|
National Quality Improvement Working Group The main purpose of the work of the group was to try and mainstream quality and safety throughout the NHS, ensuring it’s there in the refining and design of services, and to look at the management of services and how they are assessed and how they are funded. The quality working group had engaged in assessing various work, identifying excellence and looking at how the ethos in these organisations could be captured and spread throughout the NHS. Stakeholder events had been held and some two key messages that had evolved from the visits and engagement events: · The need to try an replicate high performing clinical teams across the whole NHS and · Genuinely involving patients in the planning, design and delivery of services Two key characteristics of high quality clinicians had emerged · Ownership of the management agenda clinically · The extent to which data are used in terms of managing performance There was a genuine curiosity amongst high performing clinicians to see how well they were performing, and data was being used in what is being described as a scientific way, so rather than using the routinely available data that we have, they were enhancing the data with specially collected data to throw light on how their services were performing, and in all the services when you walked around, there were wall charts with trends and comparisons, and clearly the data were being used not just to assure quality but to look for opportunities for quality improvement. There was stability and continuity of senior staff. The jobs that people were doing on the units were interesting jobs they weren’t putting their nose down and seeing patients, some of the nurses were attending conference to show how they were delivering their service and achieving change, roles were being extended, leadership responsibilities were being divided out. One of the proposals for change will be to try and put in place mechanisms to spread this pattern of working amongst clinical teams and not doing it by the modernisation agency spreading good practice route, which would take 15-20 years, but to try to build in some much more concrete mechanisms to attempt to make this the norm of clinical working rather than something is just a centre of good practice that we highlight and hope that everybody takes account of. The definition of teams and how you define teams is vitally important. Working in silos in your own team prevents you from working with other teams, which is crucial if you are going to have joined up patient care. In attempting to replicate excellence around the country there is clearly a managerial element that needs to be considered to put the infrastructure in place, but there is also a clinical drive as well. Derek Butler said there’s a big gulf between what’s the best and what’s the worst, and what you’ve got to do in to try and bring them both together, because you do have to work as a team in the NHS, one unit, it’s a national institution. And bringing that team together to improve the standard is going to be difficult, but that attitude of that doctor does not help the image that the NHS gets. Doctors have a collective responsibility to groups of patients, as well as to the individual patients that they treat, you start to see it as a professional responsibility, and obviously there are situations where the infrastructure isn’t there, people can’t help not being not being able to do that, but perhaps there ought to be more of an emphasis on a collective responsibility for patients coming through a service, not just the individual patients and an individual doctor. How do we inspire clinicians with the language we use to get clinicians to aspire in being involved in achieving goals and objectives? From some of the observations we’ve seen it seems that sometimes people don’t realise just how good they really are, there is humility about the really excellent clinicians. The mediocre doctors are the ones who have the arrogance. Can we stop people behaving like this, and the answer is yes, in some areas people will say they know better than what the evidence suggests, there are some personalities like this. We must be the only industry in the world where we spend millions on research and developing policy and then say whether we apply it is down to you. Derek identified a comparison with arrogance and pride. Pride can mean an excessively high opinion of one’s ability, being self focused with pride tends to blind us to the value of what others can offer and provide, hindering teamwork. People foolish with pride think their competence is being called into question when they are corrected about their expectations. This is a human fallibility not competence. It’s about how you change that attitude. International Commission Findings The commission were asked to particularly look at our approach to standard setting in the NHS, and the comments they made were: · A plethora of standards · No clarity on which standards should be in use day to day · No clarity on what was mandatory and what was optional · Problems with definitions and taxonomy, different terms being used in standards, guidelines, pathways, no clarity on what those different terms meant · A debate about degrees of independence, with some standards set predominantly by the Department of Health, although delegated a bit, some set by independent bodies like NICE seen as working with standards set by the DoH, and then the So an argument about whether we should rationalise our standards, and whether we should get more clarity and taxonomy, whether we should get more clarity on which ones had to be followed or whether, greater clarity on whether they were optional, clarity on local versus national, and independent versus in-house. All three commissions talked about the tensions in the system at the moment, and that was reflected in their discussions with NHS staff, the phrase culture of fear was used a lot. There was talk about rifts between clinicians and managers. The point made that a lot of clinicians in the NHS were very passionate about quality, the technical skills necessary for quality improvement, the understanding and use of data – those tools were not widespread, people might be motivated on how to improve quality but they actually didn’t know how to do it, and if you put somebody in the position where they are motivated but they haven’t got the tools they’ll get bored and they’ll forget about it, so that point was made very strongly by the IHI. Their actual recommendations are quite broad based, they’re about achieving clinical leadership, dual change, enhancing the skills, getting clearer accountability for quality, so fall slightly short of very concrete mechanisms for change, but are very useful. The skills of people carrying out commissioning are very general; they haven’t got access to specific specialist skills. For example with the diabetic service, they don’t know whether it’s appropriate to draw clinicians in given that they are providers. The video conferencing event with the USA, showed that they got the impression that commissioning was about screwing the system down, by getting the highest volume of work for the least money and there was much less concern about value and quality in the process, as it currently stands. A feeling that commissioning is the great hope for the future but how long is it going to take to get there and what do we need to do to facilitate it. The Joint Commission’s main proposal is to set up an accreditation body, which would be separate from proposals for regulation in the Health Bill. We need some high level quality improvement goals which can operate at all levels, there are no organisations around the world in health or anywhere else that don’t have a clear statement about the quality and improvement that they are trying to achieve, it doesn’t mean numerical targets but it means four or five statements. Rather than having separate statements about heart disease, diabetes, why not use a statement that relates to the quality of care for patients with chronic diseases, for example that the aim was to · Detect chronic diseases early · Organise services so as to slow their progression, reduce the rate of complications and give people with disease the highest quality of life that they can achieve if they’ve got the disease. We have patient safety initiatives that have saved lives and if it can be done in one area we need to look at why this can’t be done elsewhere. Then we have the introduction of regulation of health and social care services, and we need to understand how that helps all of the things that we are trying to do, by making quality and safety mainstream, so what do we mean by inspection, how do we look at licensing work, do we want to build in this concept of accreditation, and if so how does that fit in? We are working on more detailed proposals to try and move some of those things forward, and we need to prepare a summary of where we have got to so far. The Bristol Report identified the challenge between the doctor perceiving his duty as being to a patient, as opposed to his duty to his patients, there is a self-delusion that my duty is only to the patient in front of me, but that isn’t the case as you are making the other people wait, by making that decision. So that means we have to think in terms of systems. If you formalise that as a leadership role, people think about leadership and are willing to take on a bit of extra responsibility. Derek commented that a leader is an individual who takes personal responsibility for their performance and that of their colleagues, and attempts to influence an improvement on the organisation that supports that improvement. Accountability, its not about who, it’s about what, it’s not always about the individual when something has gone wrong, it’s about what caused it that may be at fault. On quality, forgive me Minister if I say this, but at There were four questions that have to be asked about standards There should be specific standards that might address pathways of care for a patient with disease. Standards must be the product of conversations with clinicians and their patients, they must not emerge from the DoH, of course the DoH should be part of implementing the process, but if they are not recognised or if they are not understood, and the clinicians have to operate them, they are dead in the water from day one, and if they are informed by clinicians then you will build in that ambition and you will build in that sense of discipline, and they must also take account of patients, because patients are experts and they must be party to it, and if you can create that environment in which both the generic and the pathways from which they emerge then you’ll ignite that ambition and build in the notion of improvement over time. Which standards must be adopted, should be adopted. How do managers know the cost benefits and investing in an upgrade of one area compared to another area? Undoubtedly there are lots of players involved. There must be an orchestrator of that process who is the body responsible, and everything else feeds into that. Let’s only measure what we can. Derek Butler Chair MRSA Action Click here for Terms of Reference and Membership of the Group Click here for a full report of the 3rd Meeting For more information contact Derek Butler Email: derek.butler@mrsaactionuk.net Telephone: 07762 741114 |
