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

If, like me, you believe in the power and importance of clinical teams running small scale quality improvement work, then you must find 15 minutes to watch this excellent and challenging presentation by Mary Dixon-Woods describing the evaluation of the Safer Clinical system project (the full written report is available here).  If you have limited time then I would watch the video rather than reading my blog below; however, I will expand on some of her points and disagree slightly with part of what she says.  The main message is that the impact of small groups of clinicians doing quality improvement (QI) work appears to be less than we might have hoped.

QI methodology does not solve all our problems

The key point that Mary Dixon-Woods makes is that quality improvement methodology (and here I mean the model for improvement, lean etc) cannot address all problems that healthcare faces, and I fully agree with this – although I would have disagreed if you’d asked me five years ago.  The table below summaries this; if you cannot measure something often (at least monthly) in an effective and reasonable way, then improvement methodology falls down.  Equally if you are looking at things that can only be addressed at institutional (ie national) level, then small groups of frontline clinicians and managers will not be able to influence this.  For example, making epidural catheters incompatible with intravenous catheters or standardising the production of kits to place central lines.

(Adapted from Paul Batalden’s “textbook” of QI)

If you are trying to improve the care of rare conditions or presentations of diseases then QI methodology is not going to help you, and you need to target your interventions to improving culture (which of course is extremely hard).  Whereas if you want it improve the quality and timeliness of discharge summaries, then QI methodology is perfect.  Between these two relative extremes lies a grey area where small scale clinical teams doing QI are not going to achieve improvement alone, but the more comprehensive, well funded improvement work will.  Mary Dixon-Woods gives the example of improving the timeliness of angioplasty for acute myocardial infarction.  This was a very well done quality improvement programme (although the cardiologists doing it might well not have called it that).  They followed the model for improvement: a clear aim, continuous measurement (which has carried on beyond the timescale of the initial interventions), and multiple PDSA cycles.  The big difference between this and most small scale QI work is funding.  Primary angioplasty required a whole infrastructure to be built around if with a completely new set of staff; think of all those additional cardiac nurses and hundreds of interventional cardiologists.  If sepsis (and in fact more specifically time to first antibiotic) had the same resources and used QI methodology then many more septic patients would get antibiotics sooner.

Small scale QI work as a tool for staff engagement

Working in systems that are inefficient and irritating has a negative impact on our ability to deliver safer care.  For me one of the key aspects of doing small scale quality improvement work is that it can straighten out some of the irritations and genuinely engage staff in their working environment.[1]  Even if their quality improvement work does not directly increase quality, its influence on staff morale ultimately will.[2] For this reason alone it is worth doing small scale quality improvement work.  We must try and develop systems that then go on to make these changes sustainable and last beyond the enthusiasm of the clinicians and mangers involved, but this is proving to be difficult.

Finding the problems

The one area I would disagree with Professor Dixon-Woods is in identifying the quality problems.  In the safer clinical system (SCS) programme a significant amount of time (five months) is spent analysing the current state of affairs to find out where the weaknesses lie, using techniques such as failure mode effect analysis (FMEA) and hierarchical task analysis (HTA).  These methods were used in response to the inability of incident investigations in health care to find the real underlying causes of failure.  On one hand these techniques do seem to find the real issues but I would strongly say that you don’t always need to do them.  In the South West of England we have been running a programme for five years where we get first year doctors to run structured supported quality improvement work, where they chose the areas of work that they feel are the least safe and most inefficient.  The list of projects they choose correlates extremely closely to the findings from the diagnostic phase of SCS.  So you don’t need to spend five months (and a lot of money) doing HTA and FMEA, you just need to ask your frontline staff what doesn’t work and is unsafe – they have the answers!  These methods do have their uses in healthcare but I do not think they need to be done routinely.

The road ahead

As a believer in quality improvement I found Mary Dixon-Woods video challenging, but this is no bad thing. It has helped me understand better the limits of small (and large) scale QI work and will hopefully allow me to be more refined in its application as the years go on and we continue with our never ending journey to improve the care we give our patients.

1. Bethune R, Soo E, Woodhead P, Van Hamel C, Watson J. Engaging all doctors in continuous quality improvement: a structured, supported programme for first-year doctors across a training deanery in England. BMJ Qual Saf 2013;22(8):613-7.
2. West M. Employer Engagement and NHS Performance. Kings Fund 2012.

Dr. Anita Jayadev is currently a respiratory registrar and QI training fellow with a passion for teaching. As well as supporting colleagues and students with QI initiatives, she enjoys leading QI projects, for which she has won several accolades including the HSJ Rising Star Award 2014.

Having spent part of my Darzi Fellowship training clinicians and medical students in developing and completing a quality improvement project, I’ve found that the most frequent concern is, “I don’t know how to start.”

A good place is to think about, “what drives you nuts?” Being frontline, we have a unique insight into the inefficiencies and potential safety issues for patients, from streamlining the way we order blood tests in clinic, to changing surgical equipment packs to reduce waste, or improving patient experience. It doesn’t matter how small the idea seems, the best projects are those that individuals have passion for and the ability to contribute to.

In fact, aside from passion there are a few useful tips to bear in mind when starting to think about your project:

1. Start with why:

Why do you think it’s a problem? It’s useful to have somebody else who is familiar with your department or who may know more about politics and processes to discuss your idea with before you decide it needs “fixing”. We often use the “5 Why” technique in our project surgeries to ensure that the individuals really understand what it is that needs improving. For example, is it a process problem or a people problem? How much influence will you have over either?

2. Think SMART:

Once you have decided on your project aim, make it SMART (specific, measurable, attainable, realistic, and timely). This is particularly important if you are only on a three or four month rotation; what can you realistically achieve in that time? Even if it is a project that is handed over between trainees as they rotate, it is still useful to define your own aim and contribution in this time. For example, “we will eliminate all pressure ulcers in the trust” may be the over-arching goal but, “to reach 50 continuous days with no pressure ulcers >grade 1 on Ward X by March 2015” may be more SMART.

3. Plan:

It may be useful to use a driver diagram to map out your project plan. I find it easier to understand what I need to do and in which order, but if you haven’t done one before it might be easier to agree this with other stakeholders. It helps decide priorities early!

4. Stakeholder mapping and engagement:

This is quite a useful exercise to do early on to try and limit potential obstacles along the way. The idea is to firstly identify your stakeholders, i.e. anybody that you need involved or who has an interest in your project. This will range from patients to healthcare assistance, pharmacists, executive directors, managers, supervising consultants etc. You can prioritise or map them out according to their level of power and interest. A quick internet search will reveal lots of advice about how you “manage” each category of stakeholder. Although I personally find the most useful part of this exercise is highlighting who I need to involve, common sense and instinct usually dictates the level of engagement needed.

The other useful thing about involving stakeholders early is that they often have helpful insights into what has worked, what hasn’t, and why. Usually we are not the first person that has come along and tried to improve a particular service, process, or experience. If you can understand context and expectations of those that your project may affect, it will help you appreciate and plan for unintended consequences. For example, introducing “quiet prescribing desks” to reduce medication errors made in busy environments may work. However, if we were no longer able to prescribe on the ward round will patients potentially have missed or delayed doses of medications? Speaking to stakeholders early might help you consider consequences that might not have occurred to you. It also gets the potentially “difficult people” onside early and you can use their experience and ideas.

It sounds like a lot to think about, but if the first steps are done right then you’re ready for the D in PDSA (plan/predict, do, study, act)! This is the fun bit, and actually nothing to be afraid of as it’s all trial and error! It doesn’t matter if it doesn’t work, just log it as a PDSA cycle; think about why it didn’t work (study) and then try a slightly different approach next time.

Given pressured clinical rotas, hectic and often unpredictable work environments with mounting commitments, finding the time to fit in what can seem like another “tick box” exercise can be stressful. It is perhaps more feasible and productive not to work in isolation. A project where a nurse, pharmacist, ward clerk, manager etc. is buddied up will be a lot less stressful and the project itself more sustainable. If you can find someone that shares the passion, it’s easier to keep the momentum going, coach each other, and help with data!

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.

Caroline Dearson is the founder of the Mickey Payne Memorial Foundation and the Dementia Buddy Scheme.

Caroline Dearson is a passionate carer and volunteer who founded the Dementia Buddy Scheme, and we at BMJ Quality are pleased to share her story. Here she describes how she collaborated with patients, volunteers, and carers after identifying that support after diagnosis was a major need for people who have dementia, as well as their carers. It was a small idea that became a big story (#smallthingsbigwins).

The Dementia Buddy Scheme was born as a result of the journey my family and I had to go through after my father was diagnosed with vascular dementia in 2005. He was a Regimental Sergeant Major in the Royal Artillery for 22 years and a Yeoman Warder at The Tower of London for 23 years. Even with all that knowledge, he still got dementia.

My father went in and out of hospital through the A&E departments due to falls, confusion, and many other problems. He went into different wards for different reasons. These wards were equipped to look after other medical conditions – but were not prepared for someone with dementia. On several occasions, I offered to stay with him after he was admitted but was frequently told no, and referred to the visiting hours. Inevitably I would get calls at all times of the day, especially late night and in the early hours of the morning, to come and sit with him as he was disrupting the wards. The lack of support from the hospital wards put an unbearable strain on my family life, and I didn’t want other families to relive our experience.

In 2013 I met the ex-chief executive of South Essex Partnership University NHS Foundation Trust (SEPT), Dr Patrick Geoghegan, and explained my vision for the Dementia Buddies. Straight away he wanted to be involved, and pulled out all the stops to get us onto his wards.

The Dementia Buddy Scheme was set up in 2013 on one ward at Thurrock Hospital in Essex. It is a voluntary scheme that involves individuals getting to know patients with dementia and visiting them as a friend a few times a week.

Buddies are now in place in three locations across Essex managed by SEPT, and are currently Buddied up with twelve patients at the moment. This can vary from week to week, due to new referrals and patients leaving.

The Buddies are person-centred and are on a rota that goes to the wards at the beginning of each week. This helps the staff to know exactly who is coming in and who they will be seeing. The Buddy’s individual rota goes out to them on the weekend before that week starts, letting them know exactly who they will be going into see. We try to keep the same Buddies to the same people while on the wards, ensuring that a trusting relationship can be in place as much as possible.

Each person will have three Buddies and each Buddy will see three people, which is due to holidays, sickness, etc. As a Buddy, I research the background of each person on the wards; I go back in time with them, as this is where I find the memories are still active. Once I’ve done this, I put activities and games in place in our Buddy cupboard and let each Buddy know about that person’s background, giving them gentle advice (at first) about how they may be able to interact with them. For example, someone might enjoy the giant jigsaws (helpful for those with poor eyesight) or magic painting sets (which reveal a picture when activated with water) that I can respectfully photograph and laminate. Once laminated I can then give the picture to that person to put up in their room. The joy on that person’s face is just so rewarding each time we do this since they are so proud of what they are achieving. We have also done knitting with the ladies, and used Meccano (using a plastic set to avoid people getting hurt). On one occasion I took the Meccano with me to see if the gentleman I was visiting would be interested. I showed him the catalogue and let him choose, and eventually he chose to build a yacht. His focus and determination was immense. I mentioned this to his family and they told me he had been in the Navy, but had forgotten to let me know about this.

Since we are now in the second year of the Buddies, Anglia Ruskin University are evaluating the scheme to determine how much this is helping patients with dementia. The scheme also provides some respite for family members by giving them time to spend time with their sons, daughters, and grandchildren without carrying any guilt, as well as freeing up staff on the wards. Currently we are supporting the families with seven Buddies (myself included) with five more waiting to be trained; I couldn’t have set this up without being actively involved myself.

Although this evaluation is important to the scheme and our future on wards and care homes, I personally see the successes on a daily basis through my interaction with the families and the Buddies. As the daughter of one of our patients recently commented, “I have the utmost respect and appreciation for the buddies and gather great comfort from knowing that someone is there for mum when I can’t be. Caring for a relative with dementia is a very hard journey for all involved, with good, bad, and sad days; the buddies help make my sad days, good days.”

Our training and disclosure and barring service (DBS) checks were carried out by SEPT NHS, but now I carry out the training and the DBS and occupational health checks are paid for by SEPT. The Buddies have the support of the staff on both of the wards.

The Foundation and I would eventually like to see Dementia Buddy Schemes in all hospitals, as well as all wards that have dementia patients, not just specialist dementia wards. I would like to also use our idea in care homes – that is my vision.

If you would like to know more about the Dementia Buddies, or would like to know how to become one in our area of Essex, please contact me on our email address: Mickeypaynememorialfoundation@hotmail.co.uk or mobile: 07539567553.

Dr Sharryn Gardner is a paediatric emergency consultant and practicing paediatrician. She has a special interest in psychological aspects of wellness and illness and started the first solution focused paediatric clinic nationally.

Sharryn Gardner recently published her report “Compassionate Conversations” in BMJ Quality Improvement Reports. Compassionate Conversations are a ground-level initiative focused primarily on supporting and motivating individual staff as the primary focus. They are led by a Psychologist and Consultant in a coaching supportive atmosphere in an open or selected group. Here she talks about her inspirations for quality improvement and thoughts on customer service for quality.

Once I’d finished professional exams I certainly never expected to become a bookworm again.  While as a trainee books were for specific purposes, after several years as a consultant they’re now for real professional development. However, I’ve found that as a consultant it has been possible to develop some new ways of getting things done. It started by embracing solution focused practice in my clinical work, which has inevitably led to me considering new ways of working and interacting with colleagues.

The scope of this reading has been wide – I’m a huge fan of Seth Godin’s blog[1] as I’m sure many readers are. Two books have been particularly influential. The first is the Disney book (more of that later), and the second is a Kindle book called “A Simpler NHS.” Its basic premise is simplicity, starting from the proposition that NHS management could be much simpler and at the same time be more effective (sample that simplicity here). It is a step back from the treadmill of measuring everything that can be measured. And unusually, our quality improvement project is the result of collaborating with like-minded individuals who met through Twitter; three managers and three consultants (including myself).

Bringing Disney to healthcare

While Disney may conjure up visions of severe consultants as Captain Hook or senior sisters as fairy godmothers, it might actually be a profound change in thinking. Fred Lee’s book “If Disney Ran Your Hospital – 9 1/2 Things You’d Do Differently” (read a sample here) helped make many of the practices my colleagues and I had already introduced into something more concrete. It turns out that Disney’s relentless focus on the customer experience is what ultimately keeps them at the top of their industry. That same constant focus on “customer experience” can be equally effective in almost any industry, including healthcare.

If I’m honest, I found this book to be life-changing, even if some of the core messages were seemingly obvious. What’s all that got to do with Healthcare? Fred Lee was a hospital manager. He learned from Disney’s values and fabric as much as their processes. More importantly he took them back to where they led directly to big improvements in healthcare. The NHS hasn’t previously had hospitals in direct competition for patients (and income), though that situation is evolving.  Lee suggests that even without this competition, embracing the customer experience culture should lead to happier, more productive staff and a much more collegiate approach to running organisations in any sphere.

As a fellow BMJ Quality blogger notes, staff like us have an innate desire to do well, to do better, and to be appreciated, and this is not confined to the so-called “caring” professions. Financial and other material rewards are apparently surprisingly poor motivators; genuine appreciation is much more effective.

Reading back through previous blog entries here on BMJ Quality, they almost universally highlight the fundamental need to not just involve frontline staff and open the process to engage everyone, using everyone’s skills and ideas to move forward as a team.[2] “Freeing up The Frontline” and “Customers, Simplicity and the Frontline” from A Simpler NHS[3] describe how much more effective devolving power to the frontline is, and how we “live or die” by our customer service. That might make us sound like a business, but that’s exactly the point. Patients compare our levels of service with them rather than other hospitals.

Perhaps we’re not yet shouting that message loudly enough, or at least not in the right ears.

Handy’s Curve and scepticism

The simplicity chapter also describes Handy’s Curve. This is a well-known phenomenon in general management where any new initiative takes a short period to amass expertise or resources to get going and then has steady upwards growth. The sting in the tail is that by not planning the next steps or spread of the idea, death of the initiative is virtually guaranteed. The new ideas or changes need to be in place from the mid-point of the upwards curve – point A on the diagram. The NHS, as much of business, repeatedly fails to plan for the next steps early enough. Little wonder that staff get more and more sceptical about any shiny new initiatives delivering real sustainable change.

Quality improvement project

Our project started from a grassroots implementation of the solution focused practice principles in the workplace. Our local psychology department had already embraced this as their primary model. Staff were individually given personal feedback from colleagues who attended sessions as groups. Some staff groups had separate sessions leading to spotlighting and showcasing of their people and achievements.

In the future, the same principles will be used in more and more diverse areas, and the sessions at the core are being further spread locally and within teams.

Compassionate Conversations was shortlisted for the following national awards:

• BMJ Clinical Leadership
• HSJ Patient Safety Award for Changing Culture
• HSJ Value in Healthcare Award for communication.

References

1. Seth Godin’s blog www.sethgodin.com

2. Amar Shah. Embedding continuous improvement to achieve transformational change, BMJ Quality blog. https://blogs.bmj.com/quality/2014/08/06/embedding-continuous-improvement-to-achieve-transformational-change/

3. Cantley P, Finegan M, Nisbet A, O’Regan D, Gardner S, Gay T, Oldham J. Freeing up The Frontline from “Customers, Simplicity and the Frontline” from A Simpler NHS. A Simpler NHS: A fresh look at management in the NHS (Simplicity Book 1).

Dr Sophie Edwards is a consultant geriatrician, older persons’ advocate, and dementia trainer.

Dr Sophie Edwards is a consultant geriatrician, older persons’ advocate, and dementia trainer with a passion for instilling the values of high quality, person centred care for all @docofagesSophie. Here she describes some of the challenges she faces embedding quality improvement in an organisation.

I work on an acute geriatric ward in a busy district general hospital, where we serve a diverse ethnic and socioeconomic area – we have one of the busiest accident and emergency departments in London. Recruitment and retention of staff is difficult; morale is low, and fatigue is high. I’m not dismissing our service but I am keen to be honest and realistic about the challenges we face.

I’m sure many of you will recognise this picture. So, how on earth do we maintain a safe, high quality service when we are effectively working with one hand behind our backs?

I reflected on what I would expect from a high quality service as a client or customer. Competency in knowledge and skills is taken as a given. So what makes the difference between timely, correct treatment and high quality, memorable treatment?

Much of my workload includes caring for people with dementia or delirium. A person with dementia or delirium needs focused and flexible care. They need to know what is happening and when. They need to be reassured that their needs are being met. They need the involvement of their family and carers and they need staff to know who they were and who is important to them now.

Much of this can be achieved through good communication. It’s more than introducing ourselves properly, although this is absolutely vital; it’s about standing back and listening. It’s about watching the subtleties in body language and facial expression. It’s about picking up the little clues from the midsts of a patient’s delirious mutterings (many of my patients provide some superb insights while in the throws of their delirium). Ultimately, it’s about really knowing what makes each patient tick.

I would suggest that high quality care needs connectivity. It needs staff to be connected to each other and with the reasons that they went into health care in the first place. It needs staff to be connecting with patients and not shying away from the emotional investment that caring for people needs. It also needs staff to have the opportunity and space to reflect when things are overwhelming.

I wanted staff to really know the person behind the patient, so we introduced “Ten important things you need to know about me” based on “The important things you need to know about me” from The Alzheimer’s Society. It was originally for use with people with dementia so that staff would know what to say or do when someone was distressed or agitated. I think everyone should be able to tell us their story, who they need when things are tough, and what their likes and dislikes are. I’m keen that we use it for all inpatients if they wish.

Embedding this initiative has not been easy. I’ve personally filled up trays of it around the hospital, but it is yet to be part of our standard care. If it really works once and provides a key piece of information that calms a patient, or provides an insight that allows staff and patient to connect in a way they hadn’t done before, then the benefits will be seen and staff will want to use it again.

No one intervention will work in isolation, and the importance of supporting our staff to care cannot be underestimated. A chance meeting with a sports masseur led me to applying to our local training board for some funding to train some staff in hand massage. The trainers provide a course which includes massage techniques but also teaching around dignity and person-centred care. It gives staff a bit of much needed breathing space away from the ward that isn’t just mandatory training or e-learning.

Back on the wards, it allows them to sit down and spend time connecting with the people they wash, dress, and provide medication to. In the rush of the hospital that talking time is lost. This was about connecting staff back to their role as a carer and a provider of comfort. We use if for people with dementia, for end of life care, overwrought carers, and anyone who might be in need of the contact.

Again, encouraging staff to keep using these skills has been hard. Time is scarce, and it needs good support from the development nurses to ensure that the skills are used regularly.

It is frustrating that many of these small, quality interventions often save time in the long run. Calmer, informed patients can translate to less behavioural problems reducing the need for one to one nursing, less incidents, and less complaints. Staff that are motivated, connected, and supported are more likely to care about the quality of care they provide.

The prospect of trying to change or improve can feel overwhelming and daunting, but I’m a great believer that sometimes small, simple ideas can have a local impact that can ripple through an organisation and before long can establish a culture of improving and quality improvement. We may only be at the starting blocks of this journey on our ward, but at least we are out of the changing rooms!

Dr Kate Granger is an acting consultant in medicine for older people working at Pinderfields hospital in Yorkshire, and also blogs and writes about her own experiences as a cancer patient

Hello, my name is Dr Kate Granger. I’m an acting consultant in medicine for older people working at Pinderfields hospital in Yorkshire. I’m also a terminally ill cancer patient diagnosed with a rare sarcoma just over three years ago.

I have been a keen observer of my healthcare throughout this difficult journey and it was apparent to me early on just how much the little things mattered to my experience as a patient. When somebody smiled, sat, or crouched down instead of towering over me, gave that extra moment to allow me to express my fears, or took the time to introduce themselves in a welcoming manner, it meant a huge amount and made me feel human again.

The #hellomynameis campaign was born out of a hospital experience I had when I was admitted to a urology ward with a post-operative infection following a routine stent exchange procedure. There were lots of problems with my care, but most distressing was that hardly anyone took the time to introduce themselves. This left me feeling like a diseased body in a hospital bed and nothing more. I firmly believe after much reflection that an introduction represents far more than just common courtesy, but rather the start of a connection between human beings; it is about the therapeutic relationship, building trust and rapport, and providing truly compassionate, person-centred healthcare.

I am a strong advocate for quality improvement in my daily work and am always striving to improve the care we deliver with my team. The most interesting area of quality improvement for me is how to change behaviour with lasting effect. I firmly believe that narratives have a vital role to play in behaviour change and decided that my story, which I knew from interactions on social media was not a unique one, was going to be central to instigating that change.

I started to tweet using the hashtag and wrote a blog inviting people to pledge their support, similar to the style of NHS Change Day. We designed a freely available logo and a website to collate resources and ideas, and within weeks I had a social movement on my hands!

We launched the campaign a few months ago in my previous hospital, and within just a couple of weeks one third of the fifteen thousand strong workforce had pledged their support in return for a name badge displaying the logo. We received thousands of pictures from staff across the organisation holding #hellomynameis signs as a symbolic gesture of their support. Everyone from student nurse and porter to medical director and chief executive were engaged.

It is very difficult to evaluate the impact of a campaign like this. We can, however, measure how much people are talking about it on social media fairly easily, and those numbers are impressive: over 70 million Twitter impressions in just 16 months, which is 4 tweets per hour. The campaign has spread beyond social media right out into health and social care across the UK. It has even had a global reach; people are using the campaign in the United States, Canada, Australia, New Zealand, India, and South Africa.

Some junior doctors at Bolton hospital are using traditional improvement science methodology and have measured the frequency of introductions in the emergency department.  They will be repeating their observations after the campaign has been launched there, with follow-up PDSA cycles planned. There are several other similar projects currently ongoing across the country.

The campaign has caught the attention of the Prime Minister and the Secretary of State for Health. Although it may seem a little gimmicky, we have even had some support from celebrities such as Kyle Minogue, Drew Barrymore, and Michel Roux Jr, which all helps to raise the profile of the campaign and spread the message further.

This is an aspirational idea. It is about saying, “This is me and I am proud to be able to look after you”. It is a behaviour that cannot be trained into people with mandatory learning objectives – it has to come from within. The power of my voice is that I am “one of us” but also “one of them”. No-one knows when that terminal cancer diagnosis may appear in their lives so seeing the patient in front of you first and foremost as another person is a great way to begin care.

www.hellomynameis.org.uk

Dr Paul Shannon is a practising NHS consultant anaesthetist with an extensive clinical leadership record in the NHS at local, regional and national level. He is a member of the new Yorkshire and Humber Clinical Senate Assembly. His passion is to improve patient care.

I once asked an eminent doctor why he didn’t publicise the shocking figures of avoidable patient deaths in the NHS that he’d just presented to us at a closed meeting. He answered, “how could I; can you imagine the outcry?” Indeed, I could imagine the outcry – from politicians, professional organisations, and even patients themselves. And that was really the point of my question; the energy released would be disruptive and facilitate change.

It’s in this context that the statement by the Secretary of State for Health is remarkable, that 6,000 lives could be saved each year by improving safety in the NHS. Mr Hunt is promoting “openness” and this is the first step to patient empowerment; to let the public know what’s going on. In other words, share the data with them. Knowledge is power, so empowering someone involves giving them the same information that you’ve got. Knowledge is organised information.

Show them the data

“Discontent is the first step in the success of a man or nation” (Oscar Wilde)

Patients need to know how dangerous healthcare can be. They need to understand that all hospitals are not alike, not all doctors are competent all the time, and not all nurses are compassionate all the time. In short, they need to become discontent with the status quo.

But where can they get the requisite information?  In general, data is held by professionals and carefully dispensed to patients. It’s often a paternalistic relationship, like a parent/child transaction. Just try getting access to your records. You will be treated as a nuisance, or as a “rebellious child”, and punished by having to pay for the privilege!  It will be made as difficult and laborious as possible so that you don’t ask again.

In reality, it is easy to give patients ready access to their records, and some countries do this already, but commonly it is “cumbersome”, or somehow considered just plain “wrong.”

Sensational

“I never travel without my diary. One should always have something sensational to read in the train” (Oscar Wilde)

As a doctor, I’ve never come across a patient who doesn’t want to read their medical records. Human beings are fascinated by their own condition and by their own lives, and especially by what other people think of them!  Harnessing this natural self-interest is a good way to involve people in their own care; it’s a natural “pull factor.”

Once lured in by curiosity, they’ll stay to contribute and learn. I recently held a consultation with a patient with a chronic haematological condition. I asked her what her latest test result was. Of course, she didn’t know, so we looked it up on the hospital pathology system. Seeing her results made her feel like she was being shown something illicit!  She said it was the first time in her life that anyone had shown her her own results. She was delighted and intrigued to know more. That’s a pull factor.

Another pull factor is correcting and updating data. Usually, this is done in the form of amendments so that original information is not lost. Patients are sometimes horrified at the errors within their records. This alone is a good reason for patients to see their records, to cleanse wrong information and improve quality.

Choose the best, or avoid the worst?

When a doctor, or their loved one, has a medical problem, they ask their friends, “who should I go to?” or, “who should I avoid?”  They know there’s wide spectrum of performance, so why don’t ordinary patients deserve this level of knowledge?  Of course, it’s mainly word of mouth opinion because the hard data to substantiate it just doesn’t exist, or isn’t easily accessible. Nevertheless, I’d hesitate to be treated by a doctor who never treats his/her colleagues!  League tables are a great way to present performance data easily. Just like in sport, no doctor wants to be in the relegation zone!

In the past, the NHS has tried in various ways to push information towards reluctant patients. Similarly, the Department of Health has tried to encourage the NHS to look at performance data, which the doctors happily rubbish. Now, it’s time to look at the other end of the pipeline and utilise the power of the consumer to suck as much information as they want and need out of health IT systems. As in other industries, patients, as consumers, will demand better access to information streams about the quality of services and doctors, which will allow them to contribute to their own health and well-being. And, doctors will want to know how they’re performing. In the end, better information produces better decisions for all.