Archives 2014

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.

A health foundation research scan (2) suggests three key causes of harm in primary care: clinical complexity, systems issues and human factors. Paresh Dawda’s Human Reliability in Primary Care blog brought to you by BMJ Quality, focuses on the human factors element.

We hear lots about patient safety, but the voice of primary care is not heard as loudly as that from the acute sector. Primary care is equally prone to patient safety threats and risks. The research is limited, but estimates of patient safety incidents are estimated at between 0.004-240.0 per 1000 primary care consultations with 45%-76% of all “errors” thought to be preventable.(1)

Spend a few minutes and reflect on:

• Interruptions during your consultations
• How alert you feel towards the end of a three hour session compared to the beginning
• How often you find that something you need, e.g. a form, a piece of equipment is not there and you have to go looking for it
• How often do you experience communication related misunderstandings between yourself and others e.g. receptionists, nurses, care home staff, other doctors or patients.

These are just a few everyday common occurrences. Of course, they do not always lead to patient harm but still they have the potential to do so. Clinical human factors are about “enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture, organisation on human behaviour and abilities, and application of that knowledge in clinical settings.” (3) Put another way, “human factors are all the things that make us different from logical, completely predictable machines. In simple terms they are all those things that enhance or reduce human performance.” (3)

The delivery of healthcare relies on us, as humans, interacting in a multitude of ways with the health care system; whether it is operating our clinical computer system, undertaking a procedure, or talking with colleagues or patients. Moreover, it also encompasses the way our patients relate to the system since those same human factors that affect us also affect our patients. Recognising and appreciating this is the first step in enhancing clinical performance. The second step is to understand how, as humans, we interact with other components of the system and carry out tasks. The third is to understand the multiple variables that impact on the quality of that interaction and strategies to reduce that impact. These may be personal factors such as fatigue, illness, irregular work patterns, and reliance on memory, or they may be environmental factors such as distractions (through noise, motion, clutter, heat, lighting), poorly designed procedures, or simply lack of training.

When I was on the faculty of the NHS Institute’s (now NHS IQ) safer care faculty, we had a simple mantra: “make it easier to do the right thing, make it harder to do the wrong thing.” However, in order to improve human reliability we have to go a step further and appreciate the inevitability of human error. Therefore we also have to put in place mechanisms to spot and stop errors before they become a safety threat.

My first purposeful application of this understanding was in a project implementing the NICE guidelines on assessing febrile children (CG160) (4), and in particular the clinical assessment of febrile children, a key priority for implementation. One of the NICE recommendations is to “measure and record temperature, heart rate, respiratory rate and capillary refill time as part of the routine assessment of a child with fever.” On the face of it this is a simple recommendation, but to reliably implement it required many human factor related interventions. One simple example is a prompt to measure the four items. We knew from our data that the temperature was beings checked 70% of the time. Therefore, associating the reminder prompt with the task of checking the temperature would potential yield positive results. The task of checking the temperature mostly entails using a tympanic thermometer and then reading the temperature on the LCD screen, so a prompt at this point would achieve the objective. Just as with any other change idea, the model for improvement can then be used to test out the idea and refine it using iterative cycles.

More information on this and other examples from the project are given in the video and in either the NICE shared learning example or the Clinical Human Factors Group’s ‘How to Guide’ ( ), whose website hosts resources on clinical human factors.

The Health Foundation’s research scan concluded that “the potential for improving safety in primary care is significant, not least because of the volume of consultations taking place, the complexity of the interactions involved and the uncertainty associated with providing care in the community.” Applying clinical human factors is a powerful mechanism to achieve that improvement.

Paresh has worked in UK general practice, is an experienced trainer, and developed, delivered and coached on leadership, quality and patient safety improvement programs for NHS Institute for Innovation and Improvement before migrating to Australia in 2012.  He is a member of WONCA’s working party on quality and safety, leading a chapter on transitions of care for WHO and on the editorial board of the Australasian Medical Journal.  Paresh has published articles on quality and patient safety improvement and has delivered presentations and workshops at national and international conferences. Watch more here.

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.

References

1. Makeham M, Dovey S, Runciman W, Larizgoitia I. Methods and Measures used in Primary Care Patient Safety Research. Review of the literature. 2008
2. Research scan: Improving safety in primary care [Internet]. Health Foundation; 2011 [cited May 2014 ]. Available from: http://www.health.org.uk/public/cms/75/76/313/3077/Improving%20safety%20in%20primary%20care.pdf?realName=VzT40H.pdf
3. Towards a working definition of human factors in healthcare [Internet]. Clinical Human Factors Group[cited May 2014]. Available from: http://chfg.org/definition/towards-a-working-definition-of-human-factors-in-healthcare
4. Feverish illness in children (CG160) [Internet]. NICE; 2013 [cited 2014 May]. Available from:

Dr Marc Wittenberg

It’s just under a month to go until the Agents for Change 2014 conference [http://www.agentsforchange.org.uk], the biggest national medical event for trainee doctors, by trainee doctors, and it’s being held on 26-27 June at BMA House in London.

This year, the theme is ‘Right Skills, Right Team, Right Now’. What does that mean? It means equipping trainee doctors with the capacity and capability to make healthcare better. This might be quite a grand statement but as Sir Bruce noted in his report on the 14 hospitals, “trainee doctors are our most powerful agents for change.”

For me, this means that there is an expectation from the system, and particular from patients, that trainee doctors need to step up and make change happen to secure the future of high quality healthcare. This means constantly questioning the norms, not accepting the status quo, and making the business of quality improvement part of our daily work.

Many trainee doctors are already doing fantastic work around the country, working above and beyond to improve patient care. It is worth taking a look at  the open-access BMJ Quality Improvement Reports journal to be inspired and get ideas:

Improving the accessibility of trust guidelines for juniors doctors

Instituting a block room for regional anaesthesia 

Signposting GP trainees to learning opportunities

Agents for Change is In its 6th year now. This will be the first two day event and will include video and poster entries, both of which will be published in a special BMJ QIR supplement. All delegates will also get free access to BMJ Quality, which will enable them to undertake QI projects and submit their own work for publication.

We also have key-note speakers by top medical leaders including Dr Fi Godlee, editor-in-chief of the BMJ, Sir Bruce Keogh, medical director of NHS England, Professor Ian Cummings, CEO of Health Education England, Sir Mike Richards, Chief Inspector of Hospitals, Professor Mahmood Adil, professor of value-based healthcare at Department of Health, and Dr Jennifer Dixon, CEO of the Health Foundation.

In addition, we are delighted to welcome world-renowned speakers from the US and Ireland: Dr James K Stoller will give a perspective from the Cleveland Clinic, one of the most reputable institutions in the world, and Margaret Murphy will offer a deeply moving and personal view of patient safety as one of the WHO’s patient safety envoys.

The Strategic Advisory Board, made up of fellows from the National Medical Director’s Clinical Fellow Scheme, together with BMJ colleagues are working hard putting the finishing touches to the programme, sorting last minute logistics, and compiling the abstract supplements, amongst other things. This is all to ensure that the conference is the best that it has ever been.

We hope that by attending the conference, trainee doctors will be inspired to go back to their workplaces and put this into reality. Through a series of expert workshops, delegates will acquire some of the skills and connections that they need. For example:

Getting the Right Skills in leadership, human factors, influencing others and coaching
Building the Right Team through networking with HEE, FMLM, DAPS and iwantgreatcare.com
Being inspired to start Right Now with the NHS Change Day team and Inspire Improvement project team

To paraphrase Don Berwick, doctors need to both do their jobs and also work to improve their jobs by improving the systems they are working in. In order to do this, and to be taken seriously, we need to have the ability and the confidence to make change happen.

Places are going fast, so register today at http://www.agentsforchange.org.uk then follow us @agents4c and on http://www.facebook.com/groups/agents4c/

Dr Amar Shah is the 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

Engagement is a critical factor in attempting to improve quality at scale. Our aim for engagement is to harness the energy of a critical mass of people into purposeful activity aligned to our system-level goals.

Stage 1 of our programme was about direction – working with the board and our senior leaders to understand what quality improvement would mean for the organisation, consulting widely to develop a shared mission, and developing measurable aims that will be the focus of all our improvement work.

We’re now deep in stage 2, which is about building the will within our organisation for improvement – trying to create ‘pull’ from the frontline. We’re taking a two-pronged approach to this, using traditional communication methods alongside a more campaign-style approach aimed at building a grassroots movement for change.

Traditional tactics have included a launch event (in February and attended by 250 people). We’re taking this deeper into the organisation, with a series of events aimed at inspiring and exciting the front-line staff and patients about quality improvement. We’re using the existing structures and hierarchies to gradually embed continuous improvement within our approach to quality, engaging service and clinical leaders to take ownership for nurturing improvement within their departments.

However, much more exciting is the emerging campaign. Many months ago, before we formally launched the programme, we brought together a Q30 group of staff representative of all areas and levels of our organisation.  We asked them to help us think about how to engage front-line staff, and the messaging that would help us connect with people’s internal motivations for wanting to give their best to their patients. Alongside this, we had a Q12 group of patients, carers, and governors, to give similar input from their perspective. This has been hugely valuable in helping us develop a compelling narrative and communication plan to help us reach and unleash every person in the organisation.

We’ve also tried to make every aspect of the programme as accessible and transparent as possible. We have spent many months consulting widely to develop our vision, mission, and measurable aims, and continue to ensure frontline staff and patients are integral to all our improvement and redesign work. We have developed a microsite for our QI programme that is purposely not hosted on our intranet, making it accessible to staff from anywhere and from any device, and also to make it accessible to patients, families, governors and the wider community. Even though it may sound strange to some, the use of social media channels at East London remains extremely limited. Our launch event and communications are harnessing the power of Twitter, Storify, SlideShare and other channels to extend our reach and encourage the building of more networks within our community. Finally, we chose to allow our staff to design our QI brand image, running an internal competition. We had patients, staff, and senior leaders on our shortlisting panel, and all staff were invited to vote for the winner. The response was overwhelming, with over 500 staff voting in total, and 90 votes in the first five minutes.

We recognise that engaging our staff and patients in this work is critical to success. We are beginning the long road, and starting before we’re fully ready, but trying hard to be the change that we want to see – listening, learning, involving, and innovating at every stage.

If you’d like to find out more about the East London QI programme, please visit http://QI.eastlondon.nhs.uk

Sveta Alladi is a Paediatric Registrar in London, who is currently a National Medical Director Fellow at Health Education England. She’s just joined the team at The Network and is organising the video abstracts for the Agents for Change conference, June 2014

This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

No, its not the latest Johnny Depp movie setting up on Starlight ward, (wishful thinking)….but the F1 and ST4 in Paediatrics creating and starring in their very own blockbuster hit in quality improvement. These innovative trainees have just demonstrated that using the SBAR ((situation, background, assessment and recommendation) tool in their department has vastly cut down handover times and helped prioritise the sickest children for review.

What better way to highlight their outstanding achievements than to take starring roles in their very own short video documentary. A quick and easy video shoot using their smartphone – some quick edits on a laptop and it is ready for upload and release on YouTube.

The Network (www.the-network.org.uk ) is an online forum which hopes to host and showcase the leading lights in healthcare, who work hard in their day jobs but also take time to improve services and care for patients. The Network has been set up by a passionate group of healthcare trainees who strongly believe in the value of the culture of quality improvement.

They want to recognise the achievements of frontline healthcare professionals who innovate, create, improve and deliver changes to their environment by displaying their projects for all to access, learn from and share.

I’ve recently joined the team at the Network and even I – old enough to have managed university without a mobile phone- can see it’s quite simple really. Almost all health professionals have access to a smart phone, and the majority can figure out how to use it as a video camera – even the most technologically naive.

The videos can be in any form – it can be an interview with a colleague who coordinated the project, an interview with a patient who experienced the benefits of the projects or any format you think best to showcase your work. Using the Network as a host – the video can then be shared far and wide – via Facebook/twitter (@TheNetwork001) and reach professionals all over the globe.  You can promote work you have already published in BMJ Quality Improvement Reports by making a video or create a video before submitting your work to the journal to give your project a higher impact factor.

Everyone has time to watch a quick three minute video – on the tube to work, on a quieter night shift, or waiting for the kettle to boilA short video has huge potential to inform and influence – think of the impact a TV advert or a movie trailer can have on the choices you make.

The world is moving on; you can say so much more in a 3 minute video than you can with written text.

If you are still feeling a little unsure – there is lots of advice on how to make a video on our website: http://www.the-network.org.uk/ and you can see some of the videos already uploaded here: http://youtu.be/SKQxICMUhPw

The Network is hosting a launch event in Manchester on Monday 12^th May in Salford (see www.the-network.org.uk for more details). We hope many of you will take some time to think about a project you are involved in and share it with us for this event.

Upload your video to YouTube then send the link to thenetwork.org.uk@gmail.com.  We will automatically enter you for the 2014 Network Improvement competition. There will also be prizes (including free licenses to BMJ quality and a free place to the 2015 Patient Safety Congress).

We want to connect improvers from across the globe. The videos will be indexed and accessible for all to see, learn from and then connect to the authors.

This is your opportunity to showcase your work on a global platform. So, go on – what’s stopping you? The deadline for submitting your video is 1^st April 2014.

Dr Amar Shah

Dr Amar Shah is a consultant forensic psychiatrist and quality improvement lead at East London NHS Foundation Trust. He is also the London regional lead on quality and value for the Faculty of Medical Leadership and Management. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

 Contact or follow him on twitter @DrAmarShah

At East London, the question we have been asking ourselves is, “what does it take to sustain a multi-year organisation-wide improvement programme that delivers significant improvements in quality and cost, and successfully transforms the culture of the organisation?”

Quality has been the undisputed buzzword in healthcare in 2013, with a number of seminal national reports focusing on how to improve quality of care. This blog will chronicle the journey of one provider of mental health and community services, and how we are changing our thinking and approach to quality.

At East London NHS Foundation Trust, we believe we currently deliver a good quality of care, with many ‘bright spots’ of excellent caring practice and innovation. There is also considerable inconsistency and variation, with some ‘dark spots’ of concern. This situation is not unique to East London, and most healthcare staff may be able to relate to a similar picture in their organisation. Over recent years, as with many NHS providers, our Trust has placed emphasis on quality control and quality assurance structures. This has resulted in relatively robust governance procedures, evidenced in the attainment of CQC essential standards of care for all visits and NHSLA level 3 risk management standards.

Our ambition is to deliver the best possible mental health and community care to our patients, service users, carers and families. We have made a commitment to quality of care. This is embodied in our mission to provide the highest quality mental health and community care in England by 2020. We recognise that achieving this will require a new approach to quality. The three landmark reports in 2013 on quality and safety in the NHS (Francis report, Keogh review and Berwick report) have all espoused the development of an organisational culture which prioritises patients and quality of care above all else, with clear values embedded through all aspects of organisational behaviour, and a relentless pursuit of high quality care through continuous improvement.

In addition but not unrelated, funding for the NHS is likely to remain static or possibly decline in real terms beyond the 2015 general election. Achieving year-on-year efficiency savings by focusing on rationalising inputs to the system (workforce, assets) is proving increasingly difficult and is likely to disproportionately affect staff morale and quality of care. It’s abundantly clear to anyone working in the frontline of healthcare delivery that the area of greatest inefficiency within the system lies within the clinical processes themselves, which have largely remained untouched through recent years of efficiency savings. Redesigning clinical pathways with the ambition of providing patient-centred, high value care offers the potential to realise continued savings from the health economy whilst delivering an improved quality of service to our patients. Successful redesign at this scale requires improvement expertise, dedicated resource, rigorous application of a consistent methodology and a fundamentally different approach to quality, which involves putting patients and the families at the heart of the design and improvement work.

The last year of preparation has been a steep learning curve and a great investment. We have taken time to think, talk and learn from others. Successfully embedding a new culture and achieving a step-change in quality and value of care is a huge challenge, but we now feel in a much stronger position to attempt this.

Our work began at the very top of the organisation, recognising that Board-level leadership was absolutely vital to success. Nurturing and supporting improvement to achieve better health, better care and better cost requires leaders to apply a new approach and specific set of behaviours in redesigning systems and accelerating culture change, as described in the recent IHI white paper. Our Board has invested time and energy to understand improvement, to learn from the journey of other high performing organisations, and to develop a strategy for our programme of work. Wide consultation across our clinical teams, service users, carers, Governors and commissioners has fed into the development of a strategy that we hope all can feel ownership of.

Developing the business case has been a significant challenge, with most of the evidence and experience of large scale quality improvement being in acute care. However, we believe that coordinated improvement work in mental health and community health services is just as possible, despite some additional challenges, and we are excited by the prospect of starting to work in unchartered territory.

The work before the work of improvement has been crucial in preparing the ground for applying quality improvement across a whole organisation, and eventually a whole system of care. One of our earliest decisions was that we would be more successful in this journey if we partnered with an external continuous improvement expert, to support us with strategic advice and to help us build improvement skills in our workforce at scale and at pace.

We are building a central quality improvement team in the organisation, to coordinate the programme of work and to be the internal improvement experts. Over the last few months, we have been slowly and steadily reviewing and re-aligning many of our corporate systems so that they will support our improvement work. Much of this has the potential to be transformative – for example, working towards the publication of complaints every month on our website, embedding a structure for listening at every level of the organisation, integrating quality data and making this available to every person in the organisation, reviewing all of our policies and procedures to ensure they support the development of a just culture, reviewing our clinical audit programme, refreshing our induction process, and ensuring that quality improvement is embedded within all of our internal training and development.

Alongside this, we’re developing the framework for measuring and evaluating our progress on our strategy – not an easy task, considering the lack of standardised outcome measures in mental health, and the lack of accurate tariffs and costs for patient-level activity.

We’re clear that our quality improvement programme will involve a fundamental change in the way things are done. It will seek to bring about a culture change, putting patients at the heart of all that we do and at the centre of our improvement and redesign work. We want to embed a culture of listening more to our frontline staff, service users and carers, and provide more freedom to our frontline staff to work in partnership with patients to innovate and test new ideas, whilst stopping activity of lower value. And we want to build up the skills in our workforce on improvement, and support them to use a consistent methodology to test ideas, measure their impact and then spread successful change. We’re convinced that freeing our staff to work with their patients in improving the system and pathways of care will yield the greatest improvements in quality and cost outcomes.

We’re about to open a new chapter in our organisation’s journey. It’s one that we believe could only be possible from a position of strong leadership, assurance and financial security. Our next challenge is the critical one of engaging the whole organisation in this programme, and the next blog will describe how we’re attempting to create a movement for change that is led and owned by the grassroots.

References

1. Dixon-Woods, M., Baker, R., Charles, K. et al. (2013) Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Quality Safety doi: 10.1136/bmjqs-2013-001947

2. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (chaired by Robert Francis QC), February 2013

3. Review into the quality of care and treatment provided by 14 hospital Trusts in England (Professor Sir Bruce Keogh), NHS England, July 2013

 4. A promise to learn – a commitment to act. Improving the safety of patients in England. National Advisory Group of the Safety of Patients in England, August 2013

5. Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2013.

Helen Carson, Product Manager for BMJ Quality

BMJ Quality was at the Arab Health Congress in Dubai last month. This event played host to 85,000 delegates, over 2,000 exhibitors and 19 conferences, which included topics such as quality management and diabetes. Talking to delegates was a good way to learn about the myriad uses for the term “Quality”; Accreditation, safety, performance standards, risk mitigation, innovation, process improvement and patient centred care were just a few of the phrases that were regularly used by delegates to talk about quality in their organisations. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

One of the contrasts to the UK was the sense that in the Middle East, “Quality” is very structured; delegates from the Middle East tended to talk about a very organised quality manager at their organisation who worked to devise and implement quality strategies and practical resources, whilst working to ensure that everyone adhered to the frameworks necessary for accreditation by the likes of Joint Commission International (JCI). These healthcare professionals saw their role as implementing quality controls to reduce risk, and to ensure that clinical practices are safe and consistent. Perhaps it was due to the nature of the events, but when I think back to the ‘quality themed’ conferences I attended in the UK in the summer, there was a contrast: Senior NHS figures were calling for frontline staff to take responsibility for quality improvement through critical appraisal and innovation. Many spoke of the redesigning of processes and services, due to the continued complexity and bureaucracy of many organisations, and the ability of those at the frontline to see a clearer path to improve services. This is of course in addition to adhering to the guidelines given by government and other healthcare bodies such as CQC and NICE.

Perhaps a sweeping generalisation but these are examples of a “top down” and “bottom up” approaches in action. Two very different approaches to the notion of Quality but, hopefully, both with patients as a central focus.

And this is where things (in the era of patients as customers) get complicated. For many patients high quality healthcare has strong links to service elements; speed at which they get to see a doctor, the manner in which they are treated.

While a healthcare professional or a hospital can appreciate the importance of these things their emphasis will likely be on clinical quality and the flow of services and processes. All of these elements need to be measured, improved and managed by empowering healthcare professionals and patients to contribute to the cycle of improvement.

So do we need to agree on a consistent meaning of the term “Quality” to move forward? Or do we need to be flexible and responsive to the needs of patients and organisations in order to give a notion of quality that is important to them?

I suspect that it is the latter.

But one thing that is for sure is that people working at the front line are unsure of their role and authority in Quality Improvement and innovation, so in this respect, clarity, support, and education are an important part in moving forward. And for all these phrases or interpretations of quality; change is essentially what is needed.

What does Quality Improvement mean to you? Want to tell us about it? We want more bloggers to add to the discussion! Contact us: quality@bmj.com

Clare van Hamel, Associate Postgraduate Dean and Director of Foundation School.

Severn Foundation School (FS) has embraced quality improvement (QI) as a highly effective means of achieving improvement in a wide variety of areas. Clare Van Hamel, Associate Postgraduate Dean and Director of Severn Foundation School believes QI empowers individuals, in a far more effective way than audit, helping staff to address the concerns which are directly affecting them. Here she describes ways that other Foundation Schools can follow their lead to enable foundation doctors to identify concerns and develop solutions using a multi-professional approach. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

Severn FS has been fortunate in having quality Improvement leaders as part of the foundation faculty. They have really driven the enthusiasm to use QI tools supporting foundation doctors to identify concerns. Here are my top tips to facilitate quality improvement in a post-graduate medical education setting

1. Identify trainee leaders to enable near-peer championing of QI.

Severn FS have appointed Foundation School Quality Improvement Fellows. Following allocation via FPAS to the Severn Foundation School, all incoming F1s are invited to apply in open competition to be the QI Fellow for the school. The appointee is given financial support to attend an appropriate QI conference and also invited to attend relevant regional/foundation school meetings during their tenure. F1s do not have study leave but the Trusts are asked to be as supportive as possible to facilitate attendance at meetings.

The fellow is identified as a QI contact point for the other foundation trainees. The fellow is supported and mentored by the F2 QI fellow and QI faculty. There is a little more flexibility during the F2 year for the fellow to attend conferences during their study leave time supported financially by the Foundation school.

2. Identify trainer QI leads

Severn FS has been fortunate in having faculty who are committed QI champions within the region both at consultant and senior trainee level. The foundation school has recently set up a sub-group led by one of those champions to help to promote sharing of ideas and outcomes

3. Trusts need to engage and promote QI opportunities for their staff.

Many of our trusts really encourage their foundation doctors to participate in QI work as teams; with many achieving approximately 80% participation. The trusts have seen the specific benefits of the QI outcomes leading to change but also more subtly the benefits of multi-professional working leading to increased morale and respect between different professional groups. Many of the Trust’s executive teams are recognising the significance of the QI achievements and are keen to develop and endorse the work.

4. BMJ Quality subscriptions

These licences have been purchased by the Foundation school to help to facilitate sharing and publication of the QI work that has been completed by the trainees within the school.

5. Opportunities to share the QI outcomes

Severn Foundation School runs an annual regional presentation day providing opportunities for trainees to showcase their work. As a result of the positive feedback from the regional event..

6. Severn Foundation School organises the National Foundation Doctors Presentation Day

This annual event provides an opportunity for Foundation Doctors from any foundation school to present their work. The national day has attracted an increasing number of submissions >300/annum for the last two years. This year the event was supported by HEE, UKFPO, the GMC, HQIP, the BMA and others.

 7. Encourage and support your trainees to submit their work

A very large number of our trainees have presented their work at National and International meetings. We have been over-represented compared to the size of the school at meetings such as the NACT/UKFPO Sharing Best Practice Meetings. We try to provide financial support for trainees to attend to present their work when possible and encourage trusts to release trainees to present at national and international events.

 8. Highlight achievements

The trainee and faculty achievements are highlighted on our website. These are subdivided into presentations, publications and other projects. http://www.foundation.severndeanery.nhs.uk/about-us/trainee-and-faculty-achievements-2/

In summary quality improvement has enabled our trainees to deliver change within their working environments, in a wide variety of fields. The work has delivered a huge number of changes including better patient care escalation policies;  improved handover; safer prescribing of drugs and fluids; induction to F1 and F2 programmes; improved access to rotas and access to protocols. Much of the work has centred on patient safety but also on efficacy and efficiency. Many of the projects have produced considerable cost saving whilst also improving patient safety. What could most concisely be described as a WIN- WIN for all involved.