Championing quality and seizing improvement opportunities: are we getting it right?

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Our new report on the Getting It Right First Time (GIRFT) programme describes the efforts that leading orthopaedic surgeons made to improve care in their specialty – with impressive results. It reminds me of an early clinical encounter that shaped my own interest in health and care improvement.

One day 15 years ago when I was working as a junior doctor I noticed that a patient might be showing signs of dehydration. The signs were subtle – it wasn’t clear. Maybe the treatment wasn’t quite right. Should I say something?

I am sure most of us would say we should question the situation. But in practice do we always do this? In the midst of juggling numerous things in a complex health and care system where things don’t always make sense, it is easy to brush off the feeling that something doesn’t quite add up, to tell yourself that you must be wrong or missing an obvious explanation. Those were all things that went through my mind at the time.

Such opportunities to improve practice are all around us. Previous research by The King’s Fund has identified many examples of care that is not bad enough to be deemed ‘unsafe’ but enough to cause waste, variation and reduced quality:

  • using higher cost drugs without real reasoning
  • a patient’s perspective not being understood
  • fragmented pathways, with silo working
  • management styles that compromise team morale and productivity
  • commissioning approaches that don’t ensure best value.

GIRFT demonstrates the importance of acting proactively in such situations. But evidence tells us that individuals can be reluctant to voice their concerns, and, in some cases (eg, Mid Staffordshire), when they did speak up they were ignored or victimised.

I believe that it is essential not only that individuals do speak up to champion quality but also that their voices are heard – as NHS England’s Sign up to Safety campaign shows is necessary. Our clinical leadership courses demonstrate it is possible to nurture the necessary skills.

In the case of my patient, I made the decision to speak up and question the situation. It didn’t feel easy but it felt right. I used data to highlight the problem, explore the situation and discuss possible explanations. The senior colleague (an eminent surgeon) to whom I spoke could easily have dismissed the issue or turned me away – serving to reinforce my fears and make me feel even less able to speak up next time. But instead he took time to explore the issues carefully with an open mind and a level of humility that demonstrated a dedication to quality and patient care overall. It set a standard by which I have been inspired to behave with my teams ever since.

The importance of clinical engagement and leadership in improvement efforts cannot be underestimated. Both my story and the GIRFT report highlight insights that clinicians have about practical application of theories to the complex health care system and how best to navigate this to benefit patients and communities – in a way that is unique to those with frontline experience. They also highlight the influence that clinicians have on colleagues (peers and junior staff) in strengthening improvement efforts to reach across the NHS and to future generations too.

Although the clinicians in these stories are doctors, it is important to note that ‘clinical engagement’ applies to a wide clinical workforce including allied health professionals and others such as social care workers.

Also paramount is quality patient, carer and community engagement to ensure that the care provided is based on patients’ needs.

GIRFT demonstrates that when improvement efforts are approached correctly much can be achieved. For example, better long-term clinical outcomes can be achieved through the use of cemented hip joints – improving quality of care and reducing waste at the same time.

For my patient… our efforts revealed that the lady was indeed dehydrated. The blood results had been interpreted differently due to complex features of her case. Knowing this, we were able to change her treatment from powerful, costly drugs to intensive fluid therapy – and later realised this action saved her life. She lived for several years more, reaching her 90th birthday, and spent much quality time with her family.

My early experience taught me a valuable lesson that has since been reinforced through my roles as a commissioner, a manager and public health consultant: that improving the quality of care for patients and delivering better value care are often two sides of the same coin.

Comments

Maggie Moore (…

Comment date
28 June 2017
I have just read this article whilst recouperating from surgery on my foot. I received really great treatment while I was in hospital and now I am home looking at broadening my usual reading matter. This article, hopefully the first of many for me, is also relevant in other work space. The ability to be able to question what we all do in our work place, and to have a 'mentor' to help us explore this is invaluable. We may not always hear the answer we want but as long as we have made ourselves heard we can at least, know we have done the best we can to help others. Thank you

Chris Dawson (…

Comment date
29 June 2017
Hi Durka, really interesting blog. I particularly liked the reference to where The King

Richard May

Position
FT Lead Governor,
Organisation
RD&E
Comment date
30 June 2017
I am astounded that the NHS has just woken up to GIRFT as you call it. British industry got into this back in the 90's and early 2000's and it drove a massive change in efficiency of manufacturing and service quality. Perhaps senior practitioners need to spend time with, say, the aerospace industry to see how it's done.

Durka Dougall

Comment date
30 June 2017
Dear Maggie, Chris and Richard

Thanks so much for taking the time to provide your thoughts. They are really appreciated.

Maggie and Richard - I completely agree about the value in learning, from each other and from outside the NHS or health sector too (something highlighted as a key asset of our publications at the recent FPH conference which was lovely, and something I valued in our new Advanced OD Practitioner programme last week when one of the facilitators brought their experience from the automobile industry with equally powerful effect). So much in the NHS is world-class - so many excellent initiatives happening across the country that instil such pride. But there are opportunities in areas to make it even better - something that is particularly important given various pressures faced at present (see our other blogs and publications). Creating the right conditions (through mentors but actually as commonplace throughout the system) to foster, encourage and sustain quality will be key. Wishing you a speedy recovery Maggie from your surgery.

Chris - you picked out one of the most meaningful points I was trying to make. My initial thought was to focus on this solely as it does feel so very important. We have fairly clear ways of dealing with unsafe practice, but much less so for understanding the variation below this. Something I would love to explore more through my new role - my public health practice made me realise that variations often adversely affect disadvantaged population groups the most, and it therefore essential that this is address through ongoing improvement efforts like GIRFT.

Tony T

Position
Researcher,
Organisation
Independant
Comment date
01 July 2017
Hi Durka
I agree with most of what you have written... Following on from this Richard has rightly pointed out that Industry learned this stuff many years ago and I agree with this also. What is sad is that it has taken austerity to bring the variation of services to the fore: even now it is clear from the numbers that many clinicians and managers have not yet bought in.
The fact that a few years ago a trained doctor noticing dehydration in a patient would have to think about whether or not they should bring this to the attention of other clinicians is an indication of why the outcomes of many illnesses is so poor.

Silo stuff is of course partly responsible and this needs to be addressed urgency. Well done for your Blogg I am sure this type of thing helps enormously.

Steve Bolsin

Position
Consultant Anaesthetist,
Organisation
Barwon Health
Comment date
03 July 2017
I have proposed the same process of outcome measurement to support organisational accreditation and individual revalidation (https://www.mja.com.au/node/11833). The goal would be to never have to live through another Bristol as I did.

Helen Watson (…

Comment date
03 July 2017
Interesting to also consider all this from a health in the community viewpoint Durka, Thanks for the blog!

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