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Quality improvement – the art of the possible

Bev Fitzsimons 27 January 2017


Quality improvement at a time of transformation

It’s always a treat to listen to the IHI’s Don Berwick, with his optimistic focus on the art of what is possible in improving health care. So it was at the King’s Fund webinar the other day. Never a more appropriate title than “keeping the focus on quality improvement at a time of transformation”, especially considering that it coincided with the US Presidential inauguration.

Don gave some examples from the Vanguard sites that he has been visiting in the UK. The Vanguard sites have significant advantages over the rest of the NHS system in their efforts to improve care for patients. Not least, time and resources for the whole system to devote to “the invention” of the future state. The approach in the Vanguard sites is a whole-system approach to learning. Solutions are arrived at through collaboration, sharing learning, exploration and testing – the opposite of the approaches that have been common in UK health policy in recent years, where the approach is to set top-down, target-driven goals, inspect against their achievement, and reward or punish accordingly.

That’s not to say that a top-down approach hasn’t worked for some things: thinking back to campaigns in the field of infection control, you can see they can work. But for complex, multi-faceted, system wide challenges, it is unlikely that a “one size fits all” solution is going to be the solution. The only answer is to harness the expertise that exists within local systems.

The examples Don shared had much in common with The Point of Care Foundation’s quality improvement (QI) work, which we call “patient-centred service design”. The key features he pointed out were those that we also help our partners to pay attention to: system and clinical leadership, staff engagement, patient and service users in partnership, alongside collaboration to learn from colleagues in other areas.

Vanguard improvements in practice

It was great to hear this brought to life through his description of the Morecambe Bay Vanguard, and in particular Westgate primary school where levels of obesity have been reduced by the “run a mile a day” initiative. This had systems leadership via a supportive CCG, clinical leadership through the local GP, true community engagement, and was built on the learning from elsewhere in the system – St Ninian’s Primary school in Stirling – which had had such success with this initiative.

A second example Don described was the Sutton Homes of Care Vanguard: one of six care home Vanguards that are collaborating to become a community of practice and to share their learning. The collaborative aspect particularly stood out in this example: care homes, hospital, ambulance service, General Practice and community nursing services having just enough time and head room to come together to design the service around the collective knowledge of them all, centred around the things that matter to patients. This local design group uses data intelligently in order to step in and offer support to care homes in difficulty instead of just exhorting them to do better.

Personally, I really liked the practical, patient focused improvements that had come about. For example, the “red bag” that contains everything that is needed if a resident needs to go to hospital from a care home: not just the medication and the notes, but the information that transforms a vulnerable patient into a person – even down to the simple but symbolic issue of how the resident prefers to be addressed.

Worthwhile investment?

Don recognised that investment is needed to give people a little time to work together to find out what needs to be done to make these sort of improvements. Such investment enables relationship building, promotes a culture of experimentation, and reduces the fear of failure.

But the investment is time, and there’s the rub: I went to another meeting this week with an NHS trust where staff described not even having time to go to the bathroom while on a shift.

These are difficult challenges that boil down to “what kind of health service do we want to have?”. Taking the risk to invest in these relationships and skills in sharing and learning depends on whether learning and improving is part of every NHS organisation’s strategy and on the agenda of every NHS leader.

The question I was left with was not whether we could afford to do this, but whether we could afford not to. Of course, some initiatives will fail. But Don left us with this poignant remark: “You only get one life, you can spend it afraid, or you can spend it trying. Spend it trying.”

Later on, watching the Presidential inauguration with its themes of isolationism, it never seemed more prescient.