Archives March 2015

Dr Archana Depala is an FY1 at UCLH, interested in anaesthetics and intensive care medicine. @archanadepala

Dr Liam Watson is an aspiring sailor, oarsman, and Arsenal Fan. He is also an FY1 at UCLH…hoping to do paediatrics. @liampjw

Be it a reflection of naivety, or time spent avoiding the wards, medical school painted a picture of efficiency within hospitals. Patients were admitted unwell and everything worked towards getting them better in as smooth and quick a manner as possible.

This dream rapidly eroded, starting August 5th 2014. Images of FY1-led clinical decision-making were replaced with monotonous paperwork, inefficient processes, and archaic algorithms. We may have familiarised ourselves with the minutiae of the “cheese and onion” but we were largely unfamiliar with the practicalities of how to go about our day-to-day tasks. Remind me exactly how do I go about ordering a plasma metanephrines? If only you could advise a younger you that the advanced anatomy module wouldn’t be as clinically relevant as “The beginners guide to faxing”. Annoyance at not taking this course (and that it probably doesn’t exist – a definite hole in the curriculum) was initially faced in isolation and then discussed amongst junior doctors at the pub after work. Here lay the crux of the problem: these issues were the domains of the juniors, and if changes were to happen, we had to lead it.

Annoyance had to be turned to productivity.

As fate would have it, early on in our FY1 year we were invited to be a part of a quality improvement programme. Perhaps somewhat ignorantly, 13 of us signed up. We spent the first two weeks learning about what quality improvement was: that it was not just a synonym for “audit”, and so began sharing anecdotes detailing irksome inefficiencies within our jobs in a more mild mannered and printable format than previously. However, this was not just a therapeutic talking group. By the end of the meetings we would leave feeling empowered to do something about our frustrations in the hope that we could optimise our time and that of future FY1s.

Ideas ranged from changing the whole IT system, deemed “out of scope”… what little faith our seniors have in us. An awareness campaign against the stigma of drinking mochas, which (while applicable to life) may not necessarily be applicable to hospitals lacking high end coffee shops.

After heated debate, we narrowed them down to two realistic projects. Both were inherently simple but could have a greater hospital-wide effect, in keeping with the #smallthingsbigwins message. Take phlebotomy for example: a routine procedure, carried out throughout the hospital and involving different members of the multidisciplinary team. A small intervention optimising this has the potential to have a significant institutional impact with a positive effect on staff, patients and hopefully saving the hospital money.

Will our quality improvement project save the NHS? Hubris perhaps. Can we improve things for our colleagues in the future? Now that’s achievable.

If you have any ideas or tips to help our FY1 QI team please tweet us with #UCLHQI at @UCLHmeded and @BMJQuality.

Dr Ana Sofia da Silva is an FY1 at UCLH with interests in obstetrics and gynaecology and quality improvement.

Dr Kimberly Tagle is an FY1 at UCLH. She is an aspiring ophthalmologist interested in QI, medical education, and healthcare innovations.
@KimberlyTagleMD

It is difficult to believe that we are over half way through our first year as actual doctors; when they say time flies, they weren’t kidding. We have managed to hone the craft of writing a discharge summary, learned which wards are always fully stocked with blood culture bottles, and even picked up a few phrases that will ensure we get that CT scan before the end of the day.

The learning curve of FY1 has been steep but as that learning curve has begun to plateau, the inefficiencies in the system that prevent us from doing our job properly have become increasingly apparent. Imagine the frustration during on-call due to the amount of time wasted trying to find a set of notes, or that sinking feeling when the consultant asks for an ammonia level.

Ammonia? Where do I begin? Ask a friend? Call the lab? Or consult Dr Google? Twenty minutes later and you’ve finally worked out which bottle it goes in (it has a purple top by the way) and you then find out it’s meant to be in ice! Yes, I said ICE! Therein begins your hunt for ice across a 16-floor hospital. This highlights just one of the daily struggles of a junior doctor. The question is, how does one go about improving this?

When a very enthusiastic radiologist turns up to our FY1 teaching looking for volunteers to run some quality improvement projects, the first thought that came to mind was fantastic; here is our opportunity to actually make a change. So we decided to turn up to the first meeting, which was very enlightening. During this meeting, we heard that our colleagues were experiencing similar difficulties yet were also determined to make a change. The positive energy in the room made you want to get up and start working. We were ready to audit something, make a change, and re-audit it. Right? Wrong!

To undertake a quality improvement project you need to conduct PDSA cycles. Huh? Most of us had never heard of a PDSA cycle. PDSA stands for “Plan-Do-Study-Act”. In essence it means that rather than conducting an audit (where there is only one intervention performed), QI requires that there are a number of small incremental changes conducted over time in order to make a larger change. At each stage you measure and adjust the intervention to meet your aims, altering a little bit at each stage.

Before delving into this world of quality improvement, we were sent on a mission to come up with two projects that could be translated across our trust and involved multidisciplinary teams. Thinking hats were now firmly on!

Look out for more blogs from our FY1s coming very soon! If you have any ideas or tips to help our FY1 QI team please tweet us with #UCLHQI at @UCLHmeded and @BMJQuality.

Dr Fiona Pathiraja is a radiology registrar with interests in public health, health policy and clinical leadership. Follow her at @dr_fiona

“You have two jobs: doing your job and improving your job”

Junior doctors are the eyes and the ears of the NHS. We often see opportunities for change but don’t always get a chance to make that change. As a senior house officer I was told that I should wait to become a senior registrar before getting involved with management. Undeterred, I gained management skills by taking a year out to work as a healthcare management consultant and later working at the Department of Health as clinical advisor to Sir Bruce Keogh, NHS medical director.

I am keen to bring some of the skills I learned during that time to UCLH. Doctors are so keen to make changes at the beginning of their careers but we risk becoming jaded by the system over time. FY1 doctors have the potential to be the most enthusiastic change agents in the hospital. They haven’t had a chance to become jaded and believe they can change the world. Inspired and encouraged by Rob Bethune, I set up the UCLH FY1 QI programme to enable FY1 doctors to lead QI projects at UCLH.

I was looking for a group of perhaps six FY1s with whom to run the pilot. However, interest was so great that I accepted thirteen FY1s for the pilot. We have been meeting on Monday evenings and are using QI principles and project management skills to develop two exciting FY1-led QI projects. We recognise that not all change is an improvement but believe that our grassroots initiative might have a positive organisational impact.

BMJ Quality have a great platform to help support QI projects and their idea of #smallthingsbigwins resonated with me. I am struck by the energy and enthusiasm of the FY1 doctors who clearly love their work but are also keen to improve their jobs for the next cohort of FY1 doctors. Senior buy-in has been easy to obtain due to the supportive nature of our organisation. We have secured support from the medical director, director of medical education and the lead for the Foundation Programme at UCLH. Senior backing has been useful to gain traction on projects and to help overcome potential pitfalls and obstacles to quality improvement at the early stages of this programme.

Our FY1s will be writing blogs about their QI initiatives over the next few months and we look forward to sharing our journey with you. If you have any ideas or tips to help our FY1 QI team please tweet us with #UCLHQI at @UCLHmeded and @BMJQuality.

Bruce Gray is Improvement Lead for the Strategy and Transformation Team at Heart of England NHS Foundation Trust.

We’ve probably all heard people (and if we’re honest, ourselves too) begin a sentence using the phrase “with respect, blah blah etc etc”. That this usually happens halfway through a rapidly-heating debate gives the game away in that it’s usually a coded message that says the speaker is correct and the other person is wrong and/or an idiot.

It’s a challenge alright, but it’s not respectful! Why? Because it doesn’t need an Alan Turing to break this code; people get it. They understand that they are being spoken to in a dismissive manner, indeed a disrespectful manner, and they react consciously or unconsciously by shrinking away, or possibly by upping the ante – i.e. the debate becomes a full-blown-argument of the full half-hour variety.

So this respectful challenge is a tricky business. If I say, “with respect, blah blah etc etc” it could come across as patronising, rude and, well, disrespectful. So what is going on under the hood – just what are the mechanics of genuinely respectful challenge?

I’ve been thinking about this because I’ve been asked to deliver a couple of workshops to clinical and operational teams on “respectful challenge”. So writing this blog is a useful opportunity to organise my jigsaw of thoughts into a beautiful picture in which the individual pieces blend seamlessly into the whole…and, more prosaically, with a beginning, middle, and end, with enough material to last two hours.

The “beginning”…

For me this starts with having a model with which to make (some) sense of human behaviour and interactions, with my personal favourite being transactional analysis (TA). This specifically refers to the functional ego state model; the Parent-Adult-Child formulation that you may have heard of or come across. It goes like this:

In our “parent ego state”: feelings, thoughts, and behaviours swallowed whole from our significant carers when young and copied.  This can be further characterised as follows:

• Negative controlling adult (bossy, blaming, aggressive)
• Positive controlling adult (inspiring, directing, protecting)
• Negative nurturing adult (smothering, inconsistent, patronising)
• Positive nurturing adult (understanding, compassionate).

In our “adult ego state”: feelings, thoughts, and behaviours that are based on the here and now. We use our adult to reason, evaluate, gather information, and formulate strategies.

In our “child ego state”: feelings, thoughts, and behaviours learnt as children and replayed. This can be further characterised as follows:

• Negative adapted child (anxious, rebellious, submissive)
• Positive adapted child (social, polite, considerate)
• Negative free child (egocentric, reckless, selfish)
• Positive free child (creative, expressive, playful).

The idea here is that starting from one position can “hook” a response from its complementary position, where parent is complementary to child/child is complementary to parent, and adult is complementary to adult. So saying “with respect, blah blah” (i.e. patronising) risks hooking a response from the negative adapted child ego state ranging across anxious, rebellious, or submissive, depending on the relationship and context.

The real killer is that all this goes on out of awareness and in the blink of an eye – much of the time we don’t notice but our sub-conscious does and goes on to feed us the next line which ups the ante, e.g. “don’t you patronise me, with your superior ways blah blah etc etc”.

The way out of this nosedive is to disengage the autopilot and engage thinking, and the way to achieve that is to ask a question, which is an adult ego state thing to do, that will (hopefully, if you haven’t left it too late) ‘hook’ an adult ego state response. Et voila, we are now playing the ball not the man.

The “middle”…

The “OK Corral” is another concept from TA that is incredibly useful to overlay on the functional ego state model. The essence of this is that I can consider myself as OK or Not OK, and I can consider you as OK or not OK. So if:

• I’m OK, you’re not OK        One-up position (no respect for you).
• I’m not OK, you’re not OK        Hopeless position (no respect for you or me)
• I’m not OK, you’re OK        One-down position (no respect for me).
• I’m OK, you’re OK        Healthy position (mutual respect – adult-adult)

We are constantly “decoding” these positions unconsciously in ourselves and others, and it does affect our behaviours and interactions. In other words, do-as-you-would-be-done-by, and be authentic while doing it.

The “end”…

There’s a dual-meaning at work here; end as in what follows middle, and end as in means to an end. There’s a lot written in lean circles on respectful challenge that tracks back to the Toyota Production System. Jim Womack (co-author of ‘The Machine That Changed the World’ and ‘Lean Thinking’, as well as founder and senior advisor of the Lean Enterprise Institute) has written on Toyota and their practice of “respect for people”:

Managers begin by asking employees what the problem is with the way their work is currently being done. Next they challenge the employees’ answer and enter into a dialogue about what the real problem is. (It’s rarely the problem showing on the surface).

Then they ask what is causing this problem and enter into another dialogue about its root causes. (True dialogue requires the employees to gather evidence on the gemba – the place where value is being created — for joint evaluation).

Then they ask what should be done about the problem and ask employees why they have proposed one solution instead of another. (This generally requires considering a range of solutions and collecting more evidence).

Then they ask how they – manager and employees – will know when the problem has been solved, and engage one more time in dialogue on the best indicator.

Finally, after agreement is reached on the most appropriate measure of success, the employees set out to implement the solution.

…The manager challenges the employees every step of the way, asking for more thought, more facts, and more discussion, when the employees just want to implement their favoured solution.

Does all that challenging sound like respect for people? Jim thinks so because:

…I’ve come to realize that this problem solving process is actually the highest form of respect. The manager is saying to the employees that the manager can’t solve the problem alone, because the manager isn’t close enough to the problem to know the facts. He or she truly respects the employees’ knowledge and their dedication to finding the best answer.

But the employees can’t solve the problem alone either because they are often too close to the problem to see its context and they may refrain from asking tough questions about their own work. Only by showing mutual respect – each for the other and for each other’s role – is it possible to solve problems, make work more satisfying, and move organisational performance to a higher level.

And I think so too because it’s an approach completely congruent with the ‘adult-to-adult ego state’ and the ‘I’m OK, you’re OK’ position.

The (means to an) end…

Aviation safety work emphasises the flattening of hierarchy through the ability to speak up and be listened to as important factors in safely navigating high risk and crisis situations. Both of these factors are reinforced when people interact using adult-to-adult, OK-OK, respectful challenge behaviours.

But crises only happen occasionally, so focusing only on high risk and crisis situations misses the big prize of respectful challenge which is to make it part of daily practice, like Jim Womack describes above, because then it becomes an “in-the-muscle” thing that reinforces learning, change, and improvement because it follows the trajectory of:

Different thinking     –     Different behaviours     –     Different culture

Contrast this with the prevailing and static culture in many NHS organisations where, under the barrage of command and control, the default (and usually safest) response is to demur to hierarchy.

So, this is the story I will be telling in the forthcoming workshops; that understanding, practicing and expecting respectful challenge is of critical importance in the NHS of today and the future, because the practice is at the heart of meaningful learning, change and improvement.

Brian Boyle is a healthcare advocate, public speaker, and National Volunteer Spokesman of the American Red Cross. ironheartbrianboyle.com

In the second of this two-part blog, Brian Boyle describes his personal experience of being a patient, and thanks the healthcare professionals who improved the quality of his care.

When you are a patient in the hospital, I personally find that teamwork allows progress to take place. Everyone is in it together, and within the healthcare atmosphere the people around you become a new kind of support system. In a lot of ways, they even become a new family that understands the pain and frustration you feel. This family is not traced back through genetics, but rather through life experience.

I know that healthcare providers share their experiences with their patients, coworkers, faculty and staff, and also with their administration. They care for these people that they meet and work with on a daily basis. And with each day, through a smile or a handshake, a bond forms that develops into friendship, leading to a sense of teamwork and ultimately to a sense of accomplishment when various goals are achieved.

When you are in this atmosphere as a patient, you are depending on others to help you and assist you; to share in your triumphs and tragedies, to understand your background and beliefs, and to support you through various degrees of sickness and in health.

The power that healthcare providers have is extraordinary. On a daily basis they are not only caring for the health of their patients, but are also creating reasons to smile, making living conditions suitable and pleasant, and forming connections with their patients who not only need them, but depend on them.

At a very young age I found out what it really means to depend on others. At the age of 18, I wasn’t living the normal life of a high school graduate – instead I was pretty much reborn. I had to re-learn how to blink, move my fingers, talk, eat, tie my shoes, shower, and do everything in my own strength to live independently again, at least somewhat close to the way things used to be with a lot of help from those around me.

Within each person, whether said or not, the challenge remains an internal battle, conducted within our own private self, both for the patient and equally for the healthcare provider as well. Victory is measured in the smallest achievable increments, like blinking, or moving a finger, but most importantly, victory is being achieved no matter how big or small the achievement through the work that healthcare providers do.

I know that I’m not a doctor, nurse, physical therapist, or work in hospital administration. But my perspective is based on being a former intensive care patient and also a healthcare advocate. I have traveled the country and visited and spoke to dozens of medical groups, healthcare organizations, and state hospital associations. My knowledge is based on personal experience and I know that working in the field of healthcare can be a challenge sometimes because there are goals that have to be reached, and things that have to be financially managed and accounted for.

But when all is said and done, the impact that is being made is not just affecting numbers, it’s affecting people. And these people have backgrounds, they have families, and they have lives. That body on the hospital bed is a person, and it’s so important to remember this when the numbers and financial goals are being discussed in the media. Healthcare providers do not get the credit they truly deserve because what they are doing is saving these people, saving hopes for the future, saving families, and saving communities. And that is the result of their hard work, their expertise, and their dedication to what they do.

As a former patient who has been transferred throughout the many divisions of the healthcare system, I would like to say thank you to all healthcare providers for all that they do. When you work in the field of healthcare you are responsible for either bringing people back to life or making them comfortable for the rest of their life. Yes, some days are better than others, but every day is a great day when you help others in need – especially when they depend on you to not only live, but to enjoy life too.

This is a message of appreciation to healthcare providers, and in whichever part of the hospital that you work in: thank you for choosing this path in life, and for all that you do on a daily basis for your patients and their families.