Category Opinion

Angelika Zarkali is a core medical trainee in Health Education East of England. She is currently an FMLM national medical director’s clinical fellow at NHS England. She believes that clinicians should be the force of change and improvement in healthcare and is keen to share her experience in quality improvement.

Over the last few years, quality improvement has started to replace traditional audit in junior doctors’ training and curriculum. This was fuelled by evidence that most audits fail to deliver improvements in healthcare, with only 12% of doctors reauditing[1] and only 5% of doctors felt that their audits led to a change in clinical practice.[2] This means that doctors have more recently moved away from the traditional, unsuccessful model of tick-box exercise audits and on to quality improvement projects.

The Royal College of Physicians initiative “Learning to Make a Difference” introduced quality improvement projects to core medical trainees (CMT) in 2011 and was met with great enthusiasm. Sixty-four trainees completed 34 projects in the first pilot year.[3] All participants reported that running a quality improvement project was a valuable experience and 85% thought that they had made a difference in patient care with their projects.[3] Three years later in August 2014, quality improvement officially replaced audit in the CMT curriculum.

Similar changes are yet to happen in other specialties but there is growing awareness of the value and necessity of quality improvement among trainees. Many independent initiatives, such as BMJ Quality, the Network4, and the Institute for Healthcare Improvement[5] are growing in popularity among trainees. The Network, which was set up in 2010 by a group of junior doctors, has now reached 2883 members.[4]  At the same time, more and more conferences dedicated to quality improvement are organised, such as Agents for Change, FMLM Regional Conferences, the Network Quality Improvement conference, are all well attended by trainees.

Quality Improvement has finally become fully integrated into junior doctor’s work and training. But will this positive trend for quality improvement continue in the future?

NHS England recently published The 5 Year Forward View,[6] which sets the vision for the future of the NHS. It describes a healthcare system that is facing major challenges and needs to change and evolve in order to meet these. It describes a NHS that focuses on prevention and integrated locally provided care, a system that strives for excellence along with rapidly translated research and innovation in clinical practice.

In working towards this vision, quality improvement can be a major lever for change. The 5 Year Forward View emphasises that “one size does not fit all.” Local initiatives are necessary to instigate change that is sustainable and these initiatives should be led by clinicians. The need for medical leadership is highlighted in the report with a pledge to “review and refocus the work of the NHS Leadership Academy and NHS Improving Quality.” Trainees should share this load with more senior clinicians and lead quality improvement in their hospitals. Junior doctors are ideally placed at the coalface, working around the clock to recognise areas where improvement is needed.

In addition, the report describes the need for innovation and investment in research, but one that moves away from distant, traditional models into translational research, which has a practical implication to patient care and can be easily incorporated into clinical practice.

Quality improvement projects are an ideal example of work that directly improves outcomes for patients, is led by clinicians, and is tailored to local clinical practice. Quality improvement is in perfect accordance with the ambitions defined in the 5 Year Forward View and the publication of this report is an opportunity and a challenge to all of us to fully integrate quality improvement to our work.

Health Education England, the medical colleges, hospitals, and GP practices should rise to this challenge and support junior doctors and allied health care professionals to lead and participate in quality improvement projects.

But it is also up to us as junior doctors to become leaders and improve quality of care for our patients. If you are in search of inspiration for your next quality improvement project, take a look at the five year ambitions for dementia, cancer and mental health, as described in the 5 Year Forward View!

References:

1. Greenwood JP1, Lindsay SJ, Batin PD, Robinson MB, Junior doctors and clinical audit. J R Coll Physicians Lond 1997 Nov-Dec;31(6):648-51.
2. John CM, Mathew DE, Gnanalingham MG. An audit of paediatric audits. Arch Dis Child 2004;89:1128-9
3. Vaux E., Went S., Norris M., Ingham J. Learning to make a difference: Introducing quality improvement methods to core medical trainees. Clin Med 2012 Dec;12(6):520-5.
4. The Network: http://the-network.org.uk/
5. The Institute for Healthcare Improvement: http://www.ihi.org
6. NHS England, Public Health England, Monitor, Care Quality Commission, Health Education England. Five year forward view. Oct 2014. www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

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

Rob Bethune is a surgical registrar in the Severn Deanery. He was a founding board member of The Network (www.the-network.org.uk ) an on-line social media site for healthcare professionals wanting to share their learning and connect with other quality improvers around the world. He has been involved in a regional wide programme facilitating junior doctors to run quality improvement projects.

 This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

I have to put my hand in the air and say ‘I’m guilty.’ I, like many doctors, never really reported safety incidents in hospital, and the reason why I did not do this is complex. I am a huge believer in improving quality and safety and have spent almost all of my non-surgical time over the last 10 years working on programmes to reduce safety incidents and improve quality. So why did I not report safety incidents in my own clinical practice? I think I just went along with the prevailing culture: ‘it’s too hard’, ‘the forms take ages’, ‘nothing will ever happen as a result so there’s no point doing it.’ I just accepted these as truths and since I had a clear avenue (via quality improvement) to change the systems around me I never challenged those assumptions, until now.

So what has changed me? I read a book. Not a patient safety book, but a book about the airline safety system. If you are interested, it’s called Close Calls, by Carl Macrae (Palgrave Macmillan – you can read a sample chapter by clicking here). He spent three years with airline safety investigators really trying to understand what they do and how they do it. Here are some thoughts on the main messages I got from his book as we look towards developing the same system in healthcare:

1) The judgement of safety investigators is not directed at the specific crews in question, nor is there any individual blame. Investigators’ concerns are related to how the incident happened, and most specifically on how the systems can be improved to reduce the chance of it happening again. This ‘no blame’ culture goes even further in a statement signed by the airlines chief executive stating: ‘that investigations are to focus on learning and improving safety. No staff will be considered culpable, or will be punished, for errors or mistakes made within accepted professional conduct and that are appropriately reported’. Basically, if you’re not negligent then you will not be blamed or held accountable. Are we anywhere near that in healthcare?

2) Airline safety investigators are almost all drawn from either current or previous frontline line workers. To work as an airline safety investigator you need experience of analysis as well as knowing what gets done on the frontline. During their investigations they often refer to their own previous firsthand experience, and think: ‘I’ve done that.’ I think we do have this in healthcare too, since investigations are normally carried out by a clinician as well as a safety investigator.

3) Although they have a formal process of reporting incidents and near misses, there is also an informal system so that anyone can contact the safety investigators with more ‘feelings’ that something is not quite right. The investigators can’t do much with one report but if they start getting a multitude of ‘feelings’ then they will take action. As I say below, the reporting system in the hospital I work in does actually allow this.

4) They communicate clearly, publically, and across the industry. Flight safety investigators only significant influence is to report internally and publically the incidents. They do this in a variety of ways. On a weekly basis they report to senior management a brief summary of incidents. On an operationally useful side, they produce a monthly newsletter for all frontline staff and a more formal quarterly magazine focusing on practical safety issues. After the crash on the Hudson River, the formal report had been published online and was freely available to anyone to view (click here to see it, it makes for interesting reading). To the best of my memory I have only ever seen three reports of patient safety incidents in my 13 years of clinical practice.

5) They accept the inevitability of accidents; there are no ‘never’ events. Failure and error are inevitable features of organisational activity, and though such incidents are largely manageable, they are ultimately ineradicable. The airline industry works constantly to try and prevent them, and this perceived inevitability makes safety investigators continually attentive and worried. This is James Reason’s ‘constant sense of unease’.

6) Their work is totally dependent on incident and near miss reports. The reporting of incidents allows investigators to see what is really going on and keep in touch with the frontline. Without these reports their job would be impossible. They get very nervous when reporting starts to drop off. Is it because the frontline is losing the faith in the safety systems? You need staff to be totally happy in reporting mistakes and errors, both because they will not get in any trouble and also because something will be done to make it better. As Carl says, ‘the engine that drives safety is events.’

It’s this last point that has changed my attitude to reporting. The airline safety system is totally dependent on frontline staff putting in incident and near miss reports. Theirs has been a journey of moving from crash investigation (which they did from the beginning when there were lots of crashes) to a system that analyzes near and not so near misses.

As a result of all this, I’ve now started reporting any ‘unsafe things’ – the near misses as I have seen them. From the more serious (unfilled posts when the locum SHO did not turn up) down to the absence of marker pens on the pre-op admission ward. It may not sound like much, but this is a significant patient safety issue. I had to search around another ward to find this missing marker, but could I have just used a biro if I’d been more pressed for time? This has happened before in a hospital I worked at and actually led to an operation on the wrong lung!

So how about my initial fears. It was really easy to fill the forms out on the computer system, took hardly any time, and even had a box for free text. I got an automated reply thanking me after I’d submitted. I then emailed after a couple of weeks to find out what was happening, asking to see if I could spend some time looking at how the incident forms where handled. I was waiting for the reply and any more information about what has happened. However, it is over two months now and I am still waiting.

Perhaps my fears were well founded, I will let you know.

If you are working to improve quality in healthcare, you may wish to submit your work to BMJ Quality Improvement Reports. To find out how, go to quality.bmj.com.

As the ‘Integration Pioneers’ get off the ground, Jules Acton, director of engagement & membership, at charity coalition National Voices, explains why many patient groups are optimistic about real progress. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

If you ask people with long-term conditions about the changes they want to see in health and social care, most say: care and treatment that is coordinated around us.

A glance at National Voices’ ‘webs of care’ shows immediately why this call is so strong. The ‘webs’ were drawn up by people who use services, and their families, to demonstrate the tangle of contacts they are trying to navigate. This lack of coordination leads to stress, repetition, waste and, at times, can also threaten people’s safety.

But, of course, coordination in our vast and varied systems of health and social care isn’t straightforward. This is why, at National Voices, we were so pleased about the government announcements on ‘Integration Pioneers’: 14 local areas which could herald a new era in person-centred care.

Before the more initiative-weary of you tune out, I’d urge you to stay with me for a few minutes. There are some important aspects to the Integration Pioneers, which could propel them to success and enable them to bring about real, big and positive change.

For a start, this isn’t only about the 14 chosen Pioneers. There were a huge number of applications for the Pioneers programme – more than 100 – from two thirds of our local areas. That means over 100 different localities, each with multiple organisations, showing a will to work across boundaries: across health and social care; primary and secondary care and all the other points where patients fall through gaps. It indicates an energy for care coordination and a belief in a new way forward. And this energy is coming from the ground up, where it really matters. So, while the government support is important, this drive is less about responding to diktats from on high, but about teams of professionals seeing the Pioneers programme as an opportunity to push out the boat. And, while not all of the areas that applied could become official ‘Pioneers’, that doesn’t mean they can’t also drive forward themselves, share the learning and add to the momentum.

Another cause for optimism is that most of the above have shown a will to work towards a common vision, developed with people who use the services. This is based on the Narrative for Person-Centred Coordinated Care. This is truly significant, because ‘integrated care’ has been interpreted in a great many different ways in the past. As the Health & Social Care Act came into being there were at least 175 different definitions floating around in the ether.

In response to this confusion, NHS England commissioned National Voices to work with people who use services as well as professionals, to develop a vision we could all sign up to. This has happened. It was published in May as part of a common purpose framework to which the Department of Health, NHS England, the Local Government Association, Monitor and all the other national system leading organisations committed. And it aligns strongly ‘Making it Real’  a key personalisation initiative by TLAP. The Narrative redefines ‘integrated care’ as person-centred coordinated care, which, to the service user, means:

“I can plan my care with people who work together to understand me and my carer(s),
allow me control, and bring together services to achieve the outcomes important to me.”

It goes on to offer context in the form of more ‘I statements’ which describe, in detail, what coordinated care looks and feels like to people who use services.

So we have a common vision, we have momentum and we are optimistic. But we aren’t starry eyed. Person centred coordinated care won’t happen overnight, and certainly not across the whole country. The new programmes need time to grow and adapt. Their teams won’t get everything right first time. And this is fine as long as they are able to move on from mistakes and share the learning.

This is where the government comes back in. To nurture coordinated care and ensure the success of the new programmes, our government now needs to learn to sit back, be supportive but resist the urge to dabble, interfere and chuck in new, competing initiatives. As the election looms we hope all political parties will show maturity around this, with their manifestos underpinning solid progress towards person-centred care, rather than revolution and upheaval.

At National Voices we will be championing this need to nurture and not to keep on overhauling. We’ll also be leading work on some extra materials to support coordinated care, such as a toolkit for care and support planning. If you’d like to receive newsletter updates on these then let me know on jules.acton@nationalvoices.org.uk or @JulesActon. And if you are involved in coordinated care programmes, please let us know about your progress so we can help share the learning. We look forward to hearing from you.

Rob Bethune

Rob Bethune is a surgical registrar in the Severn Deanery. He was a founding board member of The Network (www.the-network.org.uk ) an on-line social media site for healthcare professionals wanting to share their learning and connect with other quality improvers around the world. He has been involved in a regional wide programme facilitating junior doctors to run quality improvement projects. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

Effecting change as a junior doctor with little time, power and influence can be daunting.  However there are ways of working through those difficulties.  In this article I describe a few pointers that have helped junior doctors facilitate real change.

Establish a team and allow time

This is crucial, you cannot do this alone.  Most of us do 4 or 6 month placements and this often not enough time to run a successful project and embed the changes, so develop a team of 6-10 people who will rotate through the clinical area throughout the year.  As we shall see continuously collecting small samples of data is crucial to quality improvement (QI) and practically you need a group to collect this. Working in a team also makes it fun and gives you opportunities to bounce ideas of each other.

Get help

Ideally you want to find a permanent member of staff to mentor your project who has experience of QI and has spare time to meet with you and your team.  In practice this is difficult unless you are in one of the few hospitals that has formal QI programmes for juniors.  The BMJ Quality programme  has a system of virtual mentors who can give QI advice.  It also walks you through running a QI project and there are many previous examples on the open access on-line journal. Before you start your project you really must search this journal to see if others have run similar projects elsewhere and learn from them; try not to reinvent the wheel, let alone reinventing the flat tyre.

Use the Model for Improvement

This is the key.  Clinical audit run by junior doctors has been overwhelmingly unsuccessful^1-3. There are a multitude of tools for improving quality of systems (Lean and Six Sigma are examples) but the most tried and tested model for frontline clinical care is The Model for Improvement

It consists of three steps that are outlined below; set an aim, measure progress and make changes.  The BMJ quality site has a lot more information and there are also a series of short videos on The Network YouTube site that explain the underlying methodology.

Aim: What is it you want to improve?  It is really important to carefully define exactly what you are trying to improve.  Make your aim SMART (Specific, measurable, assignable, realistic and time limited ).  An example of this would be ‘Ensuring that by March 2014 95% of discharge summaries from the medical admission unit reach the GP within 24hrs’.  Getting the aim right can be surprisingly difficult and may well change as you develop a deeper understanding of the system you are analysing. It is tempting to say ‘we want to improve discharge summaries’ but the lack of detail will make the next steps impossible.

Measure: ‘Data, data, data’ goes the drumbeat of a quality improvement project.  Without out it you will not be able to see if your changes are an improvement. But more importantly during the process of collecting good data you will develop a deeper understanding of the system you are trying to improve. We often oversimplify problems and think that solutions are obvious.  These simple solutions often fail as we don’t really understand the system we are dealing with.  The very action of measuring a system gives us much more detailed understanding.

Then display the data using a run chart (see chart below).  Collect small samples of data (10 each time is a good number) and do it as often as feasibly possible.  Try and collect 10 sets of data before you start test of change, this will allow you to get a baseline and see if changes really are an improvement.

The plan-do-study-act-cycle (PDSA)

Now you have your background data collection and a more profound understanding of the system you are ready to make some changes.  These are done in the form of PDSA cycles.  It is a simple and intuitive as it sounds; come up with a plan, trial it out on one day, study the effect and act upon the result.  One of the keys is to trial the change over a short time period in one area. If it works you can spread it but if it does not work and needs refining then you can do that easily.  If you implement your idea widely from the beginning (as we have seen so often in healthcare) and you get it wrong it is expensive both on terms of time and resources to undo it.  Make your first tests small.  You can label you PDSA cycles on your run chart as in the example graph. Almost always multiple tests of change are needed , rather than just one intervention – this might explain why audit failed.

Publish

If you have run a QI project and improved care and equally importantly if your interventions did not work then you must share this with the wider healthcare community.  The BMJ quality improvement journal is the perfect place to do this.  Provided you have used the above methodology and have created a coherent story of change that others can adapt and translate elsewhere your project will be published.

It’s up to you

Improving the systems we work in is crucial to improving the care we give to our patients.  As junior doctors we are in a unique position to see the problems in the delivery of frontline healthcare and affect the solutions.  No-one else is going to do this, therefore do not send to know for whom the bell tolls, it tolls for thee.

References

1. Greenwood JP, Lindsay SJ, Batin PD, Robinson MB. Junior doctors and clinical audit. J R Coll Physicians Lond 1997;31(6):648-51.

2. Guryel E, Acton K, Patel S. Auditing orthopaedic audit. Ann R Coll Surg Engl 2008;90(8):675-8.

3. Hillman T, Roueche A. Clincal audit is dead, long live quality improvement. BMJ Careers 2011  http://careers.bmj.com/careers/advice/view-article.html?id=20002524.

Dr Marc Wittenberg

Dr Marc Wittenberg gives us a personal view of what Quality Improvement is, ending with some top tips for those interested in starting a project. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

I have recently, albeit temporarily, taken the leap from full-time clinical medicine, into a world of strategy, policy and thinking on a completely different level, and one which is not normally evident to a jobbing senior anaesthetic registrar. As one of the National Medical Director’s Clinical Fellows, I have joined the BMJ and NHS England on a one year secondment and will be spending a significant proportion of my time with the BMJ Quality team.

Prior to starting this post, my days (and nights) were filled with talk of service, examinations, audit, CV improvement, recounting individual clinical tales and the, occasionally dark, humour and banter that enables a hospital to churn on despite the challenges that face us. In sharp contrast, the conversation is now dominated by the latest concepts in Quality Improvement (QI), project management and change management.

Why so different? Well, it is actually not, but I now feel that I have the luxury to step back and look at the picture from a different perspective.

To illustrate this, I had an experience that made me realise that all it takes is a small adjustment in thinking: I still do the occasional shift in hospital in my own time to keep my feet on the ground, and one recent weekend, I was sitting in the intensive care unit coffee room, chatting with a consultant. He happened to remark that one of the trainee doctors had gone off to insert a central venous line into one of the patients, but had been gone a rather long time.

On his return, the consultant asked the trainee why it had taken him so long. He bashfully admitted that the actual procedure had not taken more than 15 minutes but that it was all the other tasks: finding the kit in the store-room, forgetting something then walking back up the corridor, having to ask the busy nurse to fetch something and having to rely on his memory to make sure all the items that he needed were there. “Wouldn’t it be great,” the consultant mused, “if we had a rapid access central line box, ready to go in the store-room?”. And there the conversation was left.

A few minutes later, it struck me that what the consultant was describing was Quality Improvement in its most usable form: they had identified a problem and a solution but had not yet made the connection between the two. It is all about the mindset, the shift from evidence-based medicine and audit where we now know what we should be doing, to guaranteeing that we are doing things right. This transition to the making the science of QI an everyday part of all healthcare workers’ lives is relatively new and sometimes requires its relevance to be realised.

For me, it was only through making the leap that I have done to realise the importance of QI to good patient care and it is vital that the message is spread: it does not just apply to large system changes or transformations, but QI is at its best at the coalface through often simple, usually cheap, and relevant projects that can make a big difference.

Through learning the relevant improvement skills and tools, all clinicians can, and should, be able to engage in Quality Improvement to ultimately improvement patient care.

So, here are my 5 top tips for quality improvement:

1. Make the link: the ideas for QI projects often come from either things that you have noticed at work that you would like to change, or situations where someone’s answer to your question of ‘why do you do it like that?’ is ‘because that’s how we have always done it’.
2. Keep it simple: often, the most effective QI projects are the simplest and cheapest.
3. Get a mentor: think about who this should be – it could be a colleague, a supervisor or even someone that you have never worked with before.
4. Keep talking: work out who is important to the success of your project and get in contact early, preferably in person. Buying someone a coffee never hurts!
5. Publicise it: once you put the work in, get the message out in whatever you can. You will undoubtedly inspire other people and people will appreciate the hard graft that you have put in.

Mareeni Raymond, GP and Clinical Advisor for BMJ Quality

It has been six months since BMJ Quality officially launched, and already we have published some amazing work at BMJ Quality Improvement Reports. Managing Editor, Mareeni Raymond, describes some of the highlights.

We started off by launching the junior doctor’s programme and have been hugely impressed with the projects that these doctors have organised and implemented. Since then, we have published work in specialties as varied as palliative care, orthopaedics, surgery, education, medicine, A&E, and more.

There are so many occasions in hospital where things can go wrong because guidance isn’t readily available or knowledge is lacking, and junior doctors are often on the sharp end. A lot of great projects introducing adaptations to handover sheets or proformas have demonstrated improvements, including this one ‘Using a proforma to improve standards of documentation of an orthopaedic post-take ward round’ and ‘Post-acute surgical ward round proforma improves documentation’.

The transition between primary and secondary care is fraught with difficulties- the postal service, the lack of clear coding, inadequate discharge summaries – all identified in many projects. In ‘Improving transmission rates of electronic discharge summaries to GPs’ transmission rates of Discharge Summaries within 24 hours of patient discharge increased from 9% to an incredible 76% post intervention.

Handover is a popular topic, and if you type in “handover” into our search bar at qir.bmj.com we currently have eight projects on the subject. Which do you think is the most cost-effective? A steady stream of small projects based on simple interventions such as these are being published and we look forward to teams reading existing projects and adapting them to create amalgamations of the most effective interventions.

We’ve been impressed with larger scale projects too, such as one team’s care plan to reduce falls. The inpatient falls rate, re-audited at one year, was 12.44 falls / 1000 patient bed days, a 15.4% reduction following introduction of a bundle of interventions such as posters, guidelines being introduced and education.  With clinical commissioning groups under pressure to create long-term solutions for improving care in areas such as these, we look forward to more large scale projects publishing their work.

In tertiary care, a fantastic project to reduce admissions of patients with diabetic foot complications resulted in the average antibiotic prescribing costs for a 3 week course of treatment reducing from £17.12 to £16.42.  Projects demonstrating both clinical improvement and cost-effectiveness are our one of our favourites – keep them coming! And the team also love to read about interventions which are delivering the highest goal – patient preference, and the improved patient journey. A palliative care service improved the rate of preferred place of death resulting in one third of patients dying at home – nearly double the proportion that died at home in the baseline audit. Seventy one per cent of patients who wished to die at home actually died at home – a substantial increase from 31% at baseline. Achievement of preferred place of death for patients wishing to die in the hospice remained high at 88%. Definitely worth reading for ideas in your unit.

It can sometimes feel like quality improvement is only about following the right pathway – this is not so. One psychiatric unit reduced violence and aggression by taking clients to a local zoo an interesting idea and the basis for further discussion. Another psychiatry team recognised the lack of cardiovascular health monitoring for patients with psychiatric illness, highlighted in their excellent project which poses solutions and again, ideas for discussion on what is frankly, a controversial subject.

All in all, our first six months has resulted in some excellent work, food for thought, and many inspiring ideas. We are really pleased to be helping doctors from all over the world to publish their quality improvement work and will continue in this vein to help encourage a global discussion on quality at every level. Lots more projects coming and lots more we haven’t mentioned here: go to Quality Improvement Reports, comment on work, and start the debate!

Rocking the boat and staying in it: how to succeed as a radical in healthcare

Part 2: Start by improving myself

Helen Bevan blogs about topics related to improvement, innovation and change on a big scale. Helen works as part of the Delivery Team of NHS Improving Quality, @NHSIQ, the national improvement team for the NHS in England. All views are her own. Follow her on Twitter @HelenBevan.

Yesterday, I was clever so I wanted to change the world.

Today, I am wise so I am changing myself

Anon via Twitter

A lot of people responded to my last blog which was an introduction to tactics for thriving and surviving as a healthcare radical. Four things struck me about that response:

1. There are a lot of radicals/rebels out there in the healthcare system; passionate people who support the patient-centred goals of healthcare organisations, who are willing to take responsibility for change but who question and challenge the current ways of going about change
2. “Radical” status isn’t related to hierarchy or position and we don’t have to work in the NHS to qualify as a healthcare radical. A wide variety of people responded to the blog; this included radical patient leaders  and radical Chief Executives
3. We have to find ways to unite and mobilise this radical community; this is a latent and potentially powerful reservoir of energy for change
4. We must help healthcare leaders to understand the difference between a radical/rebel and a troublemaker (or good rebel/bad rebel) and exploit the talents of that radical/rebel community for the greater good

As I trailed in the last blog, I’m going to discuss four of the key tactics for healthcare radicals in more depth over the next few weeks. The first of these tactics is start by improving myself.

As a change agent, I frequently look at the world around me and identify things that need improving. If we are to deliver safe, high quality care to every patient and to make the most of our precious healthcare resources, we need to continuously improve processes and systems of care. Yes, this is really important, but as healthcare radicals we have to start at an earlier point in the foodchain of improvement. To quote Aldous Huxley: “There’s only one corner of the universe you can be certain of improving, and that’s your own self.” So before I am tempted to launch into a massive effort to influence other people change the way they think or do things, I have to start by reflecting on and changing myself. I have to understand myself, because the person who will be the hardest for me to lead through change is me. I’m always inspired by the work of David Whyte who is a corporate poet. He understands this completely when he says: “I do not think you can really deal with change without a person asking real questions about who they are and how they belong in the world.’ (The Heart Aroused 1994)

I am writing this blog in the week after the publication of Don Berwick’s recommendations to improve the safety of patients in England: “A promise to learn – a commitment to act” so I thought I might use the Berwick report to illustrate some of the points I want to make about healthcare radicals. Like so many leaders of improvement in the English National Health Service, I am thrilled to see these recommendations, which are a compelling call to action for change, based on evidence, to make the English NHS the safest system for patients in the world. As Paul Batalden said in a response to the earlier report of the Francis inquiry, healthcare is at the same time a “simple, complicated and complex” phenomenon. Some of the commentators who have criticised the Berwick report wanted to see more “hard edged” recommendations related to mechanisms for enforcement or regulation, checklists, minimum standards and/or behavioural incentive systems. My response is that many of the solutions that these commentators seek are “simple” solutions which are not, on their own, reliable levers for change in a highly complex world.  Experience shows us how these simple solutions can push the system in a certain direction, distort priorities and often (unintentionally) create the opposite effect to the changes we are seeking. The gift of the Berwick recommendations is that they offer us a starting point for an aligned set of actions, at multiple levels of the system simultaneously, that give us (collectively) a fighting chance to transform patient care. As a longtime student of large scale change, I would say that the Berwick recommendations offer a more sophisticated and well-constructed blueprint for change in a complex system than we have seen in any previous change plan for the NHS.

So where do we, as healthcare radicals, fit in this complex system of change? It would be easy to look at the recommendations of the Berwick report and question whether we, as individual change agents, can make a contribution, at least in the short term, whilst our leaders work out how they are going to respond to the recommendations. After all, the Berwick report says that safety is mostly NOT about individuals; it is the systems, procedures, conditions and environments that cause the most patient harm. Consequently, many of the recommendations are for “systematic” solutions, involving setting up systems for continuous learning, innovation and improvement. There is a risk that we radicals might feel that we have to take a back seat whilst our organisations and leaders take responsibility for establishing these new systems, waiting for the patient safety change agenda to get around to including us, so we can play our part.

But we just can’t just wait whilst someone else starts the change as a) it might be a long wait and b) more patients are likely to be harmed in the waiting period. I’m not saying that we should rush off and start making changes on our own, regardless of what is being planned in the wider system. However, as healthcare radicals, we do need to be creating our own goals for change right now, strategising about how and where we can best make our contribution to the bigger purpose, reaching out and building alliances with others and demonstrating willingness to move the change agenda forward, despite the challenges and scepticism that might face us. When we have the courage to act proactively like this, we find that most organisations will value these behaviours, even where the organisation doesn’t currently have a strong improvement or learning culture. You see, each of us who leads and/or facilitates change is a signal generator. Our words and deeds are constantly scrutinised and interpreted by the people around us in our teams, organisations and in the wider system. The amplification effect of what we do and say is far greater than we imagine.  The most powerful way to inspire others to change is to be the vanguard for that change. If we want other people to take a risk and change the way they think or organise for patient safety, we have to take the lead. I like the way that Tanveer Naseer describes it:

You have to be the first one up and off the high dive you’re asking others to leap from. Ask yourself: where am I playing it too safe and what is that safety costing me? Then leap from your platform of safety into the cold water of change.

One of the aspects of the Berwick report that I most welcome (and fits with the evidence base on large scale change) is the focus on learning as a strategy for transformation. The report sets the bold goal of transforming the NHS into a learning organisation that continuously reduces patient harm through learning. I want to link this learning theme with another key theme in the report: driving out fear. The report stresses the toxic effect of fear on both safety and improvement. I would add that fear is also the biggest barrier to learning. It’s hard to learn when you feel fear.  The Berwick proposals require many organisational leaders (and even people who perceive themselves as healthcare radicals) to move away from a status quo that they feel comfortable with into a brave new world of quality control, quality improvement and quality planning on a scale never seen before and that can be a scary thing. As Peter Senge wrote in The Fifth Discipline (as quoted by Chip Bell):

“When we see that to learn we must be willing to look foolish, to let another teach us, learning doesn’t always look so good anymore…Only with the support and fellowship of another can we face the dangers of learning meaningful things.”

The evidence base on learning organisations emphasises the importance of leaders who role model humility and vulnerability. So we have to ensure that the coaches, teachers and mentors that deliver and support this learning have to be able to recognise the fear and create positive learning experiences, focused not just on safety science and quality improvement methods but on the emotional processes of change. To quote Rosabeth Moss Kantor, “Leaders are more powerful role models when they learn than when they teach”.

This situation creates a specific call to action to healthcare radicals. We, the signal generators at the vanguard of change, must embrace the spirit of the student. This means taking responsibility for our own learning and being open to continuous learning; embracing new ideas and approaches and being willing to challenge and change our existing belief systems. We have to be the best, most active, most humble learners.

In addition, our learning must move beyond knowledge and skills. For healthcare radicals it is important, but not enough, to continuously build our knowledge of improvement methods and approaches. It’s also important, but not enough, to take responsibility for our own development as skilled leaders or facilitators of change. What sets healthcare radicals apart is the extent to which we purposefully seek to live and be improvement, in the way we operate in the world and in our interactions and relationships with others. I think that the diagramme below from Rianna Moore sums this up very well. It’s only when we live the things we believe in (that is, when

we can align our sense of deeper life mission or calling, our values and the activities that we undertake every day) that we can truly energise our teams and organisations by working from our true selves and make our full contribution as healthcare radicals.

Being a great change agent is about knowing, doing, living and

 being improvement

The Berwick recommendations provide us with a one of the best opportunities ever for radical system change. However, history tells us that organisational or system transformation is always preceded by personal transformation. So if, as organisational radicals, we want to play our role in this transformation, we have to focus deeply on our own perspective and the ways we interact with and influence others. The more people we can

influence in a positive way and the more that we (as organisa

tional radicals) can unleash that powerful reservoir of energy for change, the mo

re our influence and impact will grow.

Individually and collectively, we can play a truly significant role in helping to implement the changes that are needed in healthcare processes and systems; delivering the outcomes and experiences that our patients deserve and building the continuous learning and improvement system that will make the English NHS the safest healthcare system in the world.

I declare that that I have read and understood the BMJ Group policy on declaration of interests and I have no relevant interests to declare.

Helen Bevan (@HelenBevan on Twitter) works with NHS Improving Quality, the national improvement team for the NHS in England.  

I will be writing a regular blog for the BMJ Quality Blog. So this is  my introductory blog about my work passions which give some hints about what I might write about in future blogs. I should also tell you a little bit about my background, as I don’t think you can separate the blog from the person.

I’ve worked in quality improvement in the English National Health Service for more than two decades. I’ve learnt so much first-hand about delivering change, mostly because large scale change rarely ever goes to plan. I also had a “pre-NHS” career, although it feels a long time ago now. My first degree was in social science. I am a very good advertisement for the benefits and relevance of a social science education; I still use many of the ideas and principles about large scale change that I learnt as a teenage undergraduate. In my 20s, I worked in organisational and leadership roles in local government and education. My roles were always about leading change, helping people think differently and building new skills; I worked on one of the earliest “Total Quality Management” projects in the education sector in the late 1980s. I joined the NHS in 1991 as part of a scheme to bring senior leaders from other industries into the health sector. My change management skills were identified very quickly by the NHS and since then, my entire NHS career has been about enabling big change to happen. I’ve undertaken all my subsequent education, up to doctoral level, part time whilst leading major change programmes. It isn’t something I’d recommend to the fainthearted.

I spent much of the 1990s leading The Leicester Royal Infirmary “re-engineering programme”; a massive effort to transform an NHS hospital on a scale never attempted before. Not everything we tried worked but much did and that experience was seminal for me as a leader of change. It taught me greatly about the importance of big ambition for service change and for patients. Terry McNulty and Ewan Ferlie wrote a book about it which remains one of the most informative texts on healthcare improvement ever written. If, as a country, we had followed McNulty and Ferlie’s advice on how to go about change in a clinical environment, we would be significantly more advanced in our change efforts today.

In 1998, I was given my first NHS-wide job in improvement, working with policy makers, clinicians and hospital managers from across England to eliminate waiting times for patients. And in 2013, I’m still working at a national level in the NHS, supporting quality improvement. I’d say that my biggest achievement has been helping to make improvement mainstream in the NHS, hopefully in a way that had an impact on a lot of front line clinical teams and patients. When I first started life as a healthcare improver it was a lonely occupation, undertaken by only a few enthusiasts and visionaries. Now, the systematic application of quality improvement methods happens in most NHS organisations to some degree. I think that I have helped along the way through very practical but effective strategies such as the Ten High Impact Changes for Service Improvement and Delivery, The Productive series including The Productive Ward and Productive General Practice, the use of social movement principles in healthcare improvement and more recently, the NHS Change Model. These initiatives have spread to healthcare systems around the world. I have stuck with my role at a national level in the NHS for many years and I believe the continuity has helped.

It’s obvious to me that the current era offers the best potential ever for large scale change in healthcare. The challenges that the NHS and other healthcare systems face now mean that many of the previous incremental ways of undertaking change aren’t fast enough or broad enough for the future. We need to build on the strengths that we have as an NHS system but bring in fresh perspectives.  We have to design change strategies with a “second order” mindset (possibilities, connections and innovative solutions at scale) rather than “first order” thinking (limits losses and fears, doing more of what is done already, on a bigger scale). But more of this in coming weeks.

Over the years, I have trained in many different methodologies and philosophies for quality improvement and organisational development; from Lean and Six Sigma to the Model for Improvement to Polarity Management and large group engagement to McKinsey’s five frames for organisational health and transformation to community organising and social movement thinking. I have huge respect and appreciation of all these approaches and utilise them all but I’m not a purist about any one approach. I think that the skilled improvement leader has a toolkit of approaches that can be utilised to any given situation.

And no, I’m not a direct descendent of Aneurin Bevan, although I’m proud that I share my surname with the founder of the NHS. My paternal ancestors (“the Bevans”) were seafarers and sailmakers from Bristol. At some point, centuries ago, they crossed the Bristol Channel from South Wales. My greatest NHS inspiration is my mother, Beryl Bevan who worked as an NHS domestic assistant for nearly 30 years. My mum lived out her NHS values in her job, through her hard work, her kindness and positive attitude. She epitomises thousands of NHS workers in the extent to which she was willing to help others and do far more than she was employed to do. I aspire to be like her every day in the way that I do my NHS role.

I hope this has whetted your appetite for my blog and look forward to many great comments and conversations in coming weeks.

Dr Rani Pal is a Consultant Diabetologist from the Horton General Hospital in Banbury, Oxfordshire.  Dr Pal and colleagues have developed several new initiatives to improve the care of patients with diabetes, including the “Diabetes in Primary Schools Oxfordshire” programme which won the team the “Diabetes Team of the Year” award at the BMJ awards in May 2013.  Here she reflects on another project and some challenges in taking a new direction towards self-care in diabetes.

OX-DOTS seeks to discover the key to self-service, self-control, self-care of diabetes health…..

Dr Rani Pal and colleagues at the BMJ Awards 2013

The Opt-out clause

One young person said to me: “Expectations to be fit, happy and healthy places undue pressure on young people, who can then become demoralised and demotivated. The question of perfection should not be there, because of added pressure.  There is already a ‘Constant pressure’ of not living up to standards, personal differences are to be expected. It’s your life and sometimes it takes a severe illness to jolt you into it.”

Young people are living with demands in society with the added problem that poorly controlled diabetes adversely affects concentration difficulties and alterations in mood or behaviour.

I gathered that the vast amount of printed literature and information on websites/ media sources is still an opt-out – of not paying attention to it? Or perhaps sources are not enticing or attractive enough to capture the patients’ interest.

Why Target Diabetes?

Around 3.1million people (7.4% UK population) and 347million worldwide have diabetes (T1DM, T2DM).   This is predicted to rise to 4.6million (9.5% UK population) by 2030; diabetes morbidity requires ‘a lifelong package
of care’ and remains a considerable burden for Health Services. Simple lifestyle measures (healthy diet, regular physical activity) can potentially prevent/delay the onset of Type 2 Diabetes, but Type 1 diabetes is not preventable.  Diabetes will be the 7th leading cause of death by 2030. Up to 24,000 people with diabetes are dying in England each year from avoidable causes: in those aged 15 to 34 years, compared to those without diabetes, a nine-fold increase is seen among Type 1 (1 in 360), and six-fold increase amongst T2DM (1 in 520); The 2010 National Diabetes Inpatient Audit accounts for 15% of inpatient bed days, where one third of patients experienced at least one medication error.

Why target Children and Young Adults?

Of 29,000 UK children with T1DM, around 40% are primary school age-group: a rising incidence (4% per year) and doubling for each decade is seen, with many under 5 years. A significant number of teenagers are developing secondary
complications of nephropathy and retinopathy before the age of 20years. Minimising these health effects depends on continuously accruing knowledge and retaining a positive attitude to self-health needs.

Targeted resources used to uplift health knowledge in all members of society.

Diabetes (insulin-dependent) in Children and Young Adults is different from other health conditions as it requires 24 hours close attention from carers, continuous dynamic interaction and dialogue, understanding, discussion and problem solving of specific issues, and motivating self- responsibility for life health management. To partake in all aspects of a normal life, children depend on everyone being informed – at home, during school, social or leisure
activities. Parents, friends and relatives, school staff and public all have a role to support them to retain optimum health and glucose control, so that their well-being prevents future health complications which are linked to diabetes, namely eye and kidney disease.

Although there is an array of copious electronic-information and many national and international websites relaying diabetes health information, we want to identify which channels of dialogue are used most frequently by young people with diabetes to empower self-education and management of their diabetes condition.

Questions and challenges

• What is the most effective way to impact on a change of culture and attitude for the present generation?
• How can we examine self-training methods and a variety of information sources and communications?
• What are the most likely sources of Electronic information that young people with diabetes, their families and friends are most likely to utilise?
• What other channels of dialogue and interaction can be used to empower self-education and management of health condition?
• Progressive e-tools – are they the young persons’ choice?
• Can they relate to these as they grow and develop, to progress on their life-long self-education?
• With your experience, are you able take up the chalice of self-care or propose how to develop this for young people with diabetes?

NHS Directive for Self-care

In 2006, the DOH published a white paper, “Our health, our care, our say: a new direction for community services” . It outlines a vision for healthcare as, “meeting people’s aspirations for independence and greater control over their lives, making services flexible and responsive to individual needs”. “Self care is about people taking responsibility for their own health and well being”. “Self management is about people making the most of their lives by coping with difficulties and making the most of what they have”.

OX-DOTS wants to know your views, suggestions, difficult aspirations, campaigns and solutions!

Damian Roland is pledging for NHS Change Day.

Dr. Damian Roland, who is hosting a webinar for BMJ Quality on Tuesday 19th February for BMJ Quality, talks about how your pledge could help change patient and staff experiences. Dr. Roland is a NIHR Doctoral Research Fellow at Leicester University and Senior Registrar in Paediatric Emergency Medicine at the University of Hospitals of Leicester NHS Trust. He has research interests in education evaluation and improving recognition of unwell children in acute and emergency care settings. He also has a strong interest in trainee engagement and representation and has been a past chair of the both the AoMRC and RCPCH Trainees Committees.

The NHS is currently going through big changes, however, regardless of what is happening now with reforms and financial pressures, we know that clinical and managerial management is not optimal. Following national guidance, communicating with patients, providing adequate education and training, and many small changes to current practice could have a large impact on patient outcomes and staff engagement. Junior doctors are in the best position to notice this and to help make changes, but are often limited by time, status or motivation.

It is from a group of such junior doctors that NHS Change Day was realised – but change day belongs to all who work in or for the NHS.  After all we all work closely together, and anyone who has been on a work or department night out will note the sense of camaraderie amongst health care professionals who have worked together in tough times. Despite this, the enormous NHS, much like a steam roller, is a machine that does not move quickly;  it eventually gets to its destination and achieves it goals, but the weight of the journey is slow and painful for the healthcare team that powers it.

So, although initially proposed as a junior doctor led promotion of quality improvement action to occur simultaneously on one day, it is now a call to collective action for any NHS employee to pledge to do one or more things to aid patients or staff.

Pledges can be as simple as spending time with patients to ask for their feedback,  to alter the way a routine task is carried out; or supporting campaigns such as the Sepsis Six. The hope is that others will pledge their support as well. Although

Professor Sir Bruce Edward Keogh, KBE, FRCS has been Medical Director of the National Health Service in England since 2007 and National Medical Medical Director of the NHS Commissioning Board since 2012. Here he is with junior doctors Laura-Jane Smith, Natalie Silvey, Damian Roland and Jackie Lynton who are junior doctors involved in NHS Change Day.

these actions could, and should, be taking place everyday, NHS Change Day will act as a unifying one day opportunity for groups to overcome potential bureaucracies and inertias.

The day is 13 March 2013.  It will be the single largest improvement event in the NHS to date. The goal is to mobilise 65,000 NHS staff  (1000 for each year since the NHS was first established) to take action voluntarily to demonstrate their commitment to improving patient care and create a movement which could lead to further NHS Change Days. Anyone working in the NHS can commit by signing up on NHS Change Day Pledge Wall: www.changemodel.nhs.uk/changeday

My personal pledge is to taste a variety of the paediatric medicines I prescribe. A simple, but patient centred pledge to help me understand how foul tasting some medicines are for children and the difficulties the parents may have giving them. This also demonstrates that pledges can be about anything and don’t have to be radical or process focused.   I hope other health care professionals will individually or, perhaps together, combine their talents, to take this opportunity now, during the greatest period of transformation in the NHS, to stop the weight of the steam roller getting the better of us.