Monthly ArchiveJanuary 2015

#Smallthingsbigwins: Let’s teach quality improvement at medical school

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William Calvert is a paediatric surgical registrar and clinical research fellow for patient and family centred care (PFCC) at Alder Hey Children’s Hospital. At Alder Hey he came to appreciate the importance of family involvement in healthcare, and this led to him becoming a self-taught advocate of PFCC.

William Calvert is a paediatric surgical registrar and clinical research fellow for patient and family centred care (PFCC) at Alder Hey Children’s Hospital. At Alder Hey he came to appreciate the importance of family involvement in healthcare, and this led to him becoming a self-taught advocate of PFCC.

For most medical students, formal teaching of quality improvement probably involves little more than identifying the differences between audit and research. Certainly for me it didn’t, but the rising question today is whether there is need for more than this in medical student education.

Helen Bevan, Chief of Service Transformation NHSIQ, promotes the philosophy of junior doctors as change agents and those who will be driving improvement science in the future, and I agree wholeheartedly with this. Engaging clinicians in organisational quality improvement gets results. But should this engagement start at university? The answer must be “yes”, but within a proper context.

Atul Gawande, American surgeon and professor of surgery at Harvard Medical School, identifies five lessons for medical students in his book, “Better”. These lessons are aimed at preventing those new to medicine feeling like small cogs in a vast machine. He holds to the philosophy that “better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try”. Of Prof Gawande’s five lessons, three are directly transferable to quality improvement and I would like to stress their importance in medical education.  My selected three are:

  1. Ask an unscripted question, interpreted as ”get to know your patient”
  2. Count something. Here we need to consider what we are counting, and a changeable variable would be the obvious
  3. Change an element of your practice based on your observation and counting. Then count again.

If we rephrase these three lessons in a different way, we could say that all doctors should promote change in a measurable, variable in response to the psychology of the patient whom they now consider in more ways than just their disease. Put like that, is that not clinical audit? In fact, is that not all of clinical and organisational quality improvement in a nutshell? So here we have a simple strategy for teaching medical students that is itself transferable to all aspects of quality improvement.

Having said that though, when I try to remember what I was taught about quality improvement as a medical student, I draw a fairly large blank. Now however I find it is a very active part of my practice and career. Clinical quality improvement is encompassed in the regular audits, and participation in morbidity and mortality meetings that must be every doctor’s aim. The more elusive organisational quality improvement is something that I am exposed to through a teaching program called ImERSE and my job as a clinical research fellow for patient and family centred care. ImERSE is a quality improvement and medical education tool developed and used at Alder Hey Children’s Hospital. It utilises patient shadowing as a method to capture qualitative care experience data that is thematically analysed to allow for regular feedback into service and quality improvement. The shadowing is undertaken by medical students in the surgical daycase unit, the accident and emergency department, and soon outpatients. The student is removed from any clinical responsibility and encouraged to think about the patient and their family as the centre of a care experience, considering how much the hospital and the care offered affect the psychology of the patient and their family. ImERSE identifies five major themes of medical education:

  1. Patient and family centred care as the most important concept for practice methodology
  2. Preparation for practice by encouraging authentic early years exposure, and by asking students to consider the psychological aspects of hospitalisation so that the emotive bombardment from patients and families when they graduate isn’t an unknown
  3. Identification and addressing of the “hidden curriculum”
  4. Inter-professional education and finally
  5. Patient safety and quality improvement.

ImERSE allows the students to partake in a quality improvement program run by others. It promises to feed back at the end of the placement the findings that that cohort has identified. It promises to explain how we the hospital aim to address them, and it promises that if the students  return to Alder Hey they will see those improvements made. It lets them see that quality improvement can be easy, and not something to be feared.

Herein I think lies the approach to medical students. I don’t think we need to bombard them with detail, they do not need to know about Lean and Six Sigma; armed with the three lessons extracted from Atul Gawande, and with willingness to try, they will understand that they can bring about improvement.

You can learn more about Mr Calvert’s work by joining him at our webinar – sign up here! Join the conversation by tweeting @BMJQuality or visiting

#Smallthingsbigwins – do good ideas come in small packages too?

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

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

Small and mighty. Good things come in small packages. From the tiny acorn comes the mighty oak tree. Small things, big wins. As a small person myself (I’m 5 foot – my partner tells me I’m actually shorter than that, but I’ve rounded up) I hear these sorts of statements a lot. We’ve just launched a campaign at BMJ Quality to highlight the wonders of all things small, because we are always struck by the projects that start with a small idea and make a huge difference to the care of people.

Take for example the #hellomynameis campaign. In Kate Granger’s blog last year she told us the story of how she has changed the way thousands of people introduce themselves to their patients, following her own experience as a patient. To introduce oneself by name is something so simple, but reminds us that we have a relationship with others as healthcare professionals that is much more powerful when personalised. She has inspired people around the world to change the way they see themselves, and change the way they present themselves to those people they are looking after.

At a talk I went to a few years ago, the speaker described a consultant in charge of a palliative care ward who was small and rather bedraggled looking, but who ran her ward with incredible passion, and whose junior medical staff were in awe of her for teaching them about compassion and how to deal with the sadness of families in distress when someone was dying. As a junior doctor,  unsure of what career path to follow, I was inspired by that talk being rather of the same description (small – and bedraggled!); I really am a believer in #smallthingsbigwins! I manage the journal BMJ Quality Improvement Reports, and every week I’m lucky enough to read a new story of how a group of people got together, decided they wanted to fix something, and did it. Take for example the first report we have published this year, where junior doctors introduced  a traffic light tool to categorise patients on the medical take as red, amber, or green according to their clinical status at time of admission to the acute admissions unit. Introducing this resulted in improved verbal handovers between doctors at the time of patient transfer. It’s simple idea, and one that any junior doctor could emulate in a new post. To find out how to run your own handover project, you could come to our next webinar and see how to start.

In the second article this year, a group of nursing students in Dundee, Scotland, did a small scale project to introduce a tool to screen for delirium in older people. The tool was a simple, short questionnaire that worked well, resulting in better identification of delirium by nursing staff and was then incorporated into nursing care ward round forms. From this small idea, a group of students have actually changed clinical practice, and their intervention will continue to be used even after their placement has finished – small things, big wins.

The beauty of the quality improvement reports we publish is that they don’t need to be complicated, filled with large numbers and lots of statistics. Take this project for example, where the authors introduced a patient information leaflet to dermatology clinics and used a small sample of 32 patients. They learned that new patients found the leaflet very helpful as it helped them to prepare for the consultation, whereas those who had been to the clinic before did not – and now all new patients receive this leaflet. Again, a small intervention based on a small study which has been embedded into the system long-term.

It isn’t just healthcare professionals who are doing quality improvement work. Caroline Dearson is a carer and volunteer who founded a Dementia Buddy Scheme after her own father’s experience of dementia. She knew that people with dementia needed a more tailored type of support, and set up the scheme from there. Now people with dementia on wards are better supported and she has a huge team of supporters and volunteers.

When BMJ Quality started, we’d identified that healthcare professionals were doing audits and other improvement work, but not getting a chance to publish their work. This meant that other people didn’t know that this work had been done, and it seemed such a waste. The idea was to make it easy for people to share their work, and introduce an online platform that could teach people every step of quality improvement, giving them the chance to share their work with “one click”. That is how BMJ Quality started – and again it was just a small idea that has now grown into one of the largest open access journals publishing quality improvement reports. There are over 5000 people working on projects using BMJ Quality right now, and so far 194 reports have been published. 1,658 reports are underway, and 180 new quality improvement mentors have joined us. People are working on quality improvement reports using BMJ Quality in over 35 countries, including over 2,000 healthcare professionals in the Kingdom of Saudi Arabia! And to date, improvement reports published by our community have been accessed just under 250,000 times in 2014 (QIR Report). A #smallthingbigwin indeed.

If you are interested in sharing your experience of quality improvement, please get in touch. You can email us at or use @BMJQuality and send us your ideas with #smallthingsbigwins.

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