10th August 2022 - Tomorrow's Doctor as Improvers
The context in which we now deliver medical care has changed significantly.
The Doctor When those of us over 45 were junior medical staff we would be likely to be working 80 or more hours per week, we would be on a team for six months. Our team would consist of a newly qualified houseman, a senior houseman, a registrar and possibly a senior registrar as well as a consultant. We would be in a team, part of a team and invariably on call with one or more of them.
The Ward this would be between 25 and 30 beds, chances are that would have been the consultants ward as long as he / she had been working at the hospital. It would have a clear emphasis, respiratory, cardiac, vascular surgery for example. There would be a strong culture of nursing and medical teams working together over a long period of time. The ’take’ would bring in a mixture of patients but these would mostly be dealt with by the team with specialist referral where necessary.
The Patient - patients were, as now, elderly but might have just two or three diagnoses but more often fewer. They would be in hospital for, on average, a week with a combination of more limited diagnostics and treatments. Decisions were often experience based as there was less evidence on which to rely.
Knowledge – medical knowledge though expanding had a steadier trajectory and was predominantly focused on clinical science. It was the drugs, surgery, diagnosis that was the focus of the doctor’s attention. The system in which we worked had more continuity and worked more slowly. There was deference to experience.
So, what is different now; the system is complex, the patients have multiple morbidities, the science is more complicated and intensive treatments more common in hospital and where not needed care is delivered in outpatients or a day ward. Knowledge, with 200 thousand papers per year, has a half- life of 5 to 7 years not 15. Where 3 or 4 people managed an episode from start to finish it is now more likely to be 12 -16. Some problems with delivery are wicked, sort the 4 hour wait for ED out and you gain a patient with incomplete diagnostic work up. Admit to a bed but find the only bed is one on a ward with respiratory expertise not cardiac, but then the patient has both these and diabetes so who is best able to care for them? There can be three shifts of junior medical staff each day and hours reductions have had a health and safety benefit for doctors but created a new problem with handover and team integrity.
The delivery of high reliability care in complex environments requires us to rethink how we develop our staff to do the work. In addition, in complex environments where there is new knowledge to assimilate, we need to pay attention to delivery and process as well as science and technology. If we need resilience in the system for complexity and the unexpected, we need more than control mechanisms and policies. Knowing where we are on waiting times is a simple metric that is not proxy for getting the right decisions and the right actions from the team to minimize risk and maximize outcome.
A project undertaken by the Royal College of Physicians in England 2010 along with many other Deanery and global projects in health care have shown;
- Junior doctors have a strong sense of purpose when they are involved in improving their work
- Delivery of improvement in systems of care is a much-needed activity as the numbers of people involved and the co morbidities that patients present with both increase
- The Francis Report, the demand for patient centred ness, the expectation of better patient outcomes or the demand to reducing needless harm are all drivers for a wake up
- It is a fact that junior medical staff ‘see’ the problems in the systems, feel motivated to change them, are well placed to deliver change at the front line and develop life-long skills in change management.
- All of these are much needed attributes if we want a re-moralised work force with the talent to safely adapt the system to the challenges ahead
How could this be achieved?
- In South West we have used The Model for Improvement, a three steps process that uses a simple methodology. It works and whole teams of nurses, junior doctors and their consultants have made impressive improvements
- Within the North West using the root cause analysis approach has informed juniors, built will to modify the systems of care and brought increased junior engagement in clinical projects
- In several hospitals in the Severn Deanery Foundation level doctors are using their ‘new eyes’ to rethink and improve care for patients, this works best when the senior management team are engaged and recognise their work in presentations and in modest resource support. Success builds success
- The Royal College of Physicians program ‘Learning To Make a Difference’ has shown considerable success in the pilot phase and this is being rolled out across all deaneries such that core medical trainees will move swiftly from audit to improvement, the latter being the key outcome for their work during their six month attachment
- We have supported and coached teams, individuals and education leads to understand how QI fits into the day job and the professional practice of all doctors and healthcare professionals
How could you make better use of your junior medical staff over the next 6 months?
- Introduce the need for their involvement in improvement at induction via local experts and examples
- Emulate other reliable organisations that use all their staff and expect them to ‘work on the work’ as well as ‘do the work’ each day
- Support and encourage an ‘interested group’ meeting in late September when new doctors have settled down and their eyes have seen the problems in the current delivery of care
- Harness any learning or ideas they have gained from their other experiences and allocate a senior clinician to oversee the projects as they start to take form
- Use a single system for improvement; we use the model for improvement to simplify the message, more rapidly develop skills and enable wider team involvement
- Develop a sense of purpose (show examples) but also a sense of time frame. Many organisations globally have developed a 90 or 120 days trajectory for the identification of a problem, working with others to understand the variation, system, behaviours and ideas of changes
- Ensure that senior leadership listen, quiz and reinforce the work whether it is improving quality of care or reducing costs while retaining or enhancing quality
By 2025 we will all reap benefits across the system as these juniors return as experienced ‘improvers’ with a track record of innovation and service re design. If one has to be perfectly designed to get the results you seek then more than ever before the skills to work on the work as well as do the work each day are fundamental to personal resilience and patient safety.
1st August 2022 - How best to sort a 'Wicked' problem; R&D or QI or both?
There is a lot of data in a healthcare organization. There is also a great deal of reacting to that data. I am not referring to patient specific diagnostic data but looking at how clinical staff behave with clinical data may be a useful starting place on which to reflect on how we think and use data for progress not status or performance alone.
A patient arrives in the ED in a semi comatose state. The admitting team know nothing about them, they run some selected tests known to be associated with semi comatose states and one of them is abnormal. The blood glucose is low. So, what now? Is the patient a diabetic and has not controlled their insulin or oral medications, is this some other metabolic state, was the test done appropriately, should we check our glucose meter and technique with a blood test? Is this the reason for the ECG being slightly abnormal or is something else going on? Have we done core body temperature? The diagnosis is complex.
A CT scan service takes 90 minutes to be performed, read and reported on the computer system? How come we missed our 45-minute best practice target. Does the word target instead of blood glucose mean we psychologically think that it is not quite so important, these things happen, it is too busy to meet this level of performance all the time. It is 45 minutes because in the circumstances we know every minute counts for patient outcome and as full a recovery as is possible.
Call to stent time is a great example of where best-known practices are known to determine optimal outcome and they include the operational effectiveness and interaction of several components as well as the technical expertise of the cardiologist placing the stent. The cardiologist can be the worlds best but if there are poor transfers of care, the ambulance crew cannot find the patients home, delays occur in ED on way to catheter lab and the lab is not ready to roll as the patient arrives no amount of technical skill can recover the lost muscle due to the longer ischemic time.
‘Sorry, just one of those days’ is no longer a justified position statement. That is the fundamental change we all need to address. Data is now available for all aspects of the care process and if we don’t use it all to learn how to do better tomorrow, we fail our patients, ourselves and of course the system. Failure to address defects creates waste. Waste is something we could do without.
There is much gnashing of teeth as to the relationship between fundamental research of the ‘p value’ sort and Improvement Science. Indeed, there is much lost sleep over whether improvement methods are a science at all. This is a rather futile debate in a way as it distracts us from the complex interaction of medical science, human factors and psychology, organizational and systems factors and human biology. That interaction and fixing it is fundamental to optimal care and professional practice.
The gap between what the research says is possible and what is actually delivered is in part due to failure to maximize the interactions of people, patient and system. In ‘p value’ research the system and the patient and the people delivering the care are often controlled so as to minimize variation so we spot the pure un adulterated action of a drug or treatment. The real world is a bit different! There is often a gap between what is possible and what could be possible. Failure to work on the ‘work as currently done” sustains this gap.
The aims of improving population health (all people in the population), the best patient experience and sustainable and affordable systems creates a wicked problem. We need all the tools we can get hold of to try to fix them. Pure controlled science and improvement science are just two tools. The gap in what is and what could be needs to narrow to reduce deterioration in health, improve patient well being and sustain affordability as our demographics pressurize the current models of delivery.
Rather than react to data and seek the ever-better evidence from research we could also be working on the system and the reliability of what we do and be creating solutions from which we will learn so as to generate new ideas.
This is one of many ways to actually address the wickedness of where we are. Only by creating a solution can we work out further aspects of the problem. “The best way to have good ideas is to have lots of them’" said Dr. Linus Pauling. He had an impressive record. Improvement methods generate lots of ideas, the faster they come the faster they can be tested. This is a great way to approach a wicked problem for which there is less likely to be a known or even one solution.
I have believed passionately for a long time that R&D and QI should be hand in hand not either side of the debate. This is why as doctors we need to be skilled and capable at both.