12th December 2023 - Patient Safety is no Accident - A Personal and Practical Journey

Dr Tricia Woodhead BM MBA

Quality Improvement Fellow and Advisor

Patient Safety and Person Centred Care Expert for the International Society for Quality in Healthcare (ISQUA)

Retired Consultant Radiologist and past Executive Medical Director (Weston Area Health Trust)

23 years ago, I completed my Masters in Business Administration at Bath Management School. I had combined an eight- session consultant radiology role,1 in 4 on call with a two-year part time programme. I had packed a lot in. My family remember it well. From a standing start I now knew a lot about building a strategy, operational management, lean and other process theories, financing capital projects and accounting for day-to-day costings and, not least, the managing and leading of people. It was Autumn 2000 and within days of my graduation I was asked to be the part time Medical Director, the incumbent, a full-time post-holder was leaving for personal reasons.

As Executive Medical Director of Weston Area Health Trust one of the first big documents that arrived in my in-tray was the National Patient Safety Regulations 2001- published and enacted from 2nd July 2001. This prompted many articles and reviews of leadership in healthcare. These reinforced the vital importance of collaborating, the value of taking differing viewpoints and differing professional contributions and of seeking truth when it might be hard to uncover. Useful insights that remain relevant today can be found https://qualitysafety.bmj.com/content/qhc/10/suppl_2/ii46.full.pdf and https://qualitysafety.bmj.com/content/10/suppl_2/ii3.long.

This was a springboard for me to use much of what I had learnt in my Masters programme even if many of my medical colleagues thought the diagrams and terminology that I used were confusing and from an alternative universe. But making things safer for patients is not easy and not an overnight transformation. It is about deep personal and system understanding. It is about clinical and administrative partnership and about change. Change being the hardest activity of all.

The principles that are within those Safety Regulations are very similar to those that underpin being a great doctor, a nurse or an allied health professional. As clinical diagnosticians we must be able to reconsider the situation as each piece of a complex puzzle arrives in the results tray or is evident on the observation charts or from the patient’s history. We keep our judgement open and our eyes open to evidence that does not fit with what we first thought. We keep vigilant to variation from the expected. As champions for patient safety, we need these same attributes to get beyond a root cause analysis to a wider system understanding.

The practice of medicine applies the Bayesian principle; that one explores an avenue till evidence does not fit then you retrace your steps to a point when a new avenue can be taken. This is how we learn to make a diagnosis. A useful expansion of this way to understand our own thought processes was published in 2005 here is a link. We do not go automatically go back to the beginning we go back to the point where the evidence is consistent and then take a new route with an ever-open mind https://www.ncbi.nlm.nih.gov/pmc/articles/PMC557240/.

I propose that this characteristic of our professional way of thinking is less clearly embedded in routine organizational management. The management of complex organizations, such as a hospital or the NHS, is less ‘iterative in action’ than is the skill of clinical diagnosis. Organizations create working groups, the plan is made, the changes set in motion and the outcome assumed because that is what the plan was created to deliver! Such approaches are often weakened by rarely asking in advance the question any trained engineer would ask which is ‘what could possibly go wrong?’. Perhaps it is this contrast in approaches that creates the tension between clinician and manager. The clinician learns to manage uncertainty for a long time and control of the situation is often temporary. The manager’s basic role is to always ensure control of the situation, any situation as soon as possible.

When looking back now I can see for me and my team there was a turning point taking place. Increasingly we recognized that safety required constant vigilance. High levels of attention in everyday work at the same time as everyone being on the look-out for the unusual or exceptional circumstances. More profoundly we began to consider how we might seek truth when the evidence was not obviously there, how did something happen and what is behind it before making a fast thinking decision on ‘who or why’. We learnt to replay events with judgement suspended. Judgment comes easily and is often the barrier to understanding the real reasons behind an event. The circumstantial clue is obscured by the desire to find a culprit. We know that the search for corroborative evidence can be hampered by those ever-present human factors of assuming things are as they first seem or as our assumptions make us think, that we miss crucial evidence in the hurry of work and that we can therefore be persuaded to do the wrong thing in spite of what is in front of us. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC557240/)

One important concept from Improvement Science that seems to me to be vital to systems design and team work for safer care is the concept of common cause variation and special cause variation in systems and working practices. When we have a sick patient or the need to monitor a patient because what might happen next might have swift and bad consequences, we use a suite of measures (pulse, BP, temperature, urine output, cognitive function for example). We measure these at the required interval to spot the changes in time to do something about them before any serious deterioration occurs. We know there is a common cause to the variation in the readings but we are looking out for a trend in the right direction or a spike where something is more unstable than we expect. The purpose being to act in time. The same principle applies to clinical pathways and patients as a group, such as all stroke patients in a hospital. Seeing special cause events real time enables swift action to mitigate and correct what is going adrift in the delivery of care.

When we applied the theory of ‘always looking’ at deaths in our hospital from 2006, we derived a new and powerful understanding of the standard of care we were or were not delivering day in and day out. When we saw an exceptional variation from the week-to-week undulating line we knew we needed to look at how this had occurred. We had the opportunity to seek more understanding and to explore as a team the situation/ circumstances/ patterns with an open mind and in a collaborative way.

By knowing and watching continuously we were able to take the lead when the evidence around us changed. We had the robustness of time-ordered data and a regular systematic approach to analysis that provided the best opportunity for open and honest collaboration with every single person in the system who had a role in providing care directly or indirectly by their management or resource decisions.
We had the facts to make the case for further understanding and to make changes in an iterative way. We were applying the principles of being a great physician to being a leader of quality and care in our hospital.

To work together is to build bridges with colleagues that ensure problems are robustly explored and that resilient solutions are developed, adapted, and adopted. Real time evidence is a crucial way to build the common understanding and nurture the constant vigilance that underpins patient safety. Patient Safety is not an accident it is deliberate and it is our responsibility to deliberately improve it every day.

16th May 2023 - Building a great QI Team

Dr Tricia Woodhead

A critical ingredient of successful quality improvement is the ‘TEAM’. Much has been written over the years about leadership of teams and leadership for improvement. Several references are included in the web resource on this site. Understanding the fundamentals of resilient and robust teamwork is seldom part of our formal education and even experience at work can give as many negative experiences as positive ones. What is written less about is the team itself and how leadership within it can be developed, distributed and maximally effective.

Professor Marshall Ganz, Kennedy School of Management has written about the topic from his perspective of creating the environment for shared purpose and shared action. This is exactly what the Clinical Microsystems Methodology asks teams to do first, before they get started on exploring the problem and any solution building. If we do not all feel ‘the purpose’ of the work matters, that it sits with our professional and personal values it is less likely we will stay engaged and involved over time.

At this moment in our NHS there is probably a sense that any team that was on top of the problem before is now struggling to get back that sense of control. In addition, any new problem that is the focus of a QI project will need to build and sustain a team in today’s challenges if it is to succeed.

How might we step back from any sense of chaos and reframe and restore a sense of purpose within a productive environment? I have refreshed myself of a course I was fortunate to attend during my own sabbatical in Harvard in 2011. This gives us a context in which to consider and test out participating and leading better meetings.

Ganz describes five contributions to successful leadership practice (https://wcl.nwf.org/wp-content/uploads/2018/09/Marshall-Ganz-People-Power-and-Change.pdf)

A conversation that shares values and purpose with and by the whole team.
Building an environment where each team member knows and feels part of the team and integral to the work planned.
Being creative and imaginative about what success could look like and the strategies to achieve this. Getting everyone’s perspective on what great looks and feels like.
Being flexible in how the work is done and responding to what is learnt to make progress rather than retain a set structure or set roles if they are ideal for what is needed next.
Measured action so that milestones guide the work to a successful conclusion.

What can go wrong? Common problems we may all have experienced get in the way of any team maintaining momentum and making a positive difference. Ganz gives a few examples that may ring bells with you.

The people in a team can have differing perspectives but more difficult to deal with is when they have differing objectives or definitions of what success looks like. In such circumstances the team can become multiple small groups not a whole.
During the meeting as well as between the meetings it is never clear who is supposed to do what and who might take responsibility for any tasks/ actions before the team reviews the matter the next time.
There is invariably a key piece of information, person, expertise that someone needs to contribute to the team decision. The decision is therefore deferred, sometimes repeatedly.
The members of the team seem to vary from meeting to meeting making constancy of purpose harder to sustain and requiring the repetition of the why and how and any previously agreed plans.

So, what do we do to build the positive attributes mentioned first and prevent the negative experiences listed above. How do we build a great team and deliver excellence in our work and better outcomes for patients?

First think about the structure of meetings. Ideally dovetail the new conversations into an existing forum even if only for 10-15 minutes in the first instance. This will be far easier than finding a new time and it can also happen by next week! Weekly discussions mean momentum is sustained and that actions can start to build a better understanding as well as the trying out of ideas that have been discussed.

Screenshot 1

Second within each meeting develop a discipline so that everyone can feel comfortable, contribute and that the topics are covered not left over to next time. The Clinical Microsystem approach proposes the roles below are agreed and rotate from week to week so responsibility is shared. https://www.sheffieldmca.org.uk/effective-meeting-skills

Screenshot 2 Thirdly try to build rigor into the discussions and the actions that will follow on when the meeting ends. If the actions seem to large and complex then make them smaller and simpler. Create a path that everyone can feel positive about. This will build confidence and courage quickly so that in due course the team can develop that creative environment for strategy building that is key to success.

A good checklist of important ingredients is here.

Screenshot 3

Why should you try this out? The Sheffield Clinical Microsystems site has a great log of examples within the NHS where better teams and better team meeting has been key to success. https://www.sheffieldmca.org.uk/stories. These are worth checking to give you courage and confidence to try the above ideas during May 2023.

Have this check list to ensure decisions are made, uncertainty managed and progress made.

Screenshot 4

22nd March 2023 - Being Human is the First Step in Quality Improvement

Dr. Peter Lachman

Lead Faculty Quality Improvement Programme, Royal College of Physicians of Ireland

Peter spent his consultant career at Great Ormond Street. He was an IHI/Health Foundation Quality Improvement Fellow in 2005/6 and became Chief Executive of the International Society for Quality in Healthcare (ISQUA) in 2016 until 2021.

https://www.health.org.uk/fellow/peter-lachman

As one goes on the lifelong journey that is a medical career, one finds that the journey is full of surprises, both good and bad. It was once thought that being professional was all that one had to do in order for care to be safe and of the highest quality. Unfortunately, this is only part of the solution to ensure the best outcomes for the people who seek our care.

As you browse websites and read blogs of how to provide safe care, or go on quality improvement courses, you could justifiably reflect on the lived reality of your day to day work. This can lead to the conclusion that, given the current state of the health service and the way you are asked to work, the safety and quality of care is something that is unachievable. Despite all the theory and methodology there may be a disconnect between your own lived experience and what you are asked to do to improve care.

I would like to offer a way to deal with this conundrum, i.e. how to make care better for the people you treat, starting one patient at a time. At the same time, this will improve your own sense of wellbeing. The Institute of Medicine has defined the six domains of quality that have provided the paradigm for the quality movement over the past twenty years. Unfortunately, healthcare worker wellbeing was not one of those domains. Nor was climate change, as it was not considered to be as pressing an issue then as it is now.

We have therefore developed an updated definition of quality based on core values that define the reasons we are in healthcare. Screenshot 5 The multidimensional model of quality places four core values at the centre, which is surrounded by person and kin centred care. It includes leadership, resilience and transparency as key facilitators of quality. The five remaining domains are kept with an added domain of eco-friendly care. Climate change as a domain is a vital addition, as many of our healthcare processes are carbon unfriendly and each of us can make a difference in a small way, e.g. by decreasing repeat blood tests and the use of plastics.

Unlike the original model of quality, we believe that person centred care is more than about the patient and involves a wider scope of family and community, as well as healthcare providers. Wellbeing of healthcare workers is an essential component of patient safety and quality. Patient safety and quality are simple yet complex concepts and the most important component of any improvement process is not the improvement methodology or measurement, but rather the people involved in that process. This wider definition of person centred care includes the kin of the patient, i.e. the patients, families and their wider community, as well as doctors, nurses, allied professionals and other healthcare workers. All have their own lived experience that will influence the results of any improvement project, as well as the clinical outcomes.

At the core of the multidimensional model are the values upon which healthcare is founded, i.e. kindness and compassion, respect and dignity, holistic integrated care and coproduction of care. I will focus on kindness, as it leads on to the others. A fundamental step to enhance the core values is to give small acts of kindness every day, both at home and at work. As a doctor in post graduate training there is often a harshness to the work, to what one experiences and this in turn can be translated to the lack of person centred care where people who are patients become a disease, an organ, a bed, a hospital number. There is a growing understanding of the way small acts of kindness can make a difference to one’s well-being. Intelligent kindness has been studied and provides the basis for one to be kind. Explore this informative website Kindness in healthcare which has many good lessons and examples of kindness. In Belgium there is a great programme called Mangomoments which demonstrates small acts of kindness. In the medical literature there have been papers such as Allwood et al calling for careful and kind care as this will act as the antidote to burnout, that has resulted from the industrialisation of healthcare.

You may be perplexed at the enormity of the challenge. Afterall when you went to medical school the aim was to learn about medicine. Yet, when one delivers care all that one has learnt is not a guarantee of success. People want care that is effective and safe and to be treated humanely. To provide human centred care we need to regard the clinical encounter as a meeting between two humans, one in the role of doctor, the other as patient. If we remember it is a human interaction then the core values of kindness, respect and dignity will follow easily. And when we are looking at how to solve a human problem the other values of integrated care and coproduction of solutions will follow.

Only then can you apply the improvement and patient safety theories and methods to improve patient safety and quality as part of your day to day work. Unless your own experience of work is meaningful, the safety and quality journey one embarks on will not succeed. A recent paper in JAMA called for human based design of patient safety and quality. This requires you, as clinicians, to codesign quality and safety initiatives so that they can benefit you, your colleagues and the people for whom you care.

Rather than see improvement as process change and the use of improvement tools, we can each take small steps, one at a time, starting with acts of kindness. Being kind to oneself and others will allow you to have a sense of fulfilment. Be an active co-designer and co-producer of safety and quality and as a result have a more meaningful work experience.

15th Feb 2023 – Beyond audit: Becoming a QI Fellow

Dr Charis Banks

I was an F1 in a DGH, and someone said, ‘you have to do an audit’. I panicked. I had a vague idea what an audit was, but I wasn’t sure what to do it on, or what to do with the results. I felt pretty sure I was going to have to do it on my own (I didn’t know who to ask) and I kept hearing people talking about the importance of ‘completing the cycle’ but had no idea how to go about doing that.

One of the F2’s was doing a sharps bin audit – they went round and counted the number of sharps bins on a ward and noted whether they were full or not. I have no idea why or if they thought there was a problem with sharps bins BUT it counted as an audit so big tick for the portfolio.

I felt totally clueless, I hadn’t had any formal training at med school how to do this. I spoke to another F1, also clueless, so we did one together, on stool charts. We determined they weren’t completed often enough and our solution was that the ward needed more nurses and more nurse education. I passed that on to the ward sister and said they should re-audit when they had fixed the problem. And that was it, audit done, tick.

As you can imagine, everything about this was unsatisfying. It felt like a pointless waste of time, which it was, with no discernible benefit to either staff or patients, which there wasn’t.

Fast forward a couple of years and I’m working as a clinical fellow in ICU and notice a problem. Over and over again there was accidental removal of NG tubes from patients. This was leading to missed doses of medication and missed nutrition. It was also leading to patient distress and discomfort as new NG tubes were inserted repeatedly. It felt like a solution was needed and so began my first foray away from pointless audit and into QI.

I found a mentor – a consultant who agreed to help me. I looked at some initial data, we created a measurable and specific aim and then looked at potential solutions. We started with a small group of patients to trial a way to reduce the incidence of this happening. We measured what happened with this small group, we made some changes and then we implemented these changes to the whole ICU patient population.

It was great, so simple and had a real benefit to patients. Not audit for the sake of a portfolio tick box. But real change using the QI ethos.

I am now an ST6 trainee in Intensive Care Medicine and this year I am the HEE SW Quality Improvement Fellow. I have seen how good QI can benefit both patients and staff and I want to ensure everyone has the knowledge and tools to embed change management in their clinical practice.

It’s early days (I started 2 weeks ago!) but my plan for the year is two-fold;
- To work with the HEE SW QI team to create and signpost free training and resources. This will include supporting trusts and supervisors to make QI part of every doctor’s professional working life.
- To lead by example by completing a clinical project in ICU, using my experience to help others with their own projects.

I am a big believer that a project doesn’t have to be big to make a big impact. If you’re just starting out on your QI journey there is loads of information out there – don’t be overwhelmed. I suggest you start with the Model for improvement. It’s where I started, and I think it demonstrates what QI is all about. If you can identify an issue then this can help you solve it.

Not audit for portfolio’s sake but real changes to improve the care we deliver to our patients. Isn’t that what we’re all aiming for?

How to Improve | IHI - Institute for Healthcare Improvement

30th November 2022 - How to lead for improvement?

Anna Burhouse, Consultant Child and Adolescent Psychotherapist, Northumbria Healthcare NHS FT

Anna Burhouse has a long career as a Consultant Psychotherapist for Children and Young People in Gloucestershire. She spent three years as Director for Quality Improvement at the West of England Academic Health Science Network and is now Director of Quality Development at Northumbria Healthcare Trust.

When taking on your first quality improvement (QI) work it can feel like a very new way of working and it is tempting, when you are starting out, to focus on rapidly expanding your technical knowledge of quality improvement methods. Gaining competence in the different models, how to use measurement for improvement, understanding the role of variation, how to apply run and statistical process control charts can all feel exciting, opening up a world of useful tools and techniques that can be applied in the messy reality of working in a complex adaptive system like healthcare. These technical tools help you structure your approach to improvement, to know when change is an improvement and how to display meaningful data to make a powerful case for change.

I remember when I first learnt these tools and techniques, it was like someone suddenly gave me a concrete way to make a difference. It was 2004 and I was working in a CAMHS team when the waiting list for assessment was over 4 years long (not unlike the current situation for some mental health services today I am afraid to say).

Using QI tools to process map our pathways helped us to identify and cut out waste, like multiple appointment letters. It helped us to reduce DNAs and offer more effective team diary slots. The technical approach we took as a team was extremely useful and using several core QI methods we managed to reduce our waiting list to a reliable process of 10- 14 days for many years in succession.

Working in this way also had another unexpected benefit, one I had not anticipated, it helped us to work more collaboratively as a team and feel better about our work. I had designed pre and post qualitative questionnaires to help us measure balancing measures, like how much time this new QI way of working took us and whether it made our ways of working together as a team better or worse. This data, about how we functioned as a team, demonstrated that working in this new way improved our communication and 100% of team members (clinical and administrative) reported that they felt more engaged in the team and that their enjoyment at work had increased and their levels of stress had reduced.

I was intrigued by this unexpected impact on our team functioning and started what has become a long-term interest in discovering more about the ‘people’ side of improvement.

Marjorie Godfrey (PHD, MS, BSN, FAAN), a research professor in the Department of Nursing and Executive Director and Founder of the Institute for Excellence in Health and Social Systems (IEHSS) at the University of New Hampshire, USA, states that 20% of improvement is technical (the tools, methods and measurement techniques etc) but that 80% of improvement is about people (the way we work together, communicate, interact etc). This is perhaps not surprising when you think about the common relational and psychological barriers to improvement we come across time and again in healthcare. Change is about working with people.

In fact, in a questionnaire designed for physicians, Baker, Suchman and Rawlins (2016) found that these relational factors were common, with 88% of respondents stating that “when faced with problems in quality improvement efforts, the predominant cause is relational and not technical in a majority of cases. Relational issues were defined to include quality of communication, motivation and behaviour, the way leadership is expressed and meeting structures and processes.

Nearly half of those surveyed reported that relational issues in improvement efforts demand attention four times more frequently than technical issues.92 percent answered “yes” to the statement “I am currently facing a relational problem which is having a significant impact on my work life.” 58 percent of these relationship problems had been going on for six months or longer.” (2016 p2).

They concluded that “Despite a vast amount of knowledge about the technical methods of improving quality and safety in health care, rates of success have been highly variable within and across organizations. ^1–7 In our work with many health care leaders and organizations, our observation has been that relational rather than technical issues are the most common barriers to improvement.” (from ‘Hidden in Plain View: Barriers to Quality Improvement’, Physician Leadership Journal, 2016 – available to download).

I have informally recreated this experiment here in the UK with physicians and other healthcare professionals and find similar results, with many people saying that some of the worst aspects of their job are dealing with difficult relationships at work.

Knowing these facts, knowing how to lead relationally for improvement becomes even more important as a core part of our job. An interesting recent study by Warwick Business School reported on the national evaluation of the NHS-Virginia Mason Institute (VMI) partnership which supported 5 NHS Trusts to adopt the lean QI methodology that sits at the heart of the VMI QI approach Reports (warwick.ac.uk).

The findings are key for improvement leaders as they show that a ‘coaching style’ of leadership that ‘frames ‘the problem, rather than tries to ‘fix’ the problem is crucial as it helps to flatten traditional NHS hierarchies and encourages solutions and problem solving from all staff not just those in formal leadership roles.

The study demonstrated that formal leaders had to become more open minded and curious about the issues teams were facing and get better at thinking systemically about how to find system level solutions. It also found that leadership must be shared and distributed, so that everyone feels they can contribute and take an equal part in finding the solution.

The leaders ability to build trust in the organisation and to be willing to repair trust where it had be broken was the heart of the challenge. To create a psychological contract that helped make people feel safer to raise issues, or have a different opinion or respectfully challenge each other was vital.

The goal of an improvement leader is to create a ‘values led’ improvement culture where everyone feels included and skilled in improvement. These social and relational networks are the ‘glue ‘that help create positive and reciprocal connectivity and interactions within highly complex adaptive healthcare systems.

The study used social network graphs to show the difference between the 5 trusts and the importance for successful improvement of creating cultures where people are talking together, learning from each other, and contributing improvement ideas.

They conclude that “Continuous improvement approaches such as Lean are socio-technical. This means we should pay as much attention to the social side of change (for example relationships and social structures that foster collaboration, engagement, psychological safety, and employee wellbeing), as the technical side (the infrastructure, training, methods, and tools employed to drive change). Our findings suggest high levels of technical capability are a necessary but insufficient condition to foster a sustainable culture of continuous improvement” (2022, p4).

This work chimes with the work of Professor Amy Edmondson on how to create better psychological safety in healthcare and why it matters for patient and staff experience. Check out these fantastic TED talks about the implications for creating safer teams at work https://youtu.be/LhoLuui9gX8 and https://youtu.be/3boKz0Exros . She has also worked with NHS Horizons to create A-practical-guide-to-the-art-of-psychological-safety-in-the-real-world-of-health-and-care-.pdf (horizonsnhs.com) (2021) that has lots of ideas about how to lead for improvement and some simple exercises you can do with your team to increase the likelihood of a culture of psychological safety.

In the UK, the work of Professor Michael West is leading the way on how to support compassionate collective leadership in order to support a culture for improvement. His work demonstrates that clinicians who work in what he calls ‘real teams’ with clear goals and supportive team leadership are much less stressed (West et al 2015 (West et al 2022)) and that this impacts on better patient care and improved outcomes (including mortality) (West and Dawson 2012; West et al 2011), including improved financial performance.

So, what can you do about this in your day-to-day leadership for improvement? Atkins and Parker 2012 identify four behaviours of compassionate leadership that you could start to practice reliably. They include skills in: attending, understanding, empathising and helpingWhat is compassionate leadership? | The King's Fund (kingsfund.org.uk).

You could also take Professor Amy Edmondson’s advice and get good at psychologically safe framing of the improvement task ahead, signalling that ‘no idea is a bad idea’, ‘we will learn together from our experiments to improve’ and by embracing messengers of bad news, thanking them for letting you know it didn’t go to plan and being curious about what we have learnt as a result.

There is lots to do be a successful leader for improvement, but the good news is that every day in work you will have micro-moments to practice how you react and adapt into action. Stop thinking about this ‘people stuff’ as ‘pink and fluffy’ or something that’s ‘nice to have’ and start seeing it as the most important part of any improvements you make.

You may find that just by flipping your own mindset in this way, this could enable you to become a better leader through small daily changes and experiments. Sounds like a familiar approach? It’s the PDSA of becoming a better improvement leader.

Good luck, it’s not always easy, but it is worthwhile.

If you are interested in continuing the conversation then do reach out and say hi @annaburhouse

25th October 2022 - How do we Develop a Department QI Plan?

Dr Tricia Woodhead

When looking to undertake an improvement project individuals naturally look for something that they have spotted or know could be performed differently and better, a personal bugbear. The result may be that;

improvement work only continues over time if that person is there to drive it,
the topic is important but not the focus for the overall team or department,
handing on a piece of work is harder than it might be if the topic was clearly an ongoing and more widely accepted priority

In my advice to educational supervisors and quality leaders I encourage the development of a unit/ department strategy for quality improvement. By this I mean that there has been a wider discussion grounded in information regarding current best practice and the aim to deliver excellence. How this then compares with the known facts becomes the starting point for a prioritization of what to fix first.

Where to start probably seems to be the biggest challenge so I have summarized below how one might approach the problem. Taking a wider perspective first helps to remind everyone of the main purpose of the unit’s work. What are we trying to achieve? The drivers of quality are often overlooked in operational changes over time so starting with the principles of safe, timely, effective, efficient, equitable, and person-centred care (STEEEP) helps ground the discussions in a way that enables systems thinking and systems related action. How would we know a change was an improvement? Lastly if we can see problems and align them with recognized improvement approaches and tools our chosen next steps are more easily planned, shared, and measured.

As a radiologist how might I apply this approach to my own service? Here is an approach that you may be able to adapt to your specialty area. Having a logical approach helps gain support, maintain energy when barriers arise and most importantly support the adaptation of solutions from one place in the system to another. All of these are valuable when change is needed while working at full pace day in day out.

Department Quality Strategy 2023-2025

Prevention and limiting diagnostic error

All diagnostic services (including but not limited to imaging, endoscopy, laboratory, interventional radiology) are complex systems in themselves. The risk of error is within; these departments, their interactions with referring clinicians and their patients and their families and the organisation at large. Strategies, cultures, processes, equipment, and the working environment are all critical considerations.

There is a great deal of potential for error but identifying the key components of the patient journey and designing that journey with patient safety in mind will mitigate the risk.

There has been a focus on reporting errors (missed diagnoses or mis-interpretations). A 20-year literature review in 2001 suggested the level of error for clinically significant or major error in radiology is in the range 2-20% and varies depending on the radiological investigation.

This table describes there are many more opportunities for diagnostic error to occur. By taking the patient’s imaging journey step by step we can logically follow what should happen. We can also see the common themes and approaches to improvement more easily. Human factors loom large, so this would be a valuable first topic to revise, share, develop expertise in using it to improve ‘the work as done.’

Devising something similar for the key patient steps as they journey through your service will enable you to have quality as a priority and to target in turn your QI efforts.

Sense making of what and why is a key characteristic of a high performing team. Clear purpose set in a framework of ‘systems understanding’ enables highly effective improvement efforts over time.

Our Quality Framework

Patient Journey	Step 1	Step 2	Steps 3,4,5
Dept. activity	Decision to undertake the test	Delivery of the test	Post-test care, reporting & next steps for the patient & imaging or treatments
QI themes	Technology/ culture/ system resilience	Technology/culture/human factors/design/reliability/ system resilience	Technology/culture/reliability/system resilience
Topic 1	Referrer knowledge including evidence base / decision support systems	Protocols and their adjustment to maximise diagnostic accuracy	Interpretation errors /accuracy (HF/ error reporting & review, potential double reporting, Imaging software systems to increase perception
Topic 2	Referring patient information	Scheduling and prioritisation	Reporting / transcribing accuracy
Topic 3	Referrer/ diagnostician processes and documentation	Key process reliability and protocol compliance (including radiation dose and accumulative)	Communication to referrer flagging/ prioritisation systems
Topic 4	Referrer / diagnostician communication	Team culture and team performance, safety conscience	Communication with referrer in unexpected/ significant findings
Topic 5	Referrer/ diagnostician relationships/ culture of shared responsibility for outcome	Diagnostic department safety culture and systems ( eg check lists/ ID check/ room safety/ wrong site discipline)	Confirmation of necessary next steps undertaken by referrer/ compliance with agreed patient pathway
Topic 6	Amount of Feedback and learning	Diagnostic department safety procedures (lowest possible radiation dose/ endoscope repair and maintenance/ infection control systems/ anaesthetic support, nursing skills)
Topic 7	System wide culture of QI	Amount of Feedback and learning	Amount of Feedback and learning

What we discussed as a team at our first meeting

The decision to request the test

Referrer knowledge including evidence base / decision support systems

Test requesting designated according to the experience of the referrer (consultant/ senior staff only requests or consultant/ senior staff only agreed test)
Knowledge and accreditation of referrer required (for example IRMER regulations for ionising radiation).
Easy and required access to decision support and or evidence based practice supporting appropriate test request ( I Refer, Image Wisely for example)

Patient information

More than two unique identifiers for patient on every request
Accurate and complete history of patient not just symptoms and sign to legitimise the test request
co morbidities described and defined where adding to the risk of the examination (renal function where impaired and IV contrast may be used)

Referrer / diagnostician communication and relationships

Access to and openness of communication between referrer and diagnostician
Shared responsibility for patient outcome and the place of the diagnostic test in this
Transparent and consistent approaches to the use of the evidence base to agree protocol/test

Feedback and learning system

Regular review of patients together to learn and share new knowledge or understanding of the role of the test in the patient’s journey (multidisciplinary meetings)
Regular departmental review and open discussions on errors of omission or commission identified by referring clinicians or the diagnostic service itself (READ newsletter from Royal College of Radiologists share this more widely)
Departmental review of errors or near misses related to referral or scheduling of diagnostic examinations

10th August 2022 - Tomorrow's Doctor as Improvers

Dr Tricia Woodhead

The context in which we now deliver medical care has changed significantly.

The Doctor When those of us over 45 were junior medical staff we would be likely to be working 80 or more hours per week, we would be on a team for six months. Our team would consist of a newly qualified houseman, a senior houseman, a registrar and possibly a senior registrar as well as a consultant. We would be in a team, part of a team and invariably on call with one or more of them.

The Ward this would be between 25 and 30 beds, chances are that would have been the consultants ward as long as he / she had been working at the hospital. It would have a clear emphasis, respiratory, cardiac, vascular surgery for example. There would be a strong culture of nursing and medical teams working together over a long period of time. The ’take’ would bring in a mixture of patients but these would mostly be dealt with by the team with specialist referral where necessary.

The Patient - patients were, as now, elderly but might have just two or three diagnoses but more often fewer. They would be in hospital for, on average, a week with a combination of more limited diagnostics and treatments. Decisions were often experience based as there was less evidence on which to rely.

Knowledge – medical knowledge though expanding had a steadier trajectory and was predominantly focused on clinical science. It was the drugs, surgery, diagnosis that was the focus of the doctor’s attention. The system in which we worked had more continuity and worked more slowly. There was deference to experience.

So, what is different now; the system is complex, the patients have multiple morbidities, the science is more complicated and intensive treatments more common in hospital and where not needed care is delivered in outpatients or a day ward. Knowledge, with 200 thousand papers per year, has a half- life of 5 to 7 years not 15. Where 3 or 4 people managed an episode from start to finish it is now more likely to be 12 -16. Some problems with delivery are wicked, sort the 4 hour wait for ED out and you gain a patient with incomplete diagnostic work up. Admit to a bed but find the only bed is one on a ward with respiratory expertise not cardiac, but then the patient has both these and diabetes so who is best able to care for them? There can be three shifts of junior medical staff each day and hours reductions have had a health and safety benefit for doctors but created a new problem with handover and team integrity.

The delivery of high reliability care in complex environments requires us to rethink how we develop our staff to do the work. In addition, in complex environments where there is new knowledge to assimilate, we need to pay attention to delivery and process as well as science and technology. If we need resilience in the system for complexity and the unexpected, we need more than control mechanisms and policies. Knowing where we are on waiting times is a simple metric that is not proxy for getting the right decisions and the right actions from the team to minimize risk and maximize outcome.

A project undertaken by the Royal College of Physicians in England 2010 along with many other Deanery and global projects in health care have shown;

Junior doctors have a strong sense of purpose when they are involved in improving their work
Delivery of improvement in systems of care is a much-needed activity as the numbers of people involved and the co morbidities that patients present with both increase
The Francis Report, the demand for patient centred ness, the expectation of better patient outcomes or the demand to reducing needless harm are all drivers for a wake up
It is a fact that junior medical staff ‘see’ the problems in the systems, feel motivated to change them, are well placed to deliver change at the front line and develop life-long skills in change management.
All of these are much needed attributes if we want a re-moralised work force with the talent to safely adapt the system to the challenges ahead

How could this be achieved?

In South West we have used The Model for Improvement, a three steps process that uses a simple methodology. It works and whole teams of nurses, junior doctors and their consultants have made impressive improvements
Within the North West using the root cause analysis approach has informed juniors, built will to modify the systems of care and brought increased junior engagement in clinical projects
In several hospitals in the Severn Deanery Foundation level doctors are using their ‘new eyes’ to rethink and improve care for patients, this works best when the senior management team are engaged and recognise their work in presentations and in modest resource support. Success builds success
The Royal College of Physicians program ‘Learning To Make a Difference’ has shown considerable success in the pilot phase and this is being rolled out across all deaneries such that core medical trainees will move swiftly from audit to improvement, the latter being the key outcome for their work during their six month attachment
We have supported and coached teams, individuals and education leads to understand how QI fits into the day job and the professional practice of all doctors and healthcare professionals

How could you make better use of your junior medical staff over the next 6 months?

Introduce the need for their involvement in improvement at induction via local experts and examples
Emulate other reliable organisations that use all their staff and expect them to ‘work on the work’ as well as ‘do the work’ each day
Support and encourage an ‘interested group’ meeting in late September when new doctors have settled down and their eyes have seen the problems in the current delivery of care
Harness any learning or ideas they have gained from their other experiences and allocate a senior clinician to oversee the projects as they start to take form
Use a single system for improvement; we use the model for improvement to simplify the message, more rapidly develop skills and enable wider team involvement
Develop a sense of purpose (show examples) but also a sense of time frame. Many organisations globally have developed a 90 or 120 days trajectory for the identification of a problem, working with others to understand the variation, system, behaviours and ideas of changes
Ensure that senior leadership listen, quiz and reinforce the work whether it is improving quality of care or reducing costs while retaining or enhancing quality

By 2025 we will all reap benefits across the system as these juniors return as experienced ‘improvers’ with a track record of innovation and service re design. If one has to be perfectly designed to get the results you seek then more than ever before the skills to work on the work as well as do the work each day are fundamental to personal resilience and patient safety.

1st August 2022 - How best to sort a 'Wicked' problem; R&D or QI or both?

Dr Tricia Woodhead

There is a lot of data in a healthcare organization. There is also a great deal of reacting to that data. I am not referring to patient specific diagnostic data but looking at how clinical staff behave with clinical data may be a useful starting place on which to reflect on how we think and use data for progress not status or performance alone.

A patient arrives in the ED in a semi comatose state. The admitting team know nothing about them, they run some selected tests known to be associated with semi comatose states and one of them is abnormal. The blood glucose is low. So, what now? Is the patient a diabetic and has not controlled their insulin or oral medications, is this some other metabolic state, was the test done appropriately, should we check our glucose meter and technique with a blood test? Is this the reason for the ECG being slightly abnormal or is something else going on? Have we done core body temperature? The diagnosis is complex.

A CT scan service takes 90 minutes to be performed, read and reported on the computer system? How come we missed our 45-minute best practice target. Does the word target instead of blood glucose mean we psychologically think that it is not quite so important, these things happen, it is too busy to meet this level of performance all the time. It is 45 minutes because in the circumstances we know every minute counts for patient outcome and as full a recovery as is possible.

Call to stent time is a great example of where best-known practices are known to determine optimal outcome and they include the operational effectiveness and interaction of several components as well as the technical expertise of the cardiologist placing the stent. The cardiologist can be the worlds best but if there are poor transfers of care, the ambulance crew cannot find the patients home, delays occur in ED on way to catheter lab and the lab is not ready to roll as the patient arrives no amount of technical skill can recover the lost muscle due to the longer ischemic time.

‘Sorry, just one of those days’ is no longer a justified position statement. That is the fundamental change we all need to address. Data is now available for all aspects of the care process and if we don’t use it all to learn how to do better tomorrow, we fail our patients, ourselves and of course the system. Failure to address defects creates waste. Waste is something we could do without.

There is much gnashing of teeth as to the relationship between fundamental research of the ‘p value’ sort and Improvement Science. Indeed, there is much lost sleep over whether improvement methods are a science at all. This is a rather futile debate in a way as it distracts us from the complex interaction of medical science, human factors and psychology, organizational and systems factors and human biology. That interaction and fixing it is fundamental to optimal care and professional practice.

The gap between what the research says is possible and what is actually delivered is in part due to failure to maximize the interactions of people, patient and system. In ‘p value’ research the system and the patient and the people delivering the care are often controlled so as to minimize variation so we spot the pure un adulterated action of a drug or treatment. The real world is a bit different! There is often a gap between what is possible and what could be possible. Failure to work on the ‘work as currently done” sustains this gap.

The aims of improving population health (all people in the population), the best patient experience and sustainable and affordable systems creates a wicked problem. We need all the tools we can get hold of to try to fix them. Pure controlled science and improvement science are just two tools. The gap in what is and what could be needs to narrow to reduce deterioration in health, improve patient well being and sustain affordability as our demographics pressurize the current models of delivery.

Rather than react to data and seek the ever-better evidence from research we could also be working on the system and the reliability of what we do and be creating solutions from which we will learn so as to generate new ideas.
This is one of many ways to actually address the wickedness of where we are. Only by creating a solution can we work out further aspects of the problem. “The best way to have good ideas is to have lots of them’" said Dr. Linus Pauling. He had an impressive record. Improvement methods generate lots of ideas, the faster they come the faster they can be tested. This is a great way to approach a wicked problem for which there is less likely to be a known or even one solution.

I have believed passionately for a long time that R&D and QI should be hand in hand not either side of the debate. This is why as doctors we need to be skilled and capable at both.

This page was last updated March 13th 2024 (1 month ago)