Archives 2015

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!

Abhinav Bhatia is a year 13 student at Altrincham Grammar School for Boys in Manchester and an aspiring NHS doctor

In our last blog, Dr William Calvert wrote about the importance of teaching quality improvement in medical school. BMJ Quality recently received a quest to share a school student’s experience of a quality improvement project, and it has got us thinking – should quality improvement be taught even earlier? Here’s Abhinav Bhatia’s view.

I’m a year 13 student at Altrincham Grammar School for Boys in Manchester and I plan to be an NHS doctor in future. While working as a volunteer in a district general hospital, I conducted a survey on smoking among hospital staff and started to think about ways to urge hospital policy makers to provide a better support system for staff smokers.

There are lots of support systems for patients who want to stop smoking. I’ve read many quality improvement projects focused on this, but I was really surprised to see so many staff smoking during my hospital placement and I wondered if they were accessing those same services – perhaps as medical staff they felt less inclined to attend a session where they might see their patients? The need for an opportunistic promotion of health when a patient is admitted into an acute hospital was highlighted by Sarah Cousins, who designed a checklist clerking document to enquire into four life style risk factors, including smoking, alcohol, obesity, and physical activity, so that appropriate support can be offered.[1] Gary Bickerstaff in his recent Quality Improvement Reports publication entitled ‘Smoking cessation for hospital inpatients‘ introduced a pathway for identifying and supporting inpatient smokers. The key success factor was dependent on training large numbers of existing core healthcare staff to deliver an intermediate level of smoking intervention, rather than relying on a handful of “smoking nurses” to provide satellite services that leave a huge gap in opportunities outside their limited working hours.[2]

Despite the quality improvement pathways that are being put into place for inpatient smokers, NICE recommends that smoking cessation is actively promoted among hospital staff who smoke. This is particularly important if we are to promote the health of the nation as a whole, and support the government’s Tobacco Control Plan.[3,4]

I designed a one-page questionnaire for my survey with guidance from a consultant physician and advice from research and development. I conducted five-minute face-to-face interviews with 103 hospital staff, chosen at random to ensure that I had included most staff groups.

My survey showed that 14.6% of hospital staff currently smoked as compared to 20% in HSCIC statistics (published August 2014).[7] 24.3% of the participants were previous smokers, similar to HSCIC statistics (25%). Among current smokers, the non-clinical group (porters, security, domestics, catering staff, and volunteers) accounted for the highest percentage (46.7%), followed by nurses, health care assistants and other clinical (39.9%), then 6.7% administrative staff, 6.7% managerial and 0% doctors. None of the current smokers were in contact with hospital or community SSS.

46% of current smokers were non-clinical staff, followed by nearly 40% among nurses and other health care workers, as shown in other studies.[5,6] The latest national data (HSCIC) showed that the smoking rate was highest and rising among routine or manual workers (33%). My survey results are consistent with this, with a 35% current smoking rate among non-clinical staff such as porters, domestics, security staff, and caterers.

There is a need for an innovative approach with more proactive, friendly, and non- judgmental methods to identify and target those vulnerable staff groups who may find it intimidating to contact or attend hospital SSS. As many frontline clinical staff should be trained to provide brief interventions (5-10 minutes), making it more accessible to fellow staff smokers in all work areas, at all times. Those who decline referral should be offered prescription for licensed nicotine-containing products by trained health personnel within their work areas, along with other support advice. I’ve discussed these findings with my consultant supervisor, and I know that by engaging stakeholders by sharing my data and highlighting the NICE guidance, this is the beginnings of a quality improvement project.

Hospital policy makers need to do more to promote the health of more vulnerable hospital staff. It seems hypocritical not to do this in an environment that otherwise promotes health for patients themselves. Perhaps it is now time to include issues relating to staff health such as smoking, alcohol, and obesity in mandatory hospital training programs. I’ve shared my data with the hospital and I’m hoping that the next steps will be implementing some of my suggestions. It just proves that even before medical school, if you’re pro-active enough and understand the principles of quality improvement, then you really can start early!

Got some thoughts on this that you want to share? Join the conversation by tweeting @BMJQuality or visiting quality.bmj.com/smallthings

References:

1. Sarah Cousins. Checklist clerking document improves health promotion among medical admissions. BMJ Quality Improvement Reports 2013; u202209.w1218 doi: 10.1136/bmjquality.u202209.w1218
2. Gary Bickerstaffe. Smoking cessation for hospital inpatients. BMJ Quality Improvement Programme. BMJ Qual Improv Report 2014;3: doi:10.1136/bmjquality.u204964.w2110
3. NICE Public Health Guideline PH5. Workplace interventions to promote smoking cessation. May 2007.
4. NICE Public Health Guideline PH48. Smoking Cessation, Acute, Maternity & Mental Health Services. 2014.
5. Davies PDO, Rajan K. Attitudes to smoking and smoking habit among the staff of a hospital. Thorax 1989; 44:378-81.
6. Hussain SF, Tjeder-Burton S, Campbell I A, Davies PDO. Attitudes to smoking and smoking habit among the staff of a hospital. Thorax 1993; 48:174-5.
7. Health and Social Care Information Centre. Statistics on Smoking, England 2014. www.hscic.gov.uk/pubs/smoking14
8. Bloor RN, Meeson L, Crome IB. The effects of a non-smoking policy on nursing staff smoking behaviour and attitudes in a psychiatric hospital. J Psychiatr Ment Health Nurs 2006 Apr;13(2):188-96.

Declaration of competing interest:

“We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.”

Acknowledgement:

Dr M. Aziz. Consultant Chest Physician. Tameside General Hospital, UK

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 quality.bmj.com/smallthings

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 quality@bmj.com or use @BMJQuality and send us your ideas with #smallthingsbigwins.

To get your project started today, go to quality.bmj.com.