BMJ/IHI International patient safety conference 27th April 2017

Here are some reflections having attended the conference this year… I last went in 2015 with the Yorkshire and Humber Improvement Academy. This time some things were different, some better, others missing.

Principally – where was the yoga room?

Don Berwick

Don, the IHI Patient Safety Magus discussed briefly an experience his brother had in a US hospital. Don mentioned that his brother has diabetes and is currently in rehabilitation – the two most common reasons for this (my assumption) are recovery from a stroke or amputation. I don’t know which.

The salient point of the story was that Don’s brother as part of his rehabilitation was strapped into his wheelchair; this would prevent him from getting up and going, it would also prevent him falling.

In the world of patient safety, falls are bad – so too is disempowerment.

Is independence worth a fall?

Should we anticipate more people falling in our rehabilitation settings so long as it is part of an attempt for them to regain independence?

Ara Darzi – the UK head of many things including Darzi Fellows who also sits in the House of Lords discussed the concept of shared appointments – what would be the experience of 10 patients each spending an hour together with a doctor rather than individually just six minutes?

How much could they ask?

How different would be the balance of power?

This would bring new meaning to ‘The doctor will see you now’

Sure, there are times when you need to be one on one with the doctor; this new model could help learning, adaptation and growth for people with chronic illness.

Some other areas discussed:

Transitions of care – there has been a great deal of investment in clinical handover in the past few years. For as long as I can remember, nurses have practiced one to one handover – where the nurse looking after patient J speaks directly to the nurse on the other ward or unit who will be caring for J once they have moved.

Within medicine this has become formalised only recently.

It is now commonplace to have large meetings where multiple doctors (and, sometimes nurses and therapists) meet to hand-over from one shift to the next.

Yet… Patients are still moved around hospitals in a continuous flow of morbidity. Patient A to x-ray, B to phlebotomy, C to endoscopy and outpatients and so on.

It is during these transitions when harm can occur. When nurse A who handed-over to nurse B has gone on break and nurse C speaks directly to nurse D who is also transferring a patient.

It’s complicated and difficult and we are fortunate things don’t go wrong more often, yet, this is an area that we need to look at in a great deal more depth.

… Where are my dentures…. Oh, perhaps on ward A?

How about we involve patients, their relatives and carers more in transitions of care… A text to say your mum is in x-ray? A text to tell the patient when and where they are going and even, the name of their driver?

3. Margaret Murphy – we heard the painful story of Margaret’s son Kevin who died of complications relating to primary hyperparathyroidism.

His corrected calcium level was 5.73 at time of admission to hospital – this was missed by the admitting medical team and not corrected before he died.

Systems failure, and Kevin died

4. A team from South Eastern Health and Social Care Trust in Northern Ireland described their quality improvement journey.

Their message… Quality Improvement is a journey, not a destination.

You cannot have QI projects, QI task and finish groups. You can never complete QI – there is always better, more that can be done.

5. Derek Feeley – Derek is the President and CEO of the IHI. He talked about joy at work.

Really, we should all, if we are hoping to be the best we can, to give the best care and support one another in an optimal fashion, experience joy at work.

An unhappy workplace is an unsafe one.

Components that lead to joy in the workplace are…

Does what I do make sense?
Do I have the skills to do my job?
Is my work meaningful?

What are the roles of leaders….?

Make work meaningful and purposeful
Allow individuals autonomy and a sense of control
Support camaraderie and team-working

Simples!

Some other aspects of leadership that Derek touched on, were – the immediacy of recognition – this always trumps magnitude.

Equally important, and, I suspect the conference organisers included this because of guilt over the yoga… looking after yourself – you as a leader cannot look after the wellbeing of others if you are not caring for yourself.

Steve Swensen from the Mayo Clinic discussed another aspect of joy…

How quickly do your wounds heal?

I imagine he means both physical and emotional – well, what speeds recovery, likely, more evidence based in the former, is kindness, love and joy.

If your patient experiences kindness, love and joy, their injury, wound or illness is more likely to recover. Anyone anywhere wanting to see kindness, love and joy, please visit Mallard Ward.

Remember the care home experiment with plants… those residents given plants to water, nurture and look after resulted in significantly improved outcomes – for the residents & the plants.

Love and you will be loved.

Detweiler, Mark B., et al. “What is the evidence to support the use of therapeutic gardens for the elderly?” Psychiatry investigation 9.2 (2012): 100-110.

Another interesting finding was the relationship between CEO signature and outcomes of their organisations… hbr.org/2013/05/size-does-matter-in-signatures

It seems the bigger your signature, the bigger your ego and the less healthy your organisation. Watch-out Mr T!

Here are five leadership behaviours that improve outcomes…

Provide appreciation and thanks – straight way, without thinking, calculating or weighing-up the politics
Tell your staff what you think – from the heart; anything else is obviously made-up
Be transparent… Here is everything I know – use it and be happy!
What do you want to do in five years? It isn’t just you who is growing – everyone needs to grow and experience some form of progression
Make people feel welcome and included. Don’t have a special keycode for special people, let everyone-in, even the cranks and weirdos – they often see the world differently and have the answers you seek!

> What are the pebbles in your shoe? What things get in the way of you being your best, doing a good job? What are the frustrations or obstacles? What are the impediments that leave you in limbo… Find the pebbles, examine and sort them!

Be an architect of quality improvement, not a construction worker. If the model of care isn’t working or doesn’t meet the needs of those you treat, change it… get the blueprint and re-write the process.

Commensality – or, why my patients do so well… It transpires after all these years of Mallard providing such incredible care to patients, one of the reasons has been a means to the end rather than the end in itself… Let me explain –

We have long championed communal eating. Sitting at the dinner table, our patients together, sharing the salt, breaking the bread. We have mostly focused on nutrition – occasionally I have veered into evolutionary theories.

Now the IHI explains, you see, this is commensality – doing things together; it is good for us! Sitting together sharing food, sharing time and conversation has a positive effect on our brains, reducing the level of stress hormones and improving our sense of wellbeing.

I can’t find the reference in the 2015 Journal of General Internal Medicine – but trust me, it makes sense.

Here is a business case for Quality improvement…

For every $1 you invest you get $5 back…

The safer, the happier, the more joyful the hospital or care environment, the greater the return.

This is what the evidence says… http://www.greatplacetowork.co.uk/

Here are some evidence-based practices to improve your wellbeing (and wellbeing at work…)

Laugh
Eat a healthy diet
Celebrate success
Get enough sunlight
Move around
Practice mindfulness
Get enough sleep
Forgive
Spend time with family and friends

And… there you go.

Analysis paralysis… don’t be overwhelmed by concerns about data collection and analysis – just do the improvement!

What matters to you? – this is identifying patient and staff preferences

6) Derek Feeley & Jason Leitch – keynote speakers

The cobra effect… what happens when you performance manage cobra trackers; the more cobras the more we pay; bring us your cobras and we’ll give you a dollar. When the people start breeding cobras the incentive goes and cobras are released into the wild.

This is good intentions having negative outcomes

Rat tails… another form of payment for performance – give us a rats tail and we’ll give you a dollar. What happened… lots of tail-less rats running about.

As HL Mencken says: For every complex problem, there is an answer that is clear, simple and wrong.

Here are some top-tips for complex (wicked) problems:

Address complexity with complexity
Solutions are likely to be non-linear
Be diverse in your approach
You alone will never have all the answers
The power to fix the problem is unlikely where you need it to be (i.e. with you)

Derek Introduced the current IHI model for improvement. When I attended two years ago, all the talk was about the IHI triple aim – improved quality and safety of health for more people with less waste; I suspect they are still sticking to this aim, although last week they introduced this graph…

It is the three phases of improvement; they call it getting to the third curve.

This starts with traditional target based performance management followed by Quality Improvement which is then superseded by Co-production….

Keeping power > sharing power > ceding power

Be humble in your enquiry – don’t talk; listen.

Ask more questions than you provide answers

Be curious.

15 Lessons for Leadership… http://www.barryovereem.com/15-lessons-in-leadership/

youtube.com/watch?v=BgRoiTWkBHU&ab_channel=Prudential

http://www.whatmatterstoyou.scot/ – let’s do it! (6/6/2017)

Do you want to break the rules for better care?

http://www.nhshighland.scot.nhs.uk/News/Pages/BreakingtheRulesforBetterCareWeekannounced.aspx

http://jamanetwork.com/journals/jama/fullarticle/2624332 (please read!)

Summary

I was perhaps a little harsh in my introduction. It was a great conference. Sure, I missed the yoga and I didn’t get an opportunity to cable-car across the Thames; I did have a great meal in the company of Albert Wu, Hugo Mascie-Taylor, Mike Durkin & Aloha.

What will I take away from this meeting?

I probably learned less new at this conference than I had expected; I have been given an extra level of energy to pursue some of those areas which I have not progressed; first among them is good to great.

It is no longer good enough that some of the wards in Doncaster are great – probably providing care that is amongst the best in the world – we need this care to be universal, global. The variation needs to end. If I cannot spread the effectiveness I have failed – we all have failed.

Equality means that everyone is equal, not just a select few.

Cogs turn slowly in organisations leading to shifts in care and treatment. A couple of wheels spinning round independently carry far less meaning.