Monthly ArchiveDecember 2014

‘If Disney ran your hospital…’

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Dr Sharryn Gardner is a paediatric emergency consultant and practicing paediatrician. She has a special interest in psychological aspects of wellness and illness and started the first solution focused paediatric clinic nationally.

Dr Sharryn Gardner is a paediatric emergency consultant and practicing paediatrician. She has a special interest in psychological aspects of wellness and illness and started the first solution focused paediatric clinic nationally.

Sharryn Gardner recently published her report “Compassionate Conversations” in BMJ Quality Improvement ReportsCompassionate Conversations are a ground-level initiative focused primarily on supporting and motivating individual staff as the primary focus. They are led by a Psychologist and Consultant in a coaching supportive atmosphere in an open or selected group. Here she talks about her inspirations for quality improvement and thoughts on customer service for quality.

Once I’d finished professional exams I certainly never expected to become a bookworm again.  While as a trainee books were for specific purposes, after several years as a consultant they’re now for real professional development. However, I’ve found that as a consultant it has been possible to develop some new ways of getting things done. It started by embracing solution focused practice in my clinical work, which has inevitably led to me considering new ways of working and interacting with colleagues.

The scope of this reading has been wide – I’m a huge fan of Seth Godin’s blog[1] as I’m sure many readers are. Two books have been particularly influential. The first is the Disney book (more of that later), and the second is a Kindle book called “A Simpler NHS.” Its basic premise is simplicity, starting from the proposition that NHS management could be much simpler and at the same time be more effective (sample that simplicity here). It is a step back from the treadmill of measuring everything that can be measured. And unusually, our quality improvement project is the result of collaborating with like-minded individuals who met through Twitter; three managers and three consultants (including myself).

Bringing Disney to healthcare

While Disney may conjure up visions of severe consultants as Captain Hook or senior sisters as fairy godmothers, it might actually be a profound change in thinking. Fred Lee’s book “If Disney Ran Your Hospital – 9 1/2 Things You’d Do Differently” (read a sample here) helped make many of the practices my colleagues and I had already introduced into something more concrete. It turns out that Disney’s relentless focus on the customer experience is what ultimately keeps them at the top of their industry. That same constant focus on “customer experience” can be equally effective in almost any industry, including healthcare.

If I’m honest, I found this book to be life-changing, even if some of the core messages were seemingly obvious. What’s all that got to do with Healthcare? Fred Lee was a hospital manager. He learned from Disney’s values and fabric as much as their processes. More importantly he took them back to where they led directly to big improvements in healthcare. The NHS hasn’t previously had hospitals in direct competition for patients (and income), though that situation is evolving.  Lee suggests that even without this competition, embracing the customer experience culture should lead to happier, more productive staff and a much more collegiate approach to running organisations in any sphere.

As a fellow BMJ Quality blogger notes, staff like us have an innate desire to do well, to do better, and to be appreciated, and this is not confined to the so-called “caring” professions. Financial and other material rewards are apparently surprisingly poor motivators; genuine appreciation is much more effective.

Reading back through previous blog entries here on BMJ Quality, they almost universally highlight the fundamental need to not just involve frontline staff and open the process to engage everyone, using everyone’s skills and ideas to move forward as a team.[2] “Freeing up The Frontline” and “Customers, Simplicity and the Frontline” from A Simpler NHS[3] describe how much more effective devolving power to the frontline is, and how we “live or die” by our customer service. That might make us sound like a business, but that’s exactly the point. Patients compare our levels of service with them rather than other hospitals.

Perhaps we’re not yet shouting that message loudly enough, or at least not in the right ears.

Handy’s Curve and scepticism

shafig1The simplicity chapter also describes Handy’s Curve. This is a well-known phenomenon in general management where any new initiative takes a short period to amass expertise or resources to get going and then has steady upwards growth. The sting in the tail is that by not planning the next steps or spread of the idea, death of the initiative is virtually guaranteed. The new ideas or changes need to be in place from the mid-point of the upwards curve – point A on the diagram. The NHS, as much of business, repeatedly fails to plan for the next steps early enough. Little wonder that staff get more and more sceptical about any shiny new initiatives delivering real sustainable change.

Quality improvement project

Our project started from a grassroots implementation of the solution focused practice principles in the workplace. Our local psychology department had already embraced this as their primary model. Staff were individually given personal feedback from colleagues who attended sessions as groups. Some staff groups had separate sessions leading to spotlighting and showcasing of their people and achievements.

In the future, the same principles will be used in more and more diverse areas, and the sessions at the core are being further spread locally and within teams.

Compassionate Conversations was shortlisted for the following national awards:

  • BMJ Clinical Leadership
  • HSJ Patient Safety Award for Changing Culture
  • HSJ Value in Healthcare Award for communication.

References

1. Seth Godin’s blog www.sethgodin.com

2. Amar Shah. Embedding continuous improvement to achieve transformational change, BMJ Quality blog. http://blogs.bmj.com/quality/2014/08/06/embedding-continuous-improvement-to-achieve-transformational-change/

3. Cantley P, Finegan M, Nisbet A, O’Regan D, Gardner S, Gay T, Oldham J. Freeing up The Frontline from “Customers, Simplicity and the Frontline” from A Simpler NHS. A Simpler NHS: A fresh look at management in the NHS (Simplicity Book 1).

Ten important things you need to know about me

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Dr Sophie Edwards is a consultant geriatrician, older persons' advocate, and dementia trainer.

Dr Sophie Edwards is a consultant geriatrician, older persons’ advocate, and dementia trainer.

Dr Sophie Edwards is a consultant geriatrician, older persons’ advocate, and dementia trainer with a passion for instilling the values of high quality, person centred care for all @docofagesSophie. Here she describes some of the challenges she faces embedding quality improvement in an organisation.

I work on an acute geriatric ward in a busy district general hospital, where we serve a diverse ethnic and socioeconomic area – we have one of the busiest accident and emergency departments in London. Recruitment and retention of staff is difficult; morale is low, and fatigue is high. I’m not dismissing our service but I am keen to be honest and realistic about the challenges we face.

I’m sure many of you will recognise this picture. So, how on earth do we maintain a safe, high quality service when we are effectively working with one hand behind our backs?

I reflected on what I would expect from a high quality service as a client or customer. Competency in knowledge and skills is taken as a given. So what makes the difference between timely, correct treatment and high quality, memorable treatment?

Much of my workload includes caring for people with dementia or delirium. A person with dementia or delirium needs focused and flexible care. They need to know what is happening and when. They need to be reassured that their needs are being met. They need the involvement of their family and carers and they need staff to know who they were and who is important to them now.

Much of this can be achieved through good communication. It’s more than introducing ourselves properly, although this is absolutely vital; it’s about standing back and listening. It’s about watching the subtleties in body language and facial expression. It’s about picking up the little clues from the midsts of a patient’s delirious mutterings (many of my patients provide some superb insights while in the throws of their delirium). Ultimately, it’s about really knowing what makes each patient tick.

I would suggest that high quality care needs connectivity. It needs staff to be connected to each other and with the reasons that they went into health care in the first place. It needs staff to be connecting with patients and not shying away from the emotional investment that caring for people needs. It also needs staff to have the opportunity and space to reflect when things are overwhelming.

I wanted staff to really know the person behind the patient, so we introduced “Ten important things you need to know about me” based on “The important things you need to know about me” from The Alzheimer’s Society. It was originally for use with people with dementia so that staff would know what to say or do when someone was distressed or agitated. I think everyone should be able to tell us their story, who they need when things are tough, and what their likes and dislikes are. I’m keen that we use it for all inpatients if they wish.

Embedding this initiative has not been easy. I’ve personally filled up trays of it around the hospital, but it is yet to be part of our standard care. If it really works once and provides a key piece of information that calms a patient, or provides an insight that allows staff and patient to connect in a way they hadn’t done before, then the benefits will be seen and staff will want to use it again.

No one intervention will work in isolation, and the importance of supporting our staff to care cannot be underestimated. A chance meeting with a sports masseur led me to applying to our local training board for some funding to train some staff in hand massage. The trainers provide a course which includes massage techniques but also teaching around dignity and person-centred care. It gives staff a bit of much needed breathing space away from the ward that isn’t just mandatory training or e-learning.

Back on the wards, it allows them to sit down and spend time connecting with the people they wash, dress, and provide medication to. In the rush of the hospital that talking time is lost. This was about connecting staff back to their role as a carer and a provider of comfort. We use if for people with dementia, for end of life care, overwrought carers, and anyone who might be in need of the contact.

Again, encouraging staff to keep using these skills has been hard. Time is scarce, and it needs good support from the development nurses to ensure that the skills are used regularly.

It is frustrating that many of these small, quality interventions often save time in the long run. Calmer, informed patients can translate to less behavioural problems reducing the need for one to one nursing, less incidents, and less complaints. Staff that are motivated, connected, and supported are more likely to care about the quality of care they provide.

The prospect of trying to change or improve can feel overwhelming and daunting, but I’m a great believer that sometimes small, simple ideas can have a local impact that can ripple through an organisation and before long can establish a culture of improving and quality improvement. We may only be at the starting blocks of this journey on our ward, but at least we are out of the changing rooms!

Hello, my name is…

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 Dr Kate Granger is a specialist registrar in geriatric medicine

Dr Kate Granger is an acting consultant in medicine for older people working at Pinderfields hospital in Yorkshire, and also blogs and writes about her own experiences as a cancer patient

Hello, my name is Dr Kate Granger. I’m an acting consultant in medicine for older people working at Pinderfields hospital in Yorkshire. I’m also a terminally ill cancer patient diagnosed with a rare sarcoma just over three years ago.

I have been a keen observer of my healthcare throughout this difficult journey and it was apparent to me early on just how much the little things mattered to my experience as a patient. When somebody smiled, sat, or crouched down instead of towering over me, gave that extra moment to allow me to express my fears, or took the time to introduce themselves in a welcoming manner, it meant a huge amount and made me feel human again.

The #hellomynameis campaign was born out of a hospital experience I had when I was admitted to a urology ward with a post-operative infection following a routine stent exchange procedure. There were lots of problems with my care, but most distressing was that hardly anyone took the time to introduce themselves. This left me feeling like a diseased body in a hospital bed and nothing more. I firmly believe after much reflection that an introduction represents far more than just common courtesy, but rather the start of a connection between human beings; it is about the therapeutic relationship, building trust and rapport, and providing truly compassionate, person-centred healthcare.

I am a strong advocate for quality improvement in my daily work and am always striving to improve the care we deliver with my team. The most interesting area of quality improvement for me is how to change behaviour with lasting effect. I firmly believe that narratives have a vital role to play in behaviour change and decided that my story, which I knew from interactions on social media was not a unique one, was going to be central to instigating that change.

I started to tweet using the hashtag and wrote a blog inviting people to pledge their support, similar to the style of NHS Change Day. We designed a freely available logo and a website to collate resources and ideas, and within weeks I had a social movement on my hands!

We launched the campaign a few months ago in my previous hospital, and within just a couple of weeks one third of the fifteen thousand strong workforce had pledged their support in return for a name badge displaying the logo. We received thousands of pictures from staff across the organisation holding #hellomynameis signs as a symbolic gesture of their support. Everyone from student nurse and porter to medical director and chief executive were engaged.

It is very difficult to evaluate the impact of a campaign like this. We can, however, measure how much people are talking about it on social media fairly easily, and those numbers are impressive: over 70 million Twitter impressions in just 16 months, which is 4 tweets per hour. The campaign has spread beyond social media right out into health and social care across the UK. It has even had a global reach; people are using the campaign in the United States, Canada, Australia, New Zealand, India, and South Africa.

Some junior doctors at Bolton hospital are using traditional improvement science methodology and have measured the frequency of introductions in the emergency department.  They will be repeating their observations after the campaign has been launched there, with follow-up PDSA cycles planned. There are several other similar projects currently ongoing across the country.

The campaign has caught the attention of the Prime Minister and the Secretary of State for Health. Although it may seem a little gimmicky, we have even had some support from celebrities such as Kyle Minogue, Drew Barrymore, and Michel Roux Jr, which all helps to raise the profile of the campaign and spread the message further.

This is an aspirational idea. It is about saying, “This is me and I am proud to be able to look after you”. It is a behaviour that cannot be trained into people with mandatory learning objectives – it has to come from within. The power of my voice is that I am “one of us” but also “one of them”. No-one knows when that terminal cancer diagnosis may appear in their lives so seeing the patient in front of you first and foremost as another person is a great way to begin care.

www.hellomynameis.org.uk