Creating space for quality improvementBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1924 (Published 17 May 2018) Cite this as: BMJ 2018;361:k1924
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As Dixon et al. predicted in their excellent article, many of my peers have developed cynical attitudes towards quality improvement (QI) after just twelve months of Foundation training. Audit and QI projects are mandatory for progression through Foundation training, and important criteria at professional interviews. However, these projects are often seen as hurdles to be jumped, rather than valuable exercises that benefit doctors and patients alike. Addressing this problem will require dedicated training and dismantling of the structural barriers and unhelpful beliefs that impair engagement with QI.
The General Medical Council’s Outcomes for Graduates, which informs medical school curricula, was recently amended to include a clause insisting that junior doctors must be able to apply the principles and methods of QI . Nonetheless, formal training in QI techniques at medical school remains patchy. Those students who do become involved in audit work often acquire a subject-specific and incomplete skill set through informal supervision by a junior doctor. The GMC and NHS must support medical schools in delivering high quality, standardized training in QI to their students.
For many, this situation does not improve after graduation. There is a postcode lottery for formal training and practical support for QI projects for Foundation doctors. QI Hubs, such as those at Imperial College Healthcare NHS Trust and Sheffield Teaching Hospitals NHS Foundation Trust, can provide dedicated practical support through trained QI coaches. However, these specialist units are spread thinly across the country. Post-graduate courses in QI are increasingly common, but Foundation doctors are limited in the time they can take out of their clinical placements. They may also need to prioritise other mandatory training, such as teaching, advanced life support and simulation.
One of the biggest barriers to engaging junior doctors in QI projects is a pervasive feeling of disempowerment. Changes to services often seem to be directed by managers and involve minimal consultation with front-line staff. This grievance is frequently reinforced by senior clinicians who have experienced antagonistic relations with their non-clinical colleagues. Junior doctors may feel like victims, rather than architects, of changes to services. This perpetuates problems with service delivery, as doctors place the blame for failures at the feet of managers, rather than working with them to achieve change. There is growing acceptance that front-line staff are best placed to identify and solve problems relating to service delivery, and that they must work closely with managerial staff to achieve change. However, it can be difficult to ensure that trainees’ voices are heard and their concerns addressed.
An innovative approach championed by junior doctors at North Middlesex Hospital and the Barts and the London NHS Trust brought together Foundation trainees, Consultants and senior managerial staff in a patient safety forum . This generated discussion around problems with service delivery and promoted collective responsibility in designing and testing suitable solutions. Another useful resource for trainees is the Edward Jenner programme. This online course, accredited by the NHS Leadership Academy, is targeted at health professionals at the beginning of their careers. It provides useful practical advice on working with patients and clinical and non-clinical colleagues to improve quality in healthcare.
An inexorable transfer of power from doctors to patients is underway across the NHS. QI projects can, and should, involve patients from the time of conception. As the front-line staff best placed to deliver improvements in service delivery, junior doctors can transform the NHS into an organization committed to patient-centred care.
We are beginning to respond to the realisation that effective teamwork between senior clinical and managerial staff facilitates improvements to services. A more seismic revolution in quality improvement may yet arrive when we finally draw on the views of junior doctors and patients.
1. GMC. Outcomes for graduates. https://www.gmc-uk.org/education/standards-guidance-and-curricula/standa...
2. Howlett P, et al. Improving patient safety through junior doctor forums. BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d7110
Competing interests: No competing interests
I welcome the editorial by Dixon et al1, which highlights the urgent need for an industry-wide discussion about the importance of quality improvement (QI) and how we can facilitate it to improve patient care.
More than two decades have elapsed since the UK government made it statutory for all health organisations to seek QI through clinical governance2, however the collective impact of improvement projects has been far below the potential. There are many reasons for this, and I will leave this discussion for the experts, however, as a medical student who has been involved in several QI projects, it is obvious to me that one of the reasons is the failure to recognise the role and contribution of medical students in QI.
Students are highly capable and if given an opportunity, can make a real difference. The Students section at the Royal Society of Medicine started an initiative in 2014 to promote student-driven change in national health policy. The policy recommendations3 from the first meeting were submitted to the Francis report and informed the Royal College of Nursing’s response to Health Education England’s Shape of Caring consultation4. Similarly, the Student Audit and Research in Surgery (STARSurg), is a national, student-driven collaborative founded in 2013 by a group of medical students and surgical trainees in the UK. Since its formations, it has enabled students to participate in high quality national surgical audits5-7 and empowered them to improve patient care. These are just two examples of how students have made a real difference, nationally and internationally.
Similar examples of student mobilisation in delivering QI are far and beyond. Students are always in the background, looking, listening and observing things as it happens in a busy clinical area. This enables them to recognise things that might need improvement, which clinicians working in that environment regularly may have normalised to. Students constantly move between departments as they go from one placement to another. As such, they are a good vehicle of sharing best practices between departments. Finally, students can offer more flexibility and time, something that other healthcare professionals might struggle to give to a QI project.
Of course, students need to be made aware of the need for QI. This could be done by incorporating QI as a compulsory component of the undergraduate curriculum, and not just offered as a student-selected component. Similarly, enthusiastic students need supervision and mentoring. This can be offered by experienced junior doctors and senior colleagues, and as Dixon et al1 suggested, there is no shortage of such a motivated workforce.
If we want to accelerate healthcare improvement and meet the challenges that we currently face, we need to start using students as ‘agents of change’ and build an army of change makers that will drive quality-focussed, patient-centred care for the future.
1. Allwood Dominique, Fisher Rebecca, Warburton Will, Dixon Jennifer. Creating space for quality improvement BMJ 2018; 361: k1924
2. Secretary of State for Health. The new NHS. London: Stationery Office; 1997. (Cm 3807.)
3. Nick Cork on behalf of 39 signatories, the Royal Society of Medicine Student Members Group. Working together for excellence in the NHS: student proposals. The Lancet, 2015; 385 (9971): p851-852.
4. Nick Cork, Oliver Llewellyn, James Glasbey, Chetan Khatri on behalf of the Royal Society of Medicine Student Members Group and the STARSurg Collaborative. Bridging medical education and clinical practice. The Lancet, 2014; 384(9954): p1575.
5. STARSurg Collaborative. Safety of Nonsteroidal Anti-inflammatory Drugs in Major Gastrointestinal Surgery: A Prospective, Multicentre Cohort Study. World Journal of Surgery, 2017;41(1):47-55.
6. STARSurg Collaborative. Impact of post-operative non-steroidal anti-inflammatory drugs on adverse events after gastrointestinal surgery. British Journal of Surgery, 2014 ;101(11):1413-23.
7. STARSurg Collaborative. Multicentre prospective cohort study of body mass index and postoperative complications following gastrointestinal surgery. British Journal of Surgery, 2016;103(9):1157-72.
Competing interests: I am the current President of the Students section of the Royal Society of Medicine. I am also a collaborator on the IMAGINE study, the latest international audit led by STARSurg Collaborative.
Jennifer Dixon's article raises a good point, but brushes over how involved students and junior doctors currently are in quality improvement. Many medical schools now expect students to complete a quality improvement project during their clinical years. Foundation year doctors need at least one to pass ARCP. Those juniors looking towards training programs can expect to pick up extra points for their applications by carrying out an audit or QIP.
Not that these should just be tick-box exercises, as is pointed out. I have so far been involved in three such projects, each borne out of concerns and frustrations with my experiences working on the wards. It is possible to affect small systemic change with such an approach and it is to be encouraged. Academic incentives (like application points) will lead to motivated juniors pursuing such projects. Longstanding members of staff who are aware of issues which can be corrected and improved upon, such as local audit offices and seniors, should be proactive in recruiting. The drive is certainly there, it just needs directing.
Competing interests: No competing interests
Creating space for quality improvement: But should be done in a holistic way throughout the career pathway.
We have read the article of Jennifer Dixon with interest and highly welcome it. We have a few observations to make based on clinical and managerial experience.
The concept of quality improvement is so broad-spectrum and needs to be clarified that it is not only confined to direct clinical care. In fact, it is built within the MAG document of appraisal for doctors and from experience many medical colleagues who have been appraised may not necessarily have an awareness of the full scope of quality improvement (1).
It appears from what is being proposed that this is about developing leadership and management skills with the former meaning “what needs to be done” and the latter “how do we do it”(2). This initiative of supporting clinicians to contribute to quality improvement needs to encompass all stages of the clinical professional pathway i.e. undergraduate, postgraduate and career grade level.
Doctors in training are very instrumental in suggesting new ideas and solutions and in implementing quality improvement initiatives. It is imperative therefore that whilst they are training although within a short period of time they must be given the opportunity and support to contribute to quality improvement. This should be built as an integral element as part of their training curriculum.
As for career doctors, it appears that those who are involved in quality improvement projects tend to be because of individual interest or expertise in leadership and management. What needs to happen is that everyone must be involved and therefore should be encouraged to engage in quality improvement. This is done by offering capacity, support and incentives in order to grow clinical champions of quality improvement.
Healthcare organizations are required to ensure that the contract, job planning process, design of career pathway, continuous professional development, incentivization scheme and work experience as a whole of clinicians are all geared towards quality improvement.
Competing interests: No competing interests
Healthcare has been and is turning more complex globally, the two main reasons being rising costs (to the patient / family or the providing system / service) and the (sometimes serious) mismatch that occurs between care offered and expected. It has been observed that the training of graduates was and continues to be focussed on developing and improving upon individualistic clinical skills (1) geared towards a solo practice while being a part of the 'team' or belonging to a 'cadre' remained underemphasised.
The biopsychosocial model (2) and revolution (3) was proposed and was intended to link science with humanism. Most clinicians tend to be primarily concerned with 'right /accurate diagnosis', a basic instinct to salvage and save - the expected outcome - and being sufficiently defensive to avoid 'breach of duty' and maintain reputation towards career promotions. Being passionate about and broadening the perspective of quality improvement may be a low priority to many. In fact, a few can be fiercely egoistic, not getting along well with a non-surgical / non-clinical administrator or a non-medical manager. All the same, utilising their primary motivation towards quality improvement appears definitely worthwhile.
1. Yeolekar ME. Editorial. Redefining and refining the process of clinical diagnosis. J Assoc Physicians of India. 2000 ,48 (8) , 769 -70. PMID11273466.
2. Engel GL. The clinical application of biopsychosocial model. Am . J Psychiatry 1980 ; 137 : 535 -44.
3 Smith R C .The Biopsychosocial Revolution. J Gen Intern Med. 2002 Apr ; 17 (4) : 309-10. PMC1495036
Murar E Yeolekar, Mumbai
Competing interests: No competing interests