Archives 2014

Caroline Dearson is the founder of the Mickey Payne Memorial Foundation and the Dementia Buddy Scheme.

Caroline Dearson is a passionate carer and volunteer who founded the Dementia Buddy Scheme, and we at BMJ Quality are pleased to share her story. Here she describes how she collaborated with patients, volunteers, and carers after identifying that support after diagnosis was a major need for people who have dementia, as well as their carers. It was a small idea that became a big story (#smallthingsbigwins).

The Dementia Buddy Scheme was born as a result of the journey my family and I had to go through after my father was diagnosed with vascular dementia in 2005. He was a Regimental Sergeant Major in the Royal Artillery for 22 years and a Yeoman Warder at The Tower of London for 23 years. Even with all that knowledge, he still got dementia.

My father went in and out of hospital through the A&E departments due to falls, confusion, and many other problems. He went into different wards for different reasons. These wards were equipped to look after other medical conditions – but were not prepared for someone with dementia. On several occasions, I offered to stay with him after he was admitted but was frequently told no, and referred to the visiting hours. Inevitably I would get calls at all times of the day, especially late night and in the early hours of the morning, to come and sit with him as he was disrupting the wards. The lack of support from the hospital wards put an unbearable strain on my family life, and I didn’t want other families to relive our experience.

In 2013 I met the ex-chief executive of South Essex Partnership University NHS Foundation Trust (SEPT), Dr Patrick Geoghegan, and explained my vision for the Dementia Buddies. Straight away he wanted to be involved, and pulled out all the stops to get us onto his wards.

The Dementia Buddy Scheme was set up in 2013 on one ward at Thurrock Hospital in Essex. It is a voluntary scheme that involves individuals getting to know patients with dementia and visiting them as a friend a few times a week.

Buddies are now in place in three locations across Essex managed by SEPT, and are currently Buddied up with twelve patients at the moment. This can vary from week to week, due to new referrals and patients leaving.

The Buddies are person-centred and are on a rota that goes to the wards at the beginning of each week. This helps the staff to know exactly who is coming in and who they will be seeing. The Buddy’s individual rota goes out to them on the weekend before that week starts, letting them know exactly who they will be going into see. We try to keep the same Buddies to the same people while on the wards, ensuring that a trusting relationship can be in place as much as possible.

Each person will have three Buddies and each Buddy will see three people, which is due to holidays, sickness, etc. As a Buddy, I research the background of each person on the wards; I go back in time with them, as this is where I find the memories are still active. Once I’ve done this, I put activities and games in place in our Buddy cupboard and let each Buddy know about that person’s background, giving them gentle advice (at first) about how they may be able to interact with them. For example, someone might enjoy the giant jigsaws (helpful for those with poor eyesight) or magic painting sets (which reveal a picture when activated with water) that I can respectfully photograph and laminate. Once laminated I can then give the picture to that person to put up in their room. The joy on that person’s face is just so rewarding each time we do this since they are so proud of what they are achieving. We have also done knitting with the ladies, and used Meccano (using a plastic set to avoid people getting hurt). On one occasion I took the Meccano with me to see if the gentleman I was visiting would be interested. I showed him the catalogue and let him choose, and eventually he chose to build a yacht. His focus and determination was immense. I mentioned this to his family and they told me he had been in the Navy, but had forgotten to let me know about this.

Since we are now in the second year of the Buddies, Anglia Ruskin University are evaluating the scheme to determine how much this is helping patients with dementia. The scheme also provides some respite for family members by giving them time to spend time with their sons, daughters, and grandchildren without carrying any guilt, as well as freeing up staff on the wards. Currently we are supporting the families with seven Buddies (myself included) with five more waiting to be trained; I couldn’t have set this up without being actively involved myself.

Although this evaluation is important to the scheme and our future on wards and care homes, I personally see the successes on a daily basis through my interaction with the families and the Buddies. As the daughter of one of our patients recently commented, “I have the utmost respect and appreciation for the buddies and gather great comfort from knowing that someone is there for mum when I can’t be. Caring for a relative with dementia is a very hard journey for all involved, with good, bad, and sad days; the buddies help make my sad days, good days.”

Our training and disclosure and barring service (DBS) checks were carried out by SEPT NHS, but now I carry out the training and the DBS and occupational health checks are paid for by SEPT. The Buddies have the support of the staff on both of the wards.

The Foundation and I would eventually like to see Dementia Buddy Schemes in all hospitals, as well as all wards that have dementia patients, not just specialist dementia wards. I would like to also use our idea in care homes – that is my vision.

If you would like to know more about the Dementia Buddies, or would like to know how to become one in our area of Essex, please contact me on our email address: Mickeypaynememorialfoundation@hotmail.co.uk or mobile: 07539567553.

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 Reports. Compassionate 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

The 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. https://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).

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!

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

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

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

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

Show them the data

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

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

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

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

Sensational

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

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

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

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

Choose the best, or avoid the worst?

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

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

Dr Mareeni Raymond is a GP in London, CCG lead for dementia in City and Hackney, and Managing Editor for BMJ Quality Improvement Reports.

I’ve just returned from the Royal College of General Practitioner’s conference in Liverpool and for those of you that haven’t heard, Jeremy Hunt, MP, took on questions from hundreds of GPs, many of whom expressed dissatisfaction with their increasing workloads. I, on the other hand, took on questions from a group of enthusiastic GPs, registrars, and students who wanted to know more about quality improvement, working as a salaried GP, and working for a CCG.  For me, that was rather lovely.

The question that is asked most often is “how can a GP take part in quality improvement work at the same time as doing all the other hundreds of tasks that need to be done each day?” There are so many hurdles in the job, as well as new ones “created” by the higher powers, with more hoops to jump through to make sure that targets are reached and that practices remain financially viable. Honestly, these are excellent questions and it is true that being a GP is far from easy, especially right now.

My own answer to the question about taking part in quality improvement is a simple one, and one I feel really quite passionately about: we are taking part in quality improvement every day – and it is extremely  important to let people know about that right now.

I think people have fixed beliefs about certain job roles, such as the public perception that all their GP does is see patients. After all, what do we do in those breaks of ours, apart from visit elderly patients, read all the letters received about our patients, interpret all the results of tests, and answer telephone queries from our colleagues outside of general practice? (This list could, of course, go on). Well, we also talk about how to make things better and then we try do something about it. (Sound familiar? Check out the PDSA cycle learning module).

Every week we meet and discuss how we can improve services for patients. We discuss complaints. We talk about staffing problems. We talk about telephone triage. We talk about patients who were admitted to hospital and how this could have been prevented by better community care. We meet with district nurses, community matrons, child safeguarding leads, health visitors, palliative care, and psychiatry services (to name a few) to discuss complex patients’ needs and how we can meet them better. We audit unplanned admissions, prescribing, referrals (to name a few) and discuss how we can improve their quality.

So we are already doing this every single week and recording it, as we have been doing for years. It takes years of such conversations, changes in practice and procedures, and repeated conversations for patient care to improve, and this quality improvement activity is embedded into general practice culture in the UK, and it is something we strive to do well. Yet the public, and indeed our hospital colleagues, may not be aware of this aspect of our work, and I think this is a shame.  Even we, as GPs, are not aware that this work is beyond simple audit, it is quality improvement work, and it is worth sharing. If we were all aware then we may have a lot more respect and understanding of each other, and could spread our ways of working and our ideas with the world, and collaborate with the public and colleagues better.

Taking the step to publication is next, and some GPs have already published their quality improvement reports. Here are some examples:

Telephone consultations in primary care, how to improve their safety, effectiveness and quality by Muhammad Naseer Babar Khan. Here, a literature search was done on published articles on telehealthcare which resulted in devising a telephone consultation model. Following the proposed consultation model by healthcare staff, it has improved patient satisfaction survey from 75% to 94%, face to face consultation rate was reduced by 1.6%, and home visits were reduced by 2.9%.

Another project called “General Practice Locum Improvement Tool” by Christopher Weatherburn and Shawkat Hasan initiated a process where the locum GP was emailed after their session with a one question survey enquiring about improvement suggestions for that practice. Feedback from the practice to locums included personalised specific clinical guidance, suggestions for improving documentation, and ways to optimise referrals. As a direct result of this pilot a locum box has been implemented in this practice and plans are to rerun this tool periodically.

Sarah Eccles published a report recently about bowel cancer screening. Her practice used three interventions: letter encouragement, staff education to increase opportunistic promotion of screening, and calling non- responders to identify reasons for non-participation and encourage participation. This resulted in increased uptake in screening.

These are just a few examples, and these doctors were doing the kind of quality improvement work that GPs do all the time and which goes unpublished and unrecognised. Don’t be afraid to share the good work you are doing in quality improvement.  By publishing it you can change the way people view general practice and influence others all over the world who are challenged by the same problems that we are trying to solve! Have a look at quality.bmj.com or email quality@bmj.com if you’d like to publish your work. There are also workbooks at the site specifically for GPs and CCGs to run diabetes, dementia and COPD quality improvement projects if you are stuck for ideas!

Colleen Hughes Driscoll is an assistant professor in the division of neonatology at the University of Maryland Medical Center, Baltimore, MD. She serves as the director for quality improvement in its neonatal intensive care unit.

Early in my career as a neonatologist, I began to transition into a leader in quality improvement at my institution; a transition that I continue to undergo. I was initiating a quality improvement program within my division, never an easy task in the health care setting for a variety of reasons: often there are no extrinsic fringe benefits available to motivate people, academia rarely honors performance improvement with promotion, and often the resources needed to fund quality improvement projects are non-existent. Moreover, faced with the challenge of asking my colleagues to take on more when time is a precious commodity, I was desperately in search of an instruction manual. In November of 2013, I was introduced to Daniel Pink’s book, Drive: The Surprising Truth About What Motivates Us. Drive is a synopsis of research on human motivation that spans decades, and illustrates how businesses can flourish, or destroy, the motivation of their workers. Pink uses this evidence to demonstrate the intrinsic motivation that lies at our core as humans and how this can be channeled to maximize innovation and creativity.
Whilst not an instruction manual per se, “Drive” provided insight from a body of scientific evidence and provided lessons from industries that I was not familiar with as a physician, such as manufacturing and technology. A central theme of Pink’s book is that humans possess a natural, innate drive to create, to preserve autonomy, and to learn and grow as individuals. Viewed from another angle, this means that people are born to approach their life as a series of Plan-Do-Study-Act cycles by defining what they want to achieve, having the autonomy to make strides toward that goal, learning from their actions as they move toward that goal, and altering their course to achieve mastery.
Unfortunately, in our day-to-day responsibilities we aren’t often given the autonomy we need to focus on what really motivates us. We are saddled with task lists, deadlines, and other responsibilities that are rarely make us excited to get up in the morning. However, Pink demonstrates that many successful companies, like Google, have been able to harness their employees’ “drive” by giving them the autonomy to innovate. He describes how one Australian software company encourages innovation by allowing employees to work on any idea or project that they desire within one 24 hours period per quarter. The caveat is that they must present their work to the group at the end of 24 hours time. This approach has enabled employees to solve problems with existing software and develop a variety of new product ideas.
Upon reading this, I was intrigued by how this approach might affect quality improvement in our division. Certainly, there was an infinite list of quality improvement and patient safety issues that needed to be addressed in our division. My instinct was to prioritize that list and lead the charge to tackle each one over time. But Pink’s book made me re-think how I wanted to encourage the culture of quality improvement in my unit. What if, instead of trying to rally the group’s support and effort around an agenda that was not their own, I provided a forum for them to explore their own quality and safety concerns within the unit? It turns out that the forum already existed, at least partially. The division held a monthly quality assurance meeting to discuss patient morbidities and mortalities, along with a comparison of our outcomes with other institutions. This was a trainee-driven conference that was attended by physician staff from our unit. We decided to re-purpose this meeting to give the trainee (or any other physician) autonomy to explore and highlight any safety/quality issue that they view as a problem.
The first step in achieving this was to re-name the conference as the “quality assurance/quality improvement” meeting. We wanted to signify to our staff that performance improvement is not only encouraged, but valued. Next we re-structured the agenda to include not only a review of morbidities and outcomes but also to provide a monthly progress report of our ongoing quality improvement initiatives. We believe that highlighting the QI work being done in our unit persuades others to undertake their own QI initiatives. Finally, we gave the trainees the opportunity to try to solve a quality or safety problem of their choosing, one that is important to them. They are encouraged to objectively investigate the scope of the problem, elucidate the key contributing factors, and propose potential solutions.
The outputs from these meetings over the last year have been very positive. Sometimes the trainee is able to bring an unrecognized, yet significant, safety concern to the forefront of divisional/departmental leadership. Other times the trainee finds that a safety risk can be reduced with one simple step, such as the re-organization of medical supplies on a stock shelf. Occasionally, the trainee discovers that what they assumed to be a pervasive problem in the unit isn’t prevalent when the data are examined objectively. Frequently, the trainee identifies a problem and a solution that is feasibly translated into an ongoing quality improvement project. Trainees are not required to participate in QI projects that are derived from their learning and innovations, but almost always they do. I believe this is because the projects are generated from the trainees’ instinctual need to excel at what intrigues them.
As leaders in health care quality improvement, I encourage us all to consider how we develop our culture of quality in the workplace. Do we want to work in an environment where we are asked to continually improve for an agenda not our own or one where we are valued for doing what we believe will make us better? Let’s discover the collective passions in our own workplace and promote them.
Reference
Pink, D. H. Drive: The surprising truth about what motivates us. 2009 New York, NY: Riverhead Books.

Colleen recently published her quality improvement report “A daily huddle facilitates patient transport from a neonatal intensive care unit” using BMJ Quality. Read it here.

Dr Amar Shah is the associate medical director for quality improvement and consultant forensic psychiatrist at East London NHS Foundation Trust

Amar Shah is associate medical director for quality improvement and consultant forensic psychiatrist at East London NHS Foundation Trust.

This series of blogs chronicles the journey of East London NHS Foundation Trust in embedding continuous improvement to achieve transformational change. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

Every Sunday for the past 25 years, I’ve spent my morning volunteering as part of a registered charity in London. The charity runs activities for around 500 children every Sunday morning, with the mission to develop children into well-rounded citizens and leaders of tomorrow’s society. The charity operates primarily through a network of volunteers. Working in a team of passionate volunteers, and as a board level trustee for the last decade, I’ve learnt a lot about engaging people, bringing people together in a common cause, and sustaining their motivation. In our charity, our prime asset is our people – youngsters and adults who are giving up their free time on evenings and weekends to support our goal – running activities and mentoring our children, supporting their development into leaders.
Within the NHS, our situation isn’t too dissimilar. Our staff members are hugely passionate about making a difference, driven by the desire to improve outcomes for our patients and their families. We rely on the exceptional work of all our staff to deliver the quality of care that we, and our communities, aspire to. Routinely, this involves people going far beyond what is written in their job descriptions and contracts. This discretionary effort, so precious and valuable, needs to be recognised, valued, and carefully nurtured.

One of the beautiful aspects of quality improvement is that it is all about our staff; giving everyone a voice in making things better, flattening hierarchies, giving permission, and providing the space and skills for teams to test changes. Having worked at the frontline in six different NHS providers in the past 10 years, it’s clear that we face a common challenge. The people who are closest to our patients and families have little power, access to information, skills, freedom or space to make the improvements that would make a real difference.

My work within the charitable sector has shown to me the critical need for us, as leaders within the NHS, to focus on ‘creating the conditions’ that will allow our staff to provide high quality care and continuously improve as a team. Within East London NHS Foundation Trust, we’re committed to embedding this within our philosophy, and making continuous improvement part of our day job. We’re starting the journey of flipping the way we improve quality, from large scale top-down initiatives, to supporting each team to determine what matters to them and their patients. It’s a transformation in culture that will take time, but we’re working at pace and scale while making sure that QI isn’t seen as an add-on; it must be firmly embedded into the operating structures and philosophy of our organisation.

For more information about East London’s QI programme, visit http://qi.eastlondon.nhs.uk

Debbie Davies

Debbie Davies provides leadership within MidCentral District Health Board for a range of initiatives centred on enhancing clinical integration and developing sustainable models of care within the evolving PHC context in New Zealand.  Debbie has extensive local and national involvement in service development and delivery primarily within the general practice arena.  Debbie is programme lead for implementing the Productive General Practice Programme in New Zealand. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

MidCentral District Health Board (DHB) and Central Primary Health Organisation (PHO) in New Zealand are undertaking a large-scale transformational change journey towards excellence in health outcomes, with a focus on integrated care and partnering.

For this concept to be realised, there must be distributed clinical and administrative leadership throughout the health care sector. This leadership should not only have a clear perspective on the local vision, but must be exposed to the best current thinking on health care systems development internationally. It is important that we have a strong group of leaders who are able to see beyond the thinking that binds our current systems to the status quo. Providing a mixed group of primary and secondary care colleagues with the opportunity to participate in a masterclass experience breaks down barriers and develops relationships which will support the integration agenda.

The masterclass experience took 16 people to Ontario, Scotland, England, and the International Forum for Quality and Safety in Healthcare in Paris in April 2014, where several of the participants presented.   The participants included leaders from MidCentral DHB (hospital), Central PHO, and a range of other local primary health care providers.  It included a mix of clinical and management leaders.

The masterclass experience included time with Professor Ross Baker and Dr Ed Wagner, both acknowledged world leaders in the fields of system performance and long term conditions management.  The Masterclass was organised under four broad themes:

• High performing health care systems
• Transformational change
• Integrated care
• Quality improvement.

Participants saw many examples of excellence in systems and services, and collected numerous good ideas that MidCentral can learn from and that we can introduce to our change agenda.  The experience was notable for the warmth and hospitality of the sites visited, and for the passionate, well trained, and generally youthful clinicians and managers the group met.

Health Quality Ontario

Health Quality Ontario (HQO) is a major new strategic and system integration programme for Toronto, being in place just three years.  A solid evidence based approach to determining resources is to define the evidence including evaluations, appropriateness for tests, surgical procedures, quality based payments, and mega analysis.  HQO values quality improvement plans, capacity building, and knowledge translation including data, indicator targets, tools and reporting.  We were hosted by the CEO Dr Joshua Tepper, a family physician serving homeless men in his ‘day job’, along with an extensive team of clinicians, researchers, and quality improvement gurus.

At the highest level, the health system of Ontario is driven by legislation passed in 2010, unanimously called by parliament the ‘excellent care for all’ Act. This mandate at senior government level has driven the establishment and implementation phase of the quality programme identified by Dr Ross Baker’s work.  Quality champions push the innovation and quality from the forefront. HQO are the principal advisor on quality to the Canadian government with the mandate aligned to systems, quality, frameworks, and facilitations.

We were exposed to extensive modelling of a commitment to ‘Quality by Design’ while being hosted by Health Quality Ontario, which involves embedding quality improvement through health structures and processes, from governance and planning through to team functioning.  For example, training health boards in quality improvement governance and requiring that a portion of their meeting agendas be given over to quality matters.  Another example is requiring that all health organisations have an annual quality improvement plan.

Ontario also provides key enablers for quality improvement, such as resources, evidence-based guidelines and collaborative clinical pathways, along with a variety of other programmes to support innovation and the dissemination of innovation.

Forth Valley NHS Stirling, Scotland

In Forth Valley we were hosted by Dr. Stuart Cumming alongside a committed and passionate team.  It was surprisingly similar to New Zealand in terms of demographics and the increasing complexities of people living longer, managing chronic long term conditions, and the challenges on systems that emphasise the need to re-invent health services through integrative measures.

Legislation has mandated health and social integration; concepts that will require bold measures and brave and difficult decisions to be made over time.  Integration at this level requires the stakeholders to address complex strategic issues such as combined financial considerations.

The group was shown a number of presentations or sessions specifically focussed on the ‘Shifting the Balance of Care’strategy.  This came from the Kerr Report, which defined a strategic shift of focus not dissimilar to the New Zealand Primary Health Care Strategy, 2001.

“Shifting the balance of care away from reactive episodic care in an acute setting to team based anticipatory^[1] care closer to people’s homes is a vital part of implementing our strategy”.

Strategies used to support this shifting of balance included anticipatory care, coordinated planned care, and improved communication and 24/7 partnership working with patient and families in care.  Levers to obtain the change included education and training, communication and capacity planning, and shared information.  The patient safety programme has followed a staged approach and is now focused on primary care and mental health.

What was evident across the many site visits was a clear culture of commitment to quality improvement training of all staff, and embedding systems and processes to engage and ensure continuous measurement for improvement.

The masterclass experience also gave participants an appreciation of the fact that the scope and composition of our local achievements are truly world leading. MidCentral’s efforts to achieve transformational change can be viewed as well planned, comprehensive, and well resourced.  They align with both the research base and international best practice and are very much current.

[1]Anticipatory Care is care planning much similar to advanced care planning tools with additional ‘here and now’ care planning narrative attached and updated as required.  These anticipatory care plans are paper based though shared with all clinicians involved in a person’s care.

If you are working to improve quality in healthcare, you may wish to submit your work to BMJ Quality Improvement Reports. To find out how, go to quality.bmj.com.