John Dean: Making a serious and sustained commitment to quality improvement

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  • Posted:Thursday 09 November 2017

Speaking at our Quality improvement in health care event on 9 November 2017, Dr John Dean, Clinical Lead, Quality Improvement Hub, at the Royal College of Physicians, introduces an initiative by the Royal College of Physicians to drive quality: the Future Hospital Programme.


I hope that this provides you with some context around how we can really collectively be serious and have a sustained commitment to quality improvement, take council on board in terms of making sure (a) we do it properly; (b) it works; (c) we research it; and (d) we continue to evolve and improve it because we would not do that with anything else.

So what I’m going to share with you is where we are as the Royal College of Physicians (RCP) and what our commitment is to working with our fellows and members and other people in their teams, but also other organisations to try and make sure that quality improvement does become part of a day job and done properly. 

A lot of our current thinking is built from the insights of our Future Hospital program, which some of you will know about, so I’m going to use that to illustrate some of the things that we’re planning to do.

I start from this point that all physicians, and I would extend that clearly to other members of their team, clinical and non-clinical, aim to continuously improve their services for patients. That is a given, okay. So when people talk about engagement I don’t like it, what we need is partnership for people who are all committed to improving care. I think clinicians and other members of the team need skills at four levels. We’ve heard a lot today about how they need a particular behavioural and social environment and ought to be able to use and develop and continue to improve that practice, but they need day to day problem solving skills so they can fix things that are going wrong now and they need the permission to do that, they need process improvement skills within current services, they need service design skills and knowledge when services need redesign often across pathways and they may need large scale change skills for more complex things across a population, a community working with others. I don’t think the same methodology can be applied to all of those, I think it is different and I think as we get better at improving we will know what to apply at each of those levels.

So firstly we have to start with what is quality?  From an RCP point of view we’ve taken a bit of a step back and reviewed that, a lot of stuff that’s been around before. We are quite clear this is layered, okay, and at the top layer you have the triple aim here that continues to evolve.  It’s around population health and wellbeing as well as the best possible care for the individual. Our definition of sustainability I think has evolved to include financial, environmental and resource sustainability and what we try and do is balance that to get value. I think our understanding of the domains of quality has also evolved, so that when we talk about effective care we’re not just talking about evidence based medicine we’re talking about effective teams, we’re talking about effective interactions with patients and families. So this nuances over time.  We’ve heard a lot today about actually quality improvement isn’t a golden bullet but it is a part of a whole load of stuff that we are doing all the time and part of the challenge I would give to some of the research work is how we evaluate one component of all of this stuff working together, because it has to work together if we’re going to shift that curve to the right and make it taller. 

So at RCP we have a number of functions that are working in all of these areas through education, through guideline development, through accreditation of services and developing quality improvement program.  How do they combine and be the most effective to shift that curve?  You will remember that in 2012 the Hospitals on the Edge report was produced and out of that came the Future Hospital commission and really what we were stating at that point was that the type of care that we need to deliver now for the type of patients that we see and the needs we have is very different than it was designed for and that we’re currently trying to deliver.  You all know that, you all feel that every day, I don’t need to go into any detail, and the commission report again came out with things which none of us would disagree with but actually did need stating at that time, that we work in care teams, that we work across boundaries, that we need control systems and coordination systems, that patients and families need to be true partners in care.  Now this is common language to us now, but at the time when those things were stated and in some respects many of my colleagues would say it shouldn’t have been called the Future Hospital report because it was very much more than about hospitals by the time it came out, but at that time it was seen actually as quite a statement and quite an important statement.  I think since then we are now taking many of those things as given but we are still struggling to deliver them. 

It also came out with eleven principles that again nobody would disagree with, but at roughly the same time the Berwick Report around patient safety was developing and came out with a number of recommendations including how do we build consistent skills and behaviours and organisational support for quality improvement methods and approaches to delivery? 

So the Future Hospital program came out of the Future Hospital commission report in the context of how do we put all that together as a demonstrator of this is the vision of care we want to deliver, can teams, if adequately supported, actually deliver some of those elements of care in a consistent way?  So the Future Hospital program, which I’ll go into in a little bit more detail in a minute, did a number of things, it standardised how we put patient experience and patient involvement at the centre of care redesign and delivery, it used measurement for improvement, it focused on supporting front line teams without extra resource other than some central coordination and support but nothing extra in the organisations, these weren’t vanguards that were given additional amounts of money, and about front  line clinicians leading their teams and creating effective teams.  It was also about future clinical leaders so the chief registrar program, which I’ll touch on in a minute, was about how do we develop future leaders involving them in leadership, education and quality improvement, and how can a national organisation with a certain amount of gravity, if you like, support that?  It was a tester for that.  Is that the right way for an organisation like RCP to work?  

So the Future Hospital development program had two phases of sites, for sites in each wave and I’ll touch on some of those in a minute.  These were the sites, on the left-hand side from your perspective of the slide were the first wave sites largely working on frail older people, and on the other side sites working on integration in phase two. 

Largely, I would say, they were focusing on these elements of the eleven principles of Future Hospitals and in parallel with that we ran the chief registrar program.  So the chief registrar program is for mid-level career trainees, at ST4 plus, who have a year funded by their organisations which includes two days a week for leadership, quality improvement and education development.  We finished the pilot, we’ve got a second year just started with 44 now young doctors in these roles we’ve supported and developed but supported by their organisations as well. 

In addition to that there isn’t only good stuff going on at development sites there’s lots of good stuff going on elsewhere and I think that’s again one of the challenges with evaluation, is because an intervention is being put in in one place doesn’t mean there aren’t other interventions going on in another place.  We need to understand that.  So there’s lots of good stuff going on and the tell us your story was a way of collating that through a network of people interested in improvement in physician services to tell stories around what good stuff is going on. They need more detailed evaluation but at least they’re a window on good stuff that may be happening and may be valuable. 

So I can’t share with you the details of the independent evaluation because we’re launching the report on 23rd November, I can give you a few nuggets from it and a few themes from it, but it has been independently evaluated.  At the same time as part of this and coming out of this we did some work with the Royal Academy of Engineers and the academy of Medical Sciences and you’ll have seen hopefully the publication engineering better care, which is about how do we improve improving and redesign and we’re now at the phase with this work, which isn’t a new method, it brings together a number of approaches that people have been using into a consistent approach which now needs testing and evaluation. 

So the nuggets of what the Future Hospital program found are that being in a program, having the kudos for your organisation and your colleagues and your partners of being part of a nationally driven program, can drive improvement and can deliver improvement. The patient and family involvement was central and pivotal to that being delivered and importantly sustained and resilient despite organisational changes, because they are the consistent component and that young leaders can value and deliver in their roles important improvements as part of organisational improvement programs.  So there will be more on that in the next couple of weeks.

So I’m going to share something around our local approach of an organisation that has come out of special measures that is now good and is one of those and that is in the CQC report on those organisations and our approach to improvement, which is far from perfect, is still in development, but I think has some features which are important if we’re going to make this mainstream.  I talked about the four levels at which we need to work.  So this is an example from our part of the STP of how the emergency care pathway, and it isn’t all included on this slide, needs to be developed long term through systematic working across the system with multiple partners.  The skill set around that is, as we’ve heard earlier, relationship building, public participation, a lot of social change but actually building a common pathway. 

Let’s take one bit of that, let’s take the redesigned emergency village and drill down to redesign.  So we have redesigned in a two phase, we’ve completed phase one, we’re into phase two, of what does an acute medical unit look like if it’s going to meet the needs of our current patients?  We had a forty-two-bedded medical assessment unit we’ve moved to an eighty-four-bedded acute medical unit with a different service model. That was a service redesign based on data and need and a different service model.  It wasn’t a series of quality improvement projects. 

However, in those acute medical units we have a number of quality improvement projects owned by the organisation in our quality strategy which have had a series of iterations and here’s one around care bundles which, great, we’ve all got them, but actually unless you’re delivering them at 80% reliability you won’t start to see shifts in mortality which was the driver to improve this.  Of course there are a whole series of these going on in the acute medical unit as part of a program and also through this approach we develop a culture where day by day people are seeing that there aren’t enough continuation sheets in the drug trolley. So something has gone wrong with that so they fix it real time by a conversation with the ward clerk who has a conversation with the supplier or changes the ordering system.  So you have to do those four levels at the same time. Each of those drives the culture and helps sustainability. 

Within Worthing, one of the other sites, they have very much developed a culture of continuous improvement and on their emergency floor they started with some real service redesign around a new emergency village, they did some different ways of working, they now do real time problem solving four times a day with fixes on those units with more demonstrable improvements.

In Yorkshire they developed a frailty assessment service, as many have, but the level of reliability around comprehensive geriatric assessment is probably greater than many of us have seen in many places and there are community examples in phase two as well, again more detail in the report about to come out.

But it’s not just about quantitative data, I don’t want you to look at detail on this slide, what I want you to look at is narrative.  I want you to look at the narrative, this is from our Trust, the narrative around how an individual with a particular skillset changed the way the teams were working and responding to people with frailty and with needs and I want you to read these distillations from an interview with a patient who had two experiences of care a year in between when services were better coordinated and better joined up through a whole series of iterations of improving care, improving communication for older people with multi-morbidity. So the qualitative evaluation is just as important as the quantitative evaluation in this.  More of that, as I say, in the report.

So in RCP we are developing a quality improvement program that at the moment is looking something like this.  We’re saying, and we’re starting, our own six programs of care, we need to build capability in physicians and members of their team, clinical and non-clinical members, but this is a skill development and a practice development not just knowledge.  So the way we do that we have to work with educational colleagues to develop the best way to do that.  We’re running topics specific fairly classical breakthrough series collaborative work that not only bring teams together to learn together but help and coach them through improvement techniques and behaviours.  We’re connecting people through a virtual hub to good stuff and leadership for improvement we see as really important.  We start with chief registrars we’ll build in other groups particularly if linking with specialist societies and clinical leaders in those areas. 

We’re doing R&D, I touched on the work with the engineers, and some organisations are starting to come to us, say, “Can you help us to do some improvement work and bring some coaching and skills and support?” with some kudos from a national organisation to support them for care, for example, in emergency front door care or ward based care. Underpinning that we’ve got a quality improvement faculty, we now have 30 physicians who are signed up to give some of their time and their organisations have signed them up to give their time for these programs.  These are people who have skills who have not been that well connected before and we will build other members of the team and build them as well. 

So if we tried to do this two years ago, three years ago, there would not have been that level of skill in the community that we can connect.  So I think we are at that point as a very broad system where there is the level of capacity build in that we can take it to that next level, but it’s mainly about behaviours, isn’t it?  It’s mainly about culture and behaviours of all staff and increasingly this is striking me as one of the most important pieces of work we need to understand around how we unlock and don’t block and nurture what I would say are inherent behaviours of very large numbers of health care staff but that have often been inhibited or not grown, but in addition to that organisations need structures to support this.  So this is work that we’ve done around supporting junior doctors to be doing improvement work as part of teams and these we think are the ingredients that organisations need to deliver in order for those junior doctors to work effectively and deliver effective products or learn from those projects because they won’t all deliver improvements. 

There are other things that get in the way. My premise remains that professionals have a drive, a personal and professional drive, to improve care but stuff gets in the way of them doing that and doing it well and those of us that are leaders in the room our role is to stop that stuff getting in the way and get it out of the way but have a coordinated approach and we believe that as a professional organisation we have a key role in doing that and leading some of that with our colleague organisations. 

My final point is that this is intuitive to physicians and other clinical people. We use quality improvement as clinical practice.  That’s what we do with individual patients, we assess how they are in their environment and we with them come up, when we’ve considered what we might do, with approaches that we’re going to try and test and monitor their effectiveness and then adapt them.  That is the clinical method.  What we need to do is to apply that to our services in the same way as we apply it to individual patients and then it will become mainstream.  Thank you.