Dr Clare Trevelyan and Dr Liz Ewins

Quality improvement (QI) is increasingly at the forefront of postgraduate professional skills development. The 2013 Francis report highlighted a need for a culture of collective leadership, and trainees as important agents of change¹. However, QI has not yet been fully embedded in psychiatry training. In 2014, the Medical Education Department at Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) created a team to develop a QI programme as they were keen to use the energy, enthusiasm, and talent of trainee doctors to address areas for improvement in the clinical and educational environment. This team was spearheaded by advanced trainees working as clinical teaching fellows.

The programme we developed offers trainees resources, training, project supervision, and coaching, collaborating with the Trust’s Quality Academy to create coordinated project governance procedures. Prior to this programme, no trainees in AWP were involved in QI projects. Seventy-six percent of core trainees and 60% of advanced trainees were involved in QI between 2014 to 2016, and it has become embedded as a necessary part of the Severn School of Psychiatry ARCP.

Our trainee QI projects have focused on improving safety, efficiency, and patient experiences. They have developed from a grassroots level, driven by areas for improvement identified by trainees. This has included improving multidisciplinary team communication processes and documentation, physical health training, improving liaison referrals, and patient feedback processes. Projects have also addressed Trust and Deanery level quality priorities, including improving medical handover across the Deanery, and developing professional guidance for the Place of Safety (136 suite).

Trainee projects have achieved national publication and poster prizes, and feedback indicates trainees are engaged and enjoying QI work. Through the involvement of trainee doctors and the Quality Academy’s drive to QI, there has been a shift in culture with increasing numbers of senior doctors and the wider multidisciplinary team becoming involved. We hope that this programme will help develop medical leadership with a sound understanding of effective improvement methodologies.

How we set it up

This project got started when the AWP Director of Medical Education (DME), Dr Steve Arnott, approached Dr Liz Ewins at the start of her year working as a teaching fellow for the Trust and asked her if she would set up a QI programme for trainees.  Liz was able to access local academic expertise at the University of Bristol and Severn Deanery, including the Head of School Dr Rob McPherson, to help her develop ideas for the programme by using it as the subject of an Educational Fellowship awarded by Severn Deanery. Along with her supervisor Dr Geoff Van Der Linden and AWP Medical Education Project Manager Bridget Kelly, Liz adapted training strategies employed by the local Foundation School² and the Royal College of Physician’s ‘Learning to Make a Difference’ programme³ to develop training and support to enable psychiatry trainees to undertake their own QI projects within the Trust.

A half day training session was developed to teach trainees about QI and project methodology, including using PDSA cycles in practical examples so that they could undertake their own projects. This was delivered by Liz alongside the Quality Academy local lead. Trainees were encouraged to come up with their own ideas for projects and to work with other trainees to implement changes, under the supervision of a higher trainee, specialty doctor, or consultant. They were asked to include the wider multidisciplinary team in developing and implementing projects, to support successful and sustainable changes.

Training was initially targeted at trainees, but a growing number of specialist doctors and consultants requested to attend and they were invited to a second training session. A resource handbook was developed and a series of short follow-up sessions were put in place to provide further advice about QI methodology and to help support trainees’ projects. Trainees were asked to register their projects by completing a short online form on the Trust Quality Academy website so the Trust could monitor participation.

During the pilot we found that forming close links with the Trust Quality Academy provided invaluable assistance in setting up the scheme and supporting training. They have been particularly helpful when offering guidance regarding governance and what permissions might need to be sought. Key to this process has been the support from Trust medical management leads (including the Medical Director and DME) and work by the Deanery to embed QI alongside audit into ARCP requirements.

After this successful launch, the next teaching fellow in post, Dr Clare Trevelyan, took on the role of trainee QI lead for 2015-16. The team worked with the Quality Academy to develop the governance structure and online registration process for projects. We have continued to develop training sessions on QI methodology as part of the Core Training Course for psychiatry trainees, as well as offering sessions at Local Academic Programmes, developing, and delivering workshops for the AWP Excellence in Education and Excellence in Quality Improvement conferences. During this second phase we have built up strong links with the West of England Academic Health Science Network (WEAHSN), who have helped us deliver training to senior medical staff and clinical leads. In June 2016 we helped develop and deliver a regional QI conference for all staff in the South West, “QI in Action”, in collaboration with Health Education South West, WEAHSN, and the South West Academic Health Science Network.

Challenges

One of the key challenges has been how to sustain successful changes and embed them within teams as trainees rotate through posts. Is this the responsibility of the central QI team or should it be handed to the localities? Our approach needed to be flexible for different projects. We also noticed that the same sorts of projects were getting registered all over the Trust, but getting these projects linked up to share learning was easier said than done. There needs to be development of how we link trainee grassroots projects with Trust priorities, and we also need to increase service user involvement as co-production is a key concept in QI. We are considering achieving this through the introduction of suggested projects in training sessions.

The ability of medical education to offer effective coaching to all trainee projects as the scheme developed was limited by available expertise and time. The project team were keen to keep trainee project governance within Medical Education rather than the Quality Academy so we could tailor support and training for the particular needs and ambitions of the trainee doctor. However, approving, supervising, and chasing up projects and their reports is time consuming. This has until this year been carried out by one teaching fellow with support from Bridget Kelly, but this may no longer be feasible as the project expands. Indeed it may no longer be desirable to keep trainee projects separate as projects involve more and more of the multidisciplinary team.

Top tips

Build key relationships with potential QI champions. This has been really important in building momentum and senior buy-in for the programme. The project has been well supported by key figures in the Medical Education department (where it is housed) but also at the Deanery and the Trust Quality Academy. There is no substitute for face to face meetings.

Make use of the wealth of resources out there. We have worked with the West of England Academic Health Science Network (WEAHSN) and inviting their experts to contribute to our training sessions; this has been incredibly valuable and important to ensure the quality of the training we can offer. We have attended QI training events around the country and discovered ideas for our own training, as well as using free resources for healthcare professionals available through the Health Foundation and Institute for Healthcare Improvement website (www.ihi.org).

Make a big deal out of project successes. Everyone wants to hear about this! Take any opportunity to support trainees in presenting their work internally and externally, and spread good news about prizes and publications. Get project updates onto the agenda for Trust management meetings such as Trust Medical Advisory Groups. Not only does this increase morale but also increases interest and awareness in QI and its potential.

Enjoy QI! To combat the change fatigue that NHS staff can experience you need a good dose of enthusiasm; this starts with the QI team. It’s all about communicating why QI is such an important and empowering tool for healthcare professionals, enabling front line staff to make a difference in improving patient care and experience.

References

1. Francis, R. (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London.
2. Bethune R, Soo E, Woodhead P, Van Hamel C, Watson C. 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.
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; 12(6): 520-5.

Dr Tim Yates is a registrar in neurology at the Royal Free London NHS Foundation Trust. He is currently a National Medical Director’s Clinical Fellow at NHS Digital. @drtimyates

As far as digital health is concerned, it’s not all about infrastructure, apps, and electronic health records. It’s much more about making the healthcare data work for patients, clinicians, and the service. Data should be central to everything we do; it should be used and collected at the patient’s bedside as an essential part of good clinical care, and in its secondary uses in each quality improvement project we undertake and in determining payment for every service we provide. Accurate, precise, and timely data that are also high quality data provide the tools to make healthcare safer, more effective, and better value.

But we also learned from the Francis Inquiry that when data are false or misleading, poor or dangerous care can continue. That linkage between healthcare data quality and the clinical care it drives makes it imperative for clinicians to work in partnership with analysts to derive clinically meaningful measures of data quality.

Take something as fundamental as accurately recording a patient’s diagnoses which need to be coded and passed on. Through life, a patient may lose some diagnoses and receive new ones as they age and their health changes, meaning their set of diagnostic codes can change. But there is a range of diagnoses that patients typically never should lose, like rheumatoid arthritis or Alzheimer’s disease. Examining the persistence (or otherwise) of such fixed diagnoses over time offers a new way of assessing the quality of the record: a new method of healthcare data validation termed “diagnosis reporting consistency”.

On 8 November, NHS Digital published new data (broken down by Trust) for the consistency of reporting of dementia diagnoses with its latest quarterly Data Quality Maturity Index (DQMI) at http://content.digital.nhs.uk/dq. This looked at a range of ICD10 codes for dementia in the Admitted Patient Care (APC) national clinical data set.

The findings show how questions about data quality go hand in hand with clinical questions. Only 71% of patients with a diagnosis of dementia recorded for hospital admissions in the period April 2013 to March 2016 received this diagnosis recorded for admissions April to June 2016. A dementia diagnosis persisted for only 50% of admissions where patients were not admitted by their usual provider. Could improving the quality of the data improve the quality of the clinical care?

NHS Digital has a central role in collating, analysing, and publishing the DQMI, allowing Trusts to compare their data maturity. However, a combined effort to improve healthcare data quality must involve and take inspiration from all parties including individual administrators and clinicians today, and patients tomorrow. We have two quality challenges. First, to find ways to ensure that data entry is accurate at the bedside, not least making sure the diagnoses entered are accurate and comprehensive. Second, to inspire frontline clinicians to engage with the data quality agenda because it is the great enabler for the care they want to deliver.

Trusts recognising the value of this work have embedded data quality improvement strategies in their clinical culture. They benefit from more accurate patient data and this is reflected in higher DQMI scores. Where Trusts are looking to improve, NHS Digital can help. It highlights excellent performance in the DQMI and helps the system learn from that as part of its Performance Evidence Delivery Framework. NHS Digital also hosts both electronic and face-to-face forums, where those interested in data quality improvement can discuss and take forward everything from new clinically-focused data validation methods to reports on local project work. The journey to better data and more clinically relevant data quality measures starts here with you.

Dr Emma Vaux is a consultant nephrologist and general physician at the Royal Berkshire NHS Foundation Trust. She has a research doctorate, Oxford University 2001.

Dr Jen Perry, clinical lead for BMJ Quality, talks to Dr Emma Vaux.

Moving beyond the tickbox
Quality improvement (QI) has often been seen either as a tick-box exercise; something trainees have to do in order to pass their ARCP, or as an elite sport for carefully chosen clinical fellows. We need to move the thinking beyond this so that junior doctors are able to see its wide-ranging benefits, such as the ability to improve patient care, develop transferable skills (eg leadership), and build teams.

QI is an important method of “putting the fun back into medicine”, particularly in these difficult times where morale is low among junior doctors. It is a good way for junior doctors to get to know their teams outside of the ward round and the usual day to day business.
Doctors often lament the loss of the medical firm – well, this is one way of bringing teams back together and changing the conversation. QI enables links to be made between junior doctors and the rest of the organisation; it allows them to meet and engage with senior people such as the medical director and the director of patient safety. This helps to foster a culture where organisations value their junior doctors and the work that they do.

Finding the hook
We have to find the different hooks for junior doctors to get them engaged in QI activities. For some it is simply that they want to improve patient care, but for others it is about working differently, having an opportunity to influence, learning how to understand and use data, or being able to present/publish their work. For the few, it may still just be the need to tick it off for their appraisal and the realisation that assessment drives learning.

Overcoming the barriers at a trainee level
Trainees have lots of competing demands and time is commonly cited as a barrier to QI. Trainees often have to spend time doing things which don’t add value, for example collecting large amounts of data which aren’t used to effect change. They need to be supported to use their time in a smarter way, while at the same time recognising that time in job plans is also an important factor.

QI allows trainees to work with their MDT, patients, and carers. As well as sharing ideas and collaborating they can also share the workload. This is a way in which QI often differs to the traditional audit process. With QI there is a different mindset of needing just enough data, little and often measurement, making iterative changes, and learning from them in a real time and dynamic way.

Another issue to consider is that of sustainability. In the past, projects have often been started and led by doctors, but then the projects fall through when they move on. We need to train doctors to think about what will happen when they move on from their placement. The appraisal system is geared towards leading projects, but arguably it is an equally difficult challenge to pick up someone else’s work and sustain and/or improve it further. At the moment the appraisal system doesn’t recognise that and we need to change it.

At the moment we often hear about service delivery versus training and they are seen as two separate entities when they shouldn’t be. Reframing service delivery as being hands on patient care (alongside training) gives more of a sense of learning by doing and it can be seen as an apprenticeship. Quality improvement helps to bring service delivery and training together, it bridges the gap between education and clinical work.

Overcoming the barriers at an organisational level
Board buy-in is key. There are pockets of excellent QI work going on in places like Salford Royal and North East London Foundation Trust. These hospitals all have dedicated QI teams where QI has become core hospital business. In order to convince boards of the importance of QI, we need to develop better messaging; QI leads to better value (which has a financial cost attached to it) and it can also improve the culture of an organisation and staff wellbeing.

Culture change at a ward-level
I work as a consultant nephrologist and my ward always has several projects on the go. We have incorporated QI into our daily routine such that it has become part of normal practice. We spend 10 minutes after our daily board round catching up on our projects. Our mantra is working together and for data collection, little and often -and again this has helped to make it part of the daily routine.

We ensure that the data we collect and the tools we use (eg driver diagrams) are visible on the ward for staff to see; this really helps to sustain momentum and enthusiasm. We create a space where the whole MDT can come together and share ideas. It is fairly flexible so that people can drop in and out depending on their commitments.

The doctors and nurses now jointly manage the ward’s KPIs, a task that historically used to fall to the nurses, because it is everyone’s responsibility to improve performance. What is really positive about this way of working is that staff feedback that they feel valued, feel listened to, and feel like they matter.

Chris Ham took up his post as Chief Executive of The King’s Fund in April 2010. He is currently emeritus professor at the University of Birmingham and an honorary professor at the London School of Hygiene & Tropical Medicine. He was awarded a CBE in 2004 and an honorary doctorate by the University of Kent in 2012. He was appointed Deputy Lieutenant of the West Midlands in 2013.

Professor Chris Ham has recently authored a report entitled Improving quality in the English NHS with Dr Jennifer Dixon and Professor Don Berwick. The report highlights the need for a coherent strategy for quality improvement (QI) across the NHS, and sets out some recommendations for a “system of support”. Below is a selection of some of their recommendations:

– Organisations need to build capacity and capability for QI (as has been done in trusts such as Salford Royal and East London)

– There needs to be shared learning and the provision of regional support for QI through the academic health science networks, for example

– A centre of expertise for QI should be established

– Frontline clinicians, leaders of NHS organisations, patients, and the public should be involved in designing and implementing the strategy.

Dr Jen Perry, clinical lead for BMJ Quality, met with Chris to ask him about his paper and what it means for clinicians working on the frontline.

What do you think the most important message from your report is?
I think the key message is that there needs to be a strong and consistent focus from national leaders and ministers on QI. In politics, there is always the risk that other priorities can get in the way.

How do we keep the national focus on QI?
QI isn’t just the right thing to do; it helps the NHS to use its resources better, to hit targets, and improve financial performance. These issues are important to politicians and so we need to keep this at the forefront.

What will your report mean for frontline clinical staff?
It will mean that healthcare teams will be able to develop skills in and knowledge in QI. They will be supported to undertake projects which will improve quality and make better use of resources.

What about cost?
This is something that you can’t do without money. There needs to be a strong commitment from trust boards and money will need to be found from somewhere (for example through reserves and charitable trusts) or tough decisions will be made. The money invested for QI programmes will pay off in the long run through other savings. For example, at Tees, Esk and Wear, a mental health trust in the North of England, they have been able to close 100 inpatient beds and focus more of their psychiatric care in the community.

What are the barriers to rolling out QI across the UK?
Workload pressures are the obvious one. At present, teams are already working flat out and they will struggle to find the time to do QI; it really needs to become part of everyday practice. They have a saying at Jönköping: “People are employed not only to do a job, but also to improve upon it.”
There is also the issue of board commitment. Board members are often from different walks of life and are new to the concept of QI. As a result, they often need more convincing of it as a concept. What we really need is to have a document which makes the case for QI that we can present to trust boards.

How do we engage people in QI?
I’ve visited lots of organisations which are doing great QI work and what often happens is that QI starts with the enthusiasts, such as on a few wards. The rest of the staff in the hospital then start to hear about their great successes and want to get involved; it can have a ripple effect. This needs to be supported by leadership from the top and clinical champions.

What about top down strategy vs bottom up QI?
We need both. The top-down strategy is needed to provide the framework and resources, but all of this would be nothing without the teams on the ground actually doing the QI work.

Why should frontline staff get involved in QI?
The evidence is clear: QI improves patient outcomes, increases efficiency, and decreases waste. Staff members are able to develop a wide range of skills through doing QI such as leadership skills. Junior doctors are particularly well placed to get involved in QI because they see things through fresh eyes, they question and they challenge.

Morven Millar 3^rd year Medical Student University of Dundee
Morven Millar is a 3rd year Medical Student at the University of Dundee, she wrote the blog from her experience working together with Art and Design students on this project.  We worked with Jackie Malcolm a Graphic Design Lecturer from Duncan of Jordanstone College of Art and Design at the University of Dundee and Rod Mountain an ENT surgeon in NHS Tayside who came up with the original idea of getting Medical students and Art and Design student to work together.

Art and Design and Medicine, distinct fields that I had until only recently considered as separate entities. But through taking part in a project at Ninewells Hospital in Dundee I discovered that these two disciplines can indeed work together, and are powerfully linked by a common theme: Empathy. In Medicine empathy is fundamental to how we deliver individualised care to each patient, and it is the hope that every clinician has an empathic approach to making each decision. However, as a scientific discipline, the approach can easily become “task-based” as opposed to “user-based”, and this is where the medical field could learn a thing or two from the world of design. The project I took part in, as part of a QI module, aimed to unite students from Dundee University Medical School and Duncan of Jordanstone College of Art and Design for “Empathic Redesign of the Ninewells Hospital Environment”. This involved considering the design of Ninewells Hospital with an empathic approach, with the hope of improving the overall experience for the thousands of people walking through its doors each day.

The brief for the project was to redesign the main concourse of the hospital, and to also consider how to link the inside space with the hospital’s unique and extensive grounds. The challenge was that each group was to focus on the experience of different patient groups, each with some form of disability or barrier to their environment. The six population groups that were considered were those with a physical disability, hearing impairment, visual impairment, dietary requirement, a new cancer diagnosis, and those for whom English is not their first language. The idea was that we would consider how these different patient groups would interact with the hospital environment, understand some of the challenges they might face, and what potential needs they would have and how to address them. Finally, once all this was considered, we were to redesign the hospital concourse in a way that would address some of the potential challenges for these patients, and improve their overall experience of their hospital visit. This user-focused approach is known as “empathic design”, a technique which is set apart from other product design methods in a few aspects. While most methods use observation for research, in empathic design “observation is conducted in the customer’s own environment”.[1] Another aspect unique to empathic design is the involvement of “interactions among members of an interdisciplinary team”,[1] which is beneficial in making observations as people from different disciplines will identify different information from the same situation.

Having walked through the concourse nearly every day for three years, I had become immune to its imperfections and problems, but when the design students visited the hospital they immediately picked up on several flaws and design opportunities (showing the advantages of bringing a fresh pair of eyes to a challenge, as well as a background in design). It certainly seemed ironic that there could be so many unidentified problems for the patient groups we were to focus on, as these people would undoubtedly be accessing healthcare. After conducting our initial observations and research we went, quite literally, to the drawing board (for the first time for many of the medical students). We were led by the design students in employing various methods which are often adopted in the fields of interior and graphic design. One of the techniques used included creating “personas” – fictional characters representing potential users of a particular space or product, how and why they might use it, and what sort of challenges they could face in the process. This was an interesting technique as it very much required putting oneself into the shoes of the “client” (particularly when we mapped out potential routes they would likely take through the concourse) and so entirely fit the bill for empathic design. After three weeks of work we presented our ideas to a panel of judges, and the hope is that many of these will be taken forward into the final design and renovation of the concourse and outdoor environment.

This experience was quite a unique opportunity, which was a privilege to be involved in. As students, there is a lot we can take away from this project, having had the chance to gain some insight into a different discipline. There is some debate as to whether medical students lose empathy as they progress through their studies, with evidence to support either side of the argument.[2] By taking part in a project that forced us to think about the needs of individuals from a non-medical point of view, acted as a reminder that the most important component of healthcare service we provide is the person at the centre of it, and what makes a truly patient-centred approach. Thus, regardless of the side of the debate the evidence best supports, I think this kind of project would be of benefit to all medical students, particularly those with an interest in art and design. And of course, for some of our work to improve the way patients access and experience their healthcare would be an incredibly rewarding outcome of our collaboration.

References

1. Leonard D, Rayport J. Spark innovation through empathic design [homepage on the Internet]. Harvard Business Review. November 1997 [read 10/07/16]. Available from: https://hbr.org/1997/11/spark-innovation-through-empathic-design
2. Quince T, Kinnersly P, Hales J, Silva A, Moriarty H, Thiemann P et al. Empathy among undergraduate medical students: A multicentre cross-sectional comparison of students beginning and approaching the end of their course. BMC Medical Education. [Serial on the Internet]. Mar 2016; 16:92 (read 29 Aug. 16).

Faculty:

Jackie Malcolm. Lecturer Graphic Design, Duncan of Jordanstone College of Art and Design, University of Dundee

Rod Mountain, ENT Consultant, NHS Tayside

Vicki Tully, Teaching Lead for Patient Safety, Medical School, University of Dundee/NHS Tayside

Biography
With scientific and healthcare underpinnings, Dr Nancy El-Farargy is a researcher and educationalist.  Her work covers a range of quality, improvement and safety research & development to support the delivery of safe, effective and person centred
care.  She is based at NHS Education for Scotland (NES), which is the national health board for education, training and workforce development for the NHS in Scotland.

Twitter: @NancyElFarargy

Every Person, Every Time

The Healthcare Quality Strategy (Scottish Government, 2010) aims to deliver the highest quality healthcare to the people of Scotland and in turn, it aims to make Scotland one of the international leaders in healthcare quality.  The following ‘Quality Ambitions’ (p. 7) outline the principles of safe, effective, and person centred care at every healthcare encounter, for every person, every time.

• Safe: “There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean, and safe environment will be provided for the delivery healthcare services at all times.
• Effective: “The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.
• Person centred: “Mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making”.

Person Centred Care

There is a revival in healthcare that is focusing on active engagement, patient experiences, and the power of story in driving improvements and transforming services.  As highlighted in the above person centred ‘Quality Ambition’ this also broadly involves (Ahmad, Ellins, Krelle, & Lawrie, 2014, p. 28):

1. Care that is respectful, compassionate, dignified, and sensitive to the whole person and their needs.
2. Care where individuals can participate in their own treatment.
3. Collective involvement in service design, delivery, and improvement.

Hence, in working together, people can highlight what matters the most, make decisions about care and treatment, and identify and achieve goals (Health Foundation, 2014, p. 8).

Our Voice

The following presents some examples of how experiences are being used to highlight improvements, catalyse change, and transform services.

• Recent research has highlighted how stories – based on staff and patient experiences – have the potential to support ongoing quality improvement, learning, and reflection.  For instance, they are used during team meetings, safety briefs, and formal presentations, and they appear to be powerful in catalysing positive action and sharing of good practices.  Alongside quantitative data, stories (including other qualitative data) offer a “human side” to ongoing service improvement, and could perhaps provide the impetus for swifter action.
• The ‘Patient Opinion’ website offers patients the opportunity to narrate their healthcare encounters and experiences.  In turn service providers can tune in to what really matters to users, and employ the narratives to inform patient focused service improvements.  Whilst it’s a relatively simple concept that’s grounded on user experiences, it’s the actions that result which appear to make it a useful tool for driving improvements.
• The board game ‘Whose shoes?®’ uses narrative scenarios to support participants in reflecting on their own practice and interpretations of person centred care.  The exercise also highlights the importance of practitioners/professionals of actively listening to service users and working together to reach shared goals.
• Starting out as ‘Stronger Voice’, the ‘Our Voice’ initiative aims to support people to engage with health and social care providers to continuously improve and transform services.

Summary

Stories – in their wider context – have been used throughout history for sparking knowledge, disseminating lessons, and supporting ongoing reflection.  Whilst they often reflect on the past, their power lies in their ‘memorability’ and their universal links with current contexts and situations.  Within healthcare, stories generally appeal to what people really care about and there is a growing recognition of their use to support safe, effective, and person centred care.

References

Ahmad, N., Ellins, J., Krelle, H., & Lawrie, M. (2014).  Person-centred care: from ideas to action.  London: The Health Foundation.  Retrieved from http://www.health.org.uk/publication/person-centred-care-ideas-action

Health Foundation. (2014).  Person-centred care made simple.  London: The Health Foundation.  Retrieved from http://www.health.org.uk/publication/person-centred-care-made-simple

Scottish Government. (2010).  The Healthcare Quality Strategy for NHSScotland – putting people at the heart of our NHS.  Edinburgh: Scottish Government.  Retrieved from http://www.gov.scot/Publications/2010/05/10102307/0

Dr Nancy El-Farargy, NHS Education for Scotland, Nancy.El-Farargy@nes.scot.nhs.uk.

This article was originally published (independently) on 16 August 2015.

Dr Frances Healey is the head of patient safety insight at NHS Improvement. This role includes oversight of clinical review of all nationally reported death and severe harm incidents, statutory duties to provide advice and guidance to the NHS through the NHS Improvement National Patient Safety Alerting System, and advising on the meaningful measurement and monitoring of patient safety.

A recent Patient Safety Alert issued by NHS Improvement asked trust boards to use a new resource set to assess whether previous alerts and guidance around the placement of nasogastric tubes have been implemented and embedded within their organisations. Dr Frances Healey provides her personal perspective on the continuing persistence of harm caused by misplaced nasogastric tubes from her experience both as a nurse and now as head of patient safety insight at NHS Improvement.  

In 2003, I was holding the bleep for my hospital and woke to an early morning call from night staff explaining that during an attempted resuscitation they had realised the patient had been fed through a misplaced nasogastric tube. I drove through empty streets and undertook the painful task of contacting the patient’s family and breaking the news to the devastated doctor who had misinterpreted the x ray. Those of you who’ve been in the same position may recognise how very heavy a phone feels in those circumstances, and the effort of will it takes to press dial when you know that neither the family’s lives nor the staff member’s life will ever be quite the same.

Shortly after this, I moved into my first role in national patient safety and found I was not the only new arrival with a nasogastric tube death on my watch. The National Reporting and Learning System was still in its infancy, but through clinical contacts we brought together staff involved in 11 incidents to undertake a combined root cause analysis, and issued the first National Patient Safety Agency (NPSA) alerts in 2005.

These alerts succeeded in replacing some traditional (but unsafe) testing methods with pH paper and x ray. After a further 100 incidents, another NPSA alert was published in 2011. This emphasised the need for safe purchasing choices, for competency based training, and for structured documentation to reduce the risk of error in pH paper and x ray interpretation. An NPSA Rapid Response Report in 2012 and an NHS England alert in 2013 did not add any new guidance, but highlighted aspects of the 2011 alert that appeared to be misunderstood or disregarded.

A somewhat overused conference presentation slide runs along the lines of “patient safety isn’t rocket science…it’s much more complicated”. The phrase is used to make the point that changing training, policy, or documentation may be simple, but ensuring sustained and reliable implementation can be very challenging indeed. Sadly, our analysis of a further 95 incidents of feeding through misplaced nasogastric tubes showed that all too often it has been at the “it’s simple” end, where failure to implement earlier alerts appears to have occurred. For example, you clearly cannot expect to have staff with the right competencies for checking nasogastric tube placement unless your organisation has provided such training. Of course, there are incidents from the “much more complicated” end of the spectrum too, but many more in the area where hindsight might reasonably have been expected to be foresight. For example, where there is potential for new staff not to know local procedures or for documentation that was never audited to become documentation that was rarely completed.

On the basis of these findings, we issued a further National Patient Safety Alert to the NHS in England, emphasising that the most common problem that incident investigations found was the misinterpretation of x rays by medical staff who had never received competency based training in confirming nasogastric tube placement. This was not an issue that affected only junior or inexperienced staff, but staff of all grades and levels of experience.

Given the unprecedented number of alerts that had already been issued on this single topic, you might feel our decision now to issue yet another is an unreasonable triumph of hope over experience. So why have we done so?

Firstly, we hope these extra resources convey why it is vital to act on what has been learned the hard way through lost lives, damaged respiratory systems, and traumatised patients, families, and staff.

Secondly, we hope to simplify. We have brought together all the safety-critical elements of the many previous alerts, and drawn a clear line between these and the more general advice attached to earlier alerts that can and should fall into the zone of constantly evolving clinical guidance.

Thirdly, we want to ensure that the executive responsibility for ensuring the alert’s requirements are met before declaring “action completed”. I come to work each day because I sincerely believe that a national patient safety function can enable people to act on a harmful incident in one organisation before it is repeated elsewhere. But the ultimate responsibility for taking that shared learning forward lies with organisational leaders.

Healthcare professionals take very seriously their personal responsibilities to work within the limits of their competence, but that becomes problematic when staff “don’t know what they don’t know”. The incidents we looked at typically described staff who had not known that any special skills or knowledge were required. In some cases, staff were unaware that required competencies had changed since the days when just checking that the tip of the nasogastric tube appeared to be below the diaphragm was erroneously considered sufficient to exclude respiratory placement.

A safer system does not require every doctor or every nurse to obtain the knowledge and skills to confirm nasogastric tube placement, but it does require them to “know what they don’t know”. If you are unfamiliar with terms such as “the four criteria” for x-ray interpretation, the “safe range” for pH strips, or the tests that should never be used to confirm placement, then please seek appropriate training, and please avoid undertaking confirmation of nasogastric tube placement until you have done so.

I’d never met our patient who died in 2003, but in the following weeks of investigation and the inquest I felt like I had. It was very easy to picture what a warm and delightful husband, father, and grandfather he had been when I encountered the forgiveness and understanding his family extended to us. I cannot picture as clearly the patients affected by the 100 incidents I reviewed in 2011 or the 95 incidents I reviewed in 2016, but I am not a detached party in the journey of improving nasogastric tube safety; it feels painful and it feels personal. Please make acting now personal for you too.

Dr Frances Healey, RN, RN-MH, PhD
Head of Patient Safety Insight, NHS Improvement

If this blog has left you feeling inspired, have a read of some of our recently published quality improvement projects which have a patient safety focus. You can use BMJ Quality to run and publish your own quality improvement projects.

Reducing inpatient falls in a 100% single room elderly care environment: evaluation of the impact of a systematic nurse training programme on falls risk assessment (FRA)

Improving residents’ handovers through just-in-time training for structured communication

Dr Howard Ryland is a Registrar in Forensic Psychiatry at South West London and St George’s Mental Health NHS Trust.  He was previously National Medical Director’s Clinical Fellow at the Academy of Medical Royal Colleges and the Vice-Chair of the Academy’s Trainee Doctors’ Group.  He is a member of the Academy’s Quality Improvement Task and Finish Group.

The Academy of Medical Royal Colleges Quality Improvement Task and Finish Group.  It doesn’t exactly trip off the tongue, but it certainly sounds important. And indeed it is.  The increasing focus on quality improvement and patient safety has been heralded by an explosion in the number of publications over the last few years, where the literature was previously rather threadbare (Davidoff et al., 2008). Quality improvement (QI) has been steadily moving up the agenda, with the associated language imprinting itself on the common consciousness (The Health Foundation, 2010).

Audit has long been heralded as one of the pillars of clinical governance and something that all trainees should involve themselves in. Compliance has been monitored through the ARCP process, with minimum requirements imposed.  Historically little attention has been paid to the rigour of the audit work undertaken or the usefulness of the outcome. This approach has drawn criticism of a tick-box exercise that encourages simple task completion, rather than fostering deep understanding of the core principles or underlying intentions of audit (Kidd, 2015).

The Academy’s group aims to draw on the burgeoning evidence and political will behind quality improvement and translate it in to effective training for medical trainees (Shojania & Grimshaw, 2005).  Despite the focus on doctors there is a clear recognition that health systems are complex and involve professionals from a diverse range of backgrounds interacting. Instead of a simplistic approach that seeks to just mandate quality improvement in the way that audit has been, the Academy’s approach aims to address all aspects of the quality improvement experience.  It aims to do this through dividing and conquering with its four sub-groups, looking at curriculum development, QI training, supporting infrastructure at multiple levels, and mapping resources/multiprofessional ways of working.

The work aims to address several key ‘elephants’, which have long been lurking unacknowledged in the medical training ‘room’.  Firstly, what is the relationship between QI and audit?  Is audit just a subset of QI or does it have distinct attributes? Secondly, how can a parity of esteem with research be achieved?  Trainees tend to be heavily incentivised to undertake activities that fit neatly in to the narrow concept of traditional research.  The production of papers on esoteric elements of basic science is often rewarded with career progression; yet the equivalent effort invested in the pragmatic implementation of evidence to improve clinical practice frequently yields minimal formal acknowledgement. Thirdly there is the question of engagement by senior clinicians. What will it take to get these key players on board with this concept?  Fourthly, the diversity of patient involvement in QI has been explored and how may we work most effectively in partnership. Finally, the big one: How are people going to find the time to learn about and practice QI?

A showcase event on 3^rd November 2015 brought out the main messages and central recommendations of the group.  The importance of high quality patient care was powerfully underlined by James Titcombe, whose infant son tragically died in Furness General Hospital, prompting the Kirkup inquiry in to the maternity unit there, revealing serious shortcomings (Kirkup, 2015). He spoke eloquently of how his previous experience as a project manager for the nuclear industry had informed his current role as a National Advisor on Patient Safety, Culture and Quality for the Care Quality Commission (Titcombe, 2015). He described how those who reported incidents would be entered in to a raffle to win a iPad and a fitter who had admitted to breaking some insulation was given an award instead of being reprimanded. What if a similar culture existed in the NHS?

There was recognition that QI training is important and requires adequate resourcing. The hotly anticipated publication of the General Medical Council’s Generic Professional Capabilities may add greater urgency to the need to integrate QI learning in to curricula, but the focus at the highest level needs to be flexible (General Medical Council, 2016).  Inevitably learning about QI will be incremental, with skills being acquired in a progressive fashion, starting in undergraduate years and developing throughout postgraduate training and beyond.

What is clear is that there is a huge range of diverse resources available, from intensive hi-fidelity simulation courses to democratic MOOCs.  Hubs that bring these resources together would be of enormous benefit to all, guiding the bemused neophytes and networking the QI connoisseurs.  However this is achieved, signposting will be key and there is a need to link up like-minded individuals, so that a process of effective mentoring can occur.

Other important questions were posed, such as how would the effectiveness of any changes be evaluated?  When attempting to implement such a diffuse programme of educational change, how will it be possible to know if the desired downstream impact of improved patient care has been achieved as a result of these efforts?

The final report, entitled ‘Quality Improvement – Training for better outcomes’ is to be published in March, which will set out the group’s recommendations.  This will represent a hugely exciting opportunity to enhance the training that doctors receive in QI and will represent another step towards bringing QI to its rightful place centre-stage.

References

Davidoff, F. et al., 2008. Publication guidelines for qulaity improvement in health care: evolution of the SQUIRE project. Quality and Safety in Health Care, 17(Supplement), pp.i3-i9.

General Medical Council, 2016. Development of generic professioanl capabilities. [Online] Available at: http://www.gmc-uk.org/education/23581.asp [Accessed 22 January 2016].

Kidd, L., 2015. The purpose of audit: to improve care or boost trainees’ CVs. [Online] Available at: http://careers.bmj.com/careers/advice/The_purpose_of_audit%3A_to_improve_care_or_boost_trainees’_CVs%3F [Accessed 20 January 2016].

Kirkup, W., 2015. The Report of the Morecambe Bay Investigation.

Shojania, K.G. & Grimshaw, J.M., 2005. Evidence-Based Quality Improvement: The State of the Science. Health Affairs, 24(1), pp.138-50.

The Health Foundation, 2010. How do you get clinicians involved in quality improvement? London.

Titcombe, J., 2015. Joshua’s Story: Uncovering the Morecambe Bay NHS Scandal. Anderson Wallace Publishing.

Saru Bhartia has completed the Improvement Advisor Program at the Institute for Healthcare Improvement and Advanced Lean Training at Virginia Mason Institute. She leads a portfolio of quality improvement projects spanning clinical and non-clinical services at Sitaram Bhartia.

Meta-Description: Initiating quality improvement at Sitaram Bhartia’s telephone exchange brought us better-than-expected results and gave insights on leading change.

Keywords: Quality improvement, Quality improvement in healthcare, Sitaram Bhartia, India

Change is always hard and most of the times we hate to change. Often, attempts to change or improve in an organization are met with resistance, making failure and frustration the common outcomes of change initiatives.

In the summer of 2012, I was two years into my new position as Quality Manager at our family-founded nonprofit hospital.  I had earlier completed the ten-month Improvement Advisor Professional Development Program of the Institute for Healthcare Improvement and become one of earliest professionals with such a certification in India.  

Yet my two projects attempting to improve cleanliness of public toilets and availability of quality linen had failed.  I was beginning to question the applicability of the methods I had learnt in the Indian setting.

Triggering Incident: Changing the status quo can sometimes  begin with the most unassuming catalyst. And that’s exactly what propelled our third major improvement project at Sitaram Bhartia.

One of our consultants complained to our medical director about her patients not being able to reach her through the telephone exchange, moving us towards addressing this issue. This time, we succeeded and managed to reduce missed calls to the hospital telephone exchange from about 26% to 8%. Clearly, something was different that led to success, but what?

The Story of Our Change: Engaging Frontline Staff

As I’d mentioned earlier, success had evaded us with earlier improvement projects. However, this time, we had two major differentiating factors on our side:

1. The quality of the department manager, and
2. The degree of engagement of the frontline staff.  

So how did we make it happen?

• We had good departmental leadership: Sitaram Bhartia’s telephone exchange was under Irina Sharma, a manager who had technical understanding of the job, strong people skills, and a desire to improve.  All three factors proved to be invaluable in driving success.
  

• We got organized: From the very beginning, Irina embraced the project and began by observing the staff in a non-threatening manner.  She identified system related defects – for which staff were not responsible. We collected data, created a project charter, and brainstormed for change ideas among ourselves.
  

• We began communicating more: We hear about open and transparent communication quite often, but implementing it is a different ball game altogether. At the time we began the telephone exchange project, we came across a familiar challenge.
  
  As was typical for our organization at the time, most discussions happened in a room away from where all the action was – between the department manager and the quality manager supported by a quality officer; an experienced telephone exchange officer was brought in occasionally.
  
  We changed that. 

1. We began snorkeling! Around this time I made a trip to the IHI headquarters in Cambridge, Massachusetts to help teach the Improvement Advisor program to a new cohort. I was desperate to succeed in my third project and shared details with Ron Moen and Jane Taylor, the senior faculty who I was assisting.
   
   They suggested that I re-think how the front-line staff was being involved in the project and pointed me to “Transforming Care at the Bedside How-to Guide: Engaging Front-Line Staff in Innovation and Quality Improvement”.
   
   This is how I got introduced to the Snorkel: a valuable process, not only for generating new ideas for testing, but also as a powerful way to engage the hearts and minds of frontline staff.

While still in the US, I spoke to my project team and requested them to ask the telephone exchange staff to help reduce the missed calls. Irina called for a meeting of all telephone exchange staff without a specific agenda.

Mid-Journey Roadblocks
The meeting was held in a typically formal manner with the manager doing most of the talking.  It failed as the staff did not participate in the discussion. This was the first time the management was asking the staff for their opinion and the staff was a bit suspicious.

We were disappointed with the initial failure but we brainstormed again and set up another meeting – this time for generating ideas for reducing missed calls at night. The project team had already come up with a list of change ideas for reducing missed calls during the day and believed that they had covered everything; moreover, they felt the frontline staff would not be able to add anything further.

Simple Fixes for Large Obstacles: A Snorkel in Action
For the next meeting, we created an informal round table set up with the manager, a quality officer, and our telephone exchange staff.

The manager started the meeting by sharing what was working well in the telephone exchange and acknowledged the defects in the present system. She assured the staff that the idea of the meeting was not to point fingers but to understand system-related issues. Tea was served. The manager acted as a facilitator and the quality officer, Zorba Bahlvi, took notes. A change in the meeting format led to the staff feeling relaxed. Once the first staff member started talking, others joined in.

Though the meeting had been called to get ideas to reduce missed calls at night, the staff became so engaged, they also offered ideas to reduce missed calls during the day with solutions that hadn’t occurred to anyone in the project team. At this point I realized the power of the frontline staff – they bring insights that nobody else can.

With the help of the frontline staff, we regenerated a list of change ideas. Some of the changes were implemented immediately – these were the “just do it” sort of ideas that required little effort and seemed like “no-brainers”. For some of the other change ideas we decided to run Plan-Do-Study-Act (PDSA) to test if the change would lead to an improvement.

Did we face any resistance this time? Unequivocally, no. Because the frontline was engaged in coming up with the list of change ideas there was no resistance in testing or implementing these new ideas.

You can read more about our project in the BMJ Quality Improvement Reports!

A Happy Ending for All

By the time we were done, we were looking at results we couldn’t have fathomed before getting started.

Morale in the department shot up.  Making a change seemed to become much easier.  I learnt that working with the right partner – an engaged department manager – was essential.  I learnt the critical role of the frontline staff. I also realized the importance of persevering through multiple failures as one tries to learn effective use of an improvement methodology.  

New Beginnings

At the time of writing this post, it’s my pleasure to report to you that since the telephone exchange project, we have taken up other projects in the laboratory, emergency room, labour room, operation theatre, and outpatient department – and all are progressing satisfactorily!

Here’s to new beginnings and forging ahead! And to hearing your stories of transformation! Share with us any change initiatives that you’ve had success – or failure – with.

Deborah Kirkham is an ST5 trainee in genitourinary and HIV medicine in Health Education North West. She is currently taking time out of programme in London as a National Medical Director’s Clinical Fellow at NHS England and the BMJ. Twitter: @deborahkirkham

As a genitourinary medicine (GUM) and HIV specialty registrar with six years of postgraduate training under my belt I have seen some key developments in the sphere of service improvement. When I started as a Foundation Year 1 doctor, the concept of quality improvement (QI) was not widespread and audit remained the key player. The improvement landscape has evolved quickly and audit is now often viewed as inferior to QI.

The “Learning To Make a Difference” project was a joint venture running from August 2010 to September 2011 between the Royal College of Physicians of London and the Joint Royal Colleges of Physicians Training Board (JRCPTB). It involved Core Medical Trainees (CMTs) in their first two years of broad medical speciality training participating in a QI project. The success of this pilot led to the incorporation of QI project completion into the requirements for successful sign off of CMT, but this was only implemented in 2014. The current GUM “Annual Review of of Competence Progression” (ARCP) requires participation in audit but there is no mention of QI. It is understandable therefore as an emerging addition to training programmes that QI has not yet become embedded in hospital departments across the NHS.

In GUM there is a strong culture of audit both locally and nationally. The British Association of Sexual Health and HIV (BASHH) has a national audit group and national audit programme. The British HIV Association (BHIVA) has a national audit schedule and releases regular reports as well as publishing findings in peer reviewed journals. However, we know that although audits are good at identifying areas where practice is not achieving set standards it is not always the best tool for facilitating the changes required to improve that practice. This is confirmed by research in a paediatrics department which found that over a six year period only 27.8% fulfilled the criteria for a full audit and only 22.2% of audits were re-audited (http://adc.bmj.com/content/89/12/1128.full). It is easy to see how audit can often turn into a simple exercise in data collection. (http://careers.bmj.com/careers/advice/Quality_improvement)

The key difference with QI compared to audit is that the focus is on identifying a problem, engaging with stakeholders to try out solutions, and using continuous measurements to identify what is working and what unintended consequences there may be. The data collected is to support the improvement process as opposed to being the raison d’être of the project.

Although there are undoubtedly individuals with a passion for QI within GUM and HIV medicine, they appear to be the exception rather than the norm. At this year’s BASHH conference only one abstract out of 254 mentioned QI methodology and similarly at the BHIVA spring conference only one abstract out of 208 described QI methodology. We appear to be excellent at identifying what the problems are, but less well equipped to address them in a logical, consistent, and sustainable manner. Encouragingly in September 2015 BASHH launched the Trainees Collaborative for Audit, Research, and Quality Improvement Projects (T-CARQ)

(http://www.bashh.org/BASHH/Education/Doctors_in_Training/BASHH/BASHH_Groups/Doctors_in_Training.aspx?hkey=8b7f91a3-36b0-423f-8373-61d68c14fb12). This may be a sign that the wheels of change are turning and trainees are leading on the promotion of QI within the specialty.

Searching through BMJ Quality Reports, sexual health and HIV are not well represented. There was only one report about sexual health which describes improving the sexual health of patients in stroke rehabilitation (http://qir.bmj.com/content/4/1/u207288.w2926.full?sid=4f6c6935-e453-4ebf-8a4b-9fe6827590a0), and another single project about HIV which discusses the improvement of data management in the Portugese HIV surveillance system (http://qir.bmj.com/content/4/1/u209037.w3663.full?sid=db3683f4-a460-4c36-be0c-732523ed4664). There were no results at all for the keywords “GUM” and “genitourinary,” and no mention of common infections like chlamydia, genital warts, herpes, candida, or bacterial vaginosis.

There are some barriers to the initiation of QI projects in sexual health. Many departments are small with only one or two consultants, and may not have any junior doctors working within them. This can be problematic for two reasons: firstly, small departments may not have staff availability to invest time in developing new ways of service improvement, as well as keeping up with all the mandated national audits; and secondly, it is often junior doctors who do the majority of work in both audit and QI projects. Furthermore, a department without juniors may not be aware of the benefits of QI methodology. Larger departments on the other hand may feel tied to audits by tradition and expectation.

Happily there is lots of opportunity for QI in sexual health. The robust multidisciplinary team working lends itself to the methodology of QI where stakeholder engagement is vital for the success of projects. The patient group is typically young with ideas and opinions that can easily feed into projects. While clinical outcomes and clinician experience is important the specialty of sexual health is perfect for focusing on patient experience. QI has a great opportunity to really make a difference.