Judy Howarth has been involved in dementia care for more than 20 years and getting more passionate about it the older she gets. Judy is the dementia lead for North Bristol Trust, but is also involved with memory service and research into treatments and care of people with dementia. This project was highly commended at the BMJ Awards 2015.

Getting married during my psychiatry placement as a medical student was bound to have affected my knowledge in this area. My psychiatry textbook had intimated dementia was a diagnosis where no help other than placing the person with dementia in an institution was appropriate, and when I first started work in dementia care there were two books, some Alzheimer’s Society leaflets, and little else to give carers. There were no drugs, little support, and certainly no information on “Living well with dementia.” The information superhighway did not exist.

How things have changed! Now every clinical service supports their own website and there are innumerable organisations which provide information and advice on coping with dementia.

So what should we be telling people with dementia and their carers in an acute Trust?

Admission to hospital often marks a significant milestone on the journey when the direction of travel may change. The person with dementia is understandably anxious when in a strange place, but their carer and family are also anxious and often for different reasons. The national CQUINs for dementia recognise this and include a requirement to support carers.

In our acute hospital Trust we already had a good dementia intranet through which staff could access the Alzheimer’s Society and our local carers centre. However, answering carers’ requests and understanding their needs are usually done by junior staff on the wards. Even senior staff will not be aware of all available services and information to provide comprehensive assistance.

As the local dementia lead I had a better idea than most, but couldn’t cope personally with 250 people with a diagnosis of dementia at any one time. I was aware however of the memory cafés operating locally. The ethos of a memory café is of a safe place where people with dementia and their carers can discuss their needs and receive information and support from people who are specialists in the area of care provision and local services. Negotiating the labyrinth of information, as with going through Spaghetti Junction for the first time, is much easier with local guides.

So the idea of a memory café in an acute Trust was born and has been running on a weekly basis for 18 months. After an initial period of reluctance the Alzheimer’s Society enthusiastically supported the service. The café is staffed by two dementia support workers from the Alzheimer’s Society who bring a wealth of experience, leaflets, and other resources. A member of the Trust dementia team is also present. The café is held in a public area between two complex care wards with a high proportion of patients with dementia. Cake and tea are available together with a private area for people who are distressed. We are proactive in approaching people walking through this area and many will stop and request information because of this.

Carers receive an invitation when the cognitive impairment care bundle is started for each patient; the café is advertised in the hospital atrium and also in the hospital newsletter.

There is a steady stream of visitors throughout the two hour café presence. In the first few weeks we were surprised at the number of hospital staff who visited. Many of them were carers in their private lives welcoming the opportunity to obtain information they could not usually access because of their working hours. This led us to develop a connection with the staff wellbeing team so that we could advise on their rights as carers as well.

Carers make up the vast majority of those who now come to seek information and support. Their needs are varied but often focus around the discharge process, understanding continuing healthcare applications, and how to choose a care home.

It has been helpful that much of this support is provided by people who are not Trust staff as they are seen as impartial in this process. Helping people being pressed to identify a suitable care home in a few days to understand that acute Trusts are not making the rules, but trying to interpret national guidance, has been useful in defusing anger. We can use our carer support workers to identify and support people who are most distressed; again, they are impartial members of the team who work for carers support services.

In addition to providing information the Alzheimer’s Society staff may link people into external support groups and will often arrange to visit them at home to continue the care and support. In the first year we saw over 320 attendances at the café, which has also become a space to encourage volunteers, a reception point for Twiddlemuffs, a sampling point for feedback on our services, and most recently a place to provide meaningful activities away from the ward for people with dementia.

Hopefully like marriage, the mutual support provided in the café will allow it to thrive and develop with age, perhaps down unforeseen paths, like my unexpected career in dementia despite my lack of psychiatric knowledge.

Watch BMJ Quality’s short film about the success of a memory café here:

https://www.youtube.com/watch?v=f6BmoRvtXUE

Dr Paul Bowie is programme director for safety and improvement at NHS Education for Scotland. Twitter: @pbnes

“Checking” is endemic in healthcare the world over. It is a routine everyday activity in all care settings and is fundamental to maintaining patient safety. Checking tasks go well in the great majority of cases and do contribute to a successful outcome for the patient. However, sometimes they do not, and this may lead to things going wrong that contribute to patient safety incidents – circumstances where patients could have been or were harmed. Unfortunately some of these incidents can and do have a devastating impact on the wellbeing of patients and families, as well as the care professionals involved.  

Minimising the risks of such occurrences is obviously a major safety priority. Even so, this can be very difficult to achieve given the sheer complexity of care systems and the everyday constraints that care teams often work within (eg high workloads, increasing patient demand, and limited resources). The skill and dedication of care professionals in constantly coping and adapting to these ever changing circumstances convincingly explains why things normally go well for patients, but also why sometimes they do not (see the work of Erik Hollnagel or Sidney Dekker for example).

The use of “checklists” is promoted as one approach to standardising working practices to make care systems more reliable and contribute to patient safety.[1] A checklist is a cognitive tool that may help care teams to ensure that safety critical tasks (including communicating effectively with each other) are actually carried out. Perhaps the most well known example in healthcare is the WHO Surgical Safety Checklist which is now mandated in over 150 countries worldwide.[2]  

Barriers to checklist use

The safety checklist is often seen as a simple, practical solution – even a panacea – in making sure that highly important patient care tasks are actually performed and performed on time.[3,4] The evidence base, however, shows a different reality.[3,5-9] Checklist adoption by staff groups and subsequent impacts on enhancing patient safety are fairly mixed. In some ways this is no great surprise. In the risk management world, the “hierarchy of intervention effectiveness” rates human behaviour dependent interventions such as checklists, doublechecks, and reminders towards the bottom of its scale.[10]  

A range of reasons for this are now apparent. Prime among them is that the checklist can be viewed as an inadequate “technical fix” to what is a “complex socio-cultural problem”. In other words, individual “checking” behaviours and intentions are influenced by the “social group” that people belong to, as well as local healthcare practices, values, beliefs, and traditions.  Therefore, adoption is often dependent on how seriously the issue of “checking” is taken within a team or organisation, particularly in complex and dynamic working environments. Potential users may also resist or feel threatened by checklists because they are perceived to replace their expertise or decision making, or oversimplify the complexity of work.  

Checklist success factors

On the other hand, checklist success is associated with a number of important factors in combination; it will have limited impact as a solo intervention.  Firstly it needs the commitment and the support of healthcare leaders and local promotional champions.  Success is also more likely where step by step instructions for simple or straightforward technical tasks are necessary and where staff already know that variations in checking performance exists. There is also the fact that reliance on human memory is a problem in a busy working environment.  

Importantly, any checklist should also be flexible enough to enable users to apply “common sense” judgements, otherwise it will be considered an irritation and remain unused. Checklists that are externally imposed and lack adaptability to suit local contexts can struggle to be fully accepted and implemented effectively. Ultimately, it should have a greater chance of adoption and sustainability where there is frontline consensus that checklist use is highly relevant, that it is feasible to use routinely, and is an improvement on how work is currently done.

A safety checklist for general practice?

So, given all that we know about checklists and their impacts in secondary care, why embark on such a development for the UK general practice setting?   

Well, firstly there is a potential “checking problem” in general practice. This is not at all surprising given workload pressures, the complexity and uncertainty of care, and the volume of checks that are required to be carried out on a daily, weekly, monthly, quarterly, and annual basis to help the team run the practice safely and efficiently. General practice managers and nurses in particular will all attest to that!  

Although the safety evidence base is limited in this area,[11] most who work there will be able to recall different incidents happening (and recurring) that involved a failure to check safety critical issues, or (probably more likely) when necessary checking tasks were not performed on time. Examples would include: patients with the same name being mixed up, emergency drugs being out of date when required, employing clinicians who are not currently registered to practise, emergency equipment not working or adequately calibrated, IT systems not being routinely backed up, and so on.Secondly, although numerous safety checks are always carried out, it often seems to be done in an ad hoc manner – that is, there is a lack of standardised, timely and consistent checking processes in many general practices. Again this is unsurprising.  Most practices will have limited knowledge or experience of taking a ‘systems approach’ to identifying and routinely checking safety issues of importance, measuring performance and implementing any necessary improvements.

As a starting point to understanding this issue more clearly, NHS Education for Scotland worked closely with GP managers, nurses, and doctors to identify and prioritise a comprehensive range of safety hazards across the whole working environment (box 1). This in turn informed the design of an integrated checklist; although we’ve labeled it a “checklist” it would probably be more accurately defined as a global checking system.[12] The consensus is that it would need to be applied at least every four months. Pilot testing estimated that this would take around two hours to complete, which was deemed feasible and is arguably more manageable when compared to some checking processes that are in place.  

A way forward?

It is perceived to be a very necessary intervention by those involved in the initial study, with many frontline practitioners and safety improvement decision makers, who have since attended related workshops or conference presentations, also agreeing. The RCGP clearly recognises its potential value and have included it in their recently launched national patient safety toolkit.[13]   

To some extent the most straightforward part has been achieved. The real difficulty comes in developing the checklist further to make it easier to use and implement in busy practices – this is currently under discussion with colleagues in Healthcare Improvement Scotland. The idea of using a tablet or similar device to assist users is being given serious consideration, although introducing another technology potentially raises a set of other problems.  

Importantly, how the checking process is designed, promoted, implemented, used, and supported as a patient safety intervention will largely determine its fate – we will need to understand if and how it works and why. If most GP teams believe it to be helpful and an improvement on how everyday work is currently carried out then there is hope for success.  However, if most believe it to be a hindrance then… 

Suggested reading:

1. Catchpole K and Russ S. The problem with checklists. BMJ Qual Saf 2015;24:545-549 doi:10.1136/bmjqs-2015-004431
2. Bosk CL, Dixon-Woods M, Goeschel CA, et al. The art of medicine: reality check for checklists. Lancet. 2009;374: 444–5.

Box 1. Selected examples of identified potential hazards in the general practice work environment which informed development of checklist content

References

1. Haynes AB, Weiser TG, Berry WR, et al. . A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491–9.
2. World Health Organisation. Implementation of the surgical safety checklist. WHO, Geneva; 2008.
3. Catchpole K and Russ S. The problem with checklists. BMJ Qual Saf 2015;24:545-549 doi:10.1136/bmjqs-2015-004431.
4. Bosk CL, Dixon-Woods M, Goeschel CA, et al. The art of medicine: reality check for checklists. Lancet 2009;374: 444–5.
5. Fourcade A, Blache J-L, Grenier C et al., Barriers to staff adoption of a surgical safety checklist.  BMJ Quality & Safety 2011 doi:10.1136/bmjqs-2011-000094.
6. Hillgoss B & Moffat-Bruce S.  The limits of checklists: handoff and narrative thinking. BMJ Qual Saf 2013;doi:10.1136/bmjqs-2013-002705.
7. Ko HCH, Turner TJ, Finnigan M.  Systematic review of safety checklists for use by medical care team in acute hospital settings – limited evidence of effectiveness.  BMC Health Services Research 2011;11:211.
8. Gillespie B, Marshall A. Implementation of safety checklists in surgery: a realist synthesis of evidence. Implementation Sci 2015, 10:137.
9. Russ SJ, Sevdalis N, Moorthy K, Mayer EK, Rout S, Caris J, et al. A Qualitative Evaluation of the Barriers and Facilitators Toward Implementation of the WHO Surgical Safety Checklist Across Hospitals in England Lessons From the “Surgical Checklist Implementation Project”. Ann Surg 2015;261(1):81–91. doi:10.1097/SLA.0000000000000793.
10. Caffazo JA, St-Cyr. From discovery to design: the evolution of Human Factors in healthcare.  Healthcare Quarterly 2012:(Vol.15 Special Issue);24-29.
11. Health Foundation. Evidence scan: levels of harm in primary care (2011). Available at: http://www.health.org.uk/publications/levels-of-harm-in-primary-care/ [Accessed 25th September 2015]
12. Bowie P, Ferguson J, Macleod M, Kennedy S, de Wet C, McNab D, Kelly M, McKay J, Atkinson S. Participatory design of a preliminary safety checklist for general practice. Brit J Gen Pract 2015; 65(634) DOI:10.3399/bjgp15X684865
13. Royal College of General Practitioners. Patient Safety Toolkit for General Practice. http://www.rcgp.org.uk/clinical-and-research/toolkits/patient-safety.aspx [Accessed 11th November, 2015]

Jean Slepian has been a community hospital librarian in the Northeastern United States for 37 years, with special interests in health policy and advocacy

I have been a medical librarian for nearly 40 years, and in that time we have seen a 180 degree turn-about in regard to healthcare “quality”. In the old days we never questioned the quality of medical care. In fact, such blasphemy might get a person fired. In the late 1990s we were shocked out of our oblivion by a scorching report on medical errors from the National Academies Institute of Medicine, To Err is Human.[1]  Thus began the long and arduous journey toward healthcare quality. Today we measure quality with objective indicators, such as the number of readmissions after acute care hospitalization and whether patients receive appropriate discharge instructions. Have we made progress?

On the road to quality nirvana we have encountered several gurus…the first was W. Edwards Deming, the “father” of total quality management. Largely credited with the revitalization of industry in post-WW II Japan, Deming had a 14 point plan to achieve quality. Point 10 is to “Eliminate slogans and exhortations.” One of our more recent quality gurus, Quinton Studer, has lots of catchy slogans and mnemonics to inspire quality, and I tend to favor Deming’s approach. He also said, “It is wrong  to suppose that if you can’t measure it, you can’t manage it – a costly myth.”[2]

In the past year several controversial studies have been published that seem to suggest that we may not be measuring what we think we’re measuring with objective quality indicators. In the Journal of the American Medical Association (JAMA) last February a study was published that found no difference in  inpatient complications and mortality between hospitals that participate in the National Surgical Quality Improvement Project, and hospitals that don’t participate.[3] Another study published in the same issue[4] found no difference in outcomes or expenditures for Medicare beneficiaries between hospitals that participate in NSQIP and those that don’t.

A study by Howell[5] published in JAMA in October 2014 found no correlation between two obstetric quality indicators and maternal/neonatal morbidity. In the same issue, a study by Neuman[6] of Medicare beneficiaries released to skilled nursing facilities after acute care hospitalization found no consistent association between skilled nursing facility quality indicators, and readmission or death.

In the “softer” medical literature I detect a growing dissatisfaction with the objectification of quality, and the depersonalization of patient contact with use of the electronic medical record.

Chi and Verghese [7] refer to the”iPatient” and state, ” …the abundance of dropdown menus on the EHR and the compulsion to leave no box unchecked often creates a neat construct of a patient that can be a meta-fiction. This construct is often at odds with the real patient…not always accurate in the sense of the patient’s story or the manifestations of illness on the patient’s body.” Wu[8] sadly characterizes himself as a “kind of virtual doctor”, prizing “efficiency over human contact, computerized data over stories, virtual reality over authentic life.” Patel[9] painfully relates an experience in the ER when he overlooked a patient in frank respiratory failure because of his pre-occupation with her electronic history.

Dr. Charlotte Yeh relates her experience[10] after being hit by a car when emergency department providers put quality metrics before her actual needs. Dr. Patricia Gabow, a former healthcare executive and chief medical officer[11], found that when her mother was injured in a fall, the standardized care she had always advocated was not appropriate.

In the medical library business these days, “quality” seems to equate to the number of online resources we make available to our patrons, but do we really know if patient outcomes are better when providers have instantaneous access to the medical literature, or is that just a logical yet possibly erroneous assumption?

Indeed, sometimes it seems that in our quest for the perfect data driven measure, we have devolved to the point where “quality” and “compassion” are mutually exclusive concepts.

However, I believe that we can manage quality without objectifying it into tiny measurable bites. I believe that there is someone out there who is smart enough to do it – please let us hear from you!

References

1. Committee on Quality of Healthcare in America: To Err is Human; Building a Safer Health System. Washington, D.C.: National Academies Press, 2000.
2. Deming, WE. The New Economics; Cambridge, Ma:  MIT Press, 2nd ed, 2000.
3. Etzioni DA, et al. Association of hospital participation in a surgical outcomes monitoring program with inpatient complications and mortality. JAMA 2015 Feb 3; 313(5): 505-511 .
4. Osborne NH, et al. Association of hospital participation in a quality reporting program with surgical outcomes and expenditures for Medicare beneficiaries. JAMA 2015 Feb 3;313(5):496-504.
5. Howell EA , et a. Association between hospital–level obstetric quality indicators and maternal and neonatal morbidity. JAMA 2014 Oct 15;312(15):1531-41.
6. Neuman  MD, et al. Association between Skilled Nursing Facility quality indicators and hospital re-admissions. JAMA 2014 Oct 15;312(15):1542-51.
7. Chi J, Verghese A. Clinical education and the electronic health record: The Flipped patient. JAMA 2014 Dec 10; 312(22):2331-2.
8. Wu D. Virtual grief. JAMA 2012 Nov 28;308(20):2095-6.
9. Patel JJ. Writing the wrong. JAMA 2015 Aug 18;314(7):671-2.
10. Yeh C. ‘Nothing is Broken’: For an injured  doctor, quality–focused care  misses the  mark. Health Aff (Milwood) 2014 Jun :33(6);1094–7.
11. Gabow P. The Fall: Aligning the best care with standards of care at the end of life. Health Aff (Milwood) 2015 Jun 34(5):871-4.

Deborah Kirkham and Jessamy Bagenal, clinical fellows to The BMJ.

It’s less than three weeks to go until the 2015 Agents for Change conference on Saturday 24^th October, co-hosted by NHS England, the BMJ, and the Faculty for Medical Leadership and Management (FMLM) (http://careersfair.bmj.com/registration/agents-for-change).  This is an event for junior doctors and other healthcare professionals, planned and implemented by junior doctors.  The conference title ‘Time to Listen. When to Speak Up’; describes listening to patients and colleagues, building resilience within teams, and knowing when and how to speak up, whether this is celebrating successes or raising concerns.

The conference themes are topical given the publication earlier this year of the ‘Freedom to Speak Up’ report, an independent review led by Sir Robert Francis into creating an open and honest reporting culture in the NHS.  This review followed the ‘The Francis Report’ in 2013, where serious failures in care became part of the culture at Mid Staffordshire NHS Foundation Trust.  Junior healthcare professionals are in a position to view organisations with fresh eyes and are perfectly placed to compare practice; highlighting areas of excellence and areas of improvement.

We have some big names speaking at the conference and running workshops throughout the day.  Opening the conference is the Medical Director for NHS England, Professor Sir Bruce Keogh, a staunch supporter of junior doctors and the skills and insights they bring to the NHS.   We also have lectures from Professor Wendy Reid, Director of Education and Quality at Health Education England, and James Titcombe OBE, who fought for answers after his baby son tragically died.  His endeavours led to the establishment of the Kirkup report into maternity and neonatal services.  He now works for the Care Quality Commission as their National Advisor on Patient Safety, Culture, & Quality.  Peter Lees, Chief Executive and Medical Director of the FMLM will deliver a talk on leadership for the future. We have further sessions on situational awareness, resilience, values and making change happen.

We will also have workshops covering a wide variety of topics, from quality improvement, patient involvement in projects, engagement of junior doctors, and the controversial junior doctor contracts.

The event is organised by fellows from the National Medical Director’s Clinical Fellow scheme.  These are doctors in training taking an out of programme year to work in organisations across the wider healthcare landscape, from regulatory bodies to the private sector.  The conference provides a great opportunity to meet the fellows, and find out more about the scheme and its application process.

The ticket price of £35 (early bird until 16^th October) includes:

1. The whole day conference including entry to the poster competition – be quick, abstract submission closes on Thursday 8^th
2. Entry to ‘The Big Debate’ pre-conference event on Friday 23^rd October, where clinicians including Clare Gerada, former RCGP President, will debate the motion “This house believes that medicine is the best career in the world”.  With the NHS being high on the political agenda, we can expect some heated discussions
3. Access to BMJ Quality – an online workspace that supports healthcare professionals through quality improvement projects and how to get them published.  Ten hours of online learning resources, online mentoring, and a 50% discount on costs of publication for all submissions within six months of the conference.

We think it’s a great deal and look forward to welcoming you on the 24^th October.  It promises to be an inspirational day. We hope you will leave with increased confidence and optimism about your future role in delivering excellent healthcare.

Sign up for the conference and submit your poster abstracts here: http://careersfair.bmj.com/registration/agents-for-change

Charlotte Mitchell (public health researcher) and Dr Joe Bourdillon-Schicker (BBT ST1 doctor) recently completed a six month Improving Global Health Fellowship[1] in South Africa.

In February last year we exchanged the grey, British winter for African surf and sunshine, and our jobs in the NHS for work in a far less-developed and less well-resourced health system. We have spent the last six months on a quality improvement Fellowship in South Africa’s Eastern Cape, based in the Internal Medicine department of a 737-bed district hospital.

On arrival we found both a department with some very capable and inspiring clinicians, but also an overstretched and under-resourced environment in which staff quickly became demoralised by the setting and its associated challenges.

Our fascinating challenge was therefore to consider how to help change the departmental culture to incorporate a quality improvement approach. The Lead Consultant was keen to introduce mandatory ‘system strengthening’ projects for interns (junior doctors) to conduct during their rotations. We felt that the quality improvement approaches used back home could contribute to this, so we embarked on facilitating a series of workshops and presentations.

As well as engaging with the department as a whole, (through brief, weekly QI presentations) we held weekly workshops for interns. At these workshops we introduced the Model for Improvement and as their individual projects progressed, we worked through PDSA cycles, fishbone diagrams, process maps, and suchlike.

We were delighted by the response from the doctors. Workshop attendance was high and they engaged well with the sessions and tools. Each intern progressed with a project and a number have already achieved demonstrable outcomes, with some completing PDSA cycles during the three months that we worked with them, while others were tackling more long-term projects.

However, this was not without some challenges. In particular we had to strike a balance between allowing interns time to choose and develop their projects, and encouraging them to get going quickly (to enable them to complete a PDSA cycle within their four months in the department). Senior doctors are key for the projects’ sustainability as they ensure continuity between batches of interns. However, we struggled to find hooks and ways to involve senior doctors, but this is something the new Fellows are working on.

Overall, interns’ feedback indicated that they enjoyed the support and sessions with us, and felt that they had developed knowledge and understanding. Particularly interestingly, their involvement in QI projects seemed to improve how they felt ab
out the department; their increased understanding of systems issues seemed to reduce their frustrations with them and gave hope for improvement.

It seems that our support has helped the department to move towards developing a system strengthening culture. It will take time but with encouragement from local staff and future IGH Fellows, we are sure that a quality improvement approach will be highly beneficial to the clinicians and patients. Furthermore, staff there are keen to spread their approach and learning to other departments and hospitals in the district.

Through being involved in this process and other QI work in the region we have gained an understanding of some more general strengths and challenges of quality improvement in this setting. In particular:

• The need for time and support – We all know in theory that people need time and encouragement to change. This is certainly the case in practice: the three months that we had to work with this particular group felt extremely tight. Added to this, we had a lot of time to put into this project: a lot more time than the majority of clinicians have
• Motivation and morale – It is great to see hard outcomes from particular quality improvement projects, but actually for us the most rewarding outcomes were more intangible ones such as improving the morale of the interns
• Theory and practice – Models and tools, such as the Model for Improvement, fishbone diagrams, and process maps can provide useful frameworks and prompts. However, we had to be very careful to avoid bombarding people with dry, managerial speak. Substantial flexibility was needed in our use of them it was important not to become too focussed on the tools and measurement
• A team quality improvement journey – Discussions, support from each other and thinking through possible issues and solutions seemed crucially valuable elements for the doctors.

Our Fellowship in South Africa has shown us that a quality improvement approach – in this case using the Model for Improvement – can be helpful for tackling the challenges of a resource-poor setting in Southern Africa. As a final reflection, our work here was about people and our successes were not just about numbers of quality improvement cycles but were around clinicians opening up to changing the scope of their role and taking ownership of issues and their improvement.

[1] http://www.tvwleadershipacademy.nhs.uk/improving-global-health

Dr. Ayodeji Morah is a general adult psychiatry registrar in Central and North West London (CNWL) NHS Foundation Trust.

The Care Quality Commission is the independent regulator of health and social care in England. It inspects all registered care providers on a regular basis to ensure that safe and effective care is given to patients in a caring, comforting and supportive environment. A team of inspectors would typically consist of nurses, doctors, social workers, and other relevant professionals who are experienced in their respective fields. Depending on inspection ratings, if a care provider is failing to provide an acceptable and standardised level of care then the CQC has the power to restrict the provider’s registration, fine them, or restrict the type of care a health or social care provider can give.

An impending Care Quality Commission (CQC) visit to any trust expectedly tends to cause a lot of anxiety amongst all staff members working in a trust. This is more so among doctors because although we are experts in the medical care of our patients, patient driven safety protocols on the wards or in community mental health teams (as well as other administrative and managerial information that doctors tend to be less sure about) will more often than not make doctors worried about an inspection. Central & North West London (CNWL) NHS Foundation Trust had its CQC inspection in the last week of February this year. The trust was well prepared for the inspection but both senior and junior doctors expressed concerns regarding the nature and type of questions they could be asked and what was generally expected of them.

Bearing this in mind, Dr. John Lowe, director of postgraduate medical education at CNWL, got into talks with the directors at the trust’s quality and service improvement department to discuss how best to address the aforementioned problems. Registrars were then contacted to determine who could help. Two other registrars and I indicated interest and were tasked with developing a factsheet for doctors that would contain a list of questions that were likely to be asked by a CQC Inspector.

Getting the required information:

I took a lead on this because in 2013 while I was working as a specialty doctor for another trust in London. I had been interviewed by CQC inspectors and had a fairly good idea of questions and concerns that they would want both inpatient and community team doctors to address.

First of all I visited the CQC website and also called the CQC to make informal inquiries. I then called or met up with four previous colleagues (two senior doctors and two nurses) who had worked with me at my previous trust to discuss the factsheet. They recalled questions they had been asked and also gave me tips on how they answered difficult questions.

I compiled a list of questions based on the aforementioned sources as well as my previous experience and submitted the questions to the associate director of the quality and service improvement department. The service and quality improvement department had staff members who had also previously worked in other trusts that had been previously inspected by the CQC. One of their managers had actually previously been a CQC inspector. The quality and service improvement department were thus in a position to review our questions and filter out the ones that did not need to be included in a CQC doctors factsheet. The other two registrars drew up and submitted questions which they thought would be pertinent.

A CQC Factsheet for Doctors was subsequently produced in late January. The factsheet had several headings and had relevant questions under each heading that a doctor working on a ward or in the community could be asked by a CQC inspector. The factsheet was published in the trust’s weekly newsletter on the 30th January 2015, three weeks before the CQC inspection. It was also emailed to all the trust managers, directors, and doctors. Each medical team in the trust discussed relevant parts of the factsheet and produced answers that reflected their practice.

Feedback:

Even before the visit, we started receiving positive responses from doctors working all over the trust about how useful the factsheet was. The director of post graduate medical education was impressed by and suggested that I try to get it published so that other doctors working in other mental health trusts could use it to get themselves ready for a CQC inspection. I think what really topped the good feedback we got before the visit was the even better feedback we got after the visit from various consultants and senior doctors. They said that they had been asked most of the questions in the factsheet and felt that the trust had really been supportive of its doctors by producing such a factsheet.

I am currently trying to liaise with the quality and service improvement department to determine a way to objectively measure the feedback we got regarding the factsheet, and possibly produce a quality improvement report based on the feedback. To take a look at the CQC Factsheet for Doctors, just click here.

Beth Lilja is the CEO of the Danish Society for Patient Safety.

Men did not get access to the delivery ward because obstetricians and midwives invited them to take part; they got access to be present and take part in their children’s delivery because the mother wanted them to be there. They were invited inside because it was a priority for the women’s movement and because a few friendly supporters from inside healthcare thought it was the right thing to do.

History has showed that the power of social movements is enormous. These days, we are celebrating the 100th anniversary of Danish women’s right to vote, or as the women’s movement is expressing it, “We did not get the right to vote – we took it.”

So how can this force to create change be used to improve healthcare? How do we change the balance of power between the system and the people? Several initiatives currently take place using this method. NHS Change Day (changeday.nhs.uk) is one example. On March 11^th, hundreds of NHS staff, patients, carers, and friends pledged the actions that they are taking to make a change for the better in health and care. Change Day now takes place in a number of countries across the world – Great!

Hello Healthcare is another initiative inspired by social movements. Hello Healthcare is mobilising patients, their carers, and friendly supporters from inside healthcare to create the power they need to reach a shared purpose of patients and family centeredness.

So what does this take? Knowledge, courage, and people!

Knowledge is power

We know that when the patients are fully informed about treatments, risks, and side effects, they often choose differently than their doctors’ routine recommendations. Unfortunately we also know that one out of four patients has unanswered questions and concerns when discharged from the hospital (“Patients’ perceived barriers in communication with the staff – A questionnaire among patients”, Center for Patient Experience and Evaluation, The Capital Region of Denmark for Hello Healthcare, 2014). We therefore need to empower patients to have a say in decisions; to create a new norm that supports that.

Far too many patients experience that when they come home after an outpatient visit all the questions that they could not think about in the clinic suddenly pop up in their head. This is why Hello Healthcare has developed a tool Just Ask – a small booklet of questions other patients have found helpful in their care, such as, “Could you please explain it another way?” “Is there an alternative?” and “Could my wife be present during rounds?”

This tool is distributed through many channels: digital media, at TV screens in hospital waiting rooms, soon also in pharmacies, and in August one region will run a 12 second video about the questions in all the public buses.

Strong patients and healthcare staff that are “friendly supporters” (ie our patient ambassadors) help kick start this change. As a strategic communication action our ambassadors are important. They give their personal advice in public and recommend patients to speak up about what matters to them.

The idea is that if more and more patients and their carers meet healthcare with the expectation that it is legitimate to be part of the decision making, healthcare will accommodate and eventually welcome and stimulate active and engaged patients. In the beginning, the resourceful patients will act as ice-breakers for the less resourceful patients.

Hello Healthcare works in partnerships with people and organisations who share our vision, and in this way the initiative will grow over time to become a powerful movement. We work closely together with partners such as the Danish Medical Association, Junior Doctors, Danish Nurses’ Organization, The Cancer Society, and a number of leading patient organisations.

We believe stories have the power to change the world. We want to give the patients a voice. To increase patient safety by collecting and sharing experiences, advice, knowledge, tools, and inspiration that will help you, as a patient or relative, to avoid mistakes and reduce silent misdiagnosis.

On Facebook, patients tell their own story, and read and comment on other patients’ stories. This is how we build the sense of togetherness, common purpose, and involvement which we believe to be essential.

The next revolution

In the old days, women demanded to have their men with them at the delivery ward. It is a story with a happy end because the men gained access. The men, of course, know the women better than the staff.

Nowadays, many patients demand to see a development of the relationship with healthcare. Patients want a say. And we believe patient safety and quality will improve as a result. So let’s change the balance of power. Let’s create a new norm where it is natural for patients to say, “Hello Healthcare – this matters to me!”

Hello Healthcare is a cooperation between Danish Foundation TrygFonden and The Danish Society for Patient Safety.

References

1. NHS Change Day http://changeday.nhs.uk/
2. “Patients’ perceived barriers in communication with the staff – A questionnaire among patients”, Center for Patient Experience and Evaluation, The Capital Region of Denmark for Hello Healthcare, 2014.

Dr Rory Conn, Darzi Fellow in quality improvement and patient safety, and ST5 child and adolescent psychiatry, Great Ormond Street Hospital

In 1994, aged just 40, Boston healthcare attorney Ken Schwartz was diagnosed with advanced lung cancer. Over a 10-month ordeal, Ken documented his key reflection: that what matters most during an illness is the human connection between patients and their caregivers. His writings urge healthcare professionals to stay person-centred – it is “the smallest acts of kindness”, he argues, which can make “the unbearable bearable.”

Schwartz recognised that patients are increasingly complex and their care more fragmented. Drives towards greater efficiency and cost savings, alongside greater population disease burden result in relationships between staff members and between staff and patients which are more short-lived; care under these circumstances can become rapidly depersonalised.

Increasingly, we acknowledge that all staff members are affected by the emotional demands of caring for patients, whether they are frontline clinical staff, associated healthcare professionals, or non-clinicians. Rates of work related anxiety and depression are high; recent studies revealing that staff absences for mental health problems have doubled in hospital trusts across England in the past four years alone. The knock-on effects can be startling. Staff “burnout” in the form of emotional exhaustion and depression leads to low work satisfaction and a decreased sense of personal effectiveness, alongside a deterioration in the quality of care.

After his death, the Schwartz Center for Compassionate Healthcare was established. Its mission is simple but compelling: to promote compassionate care so that patients and their caregivers relate to one another in a way that provides “hope to the patient, support to caregivers and sustenance to the healing process”.­­­­­­­

Generally speaking, staff are unaccustomed and unprepared for reflective practice, individually and collectively. We rarely stop to consider how it feels and also what it means, to do the work we do (the stresses and rewards, the ethical dilemmas, the significance of dealing with life and death). How do we find time to recognise and discuss the processes which generate these unique environments?  What narratives do we dare to share with one another, and how?

Crucially, evidence shows that the wellbeing of our patients is highly dependent on the wellbeing of staff. In order for staff to provide compassionate care, staff must themselves feel cared for, by the organisation and each other. Schwartz Rounds address a significant unmet need.

Schwartz rounds are monthly, multidisciplinary meetings of all staff working in a particular healthcare setting. They provide an inclusive, safe, confidential, and boundaried space to reflect on the human dimensions of healthcare.

Provision of food is key: the host organisation must appeal to the most basic of its staff’s needs. The symbolism of a nurturing environment acts powerfully with the anthropological significance of sharing. There is also the analogy of “digesting” something together.

A cross-disciplinary presenting team of three or four staff members talk about a single case, or a series of cases linked by a given theme. Rounds last for an hour, half of which is given over to the panellists’ stories, half to the audience to openly share their thoughts on what they have heard. The analogy I draw is to the Last Night at the Proms. The music played (in this case the stories told by the panel) is essential, but it is the contribution of the audience that gives the event its real meaning. This is an all-teach-all-learn process.

Discussion is chaired by a clinical lead and a facilitator, both of whom have received training from the Point of Care Foundation. The rounds are not problem solving fora, nor group therapy sessions. Attendance is not mandated and the atmosphere should feel non-hierarchial and non-judgemental.

This can be seen as counter-cultural. Staff come together in a way not permitted by the majority of organisational processes, which tend to enhance disengaged, silo working. Schwartz Rounds are as much about celebrating the diversity of clinical approaches and unifying staff in common goals as they are providing a supportive environment.

Ask yourself: how frequently do I consider what other multidisciplinary team members believe about the shared work being done …. what assumptions do I carry about the views of my colleagues as well as my patients, and what drives them to do what they do?

Evidence base

In the US, more than 320 organisations have implemented Schwartz Rounds, whilst the number of hospitals and hospices contracted in the UK has passed 100.  Research shows that attending staff:

• Feel they communicate better with their patients and colleagues;
• Feel less isolated and more supported;
• Feel better able to cope with the emotional pressures of their work; and
• Understand better how their colleagues think.

Schwartz Rounds are highlighted in the NHS England Business Plan 2014 as an evidence based initiative to improve patient experience and have prominence in the Francis Report as a mechanism for improving team building and cohesiveness.

To find out more, contact The Point of Care Foundation: www.pointofcarefoundation.org.uk

References

1. Ballat J and Campling P (2011) Intelligent Kindness.

Emma is completing her second year of core surgical training (otolaryngology) in the North West deanery. She is actively involved in a variety of quality improvement projects across the Deanery and has a keen interest in clinical management and leadership.

With increasing shift work, clinical handover can sometimes merely mean the passing over of a bleep rather than the sharing of responsibility. Effective handover is important for patient care as well as benefiting the multi-disciplinary team environment. Despite the clearly recognised importance and impact on continuity of care, it is rarely given appropriate airtime on teaching programmes and ultimately not assessed as a core competence of a clinical practitioner, which could lead to bad habits and loss of emphasis on the process.

In an attempt to counter this, many professional bodies have produced guidelines on written handover documentation – however, such guidelines are often seen to be both time and financially heavy to implement. As a surgical trainee wanting the best for my patients, I spent some time understanding what messages and simple measures can be taken from these guidelines and implemented without the need for large investments in time or money.

This got me wondering, what does handover really mean and what does a good handover look like?

I worked with my colleagues to trial some ideas within my current trust, which serves a population of nearly 900,000 people across four hospital sites. My departmental team consists of six junior doctors providing 24/7 care, resulting in frequent shift changes with challenging handovers.

My ideas were based on guidance from the General Medical Council’s (GMC) Good Medical Practice, (which has a section, Domain 3, dedicated to communication: “Partnership and Teamwork”), advice from the Medical Defence Union[i], and the Royal College of Surgeons of England’s Good Surgical Practice[ii]. The main focus of the guidance is on communication and documentation.

Domain 3 has a subsection titled, “continuity and co-ordination of care”, highlighting that we must contribute to the safe transfer of patients between healthcare and health and social care providers, further specifying the following:

• Share all relevant information with colleagues involved in your patients’ care within and outside the team, including when you hand over care as you go off duty, and when you delegate care or refer patients to other health or social care providers
• Check, where practical, that a named clinician or team has taken over responsibility when your role in providing a patient’s care has ended
• You must be satisfied that the person providing care has the appropriate qualifications, skills and experience to provide safe care for the patient.

Just as important as communication is record keeping and accountability; explaining observations and actions taken. This is not only important to ensure the patient gets the best care, but also to protect ourselves since we are accountable in the following areas:

• To the profession for maintaining the standards in the General Medical Council’s code of conduct
• To the public under both criminal and civil law for the safety of patients
• To our employers under employment law.

We took two actions to work towards a best practice handover;

1. We introduced a dedicated electronic handover template (figure 2) requiring key information including patient location, responsible consultant, duty consultant, management plan and any outstanding jobs. This follows the recommendations and guidelines (figure 1) from the Royal College of Physicians (RCP)[iii], Royal College of Surgeons (RCS)[iv] and the British Medical Association (BMA)[v]

Figure 1: British Medical Association/Royal College of Physicians/Royal College of Surgeons guidelines on written handover

2. A simple monitoring exercise was conducted over four weeks where juniors were asked to sign at the start of their on-call duty if they were happy with the handover they received and felt able to adequately continue patient care. Only seven of the 28 days (25%) had handover signed by junior doctors.

Figure 2: Example dedicated handover template trialled

We undertook focused teaching sessions and incorporated a 15-minute crossover period for handover in our rotas, with registrars intermittently supervising handover to provide constructive personal feedback and ensure high standards were maintained.

A second cycle of 56 days was monitored, showing an improvement with 41 days (73%) signed.

Assuming signatures related to effective handover, our results showed improved handover with simple measures. This continuous monitoring can improve and maintain high standards of handover and is easily replicable across other departments.

Got your thoughts or ideas about handover? Join junior doctors Jennifer Perry, Avi Mehra, Christin Henein, and BMJ Quality on Wednesday 29th April 17:30-18:30 GMT for a Tweet chat as they share their experiences of handover projects. Full information available here.

[i] http://www.themdu.com/guidance-and-advice/latest-updates-and-advice/gmc-publishes-new-good-medical-practice

[ii] http://www.rcseng.ac.uk/news/new-good-surgical-practice-published-by-rcs#.VQDAxELA4dU

[iii] Metz D, Chard D, Rhodes J, Pounder P. Continuity of care for medical inpatients: standards of good practice 2004 London Royal College of Physicians

[iv] The Royal College of Surgeons of England (2007) Safe handover: guidance from the Working Time Directive working party (RCS, London) www.rcseng.ac.uk/publications/docs/publication.2007-05-14.3777986999/.

[v] British Medical Association (2004) Safe handover: safe patients. Guidance on clinical handover for clinicians and managers (BMA, London).

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

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

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

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

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

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

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

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

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

For further advice and discussion around the benefits of junior doctor led quality improvement groups, check out the following: Bethune R, Soo E, Woodhead P, Van Hamel C, Watson J. Engaging all doctors in continuous quality improvement: a structured, supported programme for first-year doctors across a training deanery in England. BMJ Qual Saf 2013;22(8):613-7.

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