Archives February 2015

James Innes is head of quality improvement at East London NHS Foundation Trust. A hospital pharmacist and IHI trained improvement advisor, he has specialist skills in patient safety and leading system wide improvement initiatives. James also acts as an editor for the Journal of Psychiatric Intensive Care.

When I think back to my time as a ward-based pharmacist, I still remember the first time that I saw how commissioning arrangements could directly impact front line clinical work.  The year was 2011 and I was about to get my first taste of commissioning for quality and innovation, better known as CQUIN payments.  Our Trust had been set a target to ensure that 90% of inpatients benefited from medicines reconciliation (MR) within 72 hours. Success was to be determined by an aggregate measure of our performance over a year’s period. 

Designed to allow commissioners to reward excellence, CQUINs link the achievement of local quality improvement goals with payment.  In recent years the size of the payments linked to these goals has increased and has sometimes resulted in an uncomfortable tension.  On the one hand, Trusts want to innovate and improve quality, but on the other the financial repercussions of not meeting these could be significant.  This can have a massive impact on how Trusts choose to achieve these targets and consequently the behaviour their approach motivates.

In the case of our MR target, the focus quickly turned to achieving minimum standards (working towards the minimum percentage required and the maximum permitted period of time), we only looked at data as an aggregate (how we rated versus our overall target) and we only took action on the cases where a MR wasn’t completed. These actions display all the hallmarks of a quality assurance approach.

This style of using data for assurance is not new in the NHS.  Moreover, it is not new in healthcare across the world.  Using data for assurance is one of the favoured mechanisms for ensuring quality.  But is it the right or only one?  Serious questions have been asked, particularly in light of the Francis, Berwick, and Keogh reports, questions such as, “how could organisations that satisfied rigorous external assurance checks go on to provide care that was so sub-standard?”  Even within our own organisation we recognise that variation in quality exists between different services in the Trust, or even in the same services over the time. While assurance alone has got us so far, the only way we will begin to solve this problem is with a new approach to quality.

As an organisation we are changing the way we approach quality.  Our Quality Improvement (QI) programme is unique for the Trust in its breadth, depth, and timescale. At its centre is a mission: to provide the highest quality mental health and community care in England. Underpinning this mission are two initial stretch aims: to reduce harm by 30% every year and to ensure that every patient receives the right care, in the right place at the right time. Our mission will be delivered by transforming the culture of the organisation to one of continuous improvement, where staff in collaboration with patients and carers, are able to improve the quality of services we provide.

So how might this new approach have affected the way we targeted our MR CQUIN?  Well, for a start we would have looked at data over time rather than as an aggregate over many months.  By looking at data over time you can really start to understand variation in your processes and truly understand whether the changes you are making generate a sustained effect.  Secondly, we wouldn’t have just have taken action on the defects, but looked at improving the process as a whole by testing a number of change ideas iteratively.  Thirdly, we could have involved all types of front line staff who play a role in MR from the start.  They really are best placed to understand what changes would need to be made to improve MR overall.  But clearly when you are being motivated by financial pressures, this will still nurture a certain type of behaviour.

And this brings us full circle to the subject of commissioning. To realise the maximum potential of this new approach to quality will require collaboration with our commissioners, regulators, and external partners. That is why we are using every opportunity available to engage them; so that funding is aligned with outcomes that patients think are important and that resultant CQUINs or KPIs support iterative learning, improvement, and expansion.  We have already taken some key steps to start this happening. We now have representation from this group on our QI programme steering group, to help provide high level alignment with our organisational QI strategy. We have and continue to run numerous bespoke events to build will around QI and our organisational approach.  And we have even built capability in a few commissioners and external partners through our ‘Improvement Science in Action’ training, run in conjunction with the Institute for Healthcare Improvement.

We recognise that it will take many years of work on both sides to achieve the Trust’s ambitious mission, but there are already small signs that our engagement may be starting to pay off.  We recently celebrated our very first CQUIN that incentivised using a QI method to improve a quality problem, rather than setting a traditional target.

Brian Boyle is a healthcare advocate, public speaker, and National Volunteer Spokesman of the American Red Cross. https://blogs.bmj.com/quality/?p=290

In the first of this two-part blog, Brian Boyle describes his personal experience of being a patient.

My name is Brian Boyle, I am 28 years old, and I live near Washington D.C. I’m a healthcare advocate, public speaker, National Volunteer Spokesman of the American Red Cross, grad school student, Ironman triathlete, and marathoner. However, ten years ago, things were very different because in that time I was in the intensive care unit fighting for my life.

One month after I graduated high school in 2004, I was coming home from swim practice and was involved in a near fatal car accident with a speeding dump truck. The impact of the crash violently ripped my heart across my chest; shattering my ribs, clavicle, pelvis, collapsing my lungs; damage to practically every major organ; kidney and liver failure; removal of the spleen and gallbladder; 60 percent blood loss; severe nerve damage to my left shoulder; concussion; and in a coma on life support for over two months where I had to be resuscitated eight times.

During my time in the hospital, I was coherent during a majority of my comatose state. I couldn’t talk, move, or communicate, but my senses were highly tuned into this environment because that is all I had to obtain information on my surroundings. Due to my concussion, I woke up in a hospital bed without any memory of what happened to me; my memory of everything before the day of the accident was perfectly intact. I depended on the people who came into to my room to understand what happened to me, what was going to happen to me, whether I would survive the next day, hour, or even minute. Time was absolutely precious, and each second was a gift that I never took for granted.

With a lot of support, I clawed my way back to the living. First blinking my eyelids, then squeezing a hand, I gradually emerged from my locked-in state and went on to make a full recovery three years later, which involved swimming on my college team and crossing the finish line in the 2007 Hawaii Ironman – the healing was finally complete.

My healthcare advocacy began as a way to say thank you to my care team that saved my life. As time went on, my story spread throughout the various levels and departments of the healthcare system.

When I share my story, I highlight the needs of the patient, the awareness and thought process, make recommendations, and offer input on communication strategies between the healthcare provider and patient, and also express my sincere gratitude for people who are in the healthcare field. With my background, it is so meaningful to have the opportunity to share my story and appreciation with caregivers because in my eyes these people are superheroes. I also know that the healthcare setting can affect the provider over time because they see a lot and experience so much with their patients, and it is always my goal to reignite that motivational flame that inspired them to pursue healthcare in the first place.

As a patient, life seems to go on standby when you enter this unfamiliar realm. You frequently come face to face with the strength of the human spirit and the perseverance of the mind and the body.  Throughout this entire ordeal, my parents and I experienced how unforgiving life can be and how it can drastically change in the blink of an eye. There was no guidebook or support group to prepare us for what we were in for as a family.

What I learned throughout my time in the hospital is that while I may have been the patient lying in the hospital bed, I was not the only one in that room who was suffering.  The observations that I made truly inspired me and helped me understand how important the role of communication is among the patient, family, and healthcare provider.

Every patient has a story and an experience, and I highly encourage healthcare providers to talk to their patients. As a patient, I was grateful for any interaction at all. I could sense the energy of the people who came into my room, by their tone, body language and movement. I could tell if they were having a good day or a bad day. I also liked when my medical team would explain what they were doing. I did not need to know all the advanced details, but just enough to know what was taking place and that they were taking care of me.

When I was able to learn how to talk again, I soon discovered that the power of the voice is amplified when the message is of gratitude, that a simple smile cannot be underestimated, and that body language and tone of voice are critical components within the hospital room.

To find out more about #smallthingsbigwins and how you can get involved, visit quality.bmj.com/smallthings or Tweet us @BMJQuality

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

If, like me, you believe in the power and importance of clinical teams running small scale quality improvement work, then you must find 15 minutes to watch this excellent and challenging presentation by Mary Dixon-Woods describing the evaluation of the Safer Clinical system project (the full written report is available here).  If you have limited time then I would watch the video rather than reading my blog below; however, I will expand on some of her points and disagree slightly with part of what she says.  The main message is that the impact of small groups of clinicians doing quality improvement (QI) work appears to be less than we might have hoped.

QI methodology does not solve all our problems

The key point that Mary Dixon-Woods makes is that quality improvement methodology (and here I mean the model for improvement, lean etc) cannot address all problems that healthcare faces, and I fully agree with this – although I would have disagreed if you’d asked me five years ago.  The table below summaries this; if you cannot measure something often (at least monthly) in an effective and reasonable way, then improvement methodology falls down.  Equally if you are looking at things that can only be addressed at institutional (ie national) level, then small groups of frontline clinicians and managers will not be able to influence this.  For example, making epidural catheters incompatible with intravenous catheters or standardising the production of kits to place central lines.

(Adapted from Paul Batalden’s “textbook” of QI)

If you are trying to improve the care of rare conditions or presentations of diseases then QI methodology is not going to help you, and you need to target your interventions to improving culture (which of course is extremely hard).  Whereas if you want it improve the quality and timeliness of discharge summaries, then QI methodology is perfect.  Between these two relative extremes lies a grey area where small scale clinical teams doing QI are not going to achieve improvement alone, but the more comprehensive, well funded improvement work will.  Mary Dixon-Woods gives the example of improving the timeliness of angioplasty for acute myocardial infarction.  This was a very well done quality improvement programme (although the cardiologists doing it might well not have called it that).  They followed the model for improvement: a clear aim, continuous measurement (which has carried on beyond the timescale of the initial interventions), and multiple PDSA cycles.  The big difference between this and most small scale QI work is funding.  Primary angioplasty required a whole infrastructure to be built around if with a completely new set of staff; think of all those additional cardiac nurses and hundreds of interventional cardiologists.  If sepsis (and in fact more specifically time to first antibiotic) had the same resources and used QI methodology then many more septic patients would get antibiotics sooner.

Small scale QI work as a tool for staff engagement

Working in systems that are inefficient and irritating has a negative impact on our ability to deliver safer care.  For me one of the key aspects of doing small scale quality improvement work is that it can straighten out some of the irritations and genuinely engage staff in their working environment.[1]  Even if their quality improvement work does not directly increase quality, its influence on staff morale ultimately will.[2] For this reason alone it is worth doing small scale quality improvement work.  We must try and develop systems that then go on to make these changes sustainable and last beyond the enthusiasm of the clinicians and mangers involved, but this is proving to be difficult.

Finding the problems

The one area I would disagree with Professor Dixon-Woods is in identifying the quality problems.  In the safer clinical system (SCS) programme a significant amount of time (five months) is spent analysing the current state of affairs to find out where the weaknesses lie, using techniques such as failure mode effect analysis (FMEA) and hierarchical task analysis (HTA).  These methods were used in response to the inability of incident investigations in health care to find the real underlying causes of failure.  On one hand these techniques do seem to find the real issues but I would strongly say that you don’t always need to do them.  In the South West of England we have been running a programme for five years where we get first year doctors to run structured supported quality improvement work, where they chose the areas of work that they feel are the least safe and most inefficient.  The list of projects they choose correlates extremely closely to the findings from the diagnostic phase of SCS.  So you don’t need to spend five months (and a lot of money) doing HTA and FMEA, you just need to ask your frontline staff what doesn’t work and is unsafe – they have the answers!  These methods do have their uses in healthcare but I do not think they need to be done routinely.

The road ahead

As a believer in quality improvement I found Mary Dixon-Woods video challenging, but this is no bad thing. It has helped me understand better the limits of small (and large) scale QI work and will hopefully allow me to be more refined in its application as the years go on and we continue with our never ending journey to improve the care we give our patients.

1. Bethune R, Soo E, Woodhead P, Van Hamel C, Watson J. Engaging all doctors in continuous quality improvement: a structured, supported programme for first-year doctors across a training deanery in England. BMJ Qual Saf 2013;22(8):613-7.
2. West M. Employer Engagement and NHS Performance. Kings Fund 2012.

Dr. Anita Jayadev is currently a respiratory registrar and QI training fellow with a passion for teaching. As well as supporting colleagues and students with QI initiatives, she enjoys leading QI projects, for which she has won several accolades including the HSJ Rising Star Award 2014.

Having spent part of my Darzi Fellowship training clinicians and medical students in developing and completing a quality improvement project, I’ve found that the most frequent concern is, “I don’t know how to start.”

A good place is to think about, “what drives you nuts?” Being frontline, we have a unique insight into the inefficiencies and potential safety issues for patients, from streamlining the way we order blood tests in clinic, to changing surgical equipment packs to reduce waste, or improving patient experience. It doesn’t matter how small the idea seems, the best projects are those that individuals have passion for and the ability to contribute to.

In fact, aside from passion there are a few useful tips to bear in mind when starting to think about your project:

1. Start with why:

Why do you think it’s a problem? It’s useful to have somebody else who is familiar with your department or who may know more about politics and processes to discuss your idea with before you decide it needs “fixing”. We often use the “5 Why” technique in our project surgeries to ensure that the individuals really understand what it is that needs improving. For example, is it a process problem or a people problem? How much influence will you have over either?

2. Think SMART:

Once you have decided on your project aim, make it SMART (specific, measurable, attainable, realistic, and timely). This is particularly important if you are only on a three or four month rotation; what can you realistically achieve in that time? Even if it is a project that is handed over between trainees as they rotate, it is still useful to define your own aim and contribution in this time. For example, “we will eliminate all pressure ulcers in the trust” may be the over-arching goal but, “to reach 50 continuous days with no pressure ulcers >grade 1 on Ward X by March 2015” may be more SMART.

3. Plan:

It may be useful to use a driver diagram to map out your project plan. I find it easier to understand what I need to do and in which order, but if you haven’t done one before it might be easier to agree this with other stakeholders. It helps decide priorities early!

4. Stakeholder mapping and engagement:

This is quite a useful exercise to do early on to try and limit potential obstacles along the way. The idea is to firstly identify your stakeholders, i.e. anybody that you need involved or who has an interest in your project. This will range from patients to healthcare assistance, pharmacists, executive directors, managers, supervising consultants etc. You can prioritise or map them out according to their level of power and interest. A quick internet search will reveal lots of advice about how you “manage” each category of stakeholder. Although I personally find the most useful part of this exercise is highlighting who I need to involve, common sense and instinct usually dictates the level of engagement needed.

The other useful thing about involving stakeholders early is that they often have helpful insights into what has worked, what hasn’t, and why. Usually we are not the first person that has come along and tried to improve a particular service, process, or experience. If you can understand context and expectations of those that your project may affect, it will help you appreciate and plan for unintended consequences. For example, introducing “quiet prescribing desks” to reduce medication errors made in busy environments may work. However, if we were no longer able to prescribe on the ward round will patients potentially have missed or delayed doses of medications? Speaking to stakeholders early might help you consider consequences that might not have occurred to you. It also gets the potentially “difficult people” onside early and you can use their experience and ideas.

It sounds like a lot to think about, but if the first steps are done right then you’re ready for the D in PDSA (plan/predict, do, study, act)! This is the fun bit, and actually nothing to be afraid of as it’s all trial and error! It doesn’t matter if it doesn’t work, just log it as a PDSA cycle; think about why it didn’t work (study) and then try a slightly different approach next time.

Given pressured clinical rotas, hectic and often unpredictable work environments with mounting commitments, finding the time to fit in what can seem like another “tick box” exercise can be stressful. It is perhaps more feasible and productive not to work in isolation. A project where a nurse, pharmacist, ward clerk, manager etc. is buddied up will be a lot less stressful and the project itself more sustainable. If you can find someone that shares the passion, it’s easier to keep the momentum going, coach each other, and help with data!