Five top tips for our checklist for building organisational improvement capability

Over recent months, I’ve been testing out a checklist to help organisations assess how ready they are to start improvement projects and see what else they need to put in place.

The checklist was developed from content originally published as part of the Health Foundation’s ‘Building the Foundations for Improvement’ report. This aimed to help NHS organisations mimic or adapt ideas that had already helped others build their capacity for improvement in different clinical and service areas.

Why a checklist?

The checklist is a common tool now in clinical practice and is often used to prevent urgent demands and lack of knowledge getting in the way of busy people delivering what we know is best for patients.

When confronted with a blank sheet of paper and asked to describe a better system, busy health care leaders often focus on what others need to do, rather than on what they themselves can change. Having a more structured approach, such as a checklist, which encompasses learning from what has worked elsewhere and how it might be adapted in a local situation, can be a valuable approach to change.

Taking the time to make sure the right culture, skills and infrastructure are in place to see improvement ideas through successfully is really important. As Donebedian’s work shows, it’s both structures and processes that need to change in order to build the culture of reflection, openness and excellence needed to implement meaningful change across an organisation.

A positive response

The response to the checklist has been positive so far from the commissioner and provider leaders who’ve used it. It can be hard to identify what is already in place (perceptions and assumptions vary) and to foster the type of enquiring mindset needed to build a safer organisation. Driven by the pressure to find an urgent response to a problem, there is often a tendency to default to an immediate solution, rather than one that will last. Used carefully, the checklist is a tool that can help leaders and people working on the front line to change this mindset and ultimately to help an organisation sustain improvement over time.

However, it needs to be clear that this is a journey. Early progress may be less about immediately changing outcomes, but instead getting structures and processes in place; involving a wider range of staff, improving morale, or building the knowledge of people working at the front line.

Unless leaders make connections and pay attention to the people they work with, they may overlook the benefits of the changes that are being made (Swenson et al, 2013; Berwick, 2013). This is where regular leadership visits and conversations with staff matter. Visible evidence of wards and teams showing steady improvement over time will also reinforce everyone’s confidence that they are making progress and have energised their system to continuously improve.

How should organisations use the checklist? Five top tips

1. Decide who is best placed to use the checklist

The checklist is probably of most use as a strategic tool for a trust board or executive team, with support from improvement or transformation leads.

2. Set aside dedicated time to work through the checklist as a group

The checklist helps you assess where there is work to do to build your organisation’s capacity for improvement. As with all improvement work, it isn’t something you should rush to complete. To get the most from the checklist you need to dedicate at least 3–4 hours to go through the points on the checklist as a group.

3. Bring in an experienced facilitator to lead an exercise to use the checklist effectively

Try to find an external facilitator with a strong improvement and coaching track record. It’s important to have someone with a fresh perspective who can challenge your assumptions – in a constructive way – and expose you to new ways of thinking. An experienced coach will also help to get the most from all members of the group; give the group the confidence to explore all promising ideas; and reinforce the importance of constancy of purpose over time – especially when you hit any barriers.

4. Find time to prepare for the exercise

Consider circulating a short reading list to members of the group before the exercise. The Health Foundation’s top ten resources for senior leaders looking to deliver organisational wide improvement in safety and quality can be found in their online collection. Group members could also prepare by using this gap analysis tool to identify their organisations’ key assets, strengths, gaps and challenges in terms of building improvement capability.

5. Make sure you have a realistic outcome

A risk with using any checklist is that you can end up with a long list of actions and no means of prioritising between them or deciding where to focus your time and resources. To avoid this, you could create a driver diagram or action effect diagram to help to develop a realistic delivery plan that’s not too daunting.

Remember, it’s far better to start small and build gradually over time on the back of the confidence and enthusiasm that come with early successes. If you try to do too much, too soon, the chances are you soon lose momentum and use up people’s good will and motivation.

Tricia Woodhead is part of our clinical faculty supporting the leadership, capability and capacity building of QI skills for improvement with a particular focus on patient safety.

Article first posted on 28 April by The Health Foundation.

Could developing a deeper understanding of yourself be the first step on the road to providing safer care?

How creating a supportive safety culture starts with leading by example!

Like most people, I have felt upset watching the Hillsborough Stadium disaster documentary on TV recently. In particular, for me, it shows what happens when there is a pernicious and colluding work culture based on power and hierarchy rather than a culture based on congruent values and behaviours that support people to do the right thing.

Being supportive of colleagues can sound like motherhood and apple pie particularly with the ever increasing demands and pressures we are experiencing in general practice at present. However we risk, at our peril, crowding out the human feelings present in all of us. For me, now more than ever, actively giving people the time and safe space to be heard and voice their concerns in an open, supportive environment where defensiveness to hearing bad news is overcome and learning is encouraged seems so intuitive.

I wonder why it can be so hard?

People talk about time commitments, but the amount of time, let alone emotional upset, taken to deal with near misses and harms surely far outweighs the time it takes to talk about things in an open way and which will hopefully reduce the chances of an event occurring again.

Imagine if, back in the 1980’s, the police had taken more of a learning approach around improving the safety of their service and learning from near misses. Perhaps the Hillsborough disaster might have been averted and at the very least, the truth would have come out at the time with lessons learned rather than all these years later.  The pain for both the families and the professionals is upsetting to watch.

In my previous blogs I have mentioned various books and in this I encourage you to read ‘Intelligent Kindness’ by Ballatt and Campling. It provided some of the theoretical basis for the King’s Fund’s Top Managers Programme I was privileged to attend last year. Providing safe patient care is as much about ability as it is about motivation and attitude. An iceberg provides a useful analogy of this where the 10% of behaviours we express are driven by the 90% of feelings, attitudes and beliefs we hold below the surface. For me moving from a reactive safety culture to one that is generative relies on attitude more than anything.

My learning from the course was that the below the surface ‘attitude’ starts with ‘me’ and that ‘my’ battle over ‘myself’ has been the hardest battle I have faced. As a doctor I immediately assume a leadership role in the eyes of patients and the other professionals working with me on the front line, yet most GPs have had very little leadership training. It is so easy to retreat behind my Doctor title and the positional power that gives me. A lot of leadership comes down to emotional intelligence which starts with self-awareness. As I learned on the course I can behave as an ostrich, which although initially was quite confronting, was also a crucial first step in my quest to improve myself by better understanding my impact on others. My actions do not always have the impact on colleagues that I intend and having this fed back on the course, whilst initially threatening to my ego, provided amazing learning and an opportunity to improve my effectiveness. Being open to hearing some ‘bad news’ about my self was really hard but it was worth it!

I could write a volume on this topic as I feel so strongly about it, but as I have written in my previous blogs, it is easy to talk the talk, but walking the talk is much harder. Working in a collaborative work environment helps to frame practice discussions towards continuous learning and the improvement of patient care. A crucial part of this is the dominant leadership style that prevails in a practice system and which will either promote or inhibit a patient safety culture.

Traditional medical leadership is more hierarchical, based on a command and control style where it can hard to hear bad news. Contemporary leadership theory, together with my own experience, confirms to me that a more versatile and dynamic leadership style based around coaching is particularly empowering to the coal face. It supports the front line workers to identify their own challenges and then come up with solutions where leaders act as enablers as opposed to being perceived as blockers. Demonstrating kindness can act as a useful adjunct to forming a supportive safety culture. What I have noticed in my own practice is that the simple act of a colleague showing kindness can have an incredibly powerful impact on all of us.

Whilst acknowledging that, for some, demonstrating kindness can be psychologically complex involving personal feelings around vulnerability; the act of noticing a colleague is infectious and does bring joy and pride to a workplace.

photo taken of a popup stand, with the word kindness

One consequence of this climate is that patients and colleagues are more able to speak out about things concerning them and this can act as a vital early warning radar system both personally but also for the organisation. For me creating a supportive culture starts with leading by example. Becoming more aware of my own complex feelings and vulnerabilities has helped me to challenge my defensiveness and ego which, if left unchecked, greatly inhibits my personal learning and improvement. It can be really hard, but as Ghandi said, ‘Be the change you want to see’. A dose of humility together with trying to have some fun at work and a self-effacing sense of humour provide a useful tonic.

About the author

Since 2013, Hein has been a board member with the Gloucestershire CCG whilst also working as a half time GP in his Minchinhampton practice. The practice joined Sign up to Safety in April 2015. He is also the primary care patient safety lead for his local West of England Academic Health Science Network, where they are trying really hard to get primary care engagement (and that of commissioners) towards the patient safety agenda.

He has positively benefited from his experiences of working in several different health care systems and has developed a passion for improving the quality of healthcare, and for the impact collaborative working can have. Hein is a member of the health and wellbeing board locally and is leading a number of clinical programme groups including older people (and dementia), neurology and end of life.

This blog post was first published on the Sign up to Safety website on 20 May 2016.

The 100,000 Genomes Project: ensuring the public and patient voice is heard

Our Public & Patient Involvement (PPI) Manager, Hildegard Dumper recently took part in a consultation event focusing on the issue of informed consent for people signing up to the 100,000 Genomes Project. She shares her thoughts and reflections…

Genomics England in conjunction with NHS England are running a series of consultations is running series of consultations around the country on changes being considered in order to make it easier for people agreeing to take part in the project. The aim is to do so without compromising the necessarily rigorous framework for informed consent.

There are currently 13 GMCs in the UK, including one in the West of England, working with Genomics England to deliver the 100,000 Genomes Project, which is the largest national sequencing project of its kind in the world.

100,000 genomes from NHS patients with rare diseases and cancer will be sequenced and analysed, to better understand the genetic causes of these diseases.

The West of England AHSN is one of the partners in the West of England Genomic Medicine Centre, leading on public and patient involvement (PPI). I was invited to join a consultation workshop in Taunton, hosted by the South West AHSN, along with Adele Webb, a public contributor on both our AHSN board and the West of England Genomic Medicine Centre’s board.

So on a sunny Friday morning, Adele and I met at Taunton train station to share a taxi to the Musgrove Hospital Academy. There we met up with the two researchers running the evaluation from Imperial College London, as well as three more public contributors from the South West.

Markella Boudioni, a researcher from NIHR Imperial Biomedical Research Centre, Patient Experience Research Centre and West London Genomic Medicine Centre explained the background to the evaluation, taking us through the issues and key questions they were trying to address.

A considerable amount of time was spent on the issue of patients receiving information about other conditions that might be discovered unexpectedly, whether and how we should invite people to opt in or out of that. This opened up a particularly thoughtful discussion about the huge impact on families of sharing the information that an inherited condition was present in the family and its implications for the future. We were able to bring to this our personal experiences.

It clearly is in Genomics England’s interest to understand this, as one way or another there are clear resource implications. The current paperwork is considerable but it is difficult to know how they might get around some of the questions around consent that need to be asked.

We were asked to review current patient information material, including consent forms for both cancer and rare disorders and opt in and out forms.  The discussion ranged over the style of written material for patients, how to mitigate the bulk of text and the use of plain and accessible language.

We also covered different methods of presenting information in order to be inclusive – offering alternatives to online access, for example. In considering recruitment, we looked at the key points in the patient pathway and how recruitment might be more effectively embedded in the process, together with different PR approaches to encourage take-up.

Markella was very skilful at pursuing clarification, channelling our thinking on key issues and in encouraging suggestions and improvements to the patient approach.

The focus group was clearly helping to inform the moves to improve the material being given out. It felt like a very practical and positive contribution towards the patient experience and pathway, especially when we were invited to propose and explore solutions.

Both Adele and I found it extremely useful to have been part of the consultation as it helped us understand some of the challenges faced by NHS England in rolling this out and gave us a deeper appreciation of some of the ethical dilemmas associated with the project.

Why I’m proud to support the Don’t Wait to Anticoagulate project

Jo Jerrome is a public contributor on the steering group of our Don’t Wait to Anticoagulate project, which aims to improve the management of stroke risk for people with atrial fibrillation (AF). Here she explains why she is so proud to be part of the initiative.

It has been enlightening to be part of the Don’t Wait to Anticoagulate project. I truly believe it is an exemplar model in integrated patient decision-making tools.

I’m really keen for it to get picked up more widely as there is so much we can learn and implement from the project to benefit AF services in other parts of the country.

“I feel very privileged to be part of the project. It really is utilising all the learning available on AF to move it forward.”

For me, what makes the project special is that from the start patients and clinicians have been involved equally – identifying the challenges, listing the needs and constantly reviewing and feeding back into the draft versions.

The result is uplifting – I want to use it with my Mum. It dispels myths and fears, from aspirin to bleeding, while supporting that really important patient-GP conversation.

Until recently, I was the deputy CEO for the Atrial Fibrillation Association, a national patient charity. When I started the only anticoagulant available was warfarin and there was an awful lack of information and shared knowledge about the condition.

The prevalence of AF

What was coming through was the prevalence of AF amongst the population and the risk factors that previously had not been recognised. Very quickly on the back of that was evidence on the ineffectiveness of aspirin.

At the charity we were looking at how to make information available and accessible to patients, their families and people working with them.

But the big challenge we could see was that it’s one thing having all this knowledge but what do you do with it? I sat on five or six NICE committees and was involved in scoping NICE guidelines and in 2014 I sat on the committee to develop the NICE stroke prevention in AF patient decision-making aid.

There was a wealth of guidance then about AF pointing to what we should be doing and yet take that on a year and AF management still isn’t great. Over 40% of patients who should be anticoagulating aren’t, and there remains a real lack of confidence in knowing what the best anticoagulant is. People still ask why they can’t use aspirin – isn’t it safer? There are still myths that needed busting.

Due to my parents’ health, I stepped down from the AF Association 18 months ago. At that time I’d be liaising with the West of England AHSN on the initiation of Don’t Wait to Anticoagulate and right from the start I’d been really excited by it because it was everything could see we needed, as well as being back up by NICE guidance.

So when I stepped down, I contacted the West of England AHSN to register as a public contributor because I wanted to remain involved, and they invited me to be on the project steering group.

Translating the information

NICE had created a great deal of excellent guidance but it wasn’t particularly accessible. Their patient decision-making aid was only online and about 33 pages long. It had everything you needed in it but it wasn’t user-friendly: it needed translating.

So what excited me was that the West of England AHSN saw this; they saw the need clinically; they saw the need economically across healthcare and social services; but they also saw the patient need. And they wanted to make it accessible right at that point of partnership between the GP and the patient, because that’s when most of those conversations about AF management happen.

What’s most innovative about Don’t Wait to Anticoagulate is this toolkit they’ve developed to support that conversation that’s also accessible when the patient has left the surgery and wants to go back and read more, either online or in print.

Making an informed choice

As a carer myself, I’ve attended appointments with my parents and you hear all these figures but what you actually want to know is, what does this mean to me? Don’t Wait to Anticoagulate helps to interpret this using pictures and comparisons. For instance, if I were on a bus, how many people on that bus would be affected? It’s real life. You can put that into your life and make an informed choice.

Shared conversation

The shared conversation is the key to this project that will change things. It’s building on what was already there. It hasn’t tried to duplicate things. It’s built on solid foundations and has identified where the need is. This tool helps the patient and the general practitioner implement the NICE guidelines by having that conversation around the personal risk, your options on reducing risk, why some therapies might not be as beneficial as we once thought, and why others are really better at safeguarding you from a catastrophic stroke.

All the important stakeholders have been involved, working with clinicians, specialists and also general practitioners because they’re the ones who are going to be using it. And to my knowledge well over 20 patients have been involved in reviewing and sharing ideas. They really had all those key stakeholders at the heart. And out of all of them, patients outnumbered them all.

The team has been amazing in how they’ve constantly been reviewing and looking at ways to improve. This is always based on what the users have fed back, as well as what the steering group has commented on.

The project is so refreshing. It’s taking really good clinical evidence and guidelines into real life practice and saying, how do you make it work?

Innovative and sustainable

That’s why I think it’s innovative; it’s about sustainability; and it’s got all the voices needed represented in it. And at every phase it’s willing to amend and it does it quickly. Change can take a long time in healthcare. This project proves that’s not necessary. This project is driven by outcomes to improve the service and for the patient, and that is critical.

I feel very privileged to be part of the project. It really is utilising all the learning available on AF to move it forward.

We needed something like an algorithm from the NICE guidelines; something to simplify and interpret. And the West of England AHSN has done it with Don’t Wait to Anticoagulate and they’ve done it really well.

Visit the Don’t Wait to Anticoagulate website here.

Using QI methodology to win Euro 2016

Natasha Owen, Quality Improvement Lead at the West of England AHSN, combines her passion for improvement science with her (basic) knowledge of football to get us in the mood for Euro 2016…

This year will see the Quality Improvement (QI) team at the West of England AHSN continue in its aim to increase the capacity and capability of colleagues in our member organisations, through the understanding and use of QI methodology and tools.

What better way to achieve this than by starting with our own teams here at the AHSN office?

Sometimes when using QI tools we have to step outside our own sector, in this case healthcare and the NHS, and develop people’s understanding of the concept using a more relatable topic. Say football for instance. The impending European Football Finals (Euro 2016) felt to us like the perfect opportunity to combine some office fun, in the form of a sweepstake, with an example of how to apply the Model for Improvement.

The QI team set about thinking: how would a football team apply the Model for Improvement to their tactical approach in the competition?

When specialist knowledge and QI skills are combined you can develop what Don Berwick called ‘the knowledge base for continual improvement’, which any team in any industry or field can strive for.

I mean who wants to stand still when you could improve?

As a QI expert or trainer, you are not expected to have the specialist knowledge. The key is allowing specialist teams to apply their knowledge to the Model.

In this case, I had the knowledge of applying the model combined with just enough football knowledge to make this example work!

The Model for Improvement requires a systematic approach to its application. It is a step by step process, which, when applied as described in the correct order, will provide a consistent approach to improving the quality of your performance, or processes, as a team.

Skipping a step, doing step three before step one, or taking steps out completely will not glean the same results. More importantly it is not guaranteed to achieve an improvement every time.

However the ‘test small and quick’ method allows you to rule out bad change ideas as easily as identifying ideas that create an improvement. Both outcomes are essential to promote continuous change.

So back to our football team… How on earth can a methodology created for a healthcare environment help a football team win the Euro 2016 Final?

Picture the scene. It is the month before the finals begin, the football season has ended, and Roy has called up the England boys to play for their country. What an honour!

During the football season all the players play for different teams, where different tactics and skills are used. Bringing them together in the short term is comparable to creating a Quality Improvement team. Roy does not have long to get this team to gel together to be a high quality goal scoring machine: the finals start on 10 June!

Training as a team gets underway. In other words, the planning of the QI project begins. Step One of the Model for Improvement is to establish your aim: what are we trying to accomplish?

For this team the aim is to win the European Football Tournament by 10 July 2016. Aims should be specific. Note that the team want/need to achieve their aim by a certain date.

The next thing they need to do is decide what data they could use to decide whether an improvement has been made. This is Step Two of the Model: how will we know a change is an improvement?

Measurement is key to distinguishing between a change, and a change that makes an improvement. If we don’t know what the data looks like beforehand, the data we collect afterwards will be meaningless.

A football team may have many sources of data they can measure, from the number of goals they score to how fast each player runs during a game. However they need to decide which measures are applicable to their aim. Does running faster contribute to winning? I don’t think it would be a team’s primary concern.

Before you decide what to change, you need to decide if it can be measured. So Roy and the boys have got together and had a discussion in the changing room and came up with the following measures…

Primary measure: number of points scored. Essentially this is how football is governed so that measure is set for the team. This might happen from time to time when undertaking improvement projects where measures are set externally – by CQC or NHS England for example.

Secondary measures

  • Number of goals scored
  • Number of yellow cards given
  • Number of opponent goals saved or avoided.

Your primary measure is the main source of data you will use to establish if your aim has been achieved. Secondary measures can provide further data to indicate to what level a change is driving towards or away from making an improvement.

For example, where the team draws and only scores one point, this could be explained by the number of goals scored being equivalent to the opposing team, but an increase in yellow cards being given might suggest an underlying behavioural issue that led to a poorer performance, ultimately leading to the lack of goals scored or saved.

Now the fun begins! Step Three is all about getting creative: what changes will make an improvement? It’s all about generating ideas, no matter how crazy they might seem as long as they can be conducted within the rules of the game. I am pretty sure EUFA won’t allow players to wear rocket boosters on their shoes!

Finally we move into the testing phase. The team might decide what ideas to test using a prioritisation matrix. Remember, test one idea at a time. Test small, test quickly. This way you will limit the damage a change could cause and create less disruption in a full system which could have a ripple effect in other areas or departments.

This style of testing is called PDSA cycles (Plan-Do-Study-Act).

The team decide their first test of change will be: players will only pass the ball five times before whoever has the ball shoots for the goal during the game against Turkey on 22 May.

Plan: your change. What will you do? What measures will you use? Who will do it? When will you do it? How will you do it?

Action

Lead

Implement by

Measure of success

Install beeper on the ball that will beep after it is passed five times

Manager

16 May

Number of times players shoot after hearing the beep

Number of goals scored

Practice the five pass tactic in training

Players and Coach

16 May

Number of times ball is aimed at the goal after five passes

Use the five pass tactic during the game

Players

22 May

Number of points scored

Number of goals scored

Do: put it into practice. The timescale for the test will be the duration of the next game (around 90 minutes).

Study. Using the measures you set out, has an improvement been made? Run charts are the recommended way to present and analyse your data to indicate improvement.

Act. Did you see an improvement? Yes? Try it again in the next match see if it continues to improve the team performance. No? Reflect on why it did not create an improvement and refine the idea, or scrap it and move on to the next idea.

Now you have this knowledge, you might want to give Roy and the England boys* a call to see if you can help them with their tactics and WIN WIN WIN!

*or any other manager and team in the tournament

Driven by a shared belief and commitment

As we publish our latest annual report, our chair Steve West reflects on what our network has delivered in 2015-16.

This year the West of England AHSN received just over £3 million in funding from NHS England, our member organisations and various other sources, and in my opinion what we have achieved with this in the last 12 months represents incredible value for money.

Rather than breakdown every pound spent, this report gives a snapshot of the difference we are making from the perspective of those people we are here to work for: citizens who need and depend on our healthcare system, our colleagues in healthcare organisations, entrepreneurs wanting to partner with the health service – the ‘customers’ this AHSN was established to serve.

As well as the facts and the figures demonstrating our impact, here are stories about the difference we are making to individuals, the organisations they represent, the services they provide, the care they receive. So much of our ‘impact’ is invisible when it comes to stats – how do you put a price on connecting people who share the same beliefs, passions and concerns and, through that connection, inspire and support them to find a solution together, a new way?

The catalyst

Our people in the health service have the knowledge, skills and experience. Our role as the AHSN is to bring those people together, to find space and platforms to allow people to share and shape new plans, introduce them to innovators and academics with the new technologies and proven evidence to shape these further. We are here to act as the enabler, the space giver, the catalyst.

I am immensely proud of the important conversations we are instigating, the culture shift we are embedding, and the varied range of work we are involved in and are acting as catalysts for. This work is all bringing about needs-focused, evidence-based, citizen-centred improvement for our health systems.

The AHSN staff team is itself small in numbers but big in heart and certainly punches above its weight. They are driven by a belief in and commitment to the NHS, as well as the desire to help reshape it for the society and economic climate we find ourselves in today.

Drive and vision

That drive and vision is shared by the many colleagues from our member organisations who commit their time and energy, over and above the long hours they already work, to help steer and deliver our projects and attend our events; and by the public contributors who guide, question and bolster our work programmes by making sure the citizen voice is heard as a constant.

We all do this, put in the extra hours, attend the extra meetings, because we care and we see the need.

Bring together the need, the evidence, the people with the innovations, and the people with the skills, knowledge, experience, heart and energy, and you’ve got a recipe to make sustainable change happen.

And that’s precisely what we’ve got at the West of England AHSN. So while our licence is currently due to end in March 2018, I’m confident the legacy and impact of our work is here to stay.

Read the full annual report online or download it as a PDF here.

Joined up Research & Development – making research count

Following his keynote address at the NHS Research and Development (R&D) Forum on 24 May, Peter Brindle believes our NHS should stand out as the most evidence informed healthcare system in the world, with NHS R&D at the heart of making this a reality. Peter is Leader – Commissioning Evidence Informed Care at the West of England Academic Health Science Network, R&D Programme Director at Avon Primary Care Research Collaborative, Evaluation and Commissioner Liaison Lead at NIHR CLAHRC West and a GP.

Let’s aspire to something big: our NHS should stand out as the most evidence informed healthcare system in the world, with NHS R&D at the heart of making this a reality. At its heart – through being the trusted bridge connecting the research world with the NHS and the service world.

Let’s imagine a world in which the culture of the NHS is one of continuous improvement in finding better ways of doing things, and getting better at doing them. One in which health researchers work with patients, commissioners and those who deliver care, in teams tackling major health issues: in other words, a world in which research maximises its impact. A world in which research really counts.

The need for an evidence informed NHS

Why is this important? We hardly need reminding but our NHS is facing plenty of challenges. There is an expected £30 billion NHS funding shortfall by 2020, 96 per cent of acute trusts are in deficit, there are more pensioners than there are children, and 15 million people are living with a long term condition and needing 70 per cent of the healthcare budget. It is estimated that about 20 per cent of resources are spent on over use, under use or misuse of treatments and probably only about half of healthcare decisions are based on clinical evidence.

So we have a health system with ever-growing pressures and a near desperate need for doing things differently. But especially because resources are so tight, we can’t afford to waste time and money on changes just because we hope or believe that they will make things better. No, now more than ever we need to focus our efforts on the best evidenced interventions, stop the things that are not helping, and evaluate the impact of the changes made.

In other words we badly need applied health research.

Happily, about £1 billion gets spent each year by the National Institute for Health Research (NIHR), at least a billion more from the medical research charities and plenty more still from the research councils, EU funding and the pharma and med tech industry. But there is no point in spending these large sums if it does not have an impact on our patients who are on the receiving end of our challenged health system. No one has money to waste and there is a growing recognition that research is not making the impact that funders want.

Reasons for sub-optimal impact

Why might this massive research effort not be having the impact we need? There are many reasons for this but I think these are some of them:

  • The questions that researchers are trying to answer are perhaps not always the questions that resonate with clinical and managerial NHS staff
  • A traditional reliance on the ‘push’ of ‘excellent’ research in the expectation that it will snapped up by evidence users
  • An over reliance on the traditional and medically orientated ‘hierarchy of evidence’, with meta analyses of randomised controlled trials at the top and everything else below, leading an under recognition of the importance of the social sciences in helping us understand why things do or don’t work
  • This in turns leads to inappropriate status being given to ‘gold standards’ and expensive, time consuming and reductionist research methods. This is matched by insufficient recognition of the opportunity cost of pursuing researcher-defined ‘high quality’ research rather than considering the value that research brings to the evidence user. Who should define the ‘gold standard’ anyway – the evidence user or the evidence producer? The customer or the manufacturer?
  • Research findings are not always packaged well or appropriately disseminated – something that is hard for researchers to do without access to the right networks and contacts in the service world.

The missing link

These reasons for research not having the impact we are hoping for, come about because research is being developed in relative isolation from the environment that it is expected to influence. Getting research evidence into practice depends upon the vast workforce in health and care who commission, provide and deliver healthcare innovations. It is these people – clinicians and managers who are largely not engaged in research and have never heard of the NIHR, who lie between the research and it making a difference to our patients. They are the ones that implement it.

This is the crucial point: it doesn’t matter how important research findings might be, unless the evidence is incorporated into practice and makes a difference to patients.

If the impact of research is limited by poor engagement of the majority of the service workforce, how can we fix it? The first thing to do is to recognise that that we are talking about two very different worlds with different drivers, culture and language, requiring the research community to put themselves in the shoes of those they hope will use the evidence they produce. The best way of facilitating this is for a much stronger emphasis on the co-production of research – getting the evidence generators and the evidence users together from the beginning of the research pathway at priority setting and idea development, right the way through to the interpretation of the results and the dissemination of the findings.

This sounds reasonably straightforward but doing this properly is extremely hard. If it was easy, it would already be happening. No, bringing together distinct professional groups to create a shared endeavour requires conscious and deliberate efforts. It will rarely happen all by itself. In finding a way forward, we can learn an enormous amount from the successful engagement of patients in research activity.

This was not happening by itself and required the setting up of bodies like INVOLVE and the James Lind Alliance to help patients understand the nature of research and for researchers to understand how much better research can be with patients involved from the beginning. The engagement of the NHS workforce in research is about at the level that patient involvement was 10 or 15 years ago, and now it is the bringing together of these professional groups with researchers that requires our efforts in order to trigger a step change in research impact.

The challenge to NHS R&D

NHS R&D teams based in trusts and in CCGs, while also having close relationships with researchers, are ideally placed to bring the research and service worlds together and to drive the co-production of research. It is a challenge R&D teams need to grasp with both hands.

Properly co-produced research will address most of the major blocks to research in making a difference. The questions will be the ones the service world needs the answers to, the methods will be sensitive to the context and appropriate to the resources and time available, while dissemination will be greatly enhanced by the results being framed in an accessible way and shared with relevant networks.

Within the NHS

What specifically can NHS R&D teams do to make this vision of an evidence-informed NHS through engaging service staff in all aspects of research, a reality? Here are some suggestions:

  • Promote a culture within their organisations of looking for evidence and evaluating services and interventions. This is not routinely done, but it should be. Make it easy to do and unacceptable to ignore
  • Looking for evidence will inevitably lead to finding gaps in the evidence. This is a rich source of NHS-relevant research questions that can be fed into local and national research
  • Remind trusts that the point of research is on patient benefit and not just about maximising income
  • Drive a culture of improvement in the broadest sense. Breakdown the artificial and illogical silos of improvement science, evaluation and research and strengthen the ‘D’ in R&D. They are all about finding better ways of doing things so let’s pick the right tool for the job
  • Find and promote powerful stories of research impact to demonstrate that research is relevant and important. This is not always how NHS staff perceives it
  • Highlight the risks of not using research – it is where our evidence for improvement comes from!

Universities

NHS R&D teams are also in a good position to broker great relationships between the trusts and CCGs and their local higher education institutions through:

  • Reminding academics that it is in their long term interest to build trusted relationships through offering informal advice with evidence appraisal and evaluation
  • Recognising the value of ‘impact’ and knowledge mobilisation in university promotion criteria
  • Facilitating the co-production of research through the creation of ‘boundary spanning’ posts like researchers in residence and management fellows – individuals who understand the drivers, culture and networks of both the academic and the service worlds, and can act as translators and marriage brokers between them
  • Encouraging the formation of Health Integration Teams – academics, clinicians, commissioners and patients working as a team to tackle significant health or service problems
  • Creating more joint posts. One of the reasons why evidence based medicine is a standard concept for doctors, is due to the large number of medical academic posts. Let’s widen the concept through creating more non-medical, and in particular, more non-clinical joint posts in health research. Why shouldn’t a manager be able to combine service work with time doing research and teaching?

As well as the NHS and academia, the third piece of the jigsaw is research funding. Funders can sometimes find themselves remote from the environment they wish their research to improve. NHS R&D teams are very well placed to help keep them in touch with the NHS and help them recognise the need for greater co-production of research and that this takes additional time and resources – but it is worth it.

Conclusion

Our NHS really needs the help of the health research community like never before and we can’t afford to waste any of the research effort. The key to making the research count is through academics working with the users of evidence – the people who commission or deliver care in the NHS, to co-produce research that the NHS needs.

Through acting as brokers between the service and research worlds, we in NHS R&D have a crucial role in building the truly evidence informed NHS that our patients deserve. Let’s make it happen.

Get in touch

Email Peter at peter.brindle@nhs.net.

Breaking down our habitual silos in primary care

Collaboration is an often used word in healthcare and conjures up happy images of us healthcare professionals working jointly with our colleagues within practices, but also across healthcare settings as a joint endeavour to improve the care we deliver our patients.

The reality is probably greyer. However, working as a ‘coal face’ GP, through my involvement with Gloucestershire Clinical Commissioning Group (CCG), the Sign up to Safety campaign (SU2S) and working for the West of England AHSN, the concept of collaboration is a ‘no brainier’.

How else do health systems provide safer patient care across multiple settings and between many different professions? In addition ‘the patient’ is rapidly becoming a more informed and sophisticated service user, who, through the Internet has access to limitless information which is equalising the traditional power differential between professional and patient. In my view this is to be welcomed, but does pose challenges.

For one, more doctor training is about tasks and science and less about people. At times there can seem to be so many ‘sharp edges’ between us professionals where we focus on our differences and this can hinder collaboration which perhaps does require more oblique interactions. This is nothing new as the 1787 painting ‘Doctors differ and their patients die’ testifies. When I think back to medical school, perhaps I would have got more out of studying Dale Carnegie’s ‘How to win friends and influence people’ rather than rote learning Krebs Citric Acid Cycle.

For me collaboration is a mind-set as much as a collection of behaviors and for which the front line is not well trained in. It is about finding common solutions to our shared challenges and using the strengths of patients, carers and professionals across settings to improve the safety of care we deliver.

In my opinion the current system of competition and fragmentation in our local system can, at times, feel like a zero sum game. Different payment mechanisms for different care settings and professions are incongruent with collaborative healthcare. It can allow us to agree to disagree and encourages unwarranted variation which can then affect the quality of healthcare we deliver. An aligned, patient outcome focused payment system, as proposed by Michael Porter in his paper on ‘What is Value in Healthcare’,  would certainly provide an enabler in the quest for a safety culture based on collaboration. In practice the new Accountable Care Organisation’s proposed in the Five Year Forward View should facilitate collaboration.

Our current management of sepsis across the system provides a useful example. If a patient has suspected sepsis then a one hour care regime (called the Sepsis 6 care bundle) is instigated as soon as that person arrives in the hospital. However, the admission of many older people can involve an element of sepsis and these people might remain in the community for many hours before being seen for lack of GP visit prioritisation and coordinated ambulance response. From a patient safety and commissioning point of view a collaborative approach between care settings and professions would allow for a more joined up and timely response that would improve patient morbidity and mortality.

When I’m back on the coal face, I can see why collaboration is sometimes hard. I often only think about the patient I am seeing in front of me and in the setting in which I am seeing them. The Sign up to Safety campaign and my wider roles have helped me to reflect on the aggregation of all the single decisions I make and to see the consequences of those in terms of patient safety not just on the single patient but also on the whole population.

Our practice has the same ups and downs as all practices and there can be a tension between, on the one hand, everyone agreeing to disagree and doing things differently and ‘group think’ where people don’t adequately think things through in their quest to agree. It is important to hear all views and concerns, but it is equally important to start with a problem solving and collaborative mind set, and then to all agree to implement in the same way. My work for the Gloucestershire Clinical Commissioning Group has made me acutely aware of how, across the system, we can all work in silos and thus see patient care only from our unique perspective. How we communicate with each other is vitally important in overcoming this tendency.

From my perspective collaboration is about moving away from individual ways of working and developing effective teams particularly on the front line. Some of the dysfunction that can arise in teams is due to an absence of trust which can lead people to conceal their weaknesses and mistakes from each other whilst hesitating to provide constructive feedback. There is a fear of conflict and this can create an environment where politics and personal attacks thrive, and waste time and energy.

For me collaboration is more about the journey than a destination. Through the experience gained via my various roles and also our practice’s involvement with Sign up to Safety I have noticed that when we are working collaboratively as a team, we do 5 things well:

  1. We have a team mission with planning and goal setting which allows colleagues to gain clarity around the reasons for needing to change.
  2. Team roles are clarified so colleagues understand what is expected of them and where their accountability lies.
  3. Our team has a collaborative operating process, which, at its heart has effective teamwork
  4. We are aware of our teams’ interpersonal relationships and we actively encourage team members to engage with and support each other with open communication and a willingness to share information.
  5. We are also aware of our inter-team relationships and our impact of our work on other teams across the health system.

‘Signing up to Safety’ has given us a much needed impetus to think differently about safety. I would urge all GP surgeries to actively consider how they might better influence their health system to be more collaborative, as this would help turn our attention away from organisational silos and towards the most important people, our shared patients.

This blog post was first published on the Sign up to Safety website on 11 April 2016.

What would 2066 look like?

Some years ago I came across an interesting book while clearing out my father’s study after he passed away. In the late in 60’s The American Association for the Advancement of Science brought together the leading scientific minds of the time to speculate on what the world would be like 40 years later at the turn of the century.

Looking back

Looking back today, 60 years on it seems that some of the predictions they made were astonishingly correct and some were not.  When it comes to the physical sciences, it seems the microprocessor and the personal computer, the internet, satellite communication and mobile phones and even the iPod and digital media were to a large extent predictable from trends at that time.

In Health and Life Sciences the situation is very different. It was predicted back then that major killers such as cancer and cardiovascular disease would obviously have been vanquished by now, paraplegics would obviously be walking through regenerative medicine and we would obviously be selecting the characteristics of our children based on voluntary genetic manipulation of our genomes. So it seems that there is something fundamentally less predictable in health and life sciences than say, engineering.

So I started to think, well what if we look ahead from now to 2066, what’s it going to be like?  (Knowing full well that whatever I fantasize about is bound to be an inaccurate prediction).

50 years from now

I imagine myself 50 years from now walking around with a little microchip chip implanted in my left arm that has all my data including my personal genetic code on it. This now gets updated regularly by my health coach (used to be called a GP) during my routine visits to track any major changes. The chip also stores and tracks compliance with my life style plan that I have agreed with my health coach. It also works out how much exercise I do and tracks what I eat from edible bar codes in my food and reports that I am indeed taking the disease preventing supplements I have agreed to.  It also monitors all my bad habits and lets my health consultant know immediately if things start to go seriously wrong by tracking physiological parameters, all of this is relayed non-invasively in real time via the wristband of my phone watch.

All this data is being continuously sent to the national health data hub for general monitoring as part of my mandatory subscription to the national health system. All data is of course linked to my personal medical record in the cloud so anybody (with my permission) can know what they need to about me and I can upload any of this whenever they need it.

The national health system now works on a system of health credits but unfortunately they don’t really cover everything, but I can voluntarily top these up via my national health insurance pension plan. My employer also tops these up as part of preventing me becoming ill and remaining productive. If something bad happens my health consultant will advise me on my personalised treatment based on my genetic endophenotype. Bad luck is I may have to co-fund some of this from my voluntary health credits as my basic allocation of national health credits won’t cover everything anymore.

I can always go online to check what the latest treatments are and then enrol in a clinical trial through my relevant disease association who use my data in partnerships with companies to make new treatments (this gives me preferential access to new medicines or devices and I pay less by agreeing to take part in the trial).  Good news is I have amassed a few additional health credits for good behaviour (due to my 2 visits to the gym every week and taking my diet supplements).

The Present

Looking back 50 years to 2016 what strikes me is how little choice we had back then, we just did as we were told because we didn’t know any different. I now have a lot more data and information to make a lot of decisions about myself and invest in my own health, and I have an incentive to stock up on health credits by taking care of myself while I still can.  Anyhow life is pretty good now, I’ll be 105 next month but I am starting to wonder what will it be like for my kids in 50 years from now when they are my age?

Coming back to reality I wonder, 100 years from now, what will that look like?

What happens in Gothenburg doesn’t stay in Gothenburg

Four members of our Quality Improvement team were able to attend the Internation Forum on Quality and Safety in Healthcare held in April in Gothenburg, Sweden. Sarah White, Quality Improvement Adviser, offers this round-up of their experiences, thoughts and learning.

Four head to Sweden

Having overcome the vagaries of booking systems to organise our planes, trains and automobiles, the team set off for Gothenburg; a fairly epic trans-European trek across the hinterland of well, Belgium!

As you would expect, the conference was hugely popular and well attended with over 3,000 delegates from all over the world, including India, Australia and the USA – who presumably made far more epic treks than me in order to get there!

There is no doubt, it is exciting to be part of such a big and well-respected event and our Quality Improvement team was proud to be presenting two posters on key projects: PreCePT (Prevention of Cerebral Palsy in Pre-term births) and Don’t Wait to Anticoagulate.

The Godfather of Improvement Science

My week started first thing on Wednesday morning with Don Berwick giving the keynote speech. Natasha and I secured front row seats and settled back to enjoy the Red Bead exercise on the main stage.  If you’ve not heard of it, it’s a good tool for demonstrating that…

We as workers most of the time have no control over our experiences. We the worker did not make the company – our bosses did – and we should not be held responsible for most of the mistakes. Yes, we can control about four out each 100 problems but not the other 96. They are problems created by the system.

www.redbead.com/what

It was great to have the solid theories and principles showcased that inspired all the work we were about to see.

There was lots of talk about patient flow. Steve attended some interesting sessions on learning from supply chain management in managing patient flow, highlighting that the concept of ‘emotional flow’ is really important.

Learning and leading

Also, in support of our West of England Academy, the international stage is finding evidence that a coaching approach can be the key ingredient in successful improvement. The Vinnvard research programme demonstrated that improvement is best based around specific improvement projects, and that ‘learning by doing’ is critical, demonstrated by the experience from the Vastra Gotaland region.

In a ‘learning stuff for QI’ way, Natasha managed to get hold of a useful tool for our toolkit. In a session entitled Accountability in Care she learnt about what motivates us in the workplace and changing from a Quality Assurance culture to a Quality Improvement culture. An exercise using Polarity Maps made her think about how we get a balance between two concepts: how we identify if the balance is wrong and how we can correct it. Natasha was so enthused by the session that 1) she didn’t stop talking about it and 2) she would love to deliver something similar for our team sometime in the future.

The Sheffield Microsystem Coaching Academy team was represented by Tom Downes, whom Steve found particularly inspiring. A key piece of advice was to start each improvement meeting with a patient story to help maintain engagement with improvement work.

(I should probably mention at this point, that the conference was fuelled by coffee and cake; Fika heaven and the breaks provided loads of opportunities for networking, which seems much easier when sugar and caffeine are combined.)

Steve and I presented the PreCePT poster – tag teaming the information like we’d done it before! For me, this gave an opportunity to reflect on the work we have done as a team and what we have achieved during the last two years. Our poster was a great success; one conference attendee picked up a handful of leaflets saying…

“I will be shamelessly stealing this project and implementing it in my hospital in Scotland!”

Networking

The reception evening was held on Wednesday and delegates stayed on after the sessions finished to enjoy canapes and wine.  We spent a good deal of time speaking to our AHSN colleagues from other regions and also the delegates from East London Foundation Trust (ELFT).

The work that ELFT is doing is truly inspiring and they seem to be at the forefront of QI in secondary care in the UK, presenting four sessions during the conference and contributing to another panel discussion.  We were able to tag along with our new ELFT friends to sample some another of Gothenburg’s cultural highlights: Thai food. This was an excellent opportunity to reflect on the first day with a group of delegates and swap stories and experiences.

Thursday brought another full day of total immersion into all things QI. I found the Q Foundation’s session on Mobilising Improvement and Learning at Scale across Systems particularly interesting for the networking analysis that they undertook. It demonstrated the power of creating and sustaining viable networks across the country for sharing knowledge. The delegates were asked to indicate how comfortable they were with change and uncertainty using a clock face, acknowledging that both ends of the comfort scale were required to successfully run a programme.

Unsurprisingly, I chose the ‘five past twelve’ position which is Very Comfortable with change, but it was clear that both ends of the comfort scale are required for successful projects as someone needs to have the plan!

Different things stood out for different team members; different things resonate based on the work they’re engaged with. Here are some of the highlights…

King of Lean

Steve’s highlight was two presentations from Gary Kaplan and Jack Silversin from Virginia Mason Hospital on engaging doctors in transformation, although the learning was applicable to all clinical staff.

I also attended this session and was impressed by focus on human factors demonstrated by Virginia Mason as they transform the patient experience of healthcare, stating that organisational change is most effective when lean management method engages employees at all levels — from leaders, to providers, to frontline staff. When lean tools and methods are used at every level of the organisation, focused improvement will create value, eliminate waste and reduce the burden of work.

So I may not be a Lean convert just yet, but maybe, in time…

Rebels with a Cause

The final day came far quicker than expected and it started with Lois Kelly talking about a subject close to my heart; Rebels at Work. Lois was inspiring us to be a ‘brave-hearted rebel’ at work and empowering change within our organisations.

Improving healthcare starts one rebel spirit at a time, daring to embrace new ideas, new people, new ways of working, and our true, naked-hearted selves. Lois Kelly of the Rebels at Work movement opened our heads and hearts to what it takes to shake up healthcare-as-usual, from running with rebellious wild packs and communicating like an activist to having difficult conversations and developing practices of resiliency and optimism.

I loved this. It was inspiring and challenging but realistic. Lois also talked about knowing when to back down, which is absolutely as important as knowing when to rebel.

Innovation for Life

This was followed by Jaideep Prabhu talking about Frugal Innovation: How to Do More with Less. Jaideep Prabhu discussed the creation of better and cheaper solutions that employ fewer resources—and how it helps to meet the unmet needs of large numbers of people around the world in core areas such as health, education, energy, and financial services.

This session highlighted examples of such innovation by entrepreneurs, NGOs, emerging market firms and multinationals in the North and South, and discussed the challenges and opportunities for small and large organisations alike.

Round the World

After the obligatory coffee and cake break, we found ourselves back in the auditorium for a round the world trip in Quality Improvement in Mental Health.

This session consisted of Pecha Kucha style presentations from different groups around the world that are applying quality improvement techniques to tackle complex problems in mental health services. We got a glimpse into the breadth and scale of mental health improvement work taking place across the globe.

Don’t Wait to Anticoagulate

Friday also brought us the opportunity to show off our Don’t Wait to Anticoagulate poster.

We saw some impressive work that had a huge impact on a small scale from colleagues in Sweden and Denmark. After the group session we stood with the poster and talked to more people who were around for the session but were not in our group, and generally collared people to show off our work. It was engaging, and a great way to share learning.

Museums Theatre and Health

Finally for me there was a session on Culture on Prescription.  This session explained how undertaking cultural experiences actively can contribute to improve health and enhance rehabilitation. This was really powerful with interesting stuff on holistic healthcare emanating from School of Health Science, Jönköping University.

What I found so interesting was the massive influence on people’s lives that a seemingly simple intervention can have. The study was small with only 76 participants but showed that over 50% were able to go back to work following the project. Small changes making big impacts once again!

Twitter Meltdown

The whole team really got into the Twitter culture at Gothenburg and although the spirit was willing, the technology was weak.  The internet connection dropped out every time the audience got excited about something as we were all tweeting like mad!

Horsing Around

Any international travel is an opportunity to sample the local cuisine and our little team found some great food in Gothenburg.  The first night was spent in what could only be referred to as Hipster Heaven – bearded young men in too-short trousers drinking artisan beers, and us!  The food and ambience was great though and the team had an opportunity to plan out the sessions and seminars that we would be attending.

Poor Natasha was upset that we didn’t get a selfie with Don Berwick – but his keynote speech kicked off the conference with a good dose of ABBA!  This got two Quality Improvement leads swaying in their seats and waving (imaginary) ‘WE LOVE DON’ banners!

Gothenburg is lovely, the rain held off until the last day, the hotel staff were pleasant and effective and the public transport was on time every time.  Although, it has to be said that there are some more eccentric sights to be seen…