Archives October 2013

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.