A moment of reflection can lead to a smarter improvement aim
Learning about the Model for Improvement (Langley et al., 1996) has changed my life, and I believe it has done the same for many people: It has given me a robust change method to work with; it allows me to fail safely and learn fast; and most importantly, it allows me to measure how the changes I make have made a difference.
The first question in the Model for Improvement concerns our aim and, as we need it to answer the second question (‘have we achieved our aim?’), it needs to be a SMART one.
Now I’m going to come onto SMART aims in just a moment – but first I want to invite you to pause a moment as I share some reflections. In all the years that I’ve been learning and teaching improvement methods, I have found that this first question ‘what are you trying to accomplish?’ stumps people more than you might expect it to.
I think there are reasons for this. First, we are often asked to make a change where the aim, usually presented to us by someone more senior, is to make the change – not to achieve a specific outcome. Second, the desired outcome, if it does indeed exist, is either – not spoken (assumed to be known and understood by us) or – not known (by us or the person delegating the change action). I believe another reason is that we fail to articulate the problem that we are trying to solve when we are starting out.
So, when I say ‘take a little time to reflect’ – I’m advising us all to give our problem some quality thought, do some simple diagnostics, and think about it from our end users’ perspective. A simple articulation of the system problem, with a little bit of background data (national and local) to put it into perspective, will set a firm foundation and then we can begin thinking about our aim.
So now back to your SMART aim -As with all methods, none are perfect – and SMART has its fair share of critiques, so feel free to pick another method that allows for similar reflection, and even drop me a note to say which is your preferred method and why)
As with all things ‘QI’ we aren’t surprised that this is also an iterative activity. One well known mantra for an improvement aim – is how much by when? Our articulation of the aim can only emerge as intelligence is gathered and, from humble beginnings, its SMARTness will be formed. Check out the example below – and browse our poster gallery to see if you can spot others who have shared their ‘workings out’ with their audience.
The Importance of Having Clear Questions
by Heather Shearer
I’ve been struck recently by the importance of having clear questions or theories or hypotheses that one wishes to explore.
Otherwise simply fishing around in data we find statistically significant findings but we have no idea what they mean or how to interpret them (a bit like those correlations people use to demonstrate correlation does not equal causation).
This seems an ever bigger problem as more data is captured and computational power enables more ‘analysis’.
In fact today I was listening to a #BMJ podcast (https://soundcloud.com/bmjpodcasts/big-metadata ) which highlighted a hidden issue when clinical data is used for research – the context of the clinical data is typically absent. For example, the life expectancy of a middle-aged man with low white blood cell count at 3am is far worse than one taken at 3pm; and this is explained by the fact the patient and clinician are sufficiently concerned about the health of the man to order tests in the middle of the night, rather than a test taken in outpatients or working hours.
Reading this blog (https://www.health.org.uk/blog/measuring-humanity-marginalised-communities) made me think once more of that and the final message about rethinking our relationship with data and measurement to one that is genuinely focused on curiosity and learning seems really important.
QIClearn are pleased to announce a new Masterclass in Measurement for Improvement. For more details and to make a booking click here.
Microlearning: it’s about what you need in the moment.
How do we make sure that the QI skills and knowledge you have ‘learned’ are readily available from your memory when you need them? Because the reality is that if you can’t access your QI knowledge quickly in a real-world situation (on your ward, in general practice, in your community setting) then you can’t be the improver you aspire to be. If you are fumbling through copious notes and resources from that learning course you went to last year – trying to remember how to use that tool which is on page one-hundred and something in the manual – then forget it: the moment has passed, your attention moves on, you lose the opportunity.
Remembering something you have learned is much more effective than trying to re-learn it. So, how do we optimise the ability to remember – to retrieve knowledge from memory – in the way we design our QI learning? Well, the evidence-base from cognitive psychology demonstrates that the spaced repetition of concepts over time helps with retrieval. As teachers, if we cover concepts more than once across contexts and repeat ideas in simple bite-sized chunks then we can help narrow the achievement gap. In a QI context that’s the gap between knowing tools and having a practical day-to-day mastery over them. Microlearning – short, focussed and flexible bursts of learning in 3, 5 or 10 minute segments – can help us bridge this gap between learning and performance.
And there are other advantages to the microlearning approach.
Imagine that you are a midwife. You have identified something you would like to improve on your neonatal ward. Premature babies get cold very quickly after birth but you’ve noticed that many of them are much colder than they should be. This prolongs their stay in hospital and means they have poorer outcomes. To better understand how often this happens you have decided to gather some data and need a QI tool to help you – let’s say a histogram. You know that you can access a histogram tool very quickly on your phone. The 3-minute tool you have in mind revisits the concept of histograms and gives practical tips on how to create one. There’s also a simple template that will help you collect and present your data – there and then. So, in the moment of need you can quickly and effectively accomplish what you need to do.
Well-designed microlearning combined with good technology fits with the real-world as it is – the fast-paced, high-stakes environment of your healthcare setting – which is where you need to retrieve your learning and practice it. And supporting you when it matters most is better all round in terms of your motivation to do a really good job for your patients, improved productivity in your service, making the learning stick over time and lowered training costs. In short, it’s better for you, your patients and your organisation.
Want to find out more about QI microlearning? Take a closer look at QIClearn’s 3minuteQI™. QI tools designed for use by healthcare practitioners in the real-world.
References: Make it stick: The science of successful learning by Peter Brown et al,.
A Situational Violation
Authors: Nicola Davey (QIC) and Trevor Dale (Atrainability)
Picture yourself in this situation; you’re an Anaesthetist who has been called to attend to a patient who needs an emergency C-section.
There’s a small window to act fast and save the baby, but you notice that the patient isn’t wearing an identity wristband. Would you anaesthetise?
Before we go any further, consider this similar situation before making a decision on what your course of action would be. Again, a real-life story that we’ve been made aware of recently. A small boy and his mother are rushed into a busy A&E department at an NHS Trust, the boy having been mauled by a dog.
The child is quickly referred to the Trauma Team and there is no doubt that they have the right child; he’s covered in blood, bite marks, screaming and the mother is upset as you’d expect. They do what needs to be done, they do their jobs, clean wounds and patch him up.
Afterwards, they find out he’s got the wrong wristband on. The hospital decides to deal with this error with disciplinary action against the Clinicians.
Take a step back and you can see how a small mistake like this can occur. A busy department, a small boy screaming, arms flailing about…he requires urgent medical attention and it’s clear what he needs; but why go
Treating individuals of any specialty, nursing or clinician like responsible professionals is almost guaranteed to have a much better outcome.
This incident should have been approached as something to learn from, a discussion point. A team conversation in which this error is highlighted and shared. An opportunity for staff to explore all the circumstances which led to the name check being missed, to think about the likelihood that this could happen again, and then if necessary, think about steps that can reasonably be taken to avoid a repetition of this error.
Using a risk matrix can help differentiate between low frequency events with very serious untoward outcomes and those with much less serious outcomes. And of course, the risk of not taking action must also be assessed to give a balanced perspective.
Let’s think again about the mother who needed an emergency C-section.
On this occasion, the Anaesthetist refused to anaesthetise the patient because of the missing wristband, which lead to a ten minute delay while they got a wristband on her. The result of this, was that the precious opportunity to get the baby out safe was missed. The child is now permanently brain damaged.
The easy thing to do is blame the Anaesthetist. He or she could have acted differently, taken a risk, broken a rule to act fast and then justified his/her actions later.
Or perhaps the finger of blame points at the nurse or doctor who was responsible for making sure the patient had a wristband on?
Of course, there’s other elements to muddy the waters.
What does this individual normally do? Flout rules or routinely demonstrate good practice? Do they have previous history which led to this particular decision? Were they previously involved in, or even just exposed, to a patient misidentification that resulted in serious harm?
Patient misidentification is known to contribute to errors and is a cause of patient safety incidents; including operating on the wrong patient, or performing the wrong procedure, or performing surgery / an intervention on the wrong body part (e.g., right vs. left knee replacement operation).
So what’s the answer here?
It’s a tragic story and an upsetting, ongoing experience for all involved. We feel however that it highlights how easy it is for leaders to unintentionally get it wrong and in doing so, stopping professionals from getting it right.
One major factor in high risk decision making has to be whether your front line team feel safe and supported. Now, what that means to us is that a management system needs to be set up and run in such a way that makes front line staff feel safe. This must be borne out in reality, as opposed to being implied and then not acted on when the time comes; “Well of course you’re safe with us, we operate a no-blame culture”. Saying it doesn’t make it true.
Did the Anaesthesist feel safe?
If frontline staff feel they have to protect themselves first from disciplinary action or being struck off then that’s how hospitals end up with staff who will refuse to do something that in hindsight would have been the “sensible” action. The sense of covering one’s own back is a normal human reaction to a perceived threat and it is a clear signal that all is not well with the system.
If individuals and teams feel safe and supported it will reduce stress and they will feel enabled and empowered to make better decisions. This not only means better care and outcomes for patients, but also builds trust and team morale.
Quality Improvement Clinic are now working alongside Atrainability to offer a one-day Masterclass which combines Human Factors and QI Science. Find out more or Register for the event below.
Patient Safety Solutions you can measure.
Human Factors works alongside Quality Improvement Science
Atrainability and Quality Improvement Clinic are delighted to be partnering over the next year to bring you new and exciting courses that reflect the best our combined knowledge and experience of Human Factors and Quality Improvement Science can offer. Our aim will be to deliver a more rounded learning experience, with sustainable and measured outcomes for our customers.
“Quality Improvement and Human Factors seem like a natural fit. We believe the two concepts will take patient safety further, faster.” – Trevor Dale, Atrainability.
Clients will benefit from the way Trevor and Nikki bounce off each other, their enthusiasm and drive is captivating and participants will leave the learning sessions with a plan of action to take back to their working environment. They will learn the skills and tools needed to help identify problems, speak up, take action and measure their improvements.
“Since I first became fascinated with quality improvement I saw the strong synergy with human factors and in particular the principles that underpin both areas of expertise. I’m delighted we have the opportunity to develop together new learning that will really impact care given to patients. Our team are excited at the prospect of working with Trevor and his team” – Nicola Davey, QIC Ltd
Recent client feedback – Spoonful of Sugar
QICLearn and Atrainability recently developed and ran the first in a series of bespoke courses for the team at Spoonful of Sugar. The team were encouraged to consider working together on a small improvement piece with a series of interactive exercises to help them develop a better understanding of human factors principles and understand how they present in their working environment.
The workshop received some wonderful feedback demonstrating how our combined learning approach really added value for our client. We also helped the company pinpoint other learning pieces that their team would benefit from, which complements the ethos of their own behaviour change consultancy.
“Since the workshop I have already put into practice some of the things I have learnt about effective communication. I feel that I am able to convey the action I require in my emails. My boss has even noticed and welcomed the improvement!” Sabine Gobert, Researcher and Project Manager
Chloe Tuck, Research & Development Lead shared her feedback:
“Thank you so much for the fantastic and very insightful training session on Monday – I really enjoyed it. One of the key things I picked up (and will try to adopt) is to not be ashamed to fail and to try to use for it benefit in future. I’m really interested in QI and keen to adopt your approaches.”
Reserve your place on our next workshop: Human Factors in Healthcare
Our healthcare settings are complex systems where the stakes are high and mistakes need to be avoided. The aim of this 1-day masterclass is to learn more about how human factors and quality improvement can help you deliver and measure a better outcome.
Human Factors in Healthcare 25 June 2018 – Register now
Alternatively contact us to enquire about in-house training options.
If you’ve ever played a team game, even at school, you’ll know that different skills are required depending on the position you play on the pitch, pool or court. Read the article here.
Supporting the #10kForNurses Big Hop!
QIClearn have been proud to sponsor Joans Pons Laplana (Transformation Nurse at James Paget Hospital in Chesterfield) who has completed the #10kForNurses Big Hop in aid of the Cavell Trust! Our sponsorship will help the Cavell Trust support nurses, midwives and healthcare assistants when they need it most. #TheBigHop took place on 22 October and saw Joan completing a challenging 10k course on a space hopper! We were incredibly impressed when we heard about this and eagerly awaited the event!
You can view the action as it unfolded by checking out his Twitter feed @RoaringNurse.
The Cavell Trust is a charitable organisation formed to help nurses, midwives and health care assistants, both working and retired, who are in need of support due to ill health, injury and financial difficulties. Joan did a fantastic job of raising money for this charity, and we can see why he managed to keep a smile on his face throughout his 10k tour of Sheffield!
From all of the QIClearn team – well done!
Quality improvement: beyond the buzz
Quality improvement seem to be the latest buzzwords in the NHS. And rightly so! There is an imperative to continually improve patient care even in the face of rising demand for services and constrained finances. It is an imperative closely aligned to the Hippocratic oath of ‘do no harm.’ But how do we make sure that quality improvement – as a practical way of improving care – moves beyond buzzword status to become an embodied habit for the NHS workforce?
Excellent care is delivered by the NHS every-day, but no-one would deny that there is also ample evidence of poor care and a necessity for quality improvement. The Mid Staffs scandal is perhaps the most high-profile recent example. The subsequent public inquiry chaired by Robert Francis QC (Report of the Mid Staffordshire NHS foundation Trust Public Inquiry: 2013) and the independent report authored by Don Berwick (A Promise to learn – a commitment to act: 2013) starkly highlighted both the need for, and the challenges of, making improvements in the NHS system. The need for a systemic mindset shift was identified. Patient care needed to be relocated at the core of both clinical and non-clinical decision making, and a culture of blame replaced by support and learning. Indeed, Berwick’s underpinning challenge to the NHS was that it must become a ‘learning organisation’ which facilitates the development of its workforce and seeks to continuously improve itself.
Much was improved after the Mid Staffs experience. Despite organisational pressures (including ongoing systemic reorganisation in the NHS) there are many promising initiatives working towards improving the deficits highlighted by Francis and Berwick (Sign-up to Safety and East London Foundation Trust Quality Improvement are just two of the many ongoing initiatives).
But the reality remains that in a healthcare system where uncertainty is rife and money is tight there isn’t always time to release frontline workers to reflect on their practice and to learn from it. In fact, these pressures accentuate an approach to improvement where the emphasis is on DOING an improvement project; merely ticking it off a list of things-to-do. And this is when the phrase quality improvement is devalued as mere buzzwords rather than the watchwords they should be; because improvement is about much more than DOING a quality improvement project.
In his thought paper The Habits of an Improver: Thinking about learning for improvement in healthcare (2015) Bill Lucas underlines this risk. In the NHS, he states, “improvement tends to become ‘an improvement project’. Or, at an even more precise level, a single plan-do-study-act (PDSA) cycle.” The focus is on the underpinning improvement theory or a set of improvement tools and techniques. Theses tangible elements of improvement are easier to teach and assess. They meet the impetus to demonstrate that we are DOING improvement. But in focussing on these more tangible aspects we sidestep thinking on what it means to be an improver; to embody improvement.
Lucas suggests that alongside the tools and techniques of improvement we should also think about the habits or behaviours that improvers should embody. He outlines five key habits (Learning; Influencing; Resilience; Creativity; Systems Thinking) each of which has underpinning characteristics.
Image taken from: The habits of an improver: Thinking about learning for improvement in health care. The Health Foundation. 2015
This focus on habits enables designers and learners to focus on practical outcomes. It enables us to revisit improvement science from the learner’s perspective and to ask: What are the habits that build improvement capability? What habits are useful within your context? Which of these habits will enable you to achieve your improvement aims? How can we design our learning so that it better facilitates the development of habits?
Because above all else improvement science must be practical and it must have relevance to the real-world. By all means read about and understand improvement theory, and do select some practical tools to help you achieve your improvement aims. But developing the right habits and having the right mindset are just as important.
In this way the notion of quality improvement has a longevity beyond the buzz. It becomes a journey of continuous learning; it becomes a way of being as well as doing. If we refocus our approach with the habits of an improver in mind, perhaps we can really start to achieve Berwick’s vision of the NHS as a ‘learning organisation’.
Improve ONE thing at a time
Small changes can effect big changes. One small domino when set in motion, can topple many thousands of dominos and the progression is both linear and geometric; our small domino could topple progressively larger dominoes over time. It’s a powerful concept!
But isn’t life a bit more complicated than that I hear you cry? We all work hard to make changes or improvements but life doesn’t always line up as neatly as we would like.
Well that’s certainly true. We all acknowledge the complexity inherent in our healthcare settings and the wickedly complex problems that abound within the system. Combined with the advancements of our age – ever more sophisticated technologies and information overload – it can all feel overwhelming.
Given this context, how should we design learning for improvement? How do we best prepare our learning participants to be effective small dominoes?
Well sometimes the answer is to focus on ONE thing at a time!
The best improvers have built-up their knowledge over time. They have practiced their techniques and developed the habits of being an improver over time. They have accomplished much over time by doing one thing at a time – sequentially.
That’s why QIClearn has developed a series of Improve ONE thing at a time learning courses for professionals who want to propel their practice forwards by focussing on ONE area of improvement science at a time.
These courses are an antidote to information overload and improvement tool excess. We focus in on one key area of improvement at a time, distil the most relevant learning, champion the most effective tool and enable our participants to go straight back into their workplace energised and confident to practice their ONE thing and succeed.
Find out more about our Improve ONE thing at a time courses.
Why QIClearn is a company to watch
QIClearn launches today with a selection of high quality services that will transform the way healthcare organisations deliver quality improvement learning programmes. The QIClearn approach is founded on the principle that how we learn is just as important as what we learn. It combines excellence in learning design and digital technologies with quality improvement expertise to achieve outstanding results.
QIClearn offers a growing portfolio of courses and products. These include its’ ONE thing events series which carefully curates’ improvement tools to cut through information overload and help participants focus in on one area of improvement science at a time. Alongside this is a bespoke design service for organisations who want a learning programme (online, blended or in-person) tailored to the results they want to achieve. Deep expertise in complex systems, measurement, human factors, design thinking, service improvement, leading improvement and sustainability plays into the design and delivery of QIClearn programmes.
The QIClearn online learning space is designed around social interaction. This enables participants to learn in conversation with each other and through discussions about the learning materials. QIClearn programmes are fully responsive which means they can be accessed across a range of devices providing our participants with enormous flexibility about when and where they learn. QIClearn has partnered with Curatr whose award winning social learning technology is a great fit for the QIClearn approach.
Rachel Hammel, Head of QIClearn said, “We wanted to disrupt the way quality improvement learning programmes are traditionally approached. So, we have designed an experience that moves way beyond the ubiquitous elearning packages currently available in the healthcare sector. Our learning programmes challenge conventional methods of teaching and learning head-on with some exciting results.”
Nicola Davey, Director of the Quality Improvement Clinic said, “QIClearn provides a fresh approach to the delivery of quality and service improvement learning. Our approach is flexible, scale-able and uses new technologies creatively. It provides organisations and their learning communities with user-friendly, well-designed and effective programmes. We have a vast range of practical quality improvement expertise at our fingertips. Combine this subject-expertise with an innovative approach to learning design and what we have to offer is a very exciting prospect for healthcare organisations.’
In addition to the combined emphasis on social learning and quality improvement expertise QIClearn’s key features include:
- Hands-on learning: Everything participants learn is put into practice immediately within their healthcare setting. This culture of practice builds confidence and develops the habits of an improver.
- Curated content: There is a wealth of information available on improvement science – and frankly it can be a bit much. We curate bespoke resources for each of our courses to enhance (rather than overload) our participants learning.
- Coaching: QIClearn instructors take a coaching approach to their teaching, guiding participants through their improvement projects. They provide the support and challenge needed for success.
- Peer Review: Giving and receiving feedback are essential elements of the improvement journey. QIClearn provides the opportunity and support needed to do this successfully.
- Teamwork: Working effectively with others is an essential element of improvement. QIClearn designs its programmes to enhance these skills and provides ample opportunity for participants to practice them.
‘QIClearn is about minimum fuss and maximum impact. Why would an organisation want to procure their own learning technologies when they can use QIClearn’s online space and subject expertise to create something excellent quickly and easily. It’s a no-brainer.’ Laura Longley, QICLearn Account Manager.