Archives November 2016

Dr Emma Vaux is a consultant nephrologist and general physician at the Royal Berkshire NHS Foundation Trust. She has a research doctorate, Oxford University 2001.

Dr Jen Perry, clinical lead for BMJ Quality, talks to Dr Emma Vaux.

Moving beyond the tickbox
Quality improvement (QI) has often been seen either as a tick-box exercise; something trainees have to do in order to pass their ARCP, or as an elite sport for carefully chosen clinical fellows. We need to move the thinking beyond this so that junior doctors are able to see its wide-ranging benefits, such as the ability to improve patient care, develop transferable skills (eg leadership), and build teams.

QI is an important method of “putting the fun back into medicine”, particularly in these difficult times where morale is low among junior doctors. It is a good way for junior doctors to get to know their teams outside of the ward round and the usual day to day business.
Doctors often lament the loss of the medical firm – well, this is one way of bringing teams back together and changing the conversation. QI enables links to be made between junior doctors and the rest of the organisation; it allows them to meet and engage with senior people such as the medical director and the director of patient safety. This helps to foster a culture where organisations value their junior doctors and the work that they do.

Finding the hook
We have to find the different hooks for junior doctors to get them engaged in QI activities. For some it is simply that they want to improve patient care, but for others it is about working differently, having an opportunity to influence, learning how to understand and use data, or being able to present/publish their work. For the few, it may still just be the need to tick it off for their appraisal and the realisation that assessment drives learning.

Overcoming the barriers at a trainee level
Trainees have lots of competing demands and time is commonly cited as a barrier to QI. Trainees often have to spend time doing things which don’t add value, for example collecting large amounts of data which aren’t used to effect change. They need to be supported to use their time in a smarter way, while at the same time recognising that time in job plans is also an important factor.

QI allows trainees to work with their MDT, patients, and carers. As well as sharing ideas and collaborating they can also share the workload. This is a way in which QI often differs to the traditional audit process. With QI there is a different mindset of needing just enough data, little and often measurement, making iterative changes, and learning from them in a real time and dynamic way.

Another issue to consider is that of sustainability. In the past, projects have often been started and led by doctors, but then the projects fall through when they move on. We need to train doctors to think about what will happen when they move on from their placement. The appraisal system is geared towards leading projects, but arguably it is an equally difficult challenge to pick up someone else’s work and sustain and/or improve it further. At the moment the appraisal system doesn’t recognise that and we need to change it.

At the moment we often hear about service delivery versus training and they are seen as two separate entities when they shouldn’t be. Reframing service delivery as being hands on patient care (alongside training) gives more of a sense of learning by doing and it can be seen as an apprenticeship. Quality improvement helps to bring service delivery and training together, it bridges the gap between education and clinical work.

Overcoming the barriers at an organisational level
Board buy-in is key. There are pockets of excellent QI work going on in places like Salford Royal and North East London Foundation Trust. These hospitals all have dedicated QI teams where QI has become core hospital business. In order to convince boards of the importance of QI, we need to develop better messaging; QI leads to better value (which has a financial cost attached to it) and it can also improve the culture of an organisation and staff wellbeing.

Culture change at a ward-level
I work as a consultant nephrologist and my ward always has several projects on the go. We have incorporated QI into our daily routine such that it has become part of normal practice. We spend 10 minutes after our daily board round catching up on our projects. Our mantra is working together and for data collection, little and often -and again this has helped to make it part of the daily routine.

We ensure that the data we collect and the tools we use (eg driver diagrams) are visible on the ward for staff to see; this really helps to sustain momentum and enthusiasm. We create a space where the whole MDT can come together and share ideas. It is fairly flexible so that people can drop in and out depending on their commitments.

The doctors and nurses now jointly manage the ward’s KPIs, a task that historically used to fall to the nurses, because it is everyone’s responsibility to improve performance. What is really positive about this way of working is that staff feedback that they feel valued, feel listened to, and feel like they matter.

Chris Ham took up his post as Chief Executive of The King’s Fund in April 2010. He is currently emeritus professor at the University of Birmingham and an honorary professor at the London School of Hygiene & Tropical Medicine. He was awarded a CBE in 2004 and an honorary doctorate by the University of Kent in 2012. He was appointed Deputy Lieutenant of the West Midlands in 2013.

Professor Chris Ham has recently authored a report entitled Improving quality in the English NHS with Dr Jennifer Dixon and Professor Don Berwick. The report highlights the need for a coherent strategy for quality improvement (QI) across the NHS, and sets out some recommendations for a “system of support”. Below is a selection of some of their recommendations:

– Organisations need to build capacity and capability for QI (as has been done in trusts such as Salford Royal and East London)

– There needs to be shared learning and the provision of regional support for QI through the academic health science networks, for example

– A centre of expertise for QI should be established

– Frontline clinicians, leaders of NHS organisations, patients, and the public should be involved in designing and implementing the strategy.

Dr Jen Perry, clinical lead for BMJ Quality, met with Chris to ask him about his paper and what it means for clinicians working on the frontline.

What do you think the most important message from your report is?
I think the key message is that there needs to be a strong and consistent focus from national leaders and ministers on QI. In politics, there is always the risk that other priorities can get in the way.

How do we keep the national focus on QI?
QI isn’t just the right thing to do; it helps the NHS to use its resources better, to hit targets, and improve financial performance. These issues are important to politicians and so we need to keep this at the forefront.

What will your report mean for frontline clinical staff?
It will mean that healthcare teams will be able to develop skills in and knowledge in QI. They will be supported to undertake projects which will improve quality and make better use of resources.

What about cost?
This is something that you can’t do without money. There needs to be a strong commitment from trust boards and money will need to be found from somewhere (for example through reserves and charitable trusts) or tough decisions will be made. The money invested for QI programmes will pay off in the long run through other savings. For example, at Tees, Esk and Wear, a mental health trust in the North of England, they have been able to close 100 inpatient beds and focus more of their psychiatric care in the community.

What are the barriers to rolling out QI across the UK?
Workload pressures are the obvious one. At present, teams are already working flat out and they will struggle to find the time to do QI; it really needs to become part of everyday practice. They have a saying at Jönköping: “People are employed not only to do a job, but also to improve upon it.”
There is also the issue of board commitment. Board members are often from different walks of life and are new to the concept of QI. As a result, they often need more convincing of it as a concept. What we really need is to have a document which makes the case for QI that we can present to trust boards.

How do we engage people in QI?
I’ve visited lots of organisations which are doing great QI work and what often happens is that QI starts with the enthusiasts, such as on a few wards. The rest of the staff in the hospital then start to hear about their great successes and want to get involved; it can have a ripple effect. This needs to be supported by leadership from the top and clinical champions.

What about top down strategy vs bottom up QI?
We need both. The top-down strategy is needed to provide the framework and resources, but all of this would be nothing without the teams on the ground actually doing the QI work.

Why should frontline staff get involved in QI?
The evidence is clear: QI improves patient outcomes, increases efficiency, and decreases waste. Staff members are able to develop a wide range of skills through doing QI such as leadership skills. Junior doctors are particularly well placed to get involved in QI because they see things through fresh eyes, they question and they challenge.