Archives January 2015

Abhinav Bhatia is a year 13 student at Altrincham Grammar School for Boys in Manchester and an aspiring NHS doctor

In our last blog, Dr William Calvert wrote about the importance of teaching quality improvement in medical school. BMJ Quality recently received a quest to share a school student’s experience of a quality improvement project, and it has got us thinking – should quality improvement be taught even earlier? Here’s Abhinav Bhatia’s view.

I’m a year 13 student at Altrincham Grammar School for Boys in Manchester and I plan to be an NHS doctor in future. While working as a volunteer in a district general hospital, I conducted a survey on smoking among hospital staff and started to think about ways to urge hospital policy makers to provide a better support system for staff smokers.

There are lots of support systems for patients who want to stop smoking. I’ve read many quality improvement projects focused on this, but I was really surprised to see so many staff smoking during my hospital placement and I wondered if they were accessing those same services – perhaps as medical staff they felt less inclined to attend a session where they might see their patients? The need for an opportunistic promotion of health when a patient is admitted into an acute hospital was highlighted by Sarah Cousins, who designed a checklist clerking document to enquire into four life style risk factors, including smoking, alcohol, obesity, and physical activity, so that appropriate support can be offered.[1] Gary Bickerstaff in his recent Quality Improvement Reports publication entitled ‘Smoking cessation for hospital inpatients‘ introduced a pathway for identifying and supporting inpatient smokers. The key success factor was dependent on training large numbers of existing core healthcare staff to deliver an intermediate level of smoking intervention, rather than relying on a handful of “smoking nurses” to provide satellite services that leave a huge gap in opportunities outside their limited working hours.[2]

Despite the quality improvement pathways that are being put into place for inpatient smokers, NICE recommends that smoking cessation is actively promoted among hospital staff who smoke. This is particularly important if we are to promote the health of the nation as a whole, and support the government’s Tobacco Control Plan.[3,4]

I designed a one-page questionnaire for my survey with guidance from a consultant physician and advice from research and development. I conducted five-minute face-to-face interviews with 103 hospital staff, chosen at random to ensure that I had included most staff groups.

My survey showed that 14.6% of hospital staff currently smoked as compared to 20% in HSCIC statistics (published August 2014).[7] 24.3% of the participants were previous smokers, similar to HSCIC statistics (25%). Among current smokers, the non-clinical group (porters, security, domestics, catering staff, and volunteers) accounted for the highest percentage (46.7%), followed by nurses, health care assistants and other clinical (39.9%), then 6.7% administrative staff, 6.7% managerial and 0% doctors. None of the current smokers were in contact with hospital or community SSS.

46% of current smokers were non-clinical staff, followed by nearly 40% among nurses and other health care workers, as shown in other studies.[5,6] The latest national data (HSCIC) showed that the smoking rate was highest and rising among routine or manual workers (33%). My survey results are consistent with this, with a 35% current smoking rate among non-clinical staff such as porters, domestics, security staff, and caterers.

There is a need for an innovative approach with more proactive, friendly, and non- judgmental methods to identify and target those vulnerable staff groups who may find it intimidating to contact or attend hospital SSS. As many frontline clinical staff should be trained to provide brief interventions (5-10 minutes), making it more accessible to fellow staff smokers in all work areas, at all times. Those who decline referral should be offered prescription for licensed nicotine-containing products by trained health personnel within their work areas, along with other support advice. I’ve discussed these findings with my consultant supervisor, and I know that by engaging stakeholders by sharing my data and highlighting the NICE guidance, this is the beginnings of a quality improvement project.

Hospital policy makers need to do more to promote the health of more vulnerable hospital staff. It seems hypocritical not to do this in an environment that otherwise promotes health for patients themselves. Perhaps it is now time to include issues relating to staff health such as smoking, alcohol, and obesity in mandatory hospital training programs. I’ve shared my data with the hospital and I’m hoping that the next steps will be implementing some of my suggestions. It just proves that even before medical school, if you’re pro-active enough and understand the principles of quality improvement, then you really can start early!

Got some thoughts on this that you want to share? Join the conversation by tweeting @BMJQuality or visiting quality.bmj.com/smallthings

References:

1. Sarah Cousins. Checklist clerking document improves health promotion among medical admissions. BMJ Quality Improvement Reports 2013; u202209.w1218 doi: 10.1136/bmjquality.u202209.w1218
2. Gary Bickerstaffe. Smoking cessation for hospital inpatients. BMJ Quality Improvement Programme. BMJ Qual Improv Report 2014;3: doi:10.1136/bmjquality.u204964.w2110
3. NICE Public Health Guideline PH5. Workplace interventions to promote smoking cessation. May 2007.
4. NICE Public Health Guideline PH48. Smoking Cessation, Acute, Maternity & Mental Health Services. 2014.
5. Davies PDO, Rajan K. Attitudes to smoking and smoking habit among the staff of a hospital. Thorax 1989; 44:378-81.
6. Hussain SF, Tjeder-Burton S, Campbell I A, Davies PDO. Attitudes to smoking and smoking habit among the staff of a hospital. Thorax 1993; 48:174-5.
7. Health and Social Care Information Centre. Statistics on Smoking, England 2014. www.hscic.gov.uk/pubs/smoking14
8. Bloor RN, Meeson L, Crome IB. The effects of a non-smoking policy on nursing staff smoking behaviour and attitudes in a psychiatric hospital. J Psychiatr Ment Health Nurs 2006 Apr;13(2):188-96.

Declaration of competing interest:

“We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.”

Acknowledgement:

Dr M. Aziz. Consultant Chest Physician. Tameside General Hospital, UK

William Calvert is a paediatric surgical registrar and clinical research fellow for patient and family centred care (PFCC) at Alder Hey Children’s Hospital. At Alder Hey he came to appreciate the importance of family involvement in healthcare, and this led to him becoming a self-taught advocate of PFCC.

For most medical students, formal teaching of quality improvement probably involves little more than identifying the differences between audit and research. Certainly for me it didn’t, but the rising question today is whether there is need for more than this in medical student education.

Helen Bevan, Chief of Service Transformation NHSIQ, promotes the philosophy of junior doctors as change agents and those who will be driving improvement science in the future, and I agree wholeheartedly with this. Engaging clinicians in organisational quality improvement gets results. But should this engagement start at university? The answer must be “yes”, but within a proper context.

Atul Gawande, American surgeon and professor of surgery at Harvard Medical School, identifies five lessons for medical students in his book, “Better”. These lessons are aimed at preventing those new to medicine feeling like small cogs in a vast machine. He holds to the philosophy that “better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try”. Of Prof Gawande’s five lessons, three are directly transferable to quality improvement and I would like to stress their importance in medical education.  My selected three are:

1. Ask an unscripted question, interpreted as ”get to know your patient”
2. Count something. Here we need to consider what we are counting, and a changeable variable would be the obvious
3. Change an element of your practice based on your observation and counting. Then count again.

If we rephrase these three lessons in a different way, we could say that all doctors should promote change in a measurable, variable in response to the psychology of the patient whom they now consider in more ways than just their disease. Put like that, is that not clinical audit? In fact, is that not all of clinical and organisational quality improvement in a nutshell? So here we have a simple strategy for teaching medical students that is itself transferable to all aspects of quality improvement.

Having said that though, when I try to remember what I was taught about quality improvement as a medical student, I draw a fairly large blank. Now however I find it is a very active part of my practice and career. Clinical quality improvement is encompassed in the regular audits, and participation in morbidity and mortality meetings that must be every doctor’s aim. The more elusive organisational quality improvement is something that I am exposed to through a teaching program called ImERSE and my job as a clinical research fellow for patient and family centred care. ImERSE is a quality improvement and medical education tool developed and used at Alder Hey Children’s Hospital. It utilises patient shadowing as a method to capture qualitative care experience data that is thematically analysed to allow for regular feedback into service and quality improvement. The shadowing is undertaken by medical students in the surgical daycase unit, the accident and emergency department, and soon outpatients. The student is removed from any clinical responsibility and encouraged to think about the patient and their family as the centre of a care experience, considering how much the hospital and the care offered affect the psychology of the patient and their family. ImERSE identifies five major themes of medical education:

1. Patient and family centred care as the most important concept for practice methodology
2. Preparation for practice by encouraging authentic early years exposure, and by asking students to consider the psychological aspects of hospitalisation so that the emotive bombardment from patients and families when they graduate isn’t an unknown
3. Identification and addressing of the “hidden curriculum”
4. Inter-professional education and finally
5. Patient safety and quality improvement.

ImERSE allows the students to partake in a quality improvement program run by others. It promises to feed back at the end of the placement the findings that that cohort has identified. It promises to explain how we the hospital aim to address them, and it promises that if the students  return to Alder Hey they will see those improvements made. It lets them see that quality improvement can be easy, and not something to be feared.

Herein I think lies the approach to medical students. I don’t think we need to bombard them with detail, they do not need to know about Lean and Six Sigma; armed with the three lessons extracted from Atul Gawande, and with willingness to try, they will understand that they can bring about improvement.

You can learn more about Mr Calvert’s work by joining him at our webinar – sign up here! Join the conversation by tweeting @BMJQuality or visiting quality.bmj.com/smallthings

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

Small and mighty. Good things come in small packages. From the tiny acorn comes the mighty oak tree. Small things, big wins. As a small person myself (I’m 5 foot – my partner tells me I’m actually shorter than that, but I’ve rounded up) I hear these sorts of statements a lot. We’ve just launched a campaign at BMJ Quality to highlight the wonders of all things small, because we are always struck by the projects that start with a small idea and make a huge difference to the care of people.

Take for example the #hellomynameis campaign. In Kate Granger’s blog last year she told us the story of how she has changed the way thousands of people introduce themselves to their patients, following her own experience as a patient. To introduce oneself by name is something so simple, but reminds us that we have a relationship with others as healthcare professionals that is much more powerful when personalised. She has inspired people around the world to change the way they see themselves, and change the way they present themselves to those people they are looking after.

At a talk I went to a few years ago, the speaker described a consultant in charge of a palliative care ward who was small and rather bedraggled looking, but who ran her ward with incredible passion, and whose junior medical staff were in awe of her for teaching them about compassion and how to deal with the sadness of families in distress when someone was dying. As a junior doctor,  unsure of what career path to follow, I was inspired by that talk being rather of the same description (small – and bedraggled!); I really am a believer in #smallthingsbigwins! I manage the journal BMJ Quality Improvement Reports, and every week I’m lucky enough to read a new story of how a group of people got together, decided they wanted to fix something, and did it. Take for example the first report we have published this year, where junior doctors introduced  a traffic light tool to categorise patients on the medical take as red, amber, or green according to their clinical status at time of admission to the acute admissions unit. Introducing this resulted in improved verbal handovers between doctors at the time of patient transfer. It’s simple idea, and one that any junior doctor could emulate in a new post. To find out how to run your own handover project, you could come to our next webinar and see how to start.

In the second article this year, a group of nursing students in Dundee, Scotland, did a small scale project to introduce a tool to screen for delirium in older people. The tool was a simple, short questionnaire that worked well, resulting in better identification of delirium by nursing staff and was then incorporated into nursing care ward round forms. From this small idea, a group of students have actually changed clinical practice, and their intervention will continue to be used even after their placement has finished – small things, big wins.

The beauty of the quality improvement reports we publish is that they don’t need to be complicated, filled with large numbers and lots of statistics. Take this project for example, where the authors introduced a patient information leaflet to dermatology clinics and used a small sample of 32 patients. They learned that new patients found the leaflet very helpful as it helped them to prepare for the consultation, whereas those who had been to the clinic before did not – and now all new patients receive this leaflet. Again, a small intervention based on a small study which has been embedded into the system long-term.

It isn’t just healthcare professionals who are doing quality improvement work. Caroline Dearson is a carer and volunteer who founded a Dementia Buddy Scheme after her own father’s experience of dementia. She knew that people with dementia needed a more tailored type of support, and set up the scheme from there. Now people with dementia on wards are better supported and she has a huge team of supporters and volunteers.

When BMJ Quality started, we’d identified that healthcare professionals were doing audits and other improvement work, but not getting a chance to publish their work. This meant that other people didn’t know that this work had been done, and it seemed such a waste. The idea was to make it easy for people to share their work, and introduce an online platform that could teach people every step of quality improvement, giving them the chance to share their work with “one click”. That is how BMJ Quality started – and again it was just a small idea that has now grown into one of the largest open access journals publishing quality improvement reports. There are over 5000 people working on projects using BMJ Quality right now, and so far 194 reports have been published. 1,658 reports are underway, and 180 new quality improvement mentors have joined us. People are working on quality improvement reports using BMJ Quality in over 35 countries, including over 2,000 healthcare professionals in the Kingdom of Saudi Arabia! And to date, improvement reports published by our community have been accessed just under 250,000 times in 2014 (QIR Report). A #smallthingbigwin indeed.

If you are interested in sharing your experience of quality improvement, please get in touch. You can email us at quality@bmj.com or use @BMJQuality and send us your ideas with #smallthingsbigwins.

To get your project started today, go to quality.bmj.com.