Archives 2015

Dr. Howell T Jones is an FY1 doctor at UCLH, an aspiring clinician-scientist with interests in medical education, clinical pharmacology, and general internal medicine. @howelltjones

Dr Ranu Malhi is a FY1 doctor at UCLH. A budding paediatrician, her interest in QI developed from being on the fast-paced world of acute medicine, where every minute counts.

“To improve is to change; to be perfect is to change often” – Winston Churchill

It’s hard to believe that we are now on our final rotation at UCLH. It feels like only yesterday that we were nervous FY1s with an impending sense of doom as we shadowed our predecessors. The clocks have changed and the days of arriving and leaving work in black and white have vanished; slowly but surely technicolour is creeping in. The change is scary but exciting. We are actually trading places on the acute medical unit, with Howell finishing a job in clinical pharmacology and Ranu embarking into the world of breast surgery.

As FY1s, we have learned to expect change every day – different bosses, different colleagues, different patients. There are always new tasks to undertake, new problems to overcome, and new things to learn. When it comes to change, we have experienced the good, the bad, and the downright ugly. Regardless of how overwhelmingly off course from the yellow brick road we felt along the way, one thing is for certain: we are better doctors because of it.

As comfortable as we have become over the last eight months, there are still times where we are reminded that we have a long way to go. As a junior doctor you often feel powerless to execute change yourself. Sometimes you feel as if you are just a small cog in a giant wheel of change that is rusty and stuck; a wheel crying out for oil like the Tin Man from “The Wizard of Oz”.

This rusty, unchangeable wheel is where quality improvement groups come in. Trying to make a change in an institution as big as UCLH is hard, but it would be even harder if we were to try it alone. Working together in our #UCLHQI group has been great as it provides us and other junior doctors with a time and place to come together to develop our teamwork, leadership and communication skills. It prevents burnout by giving us a forum with which to discuss any problems or difficult scenarios we have experienced in our quality improvement journey in a safe and supportive environment.

Balancing our QI project with our day job has been tricky at times, with tight deadlines and rate limiting steps up against gruelling night shifts, stacks of unavoidable paperwork, and TTAs. We consider ourselves lucky to have each other to help pick up the slack when work becomes hectic and all you wish for is a good night’s sleep. For anyone looking to undertake a QI project at their hospital, take it from us – don’t do it alone! Working together is fun; you can bounce ideas off each other, have some interesting debates, and have people to turn to when things aren’t going to plan. It makes your journey to the Emerald City that much easier.

Good teamwork is the oil helping you move easily towards your goal. Whether it is revolutionising medical notes, reducing confusion around blood tests, or the bright lights of the Emerald City, we all need a supportive hand at some point to make our goals achievable.
If you are thinking of trying to make a change in your hospital but are worried it won’t be successful, just remember, “Dreams that you dare to dream really do come true” (take it from us!).

For further advice and discussion around the benefits of junior doctor led quality improvement groups, check out the following: 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.

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

Aidan Fowler was a consultant colorectal surgeon in Gloucestershire for ten years before entering the NHS Leadership Academy Fast Track Executive Training Programme last year. Aidan is currently working as an executive at University Hospitals Bristol, trained as an Improvement Adviser with the IHI in Boston and was IA to the South West Safer Patient Programme. He currently works as faculty with the IHI particularly in the peri-operative safety domain.

When you talk to people in quality improvement, their journey often started with an event, an epiphany of sorts. So it was with my journey. I had been a colorectal consultant for several years when in 2007 C. diff became a really big problem. Here was a disease that we learned about at medical school as something of a piece of history that was once again causing morbidity and mortality, almost from nowhere.

I carried out a major operation for cancer on an elderly patient and then she came back for a stoma closure having done really well. This was supposed to be the minor bit. She had a single prophylactic dose of antibiotics and post operatively developed diarrhoea – you can almost see the rest of the story playing out: decision to perform a colectomy, worried and scared relatives, ITU placement and their feeling she would not survive surgery, deterioration and death. My initial reaction was to complain, point fingers, be angry – but what did that achieve? Typical of a surgeon you might say; my patient had died in “their” hospital because someone had not created a safe environment.

Then someone asked, “Why don’t you help?” We worked on antibiotic stewardship, hard fought, we cohorted, we used hydrogen peroxide atomisers, and the rate of C. diff fell dramatically. What had been the monthly rate became the annual rate and then fell further. We stopped doing colectomies as there was no need.
This was the power of QI. This was what happened when you moved up a level and looked at the bigger picture without ever forgetting each individual. No-one was thanking us for saving their life, they didn’t know we had, but this work had done exactly that.

What came next was a search for knowledge in the field, a spell with NHSII, and then finding the IHI and going through their Improvement Advisor Professional Development Course. This gave me the knowledge to apply to a large, multi-provider collaborative in the South West which achieved a significant reduction in HSMR for the region. There are many things one learns on a journey like this, but I am very struck by the shifting of the norms. As I contemplate a talk to a Scottish group in a meeting about out of hospital cardiac arrest (which is not at all an area I understand) and what I should say to them, I think this norm shifting is key.

So what do I mean? Well, we used to think central Line infection was an unavoidable norm, get used to it, it happens. Even so, for three months on the South West programme no acute provider in the region recorded one in their critical care unit. This stopped us from thinking that it just happens and started us thinking about how this should not and need not happen anymore; a dramatic culture change that meant our whole approach changed.

The safest hospitals in the world have huge knowledge, great and usually tenacious leadership, and values and vision. But they also have the ability to think in different ways and not let current reality get in the way of future possibility; the problems of today do not have to be the same tomorrow. Things we thought impossible a few years ago are happening now. Have the courage to challenge and think differently, and keep it simple – what do you want done to you and yours when experiencing healthcare. Now go and make that a reality for everyone.

Dr Aarthy Uthayakumar is a retired lacrosse player who now spends her time watching American TV box sets and seeing patients. She has a strong interest in medical education and hopes to specialise in dermatology.

Dr Samantha Greenfield is an English literature graduate turned medic. Currently a prehistoric FY1 at UCLH. She used to file x-rays for a living and continues to have interests in radiology and general medicine.

So the major planning stage had come to an end. Data sources had been identified, interventions envisaged. Attainable project scopes were firmly fenced off from the wilderness of unrealistic expectation by walls of hefty, unmanageable notes, cemented with reams of underfilled blood bottles. Armed with our new QIP understanding, we felt Quite Impressively Prepared; our PDSAs were Perfectly (Demonstrably) Super-Appropriate in our opinion, yes we felt truly SMART…if a little overloaded with acronyms.

The data gathering had begun, and so had a new phase of learning. This was the practical problem phase (PPP). Though able to take a patient list on MS Word from 0-60 in under 5 seconds, even our technical skillset was challenged by the complexities surrounding the creation of a trust-wide smartphone app. For the notes group, financial restrictions and economical sustainability were to become issues all too reminiscent of budgeting out those med school loans on gel pens and baked beans. Basic things such diplomatic allocation of tasks within the groups and communication between all members in sub-teams soon emerged as challenges in themselves.

One of the things we realised early on was that our quality improvement projects were less central to (and more-wholly-external-to) everyone else’s world. Surely as a diligent ward clerk, your job satisfaction is only heightened by additional workload in the name of hypothetical FY1-led quality improvement?! Yes, phlebotomy managers, you may now fulfil your actual purpose in life- the distribution of our illustrious questionnaire to your busy-but-no-doubt-wholly-appreciative staff.

Yes, the success of our proposed data-gathering and initial interventions would rely at least 99.9% on our abilities to sweet-talk our multidisciplinary team colleagues and key administrative staff. Many were reluctant to engage initially, and the challenge was convincing them to give up their time for a concept that would have no immediate positive impact. Unfortunately for them they were up against expert hasslers. Six months of exposure to acute radiology has given us first hand experience of the benefits of perseverance against all odds, and an XXL helping of enthusiasm to go with it.

So what if our eagerness for progress resulted in an early help-seeking email to our medical director, detailing the minutiae of our project over several pages? We learnt from it, and will strive for a conciseness more consistent with his succinct reply in future communications! We have been lucky enough to have a lot of senior support, and have so far enlisted the assistance of all needed.

One of the best things about being an FY1, excluding consultant-funded coffees and 20% off at Nandos, is the camaraderie of it all. There’s something about strutting assertively round this shiny, world-class hospital, while secretly having minimal clue about what you’re doing, that binds you all together. Working with friends has been enjoyable, but where passions run high there will inevitably be conflict. Ever mulled over the impossibility of having lengthy debates with your mates about the structural design of folders with secondary loss of sleep? In our experience this is not only possible, but unavoidable. At such testing times, we have had to work hard as a team to avoid descent into a PMQs-esque verbal fracas. We are all developing our skills in the art of compromise, learning to balance the communication of our own opinions with the importance of listening to others. After a challenging contest so far: Obstacle-itis: 0 vs heroic QIP doctors: 1.

The prognosis for our projects looks good, let’s hope the challenges remain surmountable. To be continued…

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

Dr Dominic Sparkes is an FY1 at UCLH with interests in infectious diseases and global health.

Dr Soo Yoon is an FY1 at UCLH with interests in anaesthetics and quality improvement. @_SooYoon

Our second session involved brainstorming ideas for improvements in the hospital. Immediately, a million ideas were flowing from all sides of the group.  It was almost overwhelming; some ideas were ambitious, perhaps too ambitious, and others more feasible. We structured 30 potential projects according to whether they would be generic or specific to junior doctors, patients, or certain specialties.

We thought choosing projects that would make change for many healthcare professionals would allow us to create the most change in our timeframe.

Simply, we wanted to change the world (or at least the world according to UCLH).  Much debate lead to two grand plans.  The first to revolutionise the medical notes system at UCLH to make it standardised across the tower.  The second was to improve the phlebotomy process to avoid wastage of both time and resources.

Before ploughing through the minefield of ideas, we had to decide who was doing what. We each volunteered to join a group we wanted to work in and split into a group of six (notes team) and another of seven (phlebotomy team) – simple.

For the notes team it was immediately apparent that we all wanted to standardise organisation and improve quality of medical notes across the tower. How many times have we been running around unable to locate the correct folder on a busy ward round that never waits for you? By chance, if we located the folder without much delay we were lucky if it didn’t fall apart as we lifted out of the trolley due its large size. It was clear that we all shared the same frustrations.

While we knew that we wanted folders which were clearly labelled and easy to find, we knew it was going to take a lot more than just physical folders to revolutionise the notes system across the entire hospital. What could we change to improve efficiency for all staff members to allow easy access to relevant up to date list of current and past medical problems while not compromising patient safety or confidentiality? Another important aspect concerned who was going to maintain standards of the notes on a daily basis. We realised for us to create a system that would facilitate a “UCLH way” of doing ward round, and that engaging the multidisciplinary team was key for progress.

Initially, the phlebotomy group had a discrepancy between what we wanted to achieve and what was realistic. Not only had we decided that we were going to improve accuracy, we were going to develop a database of screening tools (eg what goes into a “vasculitis screen” or “confusion screen”) develop a website and apps.

After some (mostly cordial) discussion, we decided that we would concentrate on information about blood bottles, eg what colour bottle and which lab for particular tests. This is something taken for granted by busy consultants and registrars who say, “I want an ACTH and cortisol tomorrow” without consideration of exactly what that entails. Often as an FY1 you find yourself in a position where you simply don’t know what bottle to use, and it can be a massive waste of time finding out. This is what we wanted to change.  However, our intervention had to wait.  We needed to do some groundwork to establish if this was a realistic project.  We needed to start pestering labs and scouring the intranet to find what information was out there and see if we could use it, and make it accessible.

The more we thought about it, the more two seemingly simple ideas had a lot of complexity beneath them. Like a QI iceberg; although the end solutions seemed simple, there was a lot of background baseline data to be gathered and lots of planning still to do. 

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

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.

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.