Archives July 2014

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.

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

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

I have to put my hand in the air and say ‘I’m guilty.’ I, like many doctors, never really reported safety incidents in hospital, and the reason why I did not do this is complex. I am a huge believer in improving quality and safety and have spent almost all of my non-surgical time over the last 10 years working on programmes to reduce safety incidents and improve quality. So why did I not report safety incidents in my own clinical practice? I think I just went along with the prevailing culture: ‘it’s too hard’, ‘the forms take ages’, ‘nothing will ever happen as a result so there’s no point doing it.’ I just accepted these as truths and since I had a clear avenue (via quality improvement) to change the systems around me I never challenged those assumptions, until now.

So what has changed me? I read a book. Not a patient safety book, but a book about the airline safety system. If you are interested, it’s called Close Calls, by Carl Macrae (Palgrave Macmillan – you can read a sample chapter by clicking here). He spent three years with airline safety investigators really trying to understand what they do and how they do it. Here are some thoughts on the main messages I got from his book as we look towards developing the same system in healthcare:

1) The judgement of safety investigators is not directed at the specific crews in question, nor is there any individual blame. Investigators’ concerns are related to how the incident happened, and most specifically on how the systems can be improved to reduce the chance of it happening again. This ‘no blame’ culture goes even further in a statement signed by the airlines chief executive stating: ‘that investigations are to focus on learning and improving safety. No staff will be considered culpable, or will be punished, for errors or mistakes made within accepted professional conduct and that are appropriately reported’. Basically, if you’re not negligent then you will not be blamed or held accountable. Are we anywhere near that in healthcare?

2) Airline safety investigators are almost all drawn from either current or previous frontline line workers. To work as an airline safety investigator you need experience of analysis as well as knowing what gets done on the frontline. During their investigations they often refer to their own previous firsthand experience, and think: ‘I’ve done that.’ I think we do have this in healthcare too, since investigations are normally carried out by a clinician as well as a safety investigator.

3) Although they have a formal process of reporting incidents and near misses, there is also an informal system so that anyone can contact the safety investigators with more ‘feelings’ that something is not quite right. The investigators can’t do much with one report but if they start getting a multitude of ‘feelings’ then they will take action. As I say below, the reporting system in the hospital I work in does actually allow this.

4) They communicate clearly, publically, and across the industry. Flight safety investigators only significant influence is to report internally and publically the incidents. They do this in a variety of ways. On a weekly basis they report to senior management a brief summary of incidents. On an operationally useful side, they produce a monthly newsletter for all frontline staff and a more formal quarterly magazine focusing on practical safety issues. After the crash on the Hudson River, the formal report had been published online and was freely available to anyone to view (click here to see it, it makes for interesting reading). To the best of my memory I have only ever seen three reports of patient safety incidents in my 13 years of clinical practice.

5) They accept the inevitability of accidents; there are no ‘never’ events. Failure and error are inevitable features of organisational activity, and though such incidents are largely manageable, they are ultimately ineradicable. The airline industry works constantly to try and prevent them, and this perceived inevitability makes safety investigators continually attentive and worried. This is James Reason’s ‘constant sense of unease’.

6) Their work is totally dependent on incident and near miss reports. The reporting of incidents allows investigators to see what is really going on and keep in touch with the frontline. Without these reports their job would be impossible. They get very nervous when reporting starts to drop off. Is it because the frontline is losing the faith in the safety systems? You need staff to be totally happy in reporting mistakes and errors, both because they will not get in any trouble and also because something will be done to make it better. As Carl says, ‘the engine that drives safety is events.’

It’s this last point that has changed my attitude to reporting. The airline safety system is totally dependent on frontline staff putting in incident and near miss reports. Theirs has been a journey of moving from crash investigation (which they did from the beginning when there were lots of crashes) to a system that analyzes near and not so near misses.

As a result of all this, I’ve now started reporting any ‘unsafe things’ – the near misses as I have seen them. From the more serious (unfilled posts when the locum SHO did not turn up) down to the absence of marker pens on the pre-op admission ward. It may not sound like much, but this is a significant patient safety issue. I had to search around another ward to find this missing marker, but could I have just used a biro if I’d been more pressed for time? This has happened before in a hospital I worked at and actually led to an operation on the wrong lung!

So how about my initial fears. It was really easy to fill the forms out on the computer system, took hardly any time, and even had a box for free text. I got an automated reply thanking me after I’d submitted. I then emailed after a couple of weeks to find out what was happening, asking to see if I could spend some time looking at how the incident forms where handled. I was waiting for the reply and any more information about what has happened. However, it is over two months now and I am still waiting.

Perhaps my fears were well founded, I will let you know.

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.