. His passion is to improve patient care.

I once asked an eminent doctor why he didn’t publicise the shocking figures of avoidable patient deaths in the NHS that he’d just presented to us at a closed meeting. He answered, “how could I; can you imagine the outcry?” Indeed, I could imagine the outcry – from politicians, professional organisations, and even patients themselves. And that was really the point of my question; the energy released would be disruptive and facilitate change.

It’s in this context that the statement by the Secretary of State for Health is remarkable, that 6,000 lives could be saved each year by improving safety in the NHS. Mr Hunt is promoting “openness” and this is the first step to patient empowerment; to let the public know what’s going on. In other words, share the data with them. Knowledge is power, so empowering someone involves giving them the same information that you’ve got. Knowledge is organised information.

Show them the data

“Discontent is the first step in the success of a man or nation” (Oscar Wilde)

Patients need to know how dangerous healthcare can be. They need to understand that all hospitals are not alike, not all doctors are competent all the time, and not all nurses are compassionate all the time. In short, they need to become discontent with the status quo.

But where can they get the requisite information?  In general, data is held by professionals and carefully dispensed to patients. It’s often a paternalistic relationship, like a parent/child transaction. Just try getting access to your records. You will be treated as a nuisance, or as a “rebellious child”, and punished by having to pay for the privilege!  It will be made as difficult and laborious as possible so that you don’t ask again.

In reality, it is easy to give patients ready access to their records, and some countries do this already, but commonly it is “cumbersome”, or somehow considered just plain “wrong.”

Sensational

“I never travel without my diary. One should always have something sensational to read in the train” (Oscar Wilde)

As a doctor, I’ve never come across a patient who doesn’t want to read their medical records. Human beings are fascinated by their own condition and by their own lives, and especially by what other people think of them!  Harnessing this natural self-interest is a good way to involve people in their own care; it’s a natural “pull factor.”

Once lured in by curiosity, they’ll stay to contribute and learn. I recently held a consultation with a patient with a chronic haematological condition. I asked her what her latest test result was. Of course, she didn’t know, so we looked it up on the hospital pathology system. Seeing her results made her feel like she was being shown something illicit!  She said it was the first time in her life that anyone had shown her her own results. She was delighted and intrigued to know more. That’s a pull factor.

Another pull factor is correcting and updating data. Usually, this is done in the form of amendments so that original information is not lost. Patients are sometimes horrified at the errors within their records. This alone is a good reason for patients to see their records, to cleanse wrong information and improve quality.

Choose the best, or avoid the worst?

When a doctor, or their loved one, has a medical problem, they ask their friends, “who should I go to?” or, “who should I avoid?”  They know there’s wide spectrum of performance, so why don’t ordinary patients deserve this level of knowledge?  Of course, it’s mainly word of mouth opinion because the hard data to substantiate it just doesn’t exist, or isn’t easily accessible. Nevertheless, I’d hesitate to be treated by a doctor who never treats his/her colleagues!  League tables are a great way to present performance data easily. Just like in sport, no doctor wants to be in the relegation zone!

In the past, the NHS has tried in various ways to push information towards reluctant patients. Similarly, the Department of Health has tried to encourage the NHS to look at performance data, which the doctors happily rubbish. Now, it’s time to look at the other end of the pipeline and utilise the power of the consumer to suck as much information as they want and need out of health IT systems. As in other industries, patients, as consumers, will demand better access to information streams about the quality of services and doctors, which will allow them to contribute to their own health and well-being. And, doctors will want to know how they’re performing. In the end, better information produces better decisions for all.

Trainee led quality improvement: where have we gone so far and where will the 5 Year Forward View take us?

12 Nov, 14 | by BMJ Quality

Angelika is a core medical trainee in Health Education East of England. She is currently an FMLM national medical director’s clinical fellow at NHS England. She believes that clinicians should be the force of change and improvement in healthcare and is keen to share her experience in quality improvement.

Angelika Zarkali is a core medical trainee in Health Education East of England. She is currently an FMLM national medical director’s clinical fellow at NHS England. She believes that clinicians should be the force of change and improvement in healthcare and is keen to share her experience in quality improvement.

Over the last few years, quality improvement has started to replace traditional audit in junior doctors’ training and curriculum. This was fuelled by evidence that most audits fail to deliver improvements in healthcare, with only 12% of doctors reauditing[1] and only 5% of doctors felt that their audits led to a change in clinical practice.[2] This means that doctors have more recently moved away from the traditional, unsuccessful model of tick-box exercise audits and on to quality improvement projects.

The Royal College of Physicians initiative “Learning to Make a Difference” introduced quality improvement projects to core medical trainees (CMT) in 2011 and was met with great enthusiasm. Sixty-four trainees completed 34 projects in the first pilot year.[3] All participants reported that running a quality improvement project was a valuable experience and 85% thought that they had made a difference in patient care with their projects.[3] Three years later in August 2014, quality improvement officially replaced audit in the CMT curriculum.

Similar changes are yet to happen in other specialties but there is growing awareness of the value and necessity of quality improvement among trainees. Many independent initiatives, such as BMJ Quality, the Network4, and the Institute for Healthcare Improvement[5] are growing in popularity among trainees. The Network, which was set up in 2010 by a group of junior doctors, has now reached 2883 members.[4]  At the same time, more and more conferences dedicated to quality improvement are organised, such as Agents for Change, FMLM Regional Conferences, the Network Quality Improvement conference, are all well attended by trainees.

Quality Improvement has finally become fully integrated into junior doctor’s work and training. But will this positive trend for quality improvement continue in the future?

NHS England recently published The 5 Year Forward View,[6] which sets the vision for the future of the NHS. It describes a healthcare system that is facing major challenges and needs to change and evolve in order to meet these. It describes a NHS that focuses on prevention and integrated locally provided care, a system that strives for excellence along with rapidly translated research and innovation in clinical practice.

In working towards this vision, quality improvement can be a major lever for change. The 5 Year Forward View emphasises that “one size does not fit all.” Local initiatives are necessary to instigate change that is sustainable and these initiatives should be led by clinicians. The need for medical leadership is highlighted in the report with a pledge to “review and refocus the work of the NHS Leadership Academy and NHS Improving Quality.” Trainees should share this load with more senior clinicians and lead quality improvement in their hospitals. Junior doctors are ideally placed at the coalface, working around the clock to recognise areas where improvement is needed.

In addition, the report describes the need for innovation and investment in research, but one that moves away from distant, traditional models into translational research, which has a practical implication to patient care and can be easily incorporated into clinical practice.

Quality improvement projects are an ideal example of work that directly improves outcomes for patients, is led by clinicians, and is tailored to local clinical practice. Quality improvement is in perfect accordance with the ambitions defined in the 5 Year Forward View and the publication of this report is an opportunity and a challenge to all of us to fully integrate quality improvement to our work.

Health Education England, the medical colleges, hospitals, and GP practices should rise to this challenge and support junior doctors and allied health care professionals to lead and participate in quality improvement projects.

But it is also up to us as junior doctors to become leaders and improve quality of care for our patients. If you are in search of inspiration for your next quality improvement project, take a look at the five year ambitions for dementia, cancer and mental health, as described in the 5 Year Forward View!

References:
  1. Greenwood JP1, Lindsay SJ, Batin PD, Robinson MB, Junior doctors and clinical audit. J R Coll Physicians Lond 1997 Nov-Dec;31(6):648-51.
  2. John CM, Mathew DE, Gnanalingham MG. An audit of paediatric audits. Arch Dis Child 2004;89:1128-9
  3. Vaux E., Went S., Norris M., Ingham J. Learning to make a difference: Introducing quality improvement methods to core medical trainees. Clin Med 2012 Dec;12(6):520-5.
  4. The Network: http://the-network.org.uk/
  5. The Institute for Healthcare Improvement: http://www.ihi.org
  6. NHS England, Public Health England, Monitor, Care Quality Commission, Health Education England. Five year forward view. Oct 2014. www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

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