Dr Amar Shah

Dr Amar Shah is a consultant forensic psychiatrist and quality improvement lead at East London NHS Foundation Trust. He is also the London regional lead on quality and value for the Faculty of Medical Leadership and Management. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

 Contact or follow him on twitter @DrAmarShah

At East London, the question we have been asking ourselves is, “what does it take to sustain a multi-year organisation-wide improvement programme that delivers significant improvements in quality and cost, and successfully transforms the culture of the organisation?”

Quality has been the undisputed buzzword in healthcare in 2013, with a number of seminal national reports focusing on how to improve quality of care. This blog will chronicle the journey of one provider of mental health and community services, and how we are changing our thinking and approach to quality.

At East London NHS Foundation Trust, we believe we currently deliver a good quality of care, with many ‘bright spots’ of excellent caring practice and innovation. There is also considerable inconsistency and variation, with some ‘dark spots’ of concern. This situation is not unique to East London, and most healthcare staff may be able to relate to a similar picture in their organisation. Over recent years, as with many NHS providers, our Trust has placed emphasis on quality control and quality assurance structures. This has resulted in relatively robust governance procedures, evidenced in the attainment of CQC essential standards of care for all visits and NHSLA level 3 risk management standards.

Our ambition is to deliver the best possible mental health and community care to our patients, service users, carers and families. We have made a commitment to quality of care. This is embodied in our mission to provide the highest quality mental health and community care in England by 2020. We recognise that achieving this will require a new approach to quality. The three landmark reports in 2013 on quality and safety in the NHS (Francis report, Keogh review and Berwick report) have all espoused the development of an organisational culture which prioritises patients and quality of care above all else, with clear values embedded through all aspects of organisational behaviour, and a relentless pursuit of high quality care through continuous improvement.

In addition but not unrelated, funding for the NHS is likely to remain static or possibly decline in real terms beyond the 2015 general election. Achieving year-on-year efficiency savings by focusing on rationalising inputs to the system (workforce, assets) is proving increasingly difficult and is likely to disproportionately affect staff morale and quality of care. It’s abundantly clear to anyone working in the frontline of healthcare delivery that the area of greatest inefficiency within the system lies within the clinical processes themselves, which have largely remained untouched through recent years of efficiency savings. Redesigning clinical pathways with the ambition of providing patient-centred, high value care offers the potential to realise continued savings from the health economy whilst delivering an improved quality of service to our patients. Successful redesign at this scale requires improvement expertise, dedicated resource, rigorous application of a consistent methodology and a fundamentally different approach to quality, which involves putting patients and the families at the heart of the design and improvement work.

The last year of preparation has been a steep learning curve and a great investment. We have taken time to think, talk and learn from others. Successfully embedding a new culture and achieving a step-change in quality and value of care is a huge challenge, but we now feel in a much stronger position to attempt this.

Our work began at the very top of the organisation, recognising that Board-level leadership was absolutely vital to success. Nurturing and supporting improvement to achieve better health, better care and better cost requires leaders to apply a new approach and specific set of behaviours in redesigning systems and accelerating culture change, as described in the recent IHI white paper. Our Board has invested time and energy to understand improvement, to learn from the journey of other high performing organisations, and to develop a strategy for our programme of work. Wide consultation across our clinical teams, service users, carers, Governors and commissioners has fed into the development of a strategy that we hope all can feel ownership of.

Developing the business case has been a significant challenge, with most of the evidence and experience of large scale quality improvement being in acute care. However, we believe that coordinated improvement work in mental health and community health services is just as possible, despite some additional challenges, and we are excited by the prospect of starting to work in unchartered territory.

The work before the work of improvement has been crucial in preparing the ground for applying quality improvement across a whole organisation, and eventually a whole system of care. One of our earliest decisions was that we would be more successful in this journey if we partnered with an external continuous improvement expert, to support us with strategic advice and to help us build improvement skills in our workforce at scale and at pace.

We are building a central quality improvement team in the organisation, to coordinate the programme of work and to be the internal improvement experts. Over the last few months, we have been slowly and steadily reviewing and re-aligning many of our corporate systems so that they will support our improvement work. Much of this has the potential to be transformative – for example, working towards the publication of complaints every month on our website, embedding a structure for listening at every level of the organisation, integrating quality data and making this available to every person in the organisation, reviewing all of our policies and procedures to ensure they support the development of a just culture, reviewing our clinical audit programme, refreshing our induction process, and ensuring that quality improvement is embedded within all of our internal training and development.

Alongside this, we’re developing the framework for measuring and evaluating our progress on our strategy – not an easy task, considering the lack of standardised outcome measures in mental health, and the lack of accurate tariffs and costs for patient-level activity.

We’re clear that our quality improvement programme will involve a fundamental change in the way things are done. It will seek to bring about a culture change, putting patients at the heart of all that we do and at the centre of our improvement and redesign work. We want to embed a culture of listening more to our frontline staff, service users and carers, and provide more freedom to our frontline staff to work in partnership with patients to innovate and test new ideas, whilst stopping activity of lower value. And we want to build up the skills in our workforce on improvement, and support them to use a consistent methodology to test ideas, measure their impact and then spread successful change. We’re convinced that freeing our staff to work with their patients in improving the system and pathways of care will yield the greatest improvements in quality and cost outcomes.

We’re about to open a new chapter in our organisation’s journey. It’s one that we believe could only be possible from a position of strong leadership, assurance and financial security. Our next challenge is the critical one of engaging the whole organisation in this programme, and the next blog will describe how we’re attempting to create a movement for change that is led and owned by the grassroots.

References

1. Dixon-Woods, M., Baker, R., Charles, K. et al. (2013) Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Quality Safety doi: 10.1136/bmjqs-2013-001947

2. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (chaired by Robert Francis QC), February 2013

3. Review into the quality of care and treatment provided by 14 hospital Trusts in England (Professor Sir Bruce Keogh), NHS England, July 2013

 4. A promise to learn – a commitment to act. Improving the safety of patients in England. National Advisory Group of the Safety of Patients in England, August 2013

5. Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2013.

Helen Carson, Product Manager for BMJ Quality

BMJ Quality was at the Arab Health Congress in Dubai last month. This event played host to 85,000 delegates, over 2,000 exhibitors and 19 conferences, which included topics such as quality management and diabetes. Talking to delegates was a good way to learn about the myriad uses for the term “Quality”; Accreditation, safety, performance standards, risk mitigation, innovation, process improvement and patient centred care were just a few of the phrases that were regularly used by delegates to talk about quality in their organisations. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

One of the contrasts to the UK was the sense that in the Middle East, “Quality” is very structured; delegates from the Middle East tended to talk about a very organised quality manager at their organisation who worked to devise and implement quality strategies and practical resources, whilst working to ensure that everyone adhered to the frameworks necessary for accreditation by the likes of Joint Commission International (JCI). These healthcare professionals saw their role as implementing quality controls to reduce risk, and to ensure that clinical practices are safe and consistent. Perhaps it was due to the nature of the events, but when I think back to the ‘quality themed’ conferences I attended in the UK in the summer, there was a contrast: Senior NHS figures were calling for frontline staff to take responsibility for quality improvement through critical appraisal and innovation. Many spoke of the redesigning of processes and services, due to the continued complexity and bureaucracy of many organisations, and the ability of those at the frontline to see a clearer path to improve services. This is of course in addition to adhering to the guidelines given by government and other healthcare bodies such as CQC and NICE.

Perhaps a sweeping generalisation but these are examples of a “top down” and “bottom up” approaches in action. Two very different approaches to the notion of Quality but, hopefully, both with patients as a central focus.

And this is where things (in the era of patients as customers) get complicated. For many patients high quality healthcare has strong links to service elements; speed at which they get to see a doctor, the manner in which they are treated.

While a healthcare professional or a hospital can appreciate the importance of these things their emphasis will likely be on clinical quality and the flow of services and processes. All of these elements need to be measured, improved and managed by empowering healthcare professionals and patients to contribute to the cycle of improvement.

So do we need to agree on a consistent meaning of the term “Quality” to move forward? Or do we need to be flexible and responsive to the needs of patients and organisations in order to give a notion of quality that is important to them?

I suspect that it is the latter.

But one thing that is for sure is that people working at the front line are unsure of their role and authority in Quality Improvement and innovation, so in this respect, clarity, support, and education are an important part in moving forward. And for all these phrases or interpretations of quality; change is essentially what is needed.

What does Quality Improvement mean to you? Want to tell us about it? We want more bloggers to add to the discussion! Contact us: quality@bmj.com

Clare van Hamel, Associate Postgraduate Dean and Director of Foundation School.

Severn Foundation School (FS) has embraced quality improvement (QI) as a highly effective means of achieving improvement in a wide variety of areas. Clare Van Hamel, Associate Postgraduate Dean and Director of Severn Foundation School believes QI empowers individuals, in a far more effective way than audit, helping staff to address the concerns which are directly affecting them. Here she describes ways that other Foundation Schools can follow their lead to enable foundation doctors to identify concerns and develop solutions using a multi-professional approach. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

Severn FS has been fortunate in having quality Improvement leaders as part of the foundation faculty. They have really driven the enthusiasm to use QI tools supporting foundation doctors to identify concerns. Here are my top tips to facilitate quality improvement in a post-graduate medical education setting

1. Identify trainee leaders to enable near-peer championing of QI.

Severn FS have appointed Foundation School Quality Improvement Fellows. Following allocation via FPAS to the Severn Foundation School, all incoming F1s are invited to apply in open competition to be the QI Fellow for the school. The appointee is given financial support to attend an appropriate QI conference and also invited to attend relevant regional/foundation school meetings during their tenure. F1s do not have study leave but the Trusts are asked to be as supportive as possible to facilitate attendance at meetings.

The fellow is identified as a QI contact point for the other foundation trainees. The fellow is supported and mentored by the F2 QI fellow and QI faculty. There is a little more flexibility during the F2 year for the fellow to attend conferences during their study leave time supported financially by the Foundation school.

2. Identify trainer QI leads

Severn FS has been fortunate in having faculty who are committed QI champions within the region both at consultant and senior trainee level. The foundation school has recently set up a sub-group led by one of those champions to help to promote sharing of ideas and outcomes

3. Trusts need to engage and promote QI opportunities for their staff.

Many of our trusts really encourage their foundation doctors to participate in QI work as teams; with many achieving approximately 80% participation. The trusts have seen the specific benefits of the QI outcomes leading to change but also more subtly the benefits of multi-professional working leading to increased morale and respect between different professional groups. Many of the Trust’s executive teams are recognising the significance of the QI achievements and are keen to develop and endorse the work.

4. BMJ Quality subscriptions

These licences have been purchased by the Foundation school to help to facilitate sharing and publication of the QI work that has been completed by the trainees within the school.

5. Opportunities to share the QI outcomes

Severn Foundation School runs an annual regional presentation day providing opportunities for trainees to showcase their work. As a result of the positive feedback from the regional event..

6. Severn Foundation School organises the National Foundation Doctors Presentation Day

This annual event provides an opportunity for Foundation Doctors from any foundation school to present their work. The national day has attracted an increasing number of submissions >300/annum for the last two years. This year the event was supported by HEE, UKFPO, the GMC, HQIP, the BMA and others.

 7. Encourage and support your trainees to submit their work

A very large number of our trainees have presented their work at National and International meetings. We have been over-represented compared to the size of the school at meetings such as the NACT/UKFPO Sharing Best Practice Meetings. We try to provide financial support for trainees to attend to present their work when possible and encourage trusts to release trainees to present at national and international events.

 8. Highlight achievements

The trainee and faculty achievements are highlighted on our website. These are subdivided into presentations, publications and other projects. http://www.foundation.severndeanery.nhs.uk/about-us/trainee-and-faculty-achievements-2/

In summary quality improvement has enabled our trainees to deliver change within their working environments, in a wide variety of fields. The work has delivered a huge number of changes including better patient care escalation policies;  improved handover; safer prescribing of drugs and fluids; induction to F1 and F2 programmes; improved access to rotas and access to protocols. Much of the work has centred on patient safety but also on efficacy and efficiency. Many of the projects have produced considerable cost saving whilst also improving patient safety. What could most concisely be described as a WIN- WIN for all involved.

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

One of the mantras of the quality movement is copy shamelessly from others.  This is valid and sensible; there is no point inventing the wheel over and over again (and more importantly not re-inventing the flat tyre).  However there are two important caveats to this; make sure you know what you are copying and be prepared to adapt the projects to fit your local circumstances. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com

‘In the South Seas there is a Cargo Cult of people.  During the war they saw airplanes land with lots of good materials, and they want the same thing to happen now.  So they’ve arranged to make things like runways, to put fires along the runways, to make a wooden hut for a man to sit in, with two wooden pieces on his head like headphones and bars of bamboo sticking out like antennas – he’s the controller – and they wait for airplanes to land.  They’re doing everything right.  The form is perfect. It looks exactly the way it looked before.  But it doesn’t work.  No airplanes land.  So I call these things Cargo Cult Science, because the follow all the apparent precepts and forms of scientific investigation, but they’re missing something essential, because the planes don’t land.’ – Richard Feyman[1].

The clear translation for us is that if you superficially copy a quality improvement programme you may well fail.  This argument is expanded in this excellent article by Mary Dixon-Woods that evaluates in detail why the Michigan central line infection programme worked.  As it turned out it was not just about the five point checklist (and in fact by the end there were over 100 different locally adapted checklists) but a complex social intervention [2].  The cocktail hour in the evenings of the collaborative meeting was seen as crucial in creating the culture to drive improvement.  Details are really important; they also had logos for all the participating ICUs printed onto the water bottles at the joint events; that is how you change culture.

As a surgical registrar I see this cargo cult style error daily.  In almost all theatres across the UK the WHO safer surgical checklist is used before, during and after each operation; well at least that is what the data from trusts will show you.  A study was published in the NEJM that showed the benefit of this checklist and the idea was that if all UK hospitals used this checklist then they would get the same reduction in mortality and morbidity[3].  However in the same way the islanders superficially copied the Americans with their wooden huts and bamboo ear defenders we have superficially copied this quality improvement intervention.  The NEJM study did not just use a checklist they had pre-operative briefings and crucially team training on how to use the checklist.  There is a whole science around checklists and a study in the British Journal of Surgery shows that we are simply not using it properly and therefore cannot expect to get the same benefits as the NEJM study showed[4].  We may laugh at the islanders but we are doing the same thing on mass in the NHS.

Just because a quality improvement intervention worked in one place does not automatically mean that it will work in your clinical area.  In fact it is likely that without some alterations to fit your local circumstances it won’t work as well.  In this paper (co-authored by @carsonstevens) this point is expanded on  – if you are not prepared to adapt work from elsewhere and be flexible you are much more likely to fail and this is one of the reasons why so many QI initiatives do not succeed[5].  Again we have not heeded this advice during the roll out of the WHO checklist.  It must be adapted for local situations.  Some of the questions are simply not relevant to UK hospitals and equally there are other questions that need to be included. Pilots do not use the same checklist for each plane they fly and so we should not be using the same checklist for day case eye surgery as for an anterior resection for rectal cancer.  If we become more flexible with the implementation we will get more staff on board and begin to effect the cultural change that was behind the original success of the safer surgical checklist.

So if you want to avoid being one of the islanders with bamboo headsets, before you start to implement the next amazing improvement initiative make absolutely sure that you know in detail what you are copying and be prepared to be flexible in the implementation.

1. Feynman RP, Robbins J. Cargo Cult Science: Some Remarks on Science, Pseudosciene, and Learning How to Not Fool Yourself. The Pleasure of Finding Things Out. Cambridge, MA: Perseus Books, 1999:205-16.

2. Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA, Pronovost PJ. Explaining Michigan: developing an ex post theory of a quality improvement program. Milbank Q 2011;89(2):167-205 doi: 10.1111/j.1468-0009.2011.00625.x[published Online First: Epub Date]|.

3. 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(5):491-9 doi: NEJMsa0810119 [pii]

10.1056/NEJMsa0810119[published Online First: Epub Date]|.

4. Pickering SP, Robertson ER, Griffin D, et al. Compliance and use of the World Health Organization checklist in UK operating theatres. Br J Surg 2013;100(12):1664-70 doi: 10.1002/bjs.9305[published Online First: Epub Date]|.

5. Parry GJ, Carson-Stevens A, Luff DF, McPherson ME, Goldmann DA. Recommendations for evaluation of health care improvement initiatives. Acad Pediatr 2013;13(6 Suppl):S23-30 doi: S1876-2859(13)00099-5 [pii]

10.1016/j.acap.2013.04.007[published Online First: Epub Date]|.

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

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

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

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

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

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

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

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

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

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

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

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

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

Rob Bethune

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

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

Establish a team and allow time

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

Get help

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

Use the Model for Improvement

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

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

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

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

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

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

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

Publish

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

It’s up to you

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

References

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

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

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

Dr Marc Wittenberg

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

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

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

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

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

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

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

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

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

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

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

Mareeni Raymond, GP and Clinical Advisor for BMJ Quality

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

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

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

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

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

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

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

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

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

Dr Sean Elyan
Medical Director, Gloucester Hospitals NHS Foundation Trust
Trustee, The Point of Care Foundation

Dr Sean Elyan describes  undertaking a listening exercise with staff following the publication of the Francis report, at Gloucestershire Hospitals NHS Foundation Trust.

 The Director of Nursing and I did this work so I was slightly affronted when a senior nursing colleague claimed that compassionate care was the responsibility of the nursing body and doctors should not be interfering. Preparing myself to respond intelligently when next challenged in this way, I thought I would assess what emphasis was afforded to different groups in the Mid Staffordshire report.  I was reassured to find that the executive summary says:  ‘[Patients] must receive effective services from caring, compassionate and committed staff, working within a common culture’.  However it would be wrong not to acknowledge that the summary mentions compassion 16 times and of these, 11 relate directly to nursing and only five could be considered to include other staff groups.

Within our trust we have started a project, initially with The King’s Fund and now with The Point of Care Foundation, to test and disseminate an approach to strengthening relationships between staff and patients.  These Schwartz Center Rounds, adopted from an innovative approach now used in many hospitals in America, have been revealing.  Staff from any discipline use narrative to relate the challenge of providing care from their own perspective.  This reflective practice, unusual because it takes place in a multi-disciplinary forum, is followed by a facilitated discussion encouraging the audience to relay similar examples that resonate with the case they have just heard. The discussions regularly and rapidly get to the heart of the complex web of tensions that suffuse care as it is provided on a daily basis.  Ranging from the distress felt by staff following failed paediatric resuscitation, through the impossible pressures of a surgeon’s busiest day, to the observations of a bed manager trying to navigate a patient within a system of increasing demand and expectation, these sessions more than any other I have witnessed reveal how difficult our daily job is. I regularly walk away from them as the clinical lead humbled by the commitment and skill shown by healthcare assistants, physiotherapists, secretaries and porters not to mention nurses and doctors.  And within this is a clarity that these sessions are not to find solutions but just to talk and have time to share, and to recognise that as healthcare staff we all experience similar situations and emotions.  They consistently demonstrate that when staff hear a senior colleague reveal how difficult they personally found dealing with a particular situation, or confirm that they have also experienced something which another member of staff has described, they find it incredibly empowering and supportive.  I can honestly say that of all the tasks I undertake in the trust, this monthly hour is the most productive and invigorating.

The Schwartz Center Round methodology requires a doctor from the trust to act as clinical lead, championing the process and working with a trained facilitator to help plan and run the sessions. By getting a doctor to act as clinical lead, it acknowledges that caring is not just ‘nurses’ work’ and helps to ensure that doctors attend the sessions along with colleagues from other disciplines.

So as I muse on another section of the Francis report in which there is a call to arms to introduce an ‘aptitude test for compassion and caring’ I think to myself ‘what would this test look like?’  We have recently introduced a question into our consultant interviews asking for candidates to give examples of an action at work they have taken that reveals them to be a particularly compassionate doctor.  Their answers seem to range from what I would consider normal day to day work to genuine and moving illustrations of an exemplar approach.  The Schwartz Center Rounds give a tantalising glimpse into compassionate care and how to recognise it.  For something that seems so easy to identify in these session, it remains unclear to me how to measure it.  However, I for one would wholeheartedly endorse Robert Francis’ challenge, beseeching us to start exploring ways to do so. If we can develop a measure for compassion, I hope we find doctors as capable of this work as nurses or any other staff group.

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

Part 2: Start by improving myself

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

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

Today, I am wise so I am changing myself

Anon via Twitter

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 being improvement

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

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

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

re our influence and impact will grow.

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

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