Rammya Mathew: We must build capacity and infrastructure for effective quality improvementBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6150 (Published 29 October 2019) Cite this as: BMJ 2019;367:l6150
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This paper is enlightening for what it does not say about meaningful quality improvement. One would not disagree with the technical aspects of large scale quality improvement (QI) as set out in the paper and the methodology and skills required. However these activities are not likely to be relevant to front-line staff who, above all, lack ownership of the process which is driven from above. We must strive to encourage small scale QI which is meaningful to the Practice and important for patients. Examples may include improved compliance of our patients with the care processes in diabetes or actively working to reduce overuse of beta-agonists in asthma patients. These are significant QI activities which can take place at Practice level and which have been planned and executed therein.
Competing interests: No competing interests
Quality improvement is not the preserve of a trained elite it should be in the DNA of all healthcare systems and staff. In our Trust quality improvement projects (QIP) have both galvanised and injected enthusiasm for improving patient care and experience. This is something the long era of focussing on often unfinished clinical audits never really achieved.
The institution of QIP projects for undergraduate year 4 students from King's College London Medical School in our Trust in 2017 has resulted in 12 QIP projects a year supervised by senior clinicians with great results of improved patient care, presentations at local, national and international meetings and a resurgence of ideas and innovation from our frontline staff. It has also encouraged our senior clinicians and postgraduate doctors in training to get involved in QIPs which has resulted in an annual QIP all day conference showcasing transformative projects. Many topics have been presented such as smoking cessation initiatives, patient information leaflets relevant to the actual patient experience, improved prescribing using stickers and apps, introduction of a neonatal sepsis tool, improvement of aseptic technique for taking blood cultures, introducing a prescription for non-invasive ventilation, and an escalation plan for the deteriorating patient.
The supervisors of the QIP projects have engaged in e-learning and face to face training via the Medical School using the PDSA cycle model. The PDSA cycle is a good basis for understanding quality improvement projects but clearly does have some limitations. However our experience of 36 QIP undergraduate projects in the Trust over the last few years is that this methodology has yielded some extremely well thought out and innovative interventions which have improved patient care and safety.
I do not recognise the author’s assertion that a lot of QIP projects are of low quality. I however do agree that supervision must be of a high quality and some peer educational governance of supervision would be appropriate. In implementing aspirations of high quality training in supervision we must not inadvertently dampen enthusiasm. The QIP resolution is re-engaging many senior clinicians in more meaningful projects focused around improving patient's safety and care. I have noticed the QIP project supervisors have felt re- energised in addressing deficiencies in patient care and many have found it a transformative experience. I think QIP is one of those rare situations in the NHS which can be described as a “win-win situation”. There are wins of course for the patient's in improving patient care and safety but wins for the participants whether they be under graduates or doctors in training in understanding how you can innovate in the NHS and for supervisors of the QIP projects on multiple levels reconnecting them with enthusiasm and positive change in the clinical arena.
Supervision training for QIP needs to be mainstream and close to the clinical arena. Perhaps we should consider educators providing immediate support for QIP projects but also providing a peer review to provide quality assurance and clinical educational governance for supervisors. Educators on the shop floor offering help and guidance on QIP for all health care staff would be a good investment. The QIP has reignited agency among healthcare staff so let’s celebrate it as a catalyst to help improve patient safety and care. QIP is for all!
Competing interests: No competing interests
Whilst training in QI methodology is important we wholeheartedly believe that ‘anyone can have a go’; indeed for quality improvement to have the impact at pace and scale which is required, there is no other option. The answer doesn’t just lie in formal QI programmes, disseminated from top-down hierarchies. We need to mobilise informal power in an organisation to help staff to create their own short change cycles
Quality Improvement has three main elements; patient safety (doing it right); cost effectiveness (doing it well) and Joy in Work (doing it with a smile). The majority of QI work looks at process and structure, such as pathway redesign or reducing variation. While these endeavours are important and often successful, they risk overlooking Joy in Work.The Institute of HealthCare Improvement (IHI) has established that Joy in Work is the single biggest factor in improving patient safety and experience - and yet it is the branch of QI which often is left in the shadows.
The beauty of Joy in Work is that it truly is something which everyone can be involved in; that finding Joy in Work is an act of quality improvement than no course needs to teach.
But how? There are insufficient time and resources to offer QI training to simply EVERYONE. Well, we have created the answer. 15 seconds 30 minutes is a social movement, which asks members of staff to think of a small 15 second task they can do which will save someone else 30 minutes later on, and in doing so reduce frustration and increase joy for themselves, colleagues, and patients. We call these tasks 15s30m missions and anyone, from the chief executive to a hospital porter, can get involved. Since 2017 we have grown from a ‘little idea’ to a social movement which is in 100 NHS organisations, university courses and leadership training schemes.
Quality Improvement is as essential to the modern NHS as Infection control: yet Infection control isn’t something we have timetabled – “oh yes, I am the team leader for Infection Control: I have 2 hours every second Thursday afternoon protected time to really Control Infection in a big way”.
Infection control is woven through every part of our day: its included in estates planning and procurement. It’s discussed at board level. Wards display the results of their monthly Infection Control Audits. Its everyone’s job, all the time.
Time and again through our daily work, contact with patients and their families, we do good. We help. We bring joy to others. So why don’t we recognise that joy ourselves? What if once a day, we reflected on one way we or a colleague have helped someone – just 15 seconds of encouragement is all it need
The change in approach that 15s30m encourages – to do small acts to benefit someone else – can become embedded in everyday work; it has the potential to be used to examine every process a staff member undertakes, be that a phone call, filling-in a form, creating an appointment or interacting with a patient. In this way the principles of 15s30m will become sustainable.
Over time staff no longer consider these actions a 15s30m Mission, they simply become part of how you are at work, knowing that this approach will make the job more rewarding, create joy and reduce frustration. We are all about transforming mind sets, not processes. Then wherever the member of staff goes in the organisation, they carry the ethos with them.
15s30m offers an unprecedented amount of flexibility in a Quality Improvement programme – we can truly “ go where the energy is” and build momentum.
There is no standard to which participants must work; no threshold to pass to take part. 15s30m change is not driven by planning, data, spreadsheets – instead we appeal to the emotional currency, their personal convictions and values. Passion creativity and initiative are the driving forces for change.
And having dipped a toe in QI, staff who are engaged, interested and motivated may then choose to go on to formal training and larger projects - but without having a way for staff to ‘know how it feels’ very few, even with formal training, will complete successful QI projects.
You can find out more about 15s30m at http://15s30m.co.uk/, or follow us on twitter @15s30m
Competing interests: I am the co-founder of 15seconds 30 minutes, a social movement established in the NHS to reduce frustration and increase Joy in Work. Rachel Pilling and Dan Wadsworth were 2017 winners of the NHS IMprovement Peter Carr Award for Quality Improvement