Archives 2013

Rob Bethune is a surgical registrar in the Severn Deanery. Follow him on twitter – @robbethune

One of the mantras of the quality movement is copy shamelessly from others.  This is valid and sensible; there is no point inventing the wheel over and over again (and more importantly not re-inventing the flat tyre).  However there are two important caveats to this; make sure you know what you are copying and be prepared to adapt the projects to fit your local circumstances. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

‘In the South Seas there is a Cargo Cult of people.  During the war they saw airplanes land with lots of good materials, and they want the same thing to happen now.  So they’ve arranged to make things like runways, to put fires along the runways, to make a wooden hut for a man to sit in, with two wooden pieces on his head like headphones and bars of bamboo sticking out like antennas – he’s the controller – and they wait for airplanes to land.  They’re doing everything right.  The form is perfect. It looks exactly the way it looked before.  But it doesn’t work.  No airplanes land.  So I call these things Cargo Cult Science, because the follow all the apparent precepts and forms of scientific investigation, but they’re missing something essential, because the planes don’t land.’ – Richard Feyman[1].

The clear translation for us is that if you superficially copy a quality improvement programme you may well fail.  This argument is expanded in this excellent article by Mary Dixon-Woods that evaluates in detail why the Michigan central line infection programme worked.  As it turned out it was not just about the five point checklist (and in fact by the end there were over 100 different locally adapted checklists) but a complex social intervention [2].  The cocktail hour in the evenings of the collaborative meeting was seen as crucial in creating the culture to drive improvement.  Details are really important; they also had logos for all the participating ICUs printed onto the water bottles at the joint events; that is how you change culture.

As a surgical registrar I see this cargo cult style error daily.  In almost all theatres across the UK the WHO safer surgical checklist is used before, during and after each operation; well at least that is what the data from trusts will show you.  A study was published in the NEJM that showed the benefit of this checklist and the idea was that if all UK hospitals used this checklist then they would get the same reduction in mortality and morbidity[3].  However in the same way the islanders superficially copied the Americans with their wooden huts and bamboo ear defenders we have superficially copied this quality improvement intervention.  The NEJM study did not just use a checklist they had pre-operative briefings and crucially team training on how to use the checklist.  There is a whole science around checklists and a study in the British Journal of Surgery shows that we are simply not using it properly and therefore cannot expect to get the same benefits as the NEJM study showed[4].  We may laugh at the islanders but we are doing the same thing on mass in the NHS.

Just because a quality improvement intervention worked in one place does not automatically mean that it will work in your clinical area.  In fact it is likely that without some alterations to fit your local circumstances it won’t work as well.  In this paper (co-authored by @carsonstevens) this point is expanded on  – if you are not prepared to adapt work from elsewhere and be flexible you are much more likely to fail and this is one of the reasons why so many QI initiatives do not succeed[5].  Again we have not heeded this advice during the roll out of the WHO checklist.  It must be adapted for local situations.  Some of the questions are simply not relevant to UK hospitals and equally there are other questions that need to be included. Pilots do not use the same checklist for each plane they fly and so we should not be using the same checklist for day case eye surgery as for an anterior resection for rectal cancer.  If we become more flexible with the implementation we will get more staff on board and begin to effect the cultural change that was behind the original success of the safer surgical checklist.

So if you want to avoid being one of the islanders with bamboo headsets, before you start to implement the next amazing improvement initiative make absolutely sure that you know in detail what you are copying and be prepared to be flexible in the implementation.

1. Feynman RP, Robbins J. Cargo Cult Science: Some Remarks on Science, Pseudosciene, and Learning How to Not Fool Yourself. The Pleasure of Finding Things Out. Cambridge, MA: Perseus Books, 1999:205-16.

2. Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA, Pronovost PJ. Explaining Michigan: developing an ex post theory of a quality improvement program. Milbank Q 2011;89(2):167-205 doi: 10.1111/j.1468-0009.2011.00625.x[published Online First: Epub Date]|.

3. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360(5):491-9 doi: NEJMsa0810119 [pii]

10.1056/NEJMsa0810119[published Online First: Epub Date]|.

4. Pickering SP, Robertson ER, Griffin D, et al. Compliance and use of the World Health Organization checklist in UK operating theatres. Br J Surg 2013;100(12):1664-70 doi: 10.1002/bjs.9305[published Online First: Epub Date]|.

5. Parry GJ, Carson-Stevens A, Luff DF, McPherson ME, Goldmann DA. Recommendations for evaluation of health care improvement initiatives. Acad Pediatr 2013;13(6 Suppl):S23-30 doi: S1876-2859(13)00099-5 [pii]

10.1016/j.acap.2013.04.007[published Online First: Epub Date]|.

As the ‘Integration Pioneers’ get off the ground, Jules Acton, director of engagement & membership, at charity coalition National Voices, explains why many patient groups are optimistic about real progress. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

If you ask people with long-term conditions about the changes they want to see in health and social care, most say: care and treatment that is coordinated around us.

A glance at National Voices’ ‘webs of care’ shows immediately why this call is so strong. The ‘webs’ were drawn up by people who use services, and their families, to demonstrate the tangle of contacts they are trying to navigate. This lack of coordination leads to stress, repetition, waste and, at times, can also threaten people’s safety.

But, of course, coordination in our vast and varied systems of health and social care isn’t straightforward. This is why, at National Voices, we were so pleased about the government announcements on ‘Integration Pioneers’: 14 local areas which could herald a new era in person-centred care.

Before the more initiative-weary of you tune out, I’d urge you to stay with me for a few minutes. There are some important aspects to the Integration Pioneers, which could propel them to success and enable them to bring about real, big and positive change.

For a start, this isn’t only about the 14 chosen Pioneers. There were a huge number of applications for the Pioneers programme – more than 100 – from two thirds of our local areas. That means over 100 different localities, each with multiple organisations, showing a will to work across boundaries: across health and social care; primary and secondary care and all the other points where patients fall through gaps. It indicates an energy for care coordination and a belief in a new way forward. And this energy is coming from the ground up, where it really matters. So, while the government support is important, this drive is less about responding to diktats from on high, but about teams of professionals seeing the Pioneers programme as an opportunity to push out the boat. And, while not all of the areas that applied could become official ‘Pioneers’, that doesn’t mean they can’t also drive forward themselves, share the learning and add to the momentum.

Another cause for optimism is that most of the above have shown a will to work towards a common vision, developed with people who use the services. This is based on the Narrative for Person-Centred Coordinated Care. This is truly significant, because ‘integrated care’ has been interpreted in a great many different ways in the past. As the Health & Social Care Act came into being there were at least 175 different definitions floating around in the ether.

In response to this confusion, NHS England commissioned National Voices to work with people who use services as well as professionals, to develop a vision we could all sign up to. This has happened. It was published in May as part of a common purpose framework to which the Department of Health, NHS England, the Local Government Association, Monitor and all the other national system leading organisations committed. And it aligns strongly ‘Making it Real’  a key personalisation initiative by TLAP. The Narrative redefines ‘integrated care’ as person-centred coordinated care, which, to the service user, means:

“I can plan my care with people who work together to understand me and my carer(s),
allow me control, and bring together services to achieve the outcomes important to me.”

It goes on to offer context in the form of more ‘I statements’ which describe, in detail, what coordinated care looks and feels like to people who use services.

So we have a common vision, we have momentum and we are optimistic. But we aren’t starry eyed. Person centred coordinated care won’t happen overnight, and certainly not across the whole country. The new programmes need time to grow and adapt. Their teams won’t get everything right first time. And this is fine as long as they are able to move on from mistakes and share the learning.

This is where the government comes back in. To nurture coordinated care and ensure the success of the new programmes, our government now needs to learn to sit back, be supportive but resist the urge to dabble, interfere and chuck in new, competing initiatives. As the election looms we hope all political parties will show maturity around this, with their manifestos underpinning solid progress towards person-centred care, rather than revolution and upheaval.

At National Voices we will be championing this need to nurture and not to keep on overhauling. We’ll also be leading work on some extra materials to support coordinated care, such as a toolkit for care and support planning. If you’d like to receive newsletter updates on these then let me know on jules.acton@nationalvoices.org.uk or @JulesActon. And if you are involved in coordinated care programmes, please let us know about your progress so we can help share the learning. We look forward to hearing from you.

Rob Bethune

Rob Bethune is a surgical registrar in the Severn Deanery. He was a founding board member of The Network (www.the-network.org.uk ) an on-line social media site for healthcare professionals wanting to share their learning and connect with other quality improvers around the world. He has been involved in a regional wide programme facilitating junior doctors to run quality improvement projects. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

Effecting change as a junior doctor with little time, power and influence can be daunting.  However there are ways of working through those difficulties.  In this article I describe a few pointers that have helped junior doctors facilitate real change.

Establish a team and allow time

This is crucial, you cannot do this alone.  Most of us do 4 or 6 month placements and this often not enough time to run a successful project and embed the changes, so develop a team of 6-10 people who will rotate through the clinical area throughout the year.  As we shall see continuously collecting small samples of data is crucial to quality improvement (QI) and practically you need a group to collect this. Working in a team also makes it fun and gives you opportunities to bounce ideas of each other.

Get help

Ideally you want to find a permanent member of staff to mentor your project who has experience of QI and has spare time to meet with you and your team.  In practice this is difficult unless you are in one of the few hospitals that has formal QI programmes for juniors.  The BMJ Quality programme  has a system of virtual mentors who can give QI advice.  It also walks you through running a QI project and there are many previous examples on the open access on-line journal. Before you start your project you really must search this journal to see if others have run similar projects elsewhere and learn from them; try not to reinvent the wheel, let alone reinventing the flat tyre.

Use the Model for Improvement

This is the key.  Clinical audit run by junior doctors has been overwhelmingly unsuccessful^1-3. There are a multitude of tools for improving quality of systems (Lean and Six Sigma are examples) but the most tried and tested model for frontline clinical care is The Model for Improvement

It consists of three steps that are outlined below; set an aim, measure progress and make changes.  The BMJ quality site has a lot more information and there are also a series of short videos on The Network YouTube site that explain the underlying methodology.

Aim: What is it you want to improve?  It is really important to carefully define exactly what you are trying to improve.  Make your aim SMART (Specific, measurable, assignable, realistic and time limited ).  An example of this would be ‘Ensuring that by March 2014 95% of discharge summaries from the medical admission unit reach the GP within 24hrs’.  Getting the aim right can be surprisingly difficult and may well change as you develop a deeper understanding of the system you are analysing. It is tempting to say ‘we want to improve discharge summaries’ but the lack of detail will make the next steps impossible.

Measure: ‘Data, data, data’ goes the drumbeat of a quality improvement project.  Without out it you will not be able to see if your changes are an improvement. But more importantly during the process of collecting good data you will develop a deeper understanding of the system you are trying to improve. We often oversimplify problems and think that solutions are obvious.  These simple solutions often fail as we don’t really understand the system we are dealing with.  The very action of measuring a system gives us much more detailed understanding.

Then display the data using a run chart (see chart below).  Collect small samples of data (10 each time is a good number) and do it as often as feasibly possible.  Try and collect 10 sets of data before you start test of change, this will allow you to get a baseline and see if changes really are an improvement.

The plan-do-study-act-cycle (PDSA)

Now you have your background data collection and a more profound understanding of the system you are ready to make some changes.  These are done in the form of PDSA cycles.  It is a simple and intuitive as it sounds; come up with a plan, trial it out on one day, study the effect and act upon the result.  One of the keys is to trial the change over a short time period in one area. If it works you can spread it but if it does not work and needs refining then you can do that easily.  If you implement your idea widely from the beginning (as we have seen so often in healthcare) and you get it wrong it is expensive both on terms of time and resources to undo it.  Make your first tests small.  You can label you PDSA cycles on your run chart as in the example graph. Almost always multiple tests of change are needed , rather than just one intervention – this might explain why audit failed.

Publish

If you have run a QI project and improved care and equally importantly if your interventions did not work then you must share this with the wider healthcare community.  The BMJ quality improvement journal is the perfect place to do this.  Provided you have used the above methodology and have created a coherent story of change that others can adapt and translate elsewhere your project will be published.

It’s up to you

Improving the systems we work in is crucial to improving the care we give to our patients.  As junior doctors we are in a unique position to see the problems in the delivery of frontline healthcare and affect the solutions.  No-one else is going to do this, therefore do not send to know for whom the bell tolls, it tolls for thee.

References

1. Greenwood JP, Lindsay SJ, Batin PD, Robinson MB. Junior doctors and clinical audit. J R Coll Physicians Lond 1997;31(6):648-51.

2. Guryel E, Acton K, Patel S. Auditing orthopaedic audit. Ann R Coll Surg Engl 2008;90(8):675-8.

3. Hillman T, Roueche A. Clincal audit is dead, long live quality improvement. BMJ Careers 2011  http://careers.bmj.com/careers/advice/view-article.html?id=20002524.

Dr Marc Wittenberg

Dr Marc Wittenberg gives us a personal view of what Quality Improvement is, ending with some top tips for those interested in starting a project. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

I have recently, albeit temporarily, taken the leap from full-time clinical medicine, into a world of strategy, policy and thinking on a completely different level, and one which is not normally evident to a jobbing senior anaesthetic registrar. As one of the National Medical Director’s Clinical Fellows, I have joined the BMJ and NHS England on a one year secondment and will be spending a significant proportion of my time with the BMJ Quality team.

Prior to starting this post, my days (and nights) were filled with talk of service, examinations, audit, CV improvement, recounting individual clinical tales and the, occasionally dark, humour and banter that enables a hospital to churn on despite the challenges that face us. In sharp contrast, the conversation is now dominated by the latest concepts in Quality Improvement (QI), project management and change management.

Why so different? Well, it is actually not, but I now feel that I have the luxury to step back and look at the picture from a different perspective.

To illustrate this, I had an experience that made me realise that all it takes is a small adjustment in thinking: I still do the occasional shift in hospital in my own time to keep my feet on the ground, and one recent weekend, I was sitting in the intensive care unit coffee room, chatting with a consultant. He happened to remark that one of the trainee doctors had gone off to insert a central venous line into one of the patients, but had been gone a rather long time.

On his return, the consultant asked the trainee why it had taken him so long. He bashfully admitted that the actual procedure had not taken more than 15 minutes but that it was all the other tasks: finding the kit in the store-room, forgetting something then walking back up the corridor, having to ask the busy nurse to fetch something and having to rely on his memory to make sure all the items that he needed were there. “Wouldn’t it be great,” the consultant mused, “if we had a rapid access central line box, ready to go in the store-room?”. And there the conversation was left.

A few minutes later, it struck me that what the consultant was describing was Quality Improvement in its most usable form: they had identified a problem and a solution but had not yet made the connection between the two. It is all about the mindset, the shift from evidence-based medicine and audit where we now know what we should be doing, to guaranteeing that we are doing things right. This transition to the making the science of QI an everyday part of all healthcare workers’ lives is relatively new and sometimes requires its relevance to be realised.

For me, it was only through making the leap that I have done to realise the importance of QI to good patient care and it is vital that the message is spread: it does not just apply to large system changes or transformations, but QI is at its best at the coalface through often simple, usually cheap, and relevant projects that can make a big difference.

Through learning the relevant improvement skills and tools, all clinicians can, and should, be able to engage in Quality Improvement to ultimately improvement patient care.

So, here are my 5 top tips for quality improvement:

1. Make the link: the ideas for QI projects often come from either things that you have noticed at work that you would like to change, or situations where someone’s answer to your question of ‘why do you do it like that?’ is ‘because that’s how we have always done it’.
2. Keep it simple: often, the most effective QI projects are the simplest and cheapest.
3. Get a mentor: think about who this should be – it could be a colleague, a supervisor or even someone that you have never worked with before.
4. Keep talking: work out who is important to the success of your project and get in contact early, preferably in person. Buying someone a coffee never hurts!
5. Publicise it: once you put the work in, get the message out in whatever you can. You will undoubtedly inspire other people and people will appreciate the hard graft that you have put in.

Mareeni Raymond, GP and Clinical Advisor for BMJ Quality

It has been six months since BMJ Quality officially launched, and already we have published some amazing work at BMJ Quality Improvement Reports. Managing Editor, Mareeni Raymond, describes some of the highlights.

We started off by launching the junior doctor’s programme and have been hugely impressed with the projects that these doctors have organised and implemented. Since then, we have published work in specialties as varied as palliative care, orthopaedics, surgery, education, medicine, A&E, and more.

There are so many occasions in hospital where things can go wrong because guidance isn’t readily available or knowledge is lacking, and junior doctors are often on the sharp end. A lot of great projects introducing adaptations to handover sheets or proformas have demonstrated improvements, including this one ‘Using a proforma to improve standards of documentation of an orthopaedic post-take ward round’ and ‘Post-acute surgical ward round proforma improves documentation’.

The transition between primary and secondary care is fraught with difficulties- the postal service, the lack of clear coding, inadequate discharge summaries – all identified in many projects. In ‘Improving transmission rates of electronic discharge summaries to GPs’ transmission rates of Discharge Summaries within 24 hours of patient discharge increased from 9% to an incredible 76% post intervention.

Handover is a popular topic, and if you type in “handover” into our search bar at qir.bmj.com we currently have eight projects on the subject. Which do you think is the most cost-effective? A steady stream of small projects based on simple interventions such as these are being published and we look forward to teams reading existing projects and adapting them to create amalgamations of the most effective interventions.

We’ve been impressed with larger scale projects too, such as one team’s care plan to reduce falls. The inpatient falls rate, re-audited at one year, was 12.44 falls / 1000 patient bed days, a 15.4% reduction following introduction of a bundle of interventions such as posters, guidelines being introduced and education.  With clinical commissioning groups under pressure to create long-term solutions for improving care in areas such as these, we look forward to more large scale projects publishing their work.

In tertiary care, a fantastic project to reduce admissions of patients with diabetic foot complications resulted in the average antibiotic prescribing costs for a 3 week course of treatment reducing from £17.12 to £16.42.  Projects demonstrating both clinical improvement and cost-effectiveness are our one of our favourites – keep them coming! And the team also love to read about interventions which are delivering the highest goal – patient preference, and the improved patient journey. A palliative care service improved the rate of preferred place of death resulting in one third of patients dying at home – nearly double the proportion that died at home in the baseline audit. Seventy one per cent of patients who wished to die at home actually died at home – a substantial increase from 31% at baseline. Achievement of preferred place of death for patients wishing to die in the hospice remained high at 88%. Definitely worth reading for ideas in your unit.

It can sometimes feel like quality improvement is only about following the right pathway – this is not so. One psychiatric unit reduced violence and aggression by taking clients to a local zoo an interesting idea and the basis for further discussion. Another psychiatry team recognised the lack of cardiovascular health monitoring for patients with psychiatric illness, highlighted in their excellent project which poses solutions and again, ideas for discussion on what is frankly, a controversial subject.

All in all, our first six months has resulted in some excellent work, food for thought, and many inspiring ideas. We are really pleased to be helping doctors from all over the world to publish their quality improvement work and will continue in this vein to help encourage a global discussion on quality at every level. Lots more projects coming and lots more we haven’t mentioned here: go to Quality Improvement Reports, comment on work, and start the debate!

Dr Sean Elyan
Medical Director, Gloucester Hospitals NHS Foundation Trust
Trustee, The Point of Care Foundation

Dr Sean Elyan describes  undertaking a listening exercise with staff following the publication of the Francis report, at Gloucestershire Hospitals NHS Foundation Trust.

 The Director of Nursing and I did this work so I was slightly affronted when a senior nursing colleague claimed that compassionate care was the responsibility of the nursing body and doctors should not be interfering. Preparing myself to respond intelligently when next challenged in this way, I thought I would assess what emphasis was afforded to different groups in the Mid Staffordshire report.  I was reassured to find that the executive summary says:  ‘[Patients] must receive effective services from caring, compassionate and committed staff, working within a common culture’.  However it would be wrong not to acknowledge that the summary mentions compassion 16 times and of these, 11 relate directly to nursing and only five could be considered to include other staff groups.

Within our trust we have started a project, initially with The King’s Fund and now with The Point of Care Foundation, to test and disseminate an approach to strengthening relationships between staff and patients.  These Schwartz Center Rounds, adopted from an innovative approach now used in many hospitals in America, have been revealing.  Staff from any discipline use narrative to relate the challenge of providing care from their own perspective.  This reflective practice, unusual because it takes place in a multi-disciplinary forum, is followed by a facilitated discussion encouraging the audience to relay similar examples that resonate with the case they have just heard. The discussions regularly and rapidly get to the heart of the complex web of tensions that suffuse care as it is provided on a daily basis.  Ranging from the distress felt by staff following failed paediatric resuscitation, through the impossible pressures of a surgeon’s busiest day, to the observations of a bed manager trying to navigate a patient within a system of increasing demand and expectation, these sessions more than any other I have witnessed reveal how difficult our daily job is. I regularly walk away from them as the clinical lead humbled by the commitment and skill shown by healthcare assistants, physiotherapists, secretaries and porters not to mention nurses and doctors.  And within this is a clarity that these sessions are not to find solutions but just to talk and have time to share, and to recognise that as healthcare staff we all experience similar situations and emotions.  They consistently demonstrate that when staff hear a senior colleague reveal how difficult they personally found dealing with a particular situation, or confirm that they have also experienced something which another member of staff has described, they find it incredibly empowering and supportive.  I can honestly say that of all the tasks I undertake in the trust, this monthly hour is the most productive and invigorating.

The Schwartz Center Round methodology requires a doctor from the trust to act as clinical lead, championing the process and working with a trained facilitator to help plan and run the sessions. By getting a doctor to act as clinical lead, it acknowledges that caring is not just ‘nurses’ work’ and helps to ensure that doctors attend the sessions along with colleagues from other disciplines.

So as I muse on another section of the Francis report in which there is a call to arms to introduce an ‘aptitude test for compassion and caring’ I think to myself ‘what would this test look like?’  We have recently introduced a question into our consultant interviews asking for candidates to give examples of an action at work they have taken that reveals them to be a particularly compassionate doctor.  Their answers seem to range from what I would consider normal day to day work to genuine and moving illustrations of an exemplar approach.  The Schwartz Center Rounds give a tantalising glimpse into compassionate care and how to recognise it.  For something that seems so easy to identify in these session, it remains unclear to me how to measure it.  However, I for one would wholeheartedly endorse Robert Francis’ challenge, beseeching us to start exploring ways to do so. If we can develop a measure for compassion, I hope we find doctors as capable of this work as nurses or any other staff group.

Rocking the boat and staying in it: how to succeed as a radical in healthcare

Part 2: Start by improving myself

Helen Bevan blogs about topics related to improvement, innovation and change on a big scale. Helen works as part of the Delivery Team of NHS Improving Quality, @NHSIQ, the national improvement team for the NHS in England. All views are her own. Follow her on Twitter @HelenBevan.

Yesterday, I was clever so I wanted to change the world.

Today, I am wise so I am changing myself

Anon via Twitter

A lot of people responded to my last blog which was an introduction to tactics for thriving and surviving as a healthcare radical. Four things struck me about that response:

1. There are a lot of radicals/rebels out there in the healthcare system; passionate people who support the patient-centred goals of healthcare organisations, who are willing to take responsibility for change but who question and challenge the current ways of going about change
2. “Radical” status isn’t related to hierarchy or position and we don’t have to work in the NHS to qualify as a healthcare radical. A wide variety of people responded to the blog; this included radical patient leaders  and radical Chief Executives
3. We have to find ways to unite and mobilise this radical community; this is a latent and potentially powerful reservoir of energy for change
4. We must help healthcare leaders to understand the difference between a radical/rebel and a troublemaker (or good rebel/bad rebel) and exploit the talents of that radical/rebel community for the greater good

As I trailed in the last blog, I’m going to discuss four of the key tactics for healthcare radicals in more depth over the next few weeks. The first of these tactics is start by improving myself.

As a change agent, I frequently look at the world around me and identify things that need improving. If we are to deliver safe, high quality care to every patient and to make the most of our precious healthcare resources, we need to continuously improve processes and systems of care. Yes, this is really important, but as healthcare radicals we have to start at an earlier point in the foodchain of improvement. To quote Aldous Huxley: “There’s only one corner of the universe you can be certain of improving, and that’s your own self.” So before I am tempted to launch into a massive effort to influence other people change the way they think or do things, I have to start by reflecting on and changing myself. I have to understand myself, because the person who will be the hardest for me to lead through change is me. I’m always inspired by the work of David Whyte who is a corporate poet. He understands this completely when he says: “I do not think you can really deal with change without a person asking real questions about who they are and how they belong in the world.’ (The Heart Aroused 1994)

I am writing this blog in the week after the publication of Don Berwick’s recommendations to improve the safety of patients in England: “A promise to learn – a commitment to act” so I thought I might use the Berwick report to illustrate some of the points I want to make about healthcare radicals. Like so many leaders of improvement in the English National Health Service, I am thrilled to see these recommendations, which are a compelling call to action for change, based on evidence, to make the English NHS the safest system for patients in the world. As Paul Batalden said in a response to the earlier report of the Francis inquiry, healthcare is at the same time a “simple, complicated and complex” phenomenon. Some of the commentators who have criticised the Berwick report wanted to see more “hard edged” recommendations related to mechanisms for enforcement or regulation, checklists, minimum standards and/or behavioural incentive systems. My response is that many of the solutions that these commentators seek are “simple” solutions which are not, on their own, reliable levers for change in a highly complex world.  Experience shows us how these simple solutions can push the system in a certain direction, distort priorities and often (unintentionally) create the opposite effect to the changes we are seeking. The gift of the Berwick recommendations is that they offer us a starting point for an aligned set of actions, at multiple levels of the system simultaneously, that give us (collectively) a fighting chance to transform patient care. As a longtime student of large scale change, I would say that the Berwick recommendations offer a more sophisticated and well-constructed blueprint for change in a complex system than we have seen in any previous change plan for the NHS.

So where do we, as healthcare radicals, fit in this complex system of change? It would be easy to look at the recommendations of the Berwick report and question whether we, as individual change agents, can make a contribution, at least in the short term, whilst our leaders work out how they are going to respond to the recommendations. After all, the Berwick report says that safety is mostly NOT about individuals; it is the systems, procedures, conditions and environments that cause the most patient harm. Consequently, many of the recommendations are for “systematic” solutions, involving setting up systems for continuous learning, innovation and improvement. There is a risk that we radicals might feel that we have to take a back seat whilst our organisations and leaders take responsibility for establishing these new systems, waiting for the patient safety change agenda to get around to including us, so we can play our part.

But we just can’t just wait whilst someone else starts the change as a) it might be a long wait and b) more patients are likely to be harmed in the waiting period. I’m not saying that we should rush off and start making changes on our own, regardless of what is being planned in the wider system. However, as healthcare radicals, we do need to be creating our own goals for change right now, strategising about how and where we can best make our contribution to the bigger purpose, reaching out and building alliances with others and demonstrating willingness to move the change agenda forward, despite the challenges and scepticism that might face us. When we have the courage to act proactively like this, we find that most organisations will value these behaviours, even where the organisation doesn’t currently have a strong improvement or learning culture. You see, each of us who leads and/or facilitates change is a signal generator. Our words and deeds are constantly scrutinised and interpreted by the people around us in our teams, organisations and in the wider system. The amplification effect of what we do and say is far greater than we imagine.  The most powerful way to inspire others to change is to be the vanguard for that change. If we want other people to take a risk and change the way they think or organise for patient safety, we have to take the lead. I like the way that Tanveer Naseer describes it:

You have to be the first one up and off the high dive you’re asking others to leap from. Ask yourself: where am I playing it too safe and what is that safety costing me? Then leap from your platform of safety into the cold water of change.

One of the aspects of the Berwick report that I most welcome (and fits with the evidence base on large scale change) is the focus on learning as a strategy for transformation. The report sets the bold goal of transforming the NHS into a learning organisation that continuously reduces patient harm through learning. I want to link this learning theme with another key theme in the report: driving out fear. The report stresses the toxic effect of fear on both safety and improvement. I would add that fear is also the biggest barrier to learning. It’s hard to learn when you feel fear.  The Berwick proposals require many organisational leaders (and even people who perceive themselves as healthcare radicals) to move away from a status quo that they feel comfortable with into a brave new world of quality control, quality improvement and quality planning on a scale never seen before and that can be a scary thing. As Peter Senge wrote in The Fifth Discipline (as quoted by Chip Bell):

“When we see that to learn we must be willing to look foolish, to let another teach us, learning doesn’t always look so good anymore…Only with the support and fellowship of another can we face the dangers of learning meaningful things.”

The evidence base on learning organisations emphasises the importance of leaders who role model humility and vulnerability. So we have to ensure that the coaches, teachers and mentors that deliver and support this learning have to be able to recognise the fear and create positive learning experiences, focused not just on safety science and quality improvement methods but on the emotional processes of change. To quote Rosabeth Moss Kantor, “Leaders are more powerful role models when they learn than when they teach”.

This situation creates a specific call to action to healthcare radicals. We, the signal generators at the vanguard of change, must embrace the spirit of the student. This means taking responsibility for our own learning and being open to continuous learning; embracing new ideas and approaches and being willing to challenge and change our existing belief systems. We have to be the best, most active, most humble learners.

In addition, our learning must move beyond knowledge and skills. For healthcare radicals it is important, but not enough, to continuously build our knowledge of improvement methods and approaches. It’s also important, but not enough, to take responsibility for our own development as skilled leaders or facilitators of change. What sets healthcare radicals apart is the extent to which we purposefully seek to live and be improvement, in the way we operate in the world and in our interactions and relationships with others. I think that the diagramme below from Rianna Moore sums this up very well. It’s only when we live the things we believe in (that is, when

we can align our sense of deeper life mission or calling, our values and the activities that we undertake every day) that we can truly energise our teams and organisations by working from our true selves and make our full contribution as healthcare radicals.

Being a great change agent is about knowing, doing, living and

 being improvement

The Berwick recommendations provide us with a one of the best opportunities ever for radical system change. However, history tells us that organisational or system transformation is always preceded by personal transformation. So if, as organisational radicals, we want to play our role in this transformation, we have to focus deeply on our own perspective and the ways we interact with and influence others. The more people we can

influence in a positive way and the more that we (as organisa

tional radicals) can unleash that powerful reservoir of energy for change, the mo

re our influence and impact will grow.

Individually and collectively, we can play a truly significant role in helping to implement the changes that are needed in healthcare processes and systems; delivering the outcomes and experiences that our patients deserve and building the continuous learning and improvement system that will make the English NHS the safest healthcare system in the world.

I declare that that I have read and understood the BMJ Group policy on declaration of interests and I have no relevant interests to declare.

Rocking the boat and staying in it: how to succeed as a radical in healthcare

Helen Bevan (@HelenBevan on Twitter) works with NHS Improving Quality, the national improvement team for the NHS in England.

Anyone who chooses to be a change agent or improvement leader in healthcare doesn’t choose an easy life. There are so many forces opposing the changes we want to see; a system that rewards people for “keeping the trains running” rather than radical change, those with the power and/or a vested interest in keeping the status quo, colleagues and leaders who are sceptical, apathetic or scared of change.  Many times in my career in improvement, I have felt isolated, vulnerable and misunderstood. People have treated me like some kind of oddball when I have craved to be taken seriously and appreciated for my efforts as a leader of change. Yet big change only happens in healthcare organisations because of heretics and radicals; the courageous, passionate people who are willing to take responsibility for change, who support their organisation in its mission but also challenge the status quo.

As Martin Luther King described it: ‘‘The saving of our world . . . will come, not through the complacent adjustment of the conforming majority, but through the creative maladjustment of a nonconforming minority’’.

The hope of healthcare rests with the non-conformists, the radicals, the heretics and mavericks in our midst.

So who are the radicals in healthcare organisations? Research by Debra Meyerson  shows that the most effective radicals are those who have learnt to oppose and conform at the same time. Or, as she puts it, “they are able to rock the boat and yet stay in it”. These are change leaders who stand up to challenge the status quo when they see there could be a better way. They develop the ability to walk the fine line between difference and fit, inside and outside. These leaders are driven by their own convictions and values which makes them credible and authentic to others in their organisations. Most importantly of all, they take action as individuals that ignite broader collective action that leads to big change. These leaders already exist in every healthcare organisation, in many different roles and multiple levels. They aren’t typically the Chief Executives or senior clinical leaders yet the impact of their change activities are often just as significant. We saw so many examples of this on NHS Change Day 2013. Many organisation-wide change efforts that led to tangible improvements for large numbers of patients were initiated by grass roots front line leaders.

Lois Kelly has developed some fantastic resources for “rebels at work” and I would recommend a trip round her website to all healthcare radicals. Helpfully, she makes the distinction between a “rebel” and a “troublemaker” and I have adapted her table below.  As rebels, we continuously seek innovative new ways of delivering care. We are committed to the patient-centred mission and values of our organisation. We are driven by our passion for better care for patients. We are optimistic about the future, the potential for change and see many possibilities for doing things in different ways. We generate energy for change which attracts others to unite with us for a common cause

“Troublemakers” also challenge the status quo but in a way that is very different to “rebels”. Troublemakers complain about the current state of affairs but their focus tends to be around their own personal position rather than achieving the goals of the organisation.

Source: Adapted from Lois Kelly  www.foghound.com

They are angry about how things are and don’t have much confident that things will get better in the future. They alienate other people because if others link with them, troublemakers will sap their energy. This just confirms what troublemakers probably know already– they don’t belong.

There are a couple of points I wanted to make about rebels and troublemakers. Firstly, many organisational leaders view ANYONE who challenges the status quo as a troublemaker, Therefore, rebels get unfairly labelled as troublemakers. It has happened to me on more than one occasion. It feels SO unjust but we are to be effective change agents, we have to anticipate that it might happen and learn to deal with it. Secondly, lots of change leaders  in healthcare start out as rebels but their voice doesn’t get heard, they begin to stridently question the status quo in a manner which is radical and self-defeating and they cross the line from rebel to troublemaker. As rebels, we have a responsibility to look out for this and try to prevent  it happening by building relationships and forming alliances with others who challenge the status quo.

So what are the tactics to survive and thrive as a radical/rebel/heretic/maverick in healthcare? I would like to suggest four:

1. Start by improving myself
2. Build alliances for change
3. Work out what might help others to change
4. Don’t be a martyr

I will discuss each of these issues in turn in my next four blogs. If you would like a preview on these topics, you can watch this short film

Corporate Rebels United is a global movement of “corporate rebels” across multiple industries and sectors. Many healthcare rebels/radicals are part of this. This is the manifesto of Corporate Rebels United which perfectly captures the mission of organisational radicals in healthcare to deliver the new truth of healthcare transformation

We are architects and scouts into the future, and we want to guide our organisations in navigating a safe path from now to then:

Relentlessly

Challenging the status quo

Changing the rules

Saying the unsaid

Spreading the innovation virus

Seeding tribal energy

With no fear

With a cause to do good

Leading by being from our true selves

Going after the un-named quality

Relentlessly

Calls to action for this week

1. Make time to reflect on your own role as a healthcare rebel/radical; what are the implications for the ways you operate as an agent or leader of change?
2. Seek out other rebels/radicals and discuss tactics for rocking the boat and staying in it
3. Identify and support others who are at risk of crossing the line from “rebel” to “troublemaker”

Helen Bevan (@HelenBevan on Twitter) works with NHS Improving Quality, the national improvement team for the NHS in England.  

I will be writing a regular blog for the BMJ Quality Blog. So this is  my introductory blog about my work passions which give some hints about what I might write about in future blogs. I should also tell you a little bit about my background, as I don’t think you can separate the blog from the person.

I’ve worked in quality improvement in the English National Health Service for more than two decades. I’ve learnt so much first-hand about delivering change, mostly because large scale change rarely ever goes to plan. I also had a “pre-NHS” career, although it feels a long time ago now. My first degree was in social science. I am a very good advertisement for the benefits and relevance of a social science education; I still use many of the ideas and principles about large scale change that I learnt as a teenage undergraduate. In my 20s, I worked in organisational and leadership roles in local government and education. My roles were always about leading change, helping people think differently and building new skills; I worked on one of the earliest “Total Quality Management” projects in the education sector in the late 1980s. I joined the NHS in 1991 as part of a scheme to bring senior leaders from other industries into the health sector. My change management skills were identified very quickly by the NHS and since then, my entire NHS career has been about enabling big change to happen. I’ve undertaken all my subsequent education, up to doctoral level, part time whilst leading major change programmes. It isn’t something I’d recommend to the fainthearted.

I spent much of the 1990s leading The Leicester Royal Infirmary “re-engineering programme”; a massive effort to transform an NHS hospital on a scale never attempted before. Not everything we tried worked but much did and that experience was seminal for me as a leader of change. It taught me greatly about the importance of big ambition for service change and for patients. Terry McNulty and Ewan Ferlie wrote a book about it which remains one of the most informative texts on healthcare improvement ever written. If, as a country, we had followed McNulty and Ferlie’s advice on how to go about change in a clinical environment, we would be significantly more advanced in our change efforts today.

In 1998, I was given my first NHS-wide job in improvement, working with policy makers, clinicians and hospital managers from across England to eliminate waiting times for patients. And in 2013, I’m still working at a national level in the NHS, supporting quality improvement. I’d say that my biggest achievement has been helping to make improvement mainstream in the NHS, hopefully in a way that had an impact on a lot of front line clinical teams and patients. When I first started life as a healthcare improver it was a lonely occupation, undertaken by only a few enthusiasts and visionaries. Now, the systematic application of quality improvement methods happens in most NHS organisations to some degree. I think that I have helped along the way through very practical but effective strategies such as the Ten High Impact Changes for Service Improvement and Delivery, The Productive series including The Productive Ward and Productive General Practice, the use of social movement principles in healthcare improvement and more recently, the NHS Change Model. These initiatives have spread to healthcare systems around the world. I have stuck with my role at a national level in the NHS for many years and I believe the continuity has helped.

It’s obvious to me that the current era offers the best potential ever for large scale change in healthcare. The challenges that the NHS and other healthcare systems face now mean that many of the previous incremental ways of undertaking change aren’t fast enough or broad enough for the future. We need to build on the strengths that we have as an NHS system but bring in fresh perspectives.  We have to design change strategies with a “second order” mindset (possibilities, connections and innovative solutions at scale) rather than “first order” thinking (limits losses and fears, doing more of what is done already, on a bigger scale). But more of this in coming weeks.

Over the years, I have trained in many different methodologies and philosophies for quality improvement and organisational development; from Lean and Six Sigma to the Model for Improvement to Polarity Management and large group engagement to McKinsey’s five frames for organisational health and transformation to community organising and social movement thinking. I have huge respect and appreciation of all these approaches and utilise them all but I’m not a purist about any one approach. I think that the skilled improvement leader has a toolkit of approaches that can be utilised to any given situation.

And no, I’m not a direct descendent of Aneurin Bevan, although I’m proud that I share my surname with the founder of the NHS. My paternal ancestors (“the Bevans”) were seafarers and sailmakers from Bristol. At some point, centuries ago, they crossed the Bristol Channel from South Wales. My greatest NHS inspiration is my mother, Beryl Bevan who worked as an NHS domestic assistant for nearly 30 years. My mum lived out her NHS values in her job, through her hard work, her kindness and positive attitude. She epitomises thousands of NHS workers in the extent to which she was willing to help others and do far more than she was employed to do. I aspire to be like her every day in the way that I do my NHS role.

I hope this has whetted your appetite for my blog and look forward to many great comments and conversations in coming weeks.

Helen Bevan (@helenbevan on Twitter) is part of the delivery team for NHS Improving Quality, the national improvement team of the NHS in England. 

I live in a world of healthcare improvement, quality and safety. I spend my hours working with others to build action for change and transformation and seeking to solve the eternal challenge of how to help change spread from one place to another.

Increasingly in my world, people are talking about “hack days” and “hackathons”. A number of the young NHS leaders and trainee doctors that I interact with take part in “NHS Hack Days”; the Management Innovation eXchange, is running global virtual hackathons to reinvent the way that organisational leaders lead change and across the world, governments are using hack day methods to create more transparent, accessible services for citizens. A hack day is essentially an event of one or more days where people involved in software development (known as “developers” or “devs”), subject matter experts and others get together to invent creative solutions or new insights to tricky problems. I can see from my world that leaders of change are starting to apply methods that originated in the software industry (and were about technical data-driven solutions) to solving big strategic issues such as strategic planning, community building, system redesign, and transformational leadership development.

Team SGULIT hard at work at #BMJhack

So I thought I had better experience a hack day. When BMJ offered me the chance to be a judge at their hack on 6^th and 7^th July, I jumped at the opportunity to take part, observe and learn. The event started at 10am on Saturday morning and ended at 7pm on Sunday night. There were about 50 people taking part in the hack day, about two thirds of which were “devs”, many of whom had no or little health background. There were also medical students, academics and clinicians. They could choose from one of four challenges to work on. The first was around “digital medical students”, building innovative applications to help create future doctors. The second challenge was about creating a “zero harm NHS”. The third challenge was about contextualising knowledge content, such as BMJ Best Practice, to local settings around the world and the final challenge was about how to revolutionise the scholarly publication process, to enable greater collaboration and access.

So after the initial briefing, the participants started to share ideas, identify potential areas to work on, define their hacks and build teams. Some people had bought topics that they had already been working on for months, others offered their services as specialist contributors to teams. They were given access to BMJ data to work with. Over the next 24 hours, I observed the teams diagnosing problems, generating ideas, experimenting and prototyping their solutions. At first, I was surprised that some of the teams didn’t spend longer finding out about the context of the problems they were seeking to solve, by talking to the people who were present at the hack day who could give them a lot of information. Many of them dived straight into the data. What I realised after a while is that they used the data to understand the problem and the context. I was astonished at what they could do with data!

All of the developers were volunteers. They gave up their weekend to take part in the challenge. Many of them slept overnight at the venue and worked well into the night creating their solutions. There was a fantastic spirit and enthusiasm for the topics. At 4pm on Sunday, each of the 13 teams took part in a “show and tell” to present their solutions to the judges. There was a wide range of hacks, ranging from on-line calendars for clinical students in hospitals to a motion tracker to prevent patient falls and pressure ulcers to medical decision trees using basic mobile phones in locations where availability of technology is limited. In nearly every case, the presenter of the idea had actually built a computer application that they were physically able to demonstrate. They had done this in a period of a little over 24 hours. They challenged my pre-conceptions about what can be achieved in a short timescale.

Participants start to show and tell their contributions at #BMJhack

You can read about the winners in the next copy of BMJ. There is also a blog from a member of the winning team. The winning entries tended to be those where developers and clinicians had formed teams together, combining specialist developer expertise with subject-matter expertise to tackle big problems in a context-specific way.

I benefitted so much from this experience. These are some of the learning points I took away:

• We need to engage lots of different change agents to tackle the challenges of health and care and get fresh eyes on the issues. This weekend I learnt a lot about change from 15 and 17 year old developers
• Open innovation (innovating in partnership with those outside of your organisation or usual collaborators) is a very powerful way to get new ideas and perspectives and we need to do more of it
• People will volunteer and give of themselves greatly if we set the challenges in an exciting way, engage with their values, support them to work with others for a shared purpose and value their contributions
• There is massive potential to build communities of learning and action, based on hack methods, to tackle some of our biggest challenges
• The best solutions come when we combine effective data analysis with creativity and imagination and human values and intuition

Thanks BMJ for inviting me to my first hack day. I hope it is the first of many.