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

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

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

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

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

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

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

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

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

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

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

References:

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

Dr Mareeni Raymond is a GP in London, CCG lead for dementia in City and Hackney, and Managing Editor for BMJ Quality Improvement Reports.

I’ve just returned from the Royal College of General Practitioner’s conference in Liverpool and for those of you that haven’t heard, Jeremy Hunt, MP, took on questions from hundreds of GPs, many of whom expressed dissatisfaction with their increasing workloads. I, on the other hand, took on questions from a group of enthusiastic GPs, registrars, and students who wanted to know more about quality improvement, working as a salaried GP, and working for a CCG.  For me, that was rather lovely.

The question that is asked most often is “how can a GP take part in quality improvement work at the same time as doing all the other hundreds of tasks that need to be done each day?” There are so many hurdles in the job, as well as new ones “created” by the higher powers, with more hoops to jump through to make sure that targets are reached and that practices remain financially viable. Honestly, these are excellent questions and it is true that being a GP is far from easy, especially right now.

My own answer to the question about taking part in quality improvement is a simple one, and one I feel really quite passionately about: we are taking part in quality improvement every day – and it is extremely  important to let people know about that right now.

I think people have fixed beliefs about certain job roles, such as the public perception that all their GP does is see patients. After all, what do we do in those breaks of ours, apart from visit elderly patients, read all the letters received about our patients, interpret all the results of tests, and answer telephone queries from our colleagues outside of general practice? (This list could, of course, go on). Well, we also talk about how to make things better and then we try do something about it. (Sound familiar? Check out the PDSA cycle learning module).

Every week we meet and discuss how we can improve services for patients. We discuss complaints. We talk about staffing problems. We talk about telephone triage. We talk about patients who were admitted to hospital and how this could have been prevented by better community care. We meet with district nurses, community matrons, child safeguarding leads, health visitors, palliative care, and psychiatry services (to name a few) to discuss complex patients’ needs and how we can meet them better. We audit unplanned admissions, prescribing, referrals (to name a few) and discuss how we can improve their quality.

So we are already doing this every single week and recording it, as we have been doing for years. It takes years of such conversations, changes in practice and procedures, and repeated conversations for patient care to improve, and this quality improvement activity is embedded into general practice culture in the UK, and it is something we strive to do well. Yet the public, and indeed our hospital colleagues, may not be aware of this aspect of our work, and I think this is a shame.  Even we, as GPs, are not aware that this work is beyond simple audit, it is quality improvement work, and it is worth sharing. If we were all aware then we may have a lot more respect and understanding of each other, and could spread our ways of working and our ideas with the world, and collaborate with the public and colleagues better.

Taking the step to publication is next, and some GPs have already published their quality improvement reports. Here are some examples:

Telephone consultations in primary care, how to improve their safety, effectiveness and quality by Muhammad Naseer Babar Khan. Here, a literature search was done on published articles on telehealthcare which resulted in devising a telephone consultation model. Following the proposed consultation model by healthcare staff, it has improved patient satisfaction survey from 75% to 94%, face to face consultation rate was reduced by 1.6%, and home visits were reduced by 2.9%.

Another project called “General Practice Locum Improvement Tool” by Christopher Weatherburn and Shawkat Hasan initiated a process where the locum GP was emailed after their session with a one question survey enquiring about improvement suggestions for that practice. Feedback from the practice to locums included personalised specific clinical guidance, suggestions for improving documentation, and ways to optimise referrals. As a direct result of this pilot a locum box has been implemented in this practice and plans are to rerun this tool periodically.

Sarah Eccles published a report recently about bowel cancer screening. Her practice used three interventions: letter encouragement, staff education to increase opportunistic promotion of screening, and calling non- responders to identify reasons for non-participation and encourage participation. This resulted in increased uptake in screening.

These are just a few examples, and these doctors were doing the kind of quality improvement work that GPs do all the time and which goes unpublished and unrecognised. Don’t be afraid to share the good work you are doing in quality improvement.  By publishing it you can change the way people view general practice and influence others all over the world who are challenged by the same problems that we are trying to solve! Have a look at quality.bmj.com or email quality@bmj.com if you’d like to publish your work. There are also workbooks at the site specifically for GPs and CCGs to run diabetes, dementia and COPD quality improvement projects if you are stuck for ideas!

Colleen Hughes Driscoll is an assistant professor in the division of neonatology at the University of Maryland Medical Center, Baltimore, MD. She serves as the director for quality improvement in its neonatal intensive care unit.

Early in my career as a neonatologist, I began to transition into a leader in quality improvement at my institution; a transition that I continue to undergo. I was initiating a quality improvement program within my division, never an easy task in the health care setting for a variety of reasons: often there are no extrinsic fringe benefits available to motivate people, academia rarely honors performance improvement with promotion, and often the resources needed to fund quality improvement projects are non-existent. Moreover, faced with the challenge of asking my colleagues to take on more when time is a precious commodity, I was desperately in search of an instruction manual. In November of 2013, I was introduced to Daniel Pink’s book, Drive: The Surprising Truth About What Motivates Us. Drive is a synopsis of research on human motivation that spans decades, and illustrates how businesses can flourish, or destroy, the motivation of their workers. Pink uses this evidence to demonstrate the intrinsic motivation that lies at our core as humans and how this can be channeled to maximize innovation and creativity.
Whilst not an instruction manual per se, “Drive” provided insight from a body of scientific evidence and provided lessons from industries that I was not familiar with as a physician, such as manufacturing and technology. A central theme of Pink’s book is that humans possess a natural, innate drive to create, to preserve autonomy, and to learn and grow as individuals. Viewed from another angle, this means that people are born to approach their life as a series of Plan-Do-Study-Act cycles by defining what they want to achieve, having the autonomy to make strides toward that goal, learning from their actions as they move toward that goal, and altering their course to achieve mastery.
Unfortunately, in our day-to-day responsibilities we aren’t often given the autonomy we need to focus on what really motivates us. We are saddled with task lists, deadlines, and other responsibilities that are rarely make us excited to get up in the morning. However, Pink demonstrates that many successful companies, like Google, have been able to harness their employees’ “drive” by giving them the autonomy to innovate. He describes how one Australian software company encourages innovation by allowing employees to work on any idea or project that they desire within one 24 hours period per quarter. The caveat is that they must present their work to the group at the end of 24 hours time. This approach has enabled employees to solve problems with existing software and develop a variety of new product ideas.
Upon reading this, I was intrigued by how this approach might affect quality improvement in our division. Certainly, there was an infinite list of quality improvement and patient safety issues that needed to be addressed in our division. My instinct was to prioritize that list and lead the charge to tackle each one over time. But Pink’s book made me re-think how I wanted to encourage the culture of quality improvement in my unit. What if, instead of trying to rally the group’s support and effort around an agenda that was not their own, I provided a forum for them to explore their own quality and safety concerns within the unit? It turns out that the forum already existed, at least partially. The division held a monthly quality assurance meeting to discuss patient morbidities and mortalities, along with a comparison of our outcomes with other institutions. This was a trainee-driven conference that was attended by physician staff from our unit. We decided to re-purpose this meeting to give the trainee (or any other physician) autonomy to explore and highlight any safety/quality issue that they view as a problem.
The first step in achieving this was to re-name the conference as the “quality assurance/quality improvement” meeting. We wanted to signify to our staff that performance improvement is not only encouraged, but valued. Next we re-structured the agenda to include not only a review of morbidities and outcomes but also to provide a monthly progress report of our ongoing quality improvement initiatives. We believe that highlighting the QI work being done in our unit persuades others to undertake their own QI initiatives. Finally, we gave the trainees the opportunity to try to solve a quality or safety problem of their choosing, one that is important to them. They are encouraged to objectively investigate the scope of the problem, elucidate the key contributing factors, and propose potential solutions.
The outputs from these meetings over the last year have been very positive. Sometimes the trainee is able to bring an unrecognized, yet significant, safety concern to the forefront of divisional/departmental leadership. Other times the trainee finds that a safety risk can be reduced with one simple step, such as the re-organization of medical supplies on a stock shelf. Occasionally, the trainee discovers that what they assumed to be a pervasive problem in the unit isn’t prevalent when the data are examined objectively. Frequently, the trainee identifies a problem and a solution that is feasibly translated into an ongoing quality improvement project. Trainees are not required to participate in QI projects that are derived from their learning and innovations, but almost always they do. I believe this is because the projects are generated from the trainees’ instinctual need to excel at what intrigues them.
As leaders in health care quality improvement, I encourage us all to consider how we develop our culture of quality in the workplace. Do we want to work in an environment where we are asked to continually improve for an agenda not our own or one where we are valued for doing what we believe will make us better? Let’s discover the collective passions in our own workplace and promote them.
Reference
Pink, D. H. Drive: The surprising truth about what motivates us. 2009 New York, NY: Riverhead Books.

Colleen recently published her quality improvement report “A daily huddle facilitates patient transport from a neonatal intensive care unit” using BMJ Quality. Read it here.

Dr Amar Shah is the associate medical director for quality improvement and consultant forensic psychiatrist at East London NHS Foundation Trust

Amar Shah is associate medical director for quality improvement and consultant forensic psychiatrist at East London NHS Foundation Trust.

This series of blogs chronicles the journey of East London NHS Foundation Trust in embedding continuous improvement to achieve transformational change. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

Every Sunday for the past 25 years, I’ve spent my morning volunteering as part of a registered charity in London. The charity runs activities for around 500 children every Sunday morning, with the mission to develop children into well-rounded citizens and leaders of tomorrow’s society. The charity operates primarily through a network of volunteers. Working in a team of passionate volunteers, and as a board level trustee for the last decade, I’ve learnt a lot about engaging people, bringing people together in a common cause, and sustaining their motivation. In our charity, our prime asset is our people – youngsters and adults who are giving up their free time on evenings and weekends to support our goal – running activities and mentoring our children, supporting their development into leaders.
Within the NHS, our situation isn’t too dissimilar. Our staff members are hugely passionate about making a difference, driven by the desire to improve outcomes for our patients and their families. We rely on the exceptional work of all our staff to deliver the quality of care that we, and our communities, aspire to. Routinely, this involves people going far beyond what is written in their job descriptions and contracts. This discretionary effort, so precious and valuable, needs to be recognised, valued, and carefully nurtured.

One of the beautiful aspects of quality improvement is that it is all about our staff; giving everyone a voice in making things better, flattening hierarchies, giving permission, and providing the space and skills for teams to test changes. Having worked at the frontline in six different NHS providers in the past 10 years, it’s clear that we face a common challenge. The people who are closest to our patients and families have little power, access to information, skills, freedom or space to make the improvements that would make a real difference.

My work within the charitable sector has shown to me the critical need for us, as leaders within the NHS, to focus on ‘creating the conditions’ that will allow our staff to provide high quality care and continuously improve as a team. Within East London NHS Foundation Trust, we’re committed to embedding this within our philosophy, and making continuous improvement part of our day job. We’re starting the journey of flipping the way we improve quality, from large scale top-down initiatives, to supporting each team to determine what matters to them and their patients. It’s a transformation in culture that will take time, but we’re working at pace and scale while making sure that QI isn’t seen as an add-on; it must be firmly embedded into the operating structures and philosophy of our organisation.

For more information about East London’s QI programme, visit http://qi.eastlondon.nhs.uk

Debbie Davies

Debbie Davies provides leadership within MidCentral District Health Board for a range of initiatives centred on enhancing clinical integration and developing sustainable models of care within the evolving PHC context in New Zealand.  Debbie has extensive local and national involvement in service development and delivery primarily within the general practice arena.  Debbie is programme lead for implementing the Productive General Practice Programme in New Zealand. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

MidCentral District Health Board (DHB) and Central Primary Health Organisation (PHO) in New Zealand are undertaking a large-scale transformational change journey towards excellence in health outcomes, with a focus on integrated care and partnering.

For this concept to be realised, there must be distributed clinical and administrative leadership throughout the health care sector. This leadership should not only have a clear perspective on the local vision, but must be exposed to the best current thinking on health care systems development internationally. It is important that we have a strong group of leaders who are able to see beyond the thinking that binds our current systems to the status quo. Providing a mixed group of primary and secondary care colleagues with the opportunity to participate in a masterclass experience breaks down barriers and develops relationships which will support the integration agenda.

The masterclass experience took 16 people to Ontario, Scotland, England, and the International Forum for Quality and Safety in Healthcare in Paris in April 2014, where several of the participants presented.   The participants included leaders from MidCentral DHB (hospital), Central PHO, and a range of other local primary health care providers.  It included a mix of clinical and management leaders.

The masterclass experience included time with Professor Ross Baker and Dr Ed Wagner, both acknowledged world leaders in the fields of system performance and long term conditions management.  The Masterclass was organised under four broad themes:

• High performing health care systems
• Transformational change
• Integrated care
• Quality improvement.

Participants saw many examples of excellence in systems and services, and collected numerous good ideas that MidCentral can learn from and that we can introduce to our change agenda.  The experience was notable for the warmth and hospitality of the sites visited, and for the passionate, well trained, and generally youthful clinicians and managers the group met.

Health Quality Ontario

Health Quality Ontario (HQO) is a major new strategic and system integration programme for Toronto, being in place just three years.  A solid evidence based approach to determining resources is to define the evidence including evaluations, appropriateness for tests, surgical procedures, quality based payments, and mega analysis.  HQO values quality improvement plans, capacity building, and knowledge translation including data, indicator targets, tools and reporting.  We were hosted by the CEO Dr Joshua Tepper, a family physician serving homeless men in his ‘day job’, along with an extensive team of clinicians, researchers, and quality improvement gurus.

At the highest level, the health system of Ontario is driven by legislation passed in 2010, unanimously called by parliament the ‘excellent care for all’ Act. This mandate at senior government level has driven the establishment and implementation phase of the quality programme identified by Dr Ross Baker’s work.  Quality champions push the innovation and quality from the forefront. HQO are the principal advisor on quality to the Canadian government with the mandate aligned to systems, quality, frameworks, and facilitations.

We were exposed to extensive modelling of a commitment to ‘Quality by Design’ while being hosted by Health Quality Ontario, which involves embedding quality improvement through health structures and processes, from governance and planning through to team functioning.  For example, training health boards in quality improvement governance and requiring that a portion of their meeting agendas be given over to quality matters.  Another example is requiring that all health organisations have an annual quality improvement plan.

Ontario also provides key enablers for quality improvement, such as resources, evidence-based guidelines and collaborative clinical pathways, along with a variety of other programmes to support innovation and the dissemination of innovation.

Forth Valley NHS Stirling, Scotland

In Forth Valley we were hosted by Dr. Stuart Cumming alongside a committed and passionate team.  It was surprisingly similar to New Zealand in terms of demographics and the increasing complexities of people living longer, managing chronic long term conditions, and the challenges on systems that emphasise the need to re-invent health services through integrative measures.

Legislation has mandated health and social integration; concepts that will require bold measures and brave and difficult decisions to be made over time.  Integration at this level requires the stakeholders to address complex strategic issues such as combined financial considerations.

The group was shown a number of presentations or sessions specifically focussed on the ‘Shifting the Balance of Care’strategy.  This came from the Kerr Report, which defined a strategic shift of focus not dissimilar to the New Zealand Primary Health Care Strategy, 2001.

“Shifting the balance of care away from reactive episodic care in an acute setting to team based anticipatory^[1] care closer to people’s homes is a vital part of implementing our strategy”.

Strategies used to support this shifting of balance included anticipatory care, coordinated planned care, and improved communication and 24/7 partnership working with patient and families in care.  Levers to obtain the change included education and training, communication and capacity planning, and shared information.  The patient safety programme has followed a staged approach and is now focused on primary care and mental health.

What was evident across the many site visits was a clear culture of commitment to quality improvement training of all staff, and embedding systems and processes to engage and ensure continuous measurement for improvement.

The masterclass experience also gave participants an appreciation of the fact that the scope and composition of our local achievements are truly world leading. MidCentral’s efforts to achieve transformational change can be viewed as well planned, comprehensive, and well resourced.  They align with both the research base and international best practice and are very much current.

[1]Anticipatory Care is care planning much similar to advanced care planning tools with additional ‘here and now’ care planning narrative attached and updated as required.  These anticipatory care plans are paper based though shared with all clinicians involved in a person’s care.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A health foundation research scan (2) suggests three key causes of harm in primary care: clinical complexity, systems issues and human factors. Paresh Dawda’s Human Reliability in Primary Care blog brought to you by BMJ Quality, focuses on the human factors element.

We hear lots about patient safety, but the voice of primary care is not heard as loudly as that from the acute sector. Primary care is equally prone to patient safety threats and risks. The research is limited, but estimates of patient safety incidents are estimated at between 0.004-240.0 per 1000 primary care consultations with 45%-76% of all “errors” thought to be preventable.(1)

Spend a few minutes and reflect on:

• Interruptions during your consultations
• How alert you feel towards the end of a three hour session compared to the beginning
• How often you find that something you need, e.g. a form, a piece of equipment is not there and you have to go looking for it
• How often do you experience communication related misunderstandings between yourself and others e.g. receptionists, nurses, care home staff, other doctors or patients.

These are just a few everyday common occurrences. Of course, they do not always lead to patient harm but still they have the potential to do so. Clinical human factors are about “enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture, organisation on human behaviour and abilities, and application of that knowledge in clinical settings.” (3) Put another way, “human factors are all the things that make us different from logical, completely predictable machines. In simple terms they are all those things that enhance or reduce human performance.” (3)

The delivery of healthcare relies on us, as humans, interacting in a multitude of ways with the health care system; whether it is operating our clinical computer system, undertaking a procedure, or talking with colleagues or patients. Moreover, it also encompasses the way our patients relate to the system since those same human factors that affect us also affect our patients. Recognising and appreciating this is the first step in enhancing clinical performance. The second step is to understand how, as humans, we interact with other components of the system and carry out tasks. The third is to understand the multiple variables that impact on the quality of that interaction and strategies to reduce that impact. These may be personal factors such as fatigue, illness, irregular work patterns, and reliance on memory, or they may be environmental factors such as distractions (through noise, motion, clutter, heat, lighting), poorly designed procedures, or simply lack of training.

When I was on the faculty of the NHS Institute’s (now NHS IQ) safer care faculty, we had a simple mantra: “make it easier to do the right thing, make it harder to do the wrong thing.” However, in order to improve human reliability we have to go a step further and appreciate the inevitability of human error. Therefore we also have to put in place mechanisms to spot and stop errors before they become a safety threat.

My first purposeful application of this understanding was in a project implementing the NICE guidelines on assessing febrile children (CG160) (4), and in particular the clinical assessment of febrile children, a key priority for implementation. One of the NICE recommendations is to “measure and record temperature, heart rate, respiratory rate and capillary refill time as part of the routine assessment of a child with fever.” On the face of it this is a simple recommendation, but to reliably implement it required many human factor related interventions. One simple example is a prompt to measure the four items. We knew from our data that the temperature was beings checked 70% of the time. Therefore, associating the reminder prompt with the task of checking the temperature would potential yield positive results. The task of checking the temperature mostly entails using a tympanic thermometer and then reading the temperature on the LCD screen, so a prompt at this point would achieve the objective. Just as with any other change idea, the model for improvement can then be used to test out the idea and refine it using iterative cycles.

More information on this and other examples from the project are given in the video and in either the NICE shared learning example or the Clinical Human Factors Group’s ‘How to Guide’ ( ), whose website hosts resources on clinical human factors.

The Health Foundation’s research scan concluded that “the potential for improving safety in primary care is significant, not least because of the volume of consultations taking place, the complexity of the interactions involved and the uncertainty associated with providing care in the community.” Applying clinical human factors is a powerful mechanism to achieve that improvement.

Paresh has worked in UK general practice, is an experienced trainer, and developed, delivered and coached on leadership, quality and patient safety improvement programs for NHS Institute for Innovation and Improvement before migrating to Australia in 2012.  He is a member of WONCA’s working party on quality and safety, leading a chapter on transitions of care for WHO and on the editorial board of the Australasian Medical Journal.  Paresh has published articles on quality and patient safety improvement and has delivered presentations and workshops at national and international conferences. Watch more here.

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

References

1. Makeham M, Dovey S, Runciman W, Larizgoitia I. Methods and Measures used in Primary Care Patient Safety Research. Review of the literature. 2008
2. Research scan: Improving safety in primary care [Internet]. Health Foundation; 2011 [cited May 2014 ]. Available from: http://www.health.org.uk/public/cms/75/76/313/3077/Improving%20safety%20in%20primary%20care.pdf?realName=VzT40H.pdf
3. Towards a working definition of human factors in healthcare [Internet]. Clinical Human Factors Group[cited May 2014]. Available from: http://chfg.org/definition/towards-a-working-definition-of-human-factors-in-healthcare
4. Feverish illness in children (CG160) [Internet]. NICE; 2013 [cited 2014 May]. Available from:

Dr Marc Wittenberg

It’s just under a month to go until the Agents for Change 2014 conference [http://www.agentsforchange.org.uk], the biggest national medical event for trainee doctors, by trainee doctors, and it’s being held on 26-27 June at BMA House in London.

This year, the theme is ‘Right Skills, Right Team, Right Now’. What does that mean? It means equipping trainee doctors with the capacity and capability to make healthcare better. This might be quite a grand statement but as Sir Bruce noted in his report on the 14 hospitals, “trainee doctors are our most powerful agents for change.”

For me, this means that there is an expectation from the system, and particular from patients, that trainee doctors need to step up and make change happen to secure the future of high quality healthcare. This means constantly questioning the norms, not accepting the status quo, and making the business of quality improvement part of our daily work.

Many trainee doctors are already doing fantastic work around the country, working above and beyond to improve patient care. It is worth taking a look at  the open-access BMJ Quality Improvement Reports journal to be inspired and get ideas:

Improving the accessibility of trust guidelines for juniors doctors

Instituting a block room for regional anaesthesia 

Signposting GP trainees to learning opportunities

Agents for Change is In its 6th year now. This will be the first two day event and will include video and poster entries, both of which will be published in a special BMJ QIR supplement. All delegates will also get free access to BMJ Quality, which will enable them to undertake QI projects and submit their own work for publication.

We also have key-note speakers by top medical leaders including Dr Fi Godlee, editor-in-chief of the BMJ, Sir Bruce Keogh, medical director of NHS England, Professor Ian Cummings, CEO of Health Education England, Sir Mike Richards, Chief Inspector of Hospitals, Professor Mahmood Adil, professor of value-based healthcare at Department of Health, and Dr Jennifer Dixon, CEO of the Health Foundation.

In addition, we are delighted to welcome world-renowned speakers from the US and Ireland: Dr James K Stoller will give a perspective from the Cleveland Clinic, one of the most reputable institutions in the world, and Margaret Murphy will offer a deeply moving and personal view of patient safety as one of the WHO’s patient safety envoys.

The Strategic Advisory Board, made up of fellows from the National Medical Director’s Clinical Fellow Scheme, together with BMJ colleagues are working hard putting the finishing touches to the programme, sorting last minute logistics, and compiling the abstract supplements, amongst other things. This is all to ensure that the conference is the best that it has ever been.

We hope that by attending the conference, trainee doctors will be inspired to go back to their workplaces and put this into reality. Through a series of expert workshops, delegates will acquire some of the skills and connections that they need. For example:

Getting the Right Skills in leadership, human factors, influencing others and coaching
Building the Right Team through networking with HEE, FMLM, DAPS and iwantgreatcare.com
Being inspired to start Right Now with the NHS Change Day team and Inspire Improvement project team

To paraphrase Don Berwick, doctors need to both do their jobs and also work to improve their jobs by improving the systems they are working in. In order to do this, and to be taken seriously, we need to have the ability and the confidence to make change happen.

Places are going fast, so register today at http://www.agentsforchange.org.uk then follow us @agents4c and on http://www.facebook.com/groups/agents4c/

Dr Amar Shah is the associate medical director for quality improvement and consultant forensic psychiatrist at East London NHS Foundation Trust

This series of blogs chronicles the journey of East London NHS Foundation Trust in embedding continuous improvement to achieve transformational change. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

Engagement is a critical factor in attempting to improve quality at scale. Our aim for engagement is to harness the energy of a critical mass of people into purposeful activity aligned to our system-level goals.

Stage 1 of our programme was about direction – working with the board and our senior leaders to understand what quality improvement would mean for the organisation, consulting widely to develop a shared mission, and developing measurable aims that will be the focus of all our improvement work.

We’re now deep in stage 2, which is about building the will within our organisation for improvement – trying to create ‘pull’ from the frontline. We’re taking a two-pronged approach to this, using traditional communication methods alongside a more campaign-style approach aimed at building a grassroots movement for change.

Traditional tactics have included a launch event (in February and attended by 250 people). We’re taking this deeper into the organisation, with a series of events aimed at inspiring and exciting the front-line staff and patients about quality improvement. We’re using the existing structures and hierarchies to gradually embed continuous improvement within our approach to quality, engaging service and clinical leaders to take ownership for nurturing improvement within their departments.

However, much more exciting is the emerging campaign. Many months ago, before we formally launched the programme, we brought together a Q30 group of staff representative of all areas and levels of our organisation.  We asked them to help us think about how to engage front-line staff, and the messaging that would help us connect with people’s internal motivations for wanting to give their best to their patients. Alongside this, we had a Q12 group of patients, carers, and governors, to give similar input from their perspective. This has been hugely valuable in helping us develop a compelling narrative and communication plan to help us reach and unleash every person in the organisation.

We’ve also tried to make every aspect of the programme as accessible and transparent as possible. We have spent many months consulting widely to develop our vision, mission, and measurable aims, and continue to ensure frontline staff and patients are integral to all our improvement and redesign work. We have developed a microsite for our QI programme that is purposely not hosted on our intranet, making it accessible to staff from anywhere and from any device, and also to make it accessible to patients, families, governors and the wider community. Even though it may sound strange to some, the use of social media channels at East London remains extremely limited. Our launch event and communications are harnessing the power of Twitter, Storify, SlideShare and other channels to extend our reach and encourage the building of more networks within our community. Finally, we chose to allow our staff to design our QI brand image, running an internal competition. We had patients, staff, and senior leaders on our shortlisting panel, and all staff were invited to vote for the winner. The response was overwhelming, with over 500 staff voting in total, and 90 votes in the first five minutes.

We recognise that engaging our staff and patients in this work is critical to success. We are beginning the long road, and starting before we’re fully ready, but trying hard to be the change that we want to see – listening, learning, involving, and innovating at every stage.

If you’d like to find out more about the East London QI programme, please visit http://QI.eastlondon.nhs.uk

Sveta Alladi is a Paediatric Registrar in London, who is currently a National Medical Director Fellow at Health Education England. She’s just joined the team at The Network and is organising the video abstracts for the Agents for Change conference, June 2014

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

No, its not the latest Johnny Depp movie setting up on Starlight ward, (wishful thinking)….but the F1 and ST4 in Paediatrics creating and starring in their very own blockbuster hit in quality improvement. These innovative trainees have just demonstrated that using the SBAR ((situation, background, assessment and recommendation) tool in their department has vastly cut down handover times and helped prioritise the sickest children for review.

What better way to highlight their outstanding achievements than to take starring roles in their very own short video documentary. A quick and easy video shoot using their smartphone – some quick edits on a laptop and it is ready for upload and release on YouTube.

The Network (www.the-network.org.uk ) is an online forum which hopes to host and showcase the leading lights in healthcare, who work hard in their day jobs but also take time to improve services and care for patients. The Network has been set up by a passionate group of healthcare trainees who strongly believe in the value of the culture of quality improvement.

They want to recognise the achievements of frontline healthcare professionals who innovate, create, improve and deliver changes to their environment by displaying their projects for all to access, learn from and share.

I’ve recently joined the team at the Network and even I – old enough to have managed university without a mobile phone- can see it’s quite simple really. Almost all health professionals have access to a smart phone, and the majority can figure out how to use it as a video camera – even the most technologically naive.

The videos can be in any form – it can be an interview with a colleague who coordinated the project, an interview with a patient who experienced the benefits of the projects or any format you think best to showcase your work. Using the Network as a host – the video can then be shared far and wide – via Facebook/twitter (@TheNetwork001) and reach professionals all over the globe.  You can promote work you have already published in BMJ Quality Improvement Reports by making a video or create a video before submitting your work to the journal to give your project a higher impact factor.

Everyone has time to watch a quick three minute video – on the tube to work, on a quieter night shift, or waiting for the kettle to boilA short video has huge potential to inform and influence – think of the impact a TV advert or a movie trailer can have on the choices you make.

The world is moving on; you can say so much more in a 3 minute video than you can with written text.

If you are still feeling a little unsure – there is lots of advice on how to make a video on our website: http://www.the-network.org.uk/ and you can see some of the videos already uploaded here: http://youtu.be/SKQxICMUhPw

The Network is hosting a launch event in Manchester on Monday 12^th May in Salford (see www.the-network.org.uk for more details). We hope many of you will take some time to think about a project you are involved in and share it with us for this event.

Upload your video to YouTube then send the link to thenetwork.org.uk@gmail.com.  We will automatically enter you for the 2014 Network Improvement competition. There will also be prizes (including free licenses to BMJ quality and a free place to the 2015 Patient Safety Congress).

We want to connect improvers from across the globe. The videos will be indexed and accessible for all to see, learn from and then connect to the authors.

This is your opportunity to showcase your work on a global platform. So, go on – what’s stopping you? The deadline for submitting your video is 1^st April 2014.