My AHSN connection – Dr Seema Srivastava MBE

Seema was awarded an MBE in the 2018 Queen’s New Year’s Honours list for her services to the NHS in Patient Safety. Here Seema writes about her involvement with the West of England AHSN right from the start, and how we help facilitate the work she’s involved in.

I’ve been involved with the AHSN right from the start; I was already involved in regional Quality Improvement (QI) work. One of the things I remember, right back at the early meetings in 2012 was the range of people I got to meet. I was particularly interested in meeting innovators and people using technology to tackle some of the issues we were facing.

For us at North Bristol NHS Trust (NBT), the National Early Warning Score (NEWS) was high on the priority list right from the start. Working with the AHSN meant we could work alongside others, at University Hospitals Bristol and then in the community. We learn from each other’s successes and failures and take a standardised approach that has rolled out across the region and is now being implemented across the country.

One of the things I value most in working with the AHSN is the way they remove barriers and get people working together. The face to face meetings are both productive and enjoyable. The team there are also great at facilitating remote teams and keeping complex projects with dispersed teams on track.

It’s this ability to bring people together and focus their efforts that has allowed us to progress NEWS with the pace and scale that we have. I’m also working with them on approaches to Learning from Deaths and the ReSPECT advanced care planning tool. These are sensitive areas but with the support of the AHSN we are gaining wide-ranging and senior support and buy-in that will really help the development and adoption of these projects.

This story is a highlight from our 2017/18 annual review: joining the dots to healthcare innovation. Check out the full review here.

My life as a Medical Director – Dr Peter Brindle

Dr Peter Brindle, a practicing GP and previous Lead for Commissioning Evidence Informed Care at the West of England AHSN talks about his new role as Medical Director (Clinical Effectiveness) for Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group (CCG).

I’ve been in my new role for about seven months and it is a very different role for me, with an extremely steep learning curve – but I think I am beginning to get to grips with it!

What is my role?

My motivation in taking this role was to make a significant difference in improving the health of our population through looking for variation in performance and clinical practice across our healthcare system, to understand what optimum might look like and then to promote changes to reduce the unwarranted variation.

We have finite resources in terms of staff and money so on behalf of our population we need to make every effort we can to maximise value. This is exciting because this approach can both improve care and save money at the same time.

What have I actually been doing?

So far I haven’t yet done as much of this as I would have liked as I have responsibilities in a number of other specific areas, for example in cancer services, urgent care, medicines management, research and development as well as diabetes outcomes.

I have had to acquire a lot of new knowledge in these areas to that I can ask the right questions and make informed decisions. There have also been a lot of new people to get to know, both within the CCG and also our providers, and as a clinician, mastering the processes, governance and language around commissioning healthcare has been a challenge.

We have also been going through a reorganisation, with a merger of three CCGs. It takes a lot of time to design a new organisational structure, prepare job descriptions and interview many people, but we should be through that shortly.

This merger and associated restructuring is a crucial part of creating a new and functional healthcare system, but it is tremendously difficult for everyone involved. Despite this uncertainty, the staff have been amazing in the way they have kept on with the day job of planning and commissioning care for our population.

Soon the reorganisation will be complete, and I will lead a small clinical effectiveness team who will be using benchmarking tools and examples of great practice to find unwarranted variation. They will then work with clinicians and managers, using improvement techniques to promote positive changes that bring better and more efficient care to people.

Too much ‘re-invention of the wheel’ goes on, but we don’t have the time or money to waste on doing that, so it is crucial we learn from other CCGs and international health systems who have pioneered approaches and services, evaluated them and shown what ‘works’.

What are my main observations so far?

  1. The importance of working with all our providers to build a system-approach to our challenges. In the past there has been a tendency for services to be led by a provider perspective which has led to many fragmented services with variable standards. We need to plan and deliver services starting from the patient and population perspective leading to a standardised approach balanced where needed, with a strong locality emphasis sensitive to specific population needs.
  2. The constant requests and need for more investment in a range of different things. Balancing these demands is thought-provoking and challenging – every pound spent on one area is a pound less on something else. Once again, a population view is needed to prevent slipping into overspending on areas that are driven by strong and articulate interests. A relentless focus on getting value from our interventions will release resources from which all can benefit.
  3. From a personal perspective, there is a big demand for me to attend many meetings which, although they are useful, does mean I have less time to build effective relationships and to drive change arising from small group conversations. Getting the balance right is a work in progress…
  4. Sometimes the idea of ‘dedicated health service staff’ typically brings to mind the image of a nurse, doctor or someone in a clinical role, but I never cease to be impressed by the incredible efforts of the staff in the CCG who are totally committed to improving patient care, especially while going through some uncertain times. They are dedicated to the needs of patients every bit as much as their patient-facing health service colleagues.
  5. There is never a dull moment – well practically never! It’s fantastic to be in the heart of some really significant decision-making in a challenged healthcare system. There is so much potential and I’m excited about being part of the change which is already taking steps to improve healthcare for our population.

How has my time at the West of England AHSN helped me in my new role?

  • I learnt a lot about quality improvement tools and techniques from West of England AHSN colleagues which I continue to apply in my current role. I want to do everything possible to promote a strong culture of continuous improvement across BNSSG.
  • I remain a champion for the use of evidence. I have seen how through the use of the best available evidence, significant savings can be made and patient care improved. Read some examples here.
  • I have always been an advocate of evaluating our decision making and I am now better able to ensure evaluation is built into the processes of normal business, so we create our own evidence of whether our services are doing what we expect them to. Find out more about evaluation here.
  • I made some great contacts with like-minded people who are passionate about improving healthcare by looking at the evidence, learning from the experience of others and applying robust improvement techniques. Some of those have joined the clinical leadership team within BNSSG and the rest continue to be very important to me in achieving my goal of better care for patients.

If you want to get in touch, you can contact me on or @petbri on Twitter.

Goodbye 2017, hello 2018!

Drawing on lessons from our Patient Safety team’s recent away day, Nathalie Delaney shares a few creative and collaborative ideas to review what you’ve achieved as a team in the past year and how this might inform your plans for the coming year.

At the end of the year, it can be a good time to reflect on the achievements and learning of the past year and make intentional plans for a successful year ahead.

The West of England AHSN’s Patient Safety team met at the end of 2017 to do this together, and I thought I’d share our process here as you may want to reflect on this yourself or with your own team.

Goodbye 2017

As an icebreaker, we looked at the strengths of our team using the 16 personality types. Who’s in your team? What are your strengths? Then we looked back to celebrate the past year and asked ourselves:

  • What were our successes and achievements in the past 12 months?
  • What have we learned about ourselves and our members this year?
  • What were our biggest lessons this year?
  • Was there anything that surprised us?

If you are doing this as an individual, you may want to start by reviewing your calendar for the past year to identify key milestones and achievements. Alternatively you could create a shared timeline as a team. The Sign Up to Safety Kitchen Table Scribble Sheet has some other prompts that may help you do a freeform download of what’s on your mind.

Based on this we made a list of: what might we change or maintain in our work in 2018?

Looking ahead

We then had a presentation from our Managing Director, Deborah Evans, and Chief Operating Officer, Tasha Swinscoe, on the ‘big picture’ for the year ahead, both nationally and locally. From these, we identified what opportunities and challenges might arise in the year ahead?

Each member of the team was asked to nominate their theme song before the workshop. We held a short quiz to try to guess which song belongs to each team member, based on 20-second snippets from Spotify. As a team, we were surprisingly bad at this and it was a good way to find out something new about colleagues we work with. In case you’re interested, mine was ELO’s Mr Blue Sky.

Hello 2018!

The afternoon was spent creating a shared vision for 2018. We split this into aspects about how we, the team worked, and also our projects.

For our team we asked:

  • What should we stop this year?
  • What should we continue this year?
  • What should we start this year?

You can download a template to use with your team or consider the questions individually.

After a quick cake break, we discussed our projects and objectives, using the MoSCoW framework to identify our key aspirations and the impact we wanted to see:

  • Must do
  • Should do
  • Could do
  • Won’t do.

Our next steps are to identify what results we want to see and break these down into our large goals and smaller steps as driver diagrams using Quality Improvement methodology. As a team, we are moving to using Verto to manage our programme in the New Year. If you prefer paper to digital, you can print out our handy calendar for 2018 and add in your own goals and actions.

Over to you…

How can we in the West of England AHSN help you reach your goals in 2018? There are plenty of opportunities for support whatever your aspirations.

If your goal is to learn more about Quality Improvement, why not sign up to study the Quality Improvement in Healthcare MOOC starting in February 2018. This is a free six week course delivered online. You can also sign up for a free account for LifeQI which is a web-based platform designed to assist frontline staff running Quality and Safety improvement. The LifeQI system has recently been majorly upgraded and is free to access for West of England AHSN members.

Opportunities to join the Q community, an initiative connecting people with improvement expertise across the UK will re-open in 2018. Register your interest to be notified when applications are open.

If you are working in primary care, recruitment will open soon for Cohort Three of our successful primary care collaborative. Find out more and register your interest.

If your goal is to share learning from an innovative, measurable solution to a patient safety issue then why not enter the National Patient Safety and Quality Improvement Poster competition. Enter online by 16 March 2018. Short-listed entries will be invited to present a poster at the Bristol Patient Safety Conference on 16 May 2018.

If you are working in business check out our business support video which includes an introduction to our work with businesses and innovators and sign up for our newsletters including our funding finder which provides regular up-to-date funding opportunities for health innovators. This includes opportunities from Innovate UK, Department of Business, Innovation & Skills, Horizon 2020, The National Institute for Health Research and NHS England.

If you want to meet and share ideas with others who share your passion about improving and innovating healthcare, then you need to sign up for hyvr, our new social network for citizens, innovators, healthcare professionals – and well anyone really!

And if you would like to know more about evidence and evaluation or involving public contributors we have a range of toolkits to help you with practical steps in your day-to-day work. NIHR CLAHRC West provide a range of excellent training courses aimed at developing of skills in understanding, using and producing evidence for the health, public health and commissioning workforce, and patients and members of the public. You can also join our evaluation online network, a virtual peer to peer support group for all things evaluation related.

Evidence Works – an evidence-informed commissioning toolkit

Evaluation Works – a service evaluation toolkit.

Working Together – A toolkit for health professionals on how to involve the public

All the best wishes for a fantastic 2018!

What’s your best-fit coaching style?

Our quality improvement project support officer, Kate Phillips reflects on her learning from the West of England Academy Improvement Coach Programme…

I recently took part in a great two-day improvement coaching event hosted by the West of England AHSN, funded by The Health Foundation. The event was attended by 26 of the West of England Qs, a group of people who I am really enjoying getting to know as we share a passion for driving quality improvement (QI) in healthcare. Sue Mellor and Dee Wilkinson, our fabulous facilitators, guided us through three coaching approaches with an emphasis on finding our ‘best fit’ coaching style. This encouragement for honest reflection ensured I left with a bounty of personalised counselling tools.

We started the course by working out our Honey and Mumford personality type which led to conversations around team dynamics and how to make the most of individual talents. I felt a sense of belonging and of ‘finding my people’ as the room was buzzing with personality type ‘private’ jokes. A particularly comical moment was when three ‘activists’ were first up to grab the board pen, while the ‘theorists’ were still discussing the merits of the process!

I initially joined the ‘pragmatists’ as I thrive on finding evidence-based logical solutions. However, following an insightful conversation with a colleague, I scooted myself closer to the ‘reflectors’. She had noticed how I often approach tasks with a reflector mindset, which I reckon comes from a desire to learn best practice from more experienced colleagues (experienced in QI and identifying personality types!).

Having very recently made a jaunty sidestep away from a career in teaching, I am still finding my QI feet… Interestingly I think personality types are fluid and can change depending on the situation we find ourselves in.

For example, if I was to stroll back into a classroom and teach a class about displacement reactions (fire!) you would see a pragmatic Kate, but put me in the office answering the phone you would firstly see me very flustered as I juggle the telephone voice, demands of the caller and transferring the call. However after my heart rate has returned to baseline, I will reflect on the success of the phone call and how I can make it less of an ordeal next time (more fire?).

As I’m sure a lot of QI projects involve taking people out of their comfort zones, I think it is important to recognise that personality types may take a detour away from ‘the norm’ during the changing situation. I can imagine this having quite a big impact on team dynamics.

As the two-day programme unfolded, Sue and Dee skilfully balanced theory-based learning with opportunities to ‘play’ with different coaching approaches, always with the focus on our own QI projects. We worked in triads to explore the benefits of three different coaching approaches:

GROW – Goal, Reality, Options, Will

CLEAR – Contracting, Listening, Exploring, Actions, Review

OSCAR – Outcome, Situation, Choices, Actions, Review.

As both coach and coachee, the chance to experiment with these approaches and to work with different Qs was an invaluable opportunity for me.

As a coach I grasped the power of suspending judgement, in allowing silence to fall in a conversation and the truth that can be discovered by tapping into the conversation energy level as it peaked and troughed. My favourite approach was GROW, as I found the acronym was easy to remember and the conversation often flowed quite naturally along this path.

In the position of a coachee I learnt to approach the conversation honestly and openly. As a result I was rewarded with multiple light bulb moments as QI ideas and feelings bubbled to the surface, simply drawn out with a few pertinent questions and some very active, active listening. I’d like to thank my triads for these delicious moments of clarity.

I left the programme feeling excited by the power of listening and empowered by the ability to harness a 15 minute time slot. My enthusiasm was echoed amongst the other delegates. “It’s powerful stuff for fostering change,” said one.

I’d love to hear your own thoughts and tips about using coaching to promote and accelerate QI projects. You’ll find me on twitter at @IamKateP or @weahsn.

Eight ways to use QI for patient-focused care

Our Director of Quality Anna Burhouse shares eight simple techniques for how to improve patient focused care in any organisation…

I have been working with the University of Bath to design a free Future Learn course on Quality Improvement (QI) for healthcare professionals.  It has now run twice and goes live for a third time in May.  Over 7,000 people have taken part and I have felt particularly moved by how much people shared about their own experience of being a patient, family member or carer and their observations of the health and social care systems they found themselves in. It was a really rich source of examples about how important it is to have person-centred care and how we must have patient experience at the core of our improvement efforts.

I also enjoyed the discussions about how to be an improvement leader in your local team, no matter what your formal role is in an organisation, especially the need to ‘walk the talk’ and demonstrate through personal actions the improvement you want to see manifested in the organisation. All of this made me think about some simple practical ways that we, as improvement leaders, could use to encourage a culture where patients are at the heart of our health systems.

So here are eight, tried and tested ideas that might help improve the type of patient-focused care offered by your organisation:

1. Focus on the patient journey

An important element of QI is always to think about the patient journeys through your system. One simple, but effective, way to really get to know the patient journey is to experience it in ‘real time’, by asking permission to accompany a patient as they travel through your system. You will see and, more importantly feel, how they move through the care pathway. You will see how smooth, efficient and effective the care is and what really matters from the patient’s perspective. Often this process will help you to see things from a different perspective, noticing both the ‘flow’ through the system and ‘emotional touchpoints’ of the journey, the elements where the patient is pleased, frustrated, bored, vulnerable, empowered etc. This method enables you to collect powerful data and can assist you combine a process map of the patient journey with the experience of the journey.

2. Value added time

Once you have mapped the whole patient journey, you can start to ask a range of questions like:

“What parts of the journey really add value to the patient?”

“Is there any unnecessary duplication or waste?”

“Can we make the experience of the journey better?”

You can then ask both patients and staff what ideas they would suggest  to speed up this process and eradicate unnecessary steps in the journey that don’t add value. You have then started a process of co-production of improvement ideas that can be tested using Plan Do Study Act cycles. This is a quick and effective method to reduce steps in the process and can also be used to improve patient experience and safety.

3. Ask for feedback

Every NHS organisation has processes in place to gain feedback from patients about their experience of care, like the Friends and Family Test. This can help to give organisational feedback. However, what happens if you are trying out a new improvement idea in your team or microsystem and just want some very quick and direct feedback from patients as part of your improvement measures?

There are really creative ways of obtaining immediate feedback at a microsystem level, such as in a busy outpatient clinics or wards.

For instance waiting rooms can be great environments for feedback and measuring patient experience using more engaging and unique metrics. A simple yet effective technique is to give either your patient or their relatives or carers a token and ask them to drop it into one of two jars in the waiting room as they exit. You can label the jars according to the question you want answered. For instance if you were aiming to improve the running time of the clinic you might ask “Did you wait more than 5 mins after your scheduled appointment time?” and put out two jars, one labelled “yes” and one labelled “no”. This simple feedback can help you see how you are doing.

For younger patients, we recently asked them to help us generate improvement ideas by providing drawings of magic wands to colour in. We then asked “If you could make our service better today by magic, what would you do?” The children loved this idea and were colouring and writing on their wands in no time. These ideas can them be taken forward to be tested.

This type of feedback is a great option for those of you who love to get creative, as the only limit here is your own imagination!

4. Share patient’s stories

Patient stories are a core element of QI techniques and should never be underestimated. Their experiences can be a powerful way to inspire change at all levels of an organisation from a busy clinic right up to the board. Use them wisely to get buy in and describe why change is needed. Here is one we recently developed at the West of England AHSN to explain why using the National Early Warning Scores can save people’s lives.

5. Get social!

Social media is a great way both to get feedback and to help test change ideas through crowdsourcing. Often people are really keen to help and you can reach a wider and more diverse audience who have a broad range of ideas. This is an effective way of seeking active engagement on how to improve both hospitals and/or care settings.

6. Be a fantastic listener

If you are leading improvement, don’t forget that you can improve yourself too! Ask yourself do you really and truly listen to people to understand what they are saying, even when it’s a difficult conversation to have? Or do you habitually listen to answer? Be brave and ask for feedback from colleagues and patients about their experience of you.

The art of active listening is crucial for QI leaders and it’s a skill that can be learnt and improved. An easy exercise to help you understand the power and importance of this skill is to find a friendly QI colleague and both take turns to tell each other something important while the other person tries as hard as they can not to listen. It’s a good technique to show how not listening to someone impacts on us emotionally.

7. Don’t underestimate the power of a question

If you unearth a patient experience issue in your team you can help to better understand it by using the ‘Five Whys’ technique. This is a very simple QI method based on asking “why?” five times to take you on a deep dive to the root cause of the issue.  This can then help you see if this was an unfortunate ‘one-off’ variation to the norm or a systemic issue that will require wider improvement.

8. Appreciative Inquiry

Appreciative Inquiry is a technique developed by Cooperrider et al (2010). It can be used across an organisation or in a single team, for staff and patients, carers and families. It asks ‘appreciative’ questions about what’s working well and why. It is a strengths and asset led model where you actively seek to build on what you’re good at rather than ‘problem solve’ by looking only at deficits.  This doesn’t mean that you don’t uncover things that need improvement; in fact it asks people to dream about what the organisation could look like in the future in order to continuously improve and transform.

I hope you have enjoyed reading these techniques, and are inspired to give one of them a go. I’d love to hear your ideas too so that together we can spread ideas about how to improve patient-centred care approach and leadership skills. I believe no matter what your role is in your healthcare environment, we are all leaders for improvement. Please feel free to tweet us at @annaburhouse or @weahsn with your suggestions.

It’s a wrap!

In this latest blog post Sarah White, Quality Improvement Lead, has a few timely tips to share on the festive art of gift wrapping…

‘Tis the season to be jolly and to wrap presents. Some people love the wrapping part, adorning their gifts in feathers, bows and all kinds of bells and whistles. Some people, like me, only buy gifts from shops that provide a wrapping service.

Here at the West of England AHSN we decided to take the Christmas spirit and repackage it as a learning activity. Our Quality Improvement team were recently asked to deliver training to Bristol pharmacists to help them understand process mapping (or should that be process wrapping?), which presented the perfect opportunity.

The activity demonstrates how everything has a process – a flow in which smaller tasks combine together to make an overall task.

We furnished small teams with the necessary equipment: a gift, some paper, a label, sticky tape, all the accouterments required to make a lovely gift for someone.  They were then asked to spend 10 minutes setting out their workstation to make the process of wrapping the present as easy as possible.  They were given some simple rules to follow:

The gift must be neatly wrapped:

  • No bits of present visible
  • No loose corners or edges of paper
  • Sticky tape not visible.

The gift must be labelled:

  • Attached by string
  • To whom
  • Message
  • From whom.

Once they had designed the process they would have 10 seconds to wrap their present.

The teams got to work – setting out their process, discussing the merits of various techniques, laying out their equipment, labels, gift and paper in ways that would make that 10 second wrap a doddle.  The teams were working together, collaborating and generating ideas. It was all going so well until…

The trainers called time on their process mapping and everyone was all set to get down to the business of putting it into action, but (and here’s the good bit) we then asked them to swap workstations!

The teams had to use someone else’s process.

There were all kinds of complaints, but the rules were unequivocal. You have to swap teams and use a process that you have not been involved in designing.  The 10 second countdown started as did the shouts of dismay.

The presents were wrapped – kind of.  Using another team’s process was more difficult as the participants hadn’t designed the process; it slowed them down and made less sense than their own.

Afterwards, we asked them how it felt to have a process foisted upon them with no consultation and I’m sure you can guess the responses. The exercise was fun and clearly demonstrated the benefits of building consensus, utilising existing skills within the team, and having ownership of a process, whatever it may be.

In terms of Quality Improvement, this exercise is great to quickly demonstrate the importance of bringing teams together to understand their processes, especially when it comes to making changes.