What matters to you? by @jasonleitch

In July 2005 I sat in my first ever ‘Quality Improvement’ class. It was in Boston and led by Maureen Bisognano, now the CEO of the Institute for Healthcare Improvement (www.ihi.org). Maureen gave out three things: a timetable and two exercises. The schedule was a who’s who of quality and I was looking forward to it. The first exercise was predictable, we had to carry out a personal improvement project using aims, measures, changes and testing over the four weeks of the course. I chose to do “knowledge of the Boston Red Sox” as an excuse to get to games and watch ESPN. It helped that Maureen is a Red Sox fan and she was marking the exercise!

The second exercise was the intriguing one. We were asked to speak to a friend or family member who had recent experience of healthcare. The twist was we had to ask about everything except the illness or disease. We had to concentrate on the experience of care, not the care itself. We had to interview our chosen ‘patient’ for a substantial period of time and probe their experience of healthcare.

I approached a friend and colleague who was nearing the end of treatment for multiple myeloma, a blood cancer. I’d known him for years and we’d worked together although we were from different cities. He was a senior healthcare worker and understood the system well. I expected a conversation about waiting times and perhaps some nurses in a bad mood and maybe some complaints about the food. What I got changed my perspective on person-centred care forever.

Because I was in Boston and he was in London we talked on the phone, we ended up talking for over two hours. He started with exactly the list above: annoying waiting around for chemotherapy appointments, parking difficulties and ‘the food is rubbish’. As time passed and he relaxed he started to get upset. it seemed like the first time someone had allowed him space to reflect on the whole experience. What he wanted to talk about was music. I knew he was an amateur jazz musician and enjoyed playing part-time in a band. He played the clarinet. What I didn’t know was how integral and important this element of ‘him’ was and neither did the healthcare system he found himself in every day for nearly eighteen months. He described missing his music, his appointments were in a hospital some way from his rural home and he either missed rehearsals because he was in a plastic chair waiting for chemo or because he was too exhausted. He even missed just listening to music. He got upset most when he described an evening when his mates in the band came round to the house unexpectedly and played for him. He survived his cancer and he plays in his jazz band again. by his own admission he’s not even very good but he doesn’t care.

I didn’t know it at the time but others had learned this lesson before me and have described it as moving from ‘what’s the matter?’ to ‘what matters to you?’ medicine. Personalised, compassionate and person-centred. In NHSScotland we have an ambition to make all healthcare person-centred. This will mean asking patients and families what matters to them. There are examples of this everywhere, being spread as part of the person-centred care programme. In the paediatric ward in Paisley every child is asked to draw a picture or write a list of ‘what matters to them’. The answers are both inspiring and humbling. They are ‘nice nurses’, ‘good food to eat’, ‘seeing my gran’ and other similar expressions. They are not ‘on-time antibiotics’, ‘clean hands’ or ‘reduced length of stay’.

If you’re a healthcare worker, stop tomorrow and ask one patient ‘what matters to you?’, you may be surprised by what you hear. If you’re a patient or a family member of someone in the healthcare system stop tomorrow and tell the healthcare system what matters to you, you may be surprised at the response.

Professor Jason Leitch is Clinical Director for NHS Scotland

Towards an electronic Doctors Handbook by @IslesChris

Dumfries has had a Doctors Handbook since 1992.  We have revised and updated this each year to the point that it now extends to an impressive, some might say overlong, 336 pages.  The paper version was handy as a pocket book but became out of date very quickly.   Updates could only be introduced by adding sticky labels or a new and expensive print run.  It was on this background that we decided to go paperless at the end of 2012.  Our goal was to produce an app accessible on all PCs and mobile devices throughout the hospital.   We toyed with the idea of bringing in outside help but decided ultimately on an in-house solution, drawing on the expertise of Calum Murray (Education Centre) and Pete Robinson, Pete O’Connor and Brian Currie (IT).

 

Why the need for a Doctors handbook?   Mainly because we staff our hospital at night with relatively inexperienced members of the medical team ie those less likely to provide the answers to some of the problems that present out of hours than consultants.  This is a particular issue at the beginning of August (Google the “Disgruntled A&E SHO’s 7^th August” blog to see an altogether different solution!) and for hospitals such as ours because more often than not the most senior doctor on site for medicine is CT2 or less in experience (for the non-medics reading, this means less than 4 years since qualifying).  Patient expectations have increased considerably in the last 10-20 years and complaints over poor standards of care have increased dramatically.   An evidence and expert opinion based Doctors Handbook is one way of reducing risks to patients at night… and of protecting the juniors.   If a patient’s condition deteriorates but it can be shown that the doctor was following best practice then it is likely that the treatment was correct and that the doctor was not responsible for the deterioration. I should perhaps stress at this point that if a patient’s condition deteriorates unexpectedly at any time of day or night and the doctor isn’t sure what to do then he or she should of course also phone the consultant!

It could be argued that we live in a perpetual state of information overload already and don’t need yet more information.  It is certainly true that doctors on call have access to unlimited quantities of information, but is it the right information and is it readily available when needed?   Let us take Community Acquired Pneumonia (CAP) as an important and common medical condition.  Googling gives around 2,990,000 hits.  The first 5 of these are for Wikipedia, eMedicine, British Thoracic Society Guidelines (twice) and Boots Web MD.  If we discount the patient website then it’s quite likely that a junior doctor searching for information online about pneumonia will open one of the others.  For it to be worthwhile having our own handbook then we have to be seen to be offering something that the others don’t.  So do we?

Wikipedia first.  It is all too tempting to dismiss Wikipedia, though it does occasionally have its uses.  Crucially however the Wikipedia entry for Community Acquired Pneumonia makes no reference to the British Thoracic Society Guideline and doesn’t even mention the CURB65 score (non-medics, this is a score that tells us the severity of the pneumonia) though you will find this if you follow a link to ‘Pneumonia’.  It is also fairly long at 4929 words and I have no idea of the expertise of the people who wrote it.  By contrast we can see exactly who wrote the emedicine Community Acquired Pneumonia article.  This is a scholarly work but more textbook than handbook and more American than British.  No disrespect to American guidelines but we practice medicine differently and the antibiotic recommendations, for example, are not transferable. 

Which brings me to the British Thoracic Society guidelines.  These were published in 2009 and have been endorsed by a number of learned societies including, among others, the Society of Acute Medicine and the Royal College of Physicians.  They are by any criteria very well written and intensely practical guidelines but at 61 pages probably not quite the accessible read required by the on-call doctor for medicine at 2am in the morning when confronted by a febrile, breathless patient with coarse crackles and inflammatory shadowing on his or her CXR.   Excellent as a reference though.

So what parts does our handbook reach that Wikipedia, emedicine and British Thoracic Society do not?  First, we have ensured that at well under 1000 words the Community Acquired Pneumonia chapter is more handbook than textbook.  For those reading this on NHSD&G’s network, click this link to view the page, Community Acquired Pneumonia (CAP) Handbook Page .  For those reading externally, we have reproduced the page as a screenshot that can be accessed by clicking here Community Acquired Pneumonia on Flickr .(When loaded, click on image – to enlarge select ‘view all sizes’ at top of page and then click on ‘original’). Second, we have based the chapter on the British guideline distilling what we think are the really important messages from it.  Third, we have had the chapter approved by our respiratory physicians which means that it reflects current best practice in Dumfries.  And fourth we have included an electronic link to the British guideline BTS Guideline in case the on call doctor wants a little bit more advice or background to a particular recommendation.

Work on the Handbook continues apace.  At the time of writing this blog we have ‘gone live’ with around half of the content updated and converted to electronic format (see below for the sections completed so far and the respiratory chapter headings).  Juniors can access the Handbook from the intranet home page but not yet on ward iPads or their mobile phones (coming soon).  We are indebted to a huge number of colleagues Acknowledgments for their help with revision and anticipate calling on many others over the coming weeks.  We rather hope that our new improved electronic Handbook will become an indispensable part of medicine in Dumfries.  All comments, suggestions and feedback welcome, particularly if you spot a mistake.    What price a surgical, orthopaedic, obstetric, paediatric or psychiatric handbook?   Delighted also to hear from colleagues from other health boards.  Best to contact us by emailing dg.handbook@nhs.net

Professor Chris Isles is a Retired Consultant Physician and Clinical Teaching Fellow. He is also one of Dumfries and Galloways premier Baristas.

Next week will see our first guest blog by Professor Jason Leitch, Clinical Director for NHS Scotland.

‘Words’ by @mhairihastings1

I’ve been reading a lot over the last 2 years; and I don’t just mean about Edward and Bella.

Rather, I have been reading about Innovation, Creativity, Change and Research in healthcare because:

 
1. There is a lot of it going on, a lot more required!
And
2. I am undertaking a Masters Degree

There are a few things that have struck me during this reading, but there is one significant element that I wanted to write about, that which has reassured me about the development and implementation of Active Patient Care within NHS Dumfries and Galloway. (see the end of this Blog entry for more information about Active Patient Care)
The ‘Words’ that we use every day and perhaps don’t particularly think too much about.

 
Let’s take the word ‘Evidence’ first.

It can mean many different things and we hear it widely used in the media and in social contexts, ‘The evidence was the gun was in their hand’; ‘the evidence is that you have not met your Political Party Agenda’; here it is demonstrating that something happened, or didn’t happen for that matter. Similarly I have been thinking a lot about this use in the context of Nursing. We often talk about ‘if it wasn’t written it wasn’t done’ , interpreted to mean that if we didn’t write down and ‘evidence’ that care was given, we find it difficult to argue that it was. I believe we need to move away from this statement a little, or at least be considering how we provide ‘evidence’, but in a more efficient manner than we currently do. Let’s face it something must be wrong if writing about the care we give takes longer that giving the care – a U turn is required here I would say!

 
Then we have the term ‘Evidence Based Practice’. Used frequently in the context of Nursing since the early 1990’s (following hot on the heels of our Medical colleagues shift to Evidence Based Medicine. It can be used in defence of the care that we gave, or as justification for a particular local and preferred process we are going to use. That in itself I see as a good thing, surely we can’t argue with the concept, but what is the ‘Evidence’ that we refer to, thinking about it as something we can see isn’t particularly helpful. In thinking about that I would ask that you now consider the meaning of two more words.

‘Information’ versus ‘Knowledge’

Information: What is Information? Have you ever thought about this before? I think it’s difficult, particularly when you try to interpret a difference between what is ‘Information’ and what is ‘Knowledge.’ Here is what I have decided for myself, but you can make your own mind up. Information is non interpreted facts, raw data i.e. 159 patients attended A&E last Monday; there will be a 1% payrise given to public sector staff; The North West Castle Hotel is situated in Stranraer. What it isn’t saying is ‘Why’ this is the case.

So what is the difference between that and Knowledge? What is Knowledge? Don’t worry about looking this up unless you really feel the need – it is so widely contested you will be reading longer than it took me to read the Twilight Saga and the True Blood series combined!

What I would like you to do is think about my definition, I do get to a point later, honest. ‘Knowledge is a strong belief, which can be justified as true’. (Me! 2013). That’s it. Odd definition to come to? Maybe, but maybe not, Let me explain. The ancient Greeks believe that facts can only become knowledge when someone believes them to be true (information is non interpreted facts, remember what I said above?). Further to this though the facts need to be interpreted and justified. It is in this that the person reading them and believing them to be true becomes a ‘knower’ of this information. They can then claim to have this knowledge, BUT they must then be able to justify why they believe the information to be true. Knowledge is constructed from the information we have at our disposal. A good example of this is that the Earth for a long time was ‘known’ to be flat! New information, which was interpreted and justified was brought to light, people believed it and in the main we now ‘‘know’ that the earth is round.

This kind of scientific evidence is always open to disproof though!
There are of course other ways of gaining Knowledge, other than from scientific papers and written information. Think about this one a bit more the next time you can’t explain why you want to give care in a particular way and the ‘evidence’ for it is not in front of you in an Evidence Based Practice Paper, Journal, etc You just want to scream ‘because I just KNOW , ok!’ . Well you’re right, you probably do. You are gaining knowledge in healthcare all the time, the more care you give, the more you interpret individual patients responses to care and begin to believe and ‘know’ that a care method might work with an individual patient. This is Tacit Knowledge – very important, as nurses we have more or less of it depending on experiences and I would strongly encourage it’s use, remember though to ‘know’, you must also be able to justify!

So after all that, I need to explain why all these words have something, anything to do with Active Patient Care. Here’s what I want you to ask yourself now.

1. Do you believe that as nurses or healthcare providers we should continually gather information about how a patient is responding to our fundamental nursing care?

Yes No

2. Do you think that with the patient we should interpret that data, justifying it, agreeing it to be correct?

Yes No

3. Do you agree that you will then have knowledge of the patients’ response to fundamental care?

Yes No

4. With that acquired Knowledge and your previous Tacit Knowledge, do you believe you will be better placed to assist the patient to further plan more care interventions to improve their health and prevent avoidable incidents, such as Falls, Dehydration, Pressure Ulcers?

Yes No

I believe the answer to all of the above is ‘yes’. That answers why all of the above has everything to do with Active Patient Care. You see, Active Patient Care arises from what I believe are the core values and beliefs shared by nurses. As a nurse I believe in The Nursing Process; I believe that no patient should come to harm in our care; I believe that we should always aim for the best possible outcome for and with our patients. We can only do this well if we have easily captured information, which we interpret, know what it means, learn from and use to further plan and implement care with our patients – in this sense it is ‘Evidence’ Based, Patient Centred Practice.

For any nurse that answered ‘No’ to any of the above, I would be more than happy to further discuss and debate with you!

By the way, if Dr Carlisle Cullen applies to work at NHS D&G, I’d be more than happy to show him round Galloway!

Active Patient Care is NHS Dumfries and Galloway’s agreed method of planning, implementing, documenting, assessing and evaluating in patient’s fundamental nursing care. It incorporates both the SKINN Bundle and the basics of Intentional Rounding, but, with the added consideration that it is patient centred, holistic and pro active in its approach. It is planned methodically using the nursing process in order that patients receive care at regular intervals, which are agreed with them and are appropriate to meet their needs without them having to ask for care. This, rather than the standard used with Intentional Rounding, that every patient is seen ever hour but with questionable value to the patient.

Mhairi Hastings is the Nurse Manager for PCCD West, NHS Dumfries and Galloway

Sometimes its the little things …. by Stephanie Mottram

As the NHS celebrates its 65th birthday, the sun is beginning to set on the NHS of old. We are entering the dawn of a new era and are about to embark upon the two biggest programmes of change that any of us will ever likely see during our careers (1) planning for a new acute hospital and (2) integration of health and social care. There has never been a more exciting time to be an employee in NHS D&G.

Change, like it or not, it is going to happen. The following are some key
“buzz” words that we keep hearing about in relation to change:-

TRANSFORMATIONAL – a marked change, as in appearance or character, usually for the better.

INNOVATION – notion of doing something different rather than doing the same thing better

RADICAL – relating to or affecting the fundamental nature of something far-reaching or thorough.

DYNAMIC – A force that stimulates change or progress within a system or process.

The management Gurus’ are currently out there in their droves selling this concept. Now, don’t get me wrong, whilst I very much believe that delivering an NHS fit for the future does require all of the above, I sometimes wonder what happened to good old fashioned common sense to deliver change?

I have asked myself four simple questions:-

Would common sense enable us to:-

1. Deliver safe and effective care?
2. Deliver efficiency savings?
3. Enhance patient experience?
4. Motivate and develop staff?

Answer: Of course it jolly well would !!

Is it that common sense is just not trendy enough? Is it such an unmarketable concept for our modern management Gurus? Has it really been left behind in 19 canteen when there were only 3 channels on the T.V., when music came in the form of vinyl and when kids actually played outside and skint their knees?

Like everyone I love a bit of nostalgia but surely common sense is something we can all pull out of the closet, dust down and utilise to its full potential, when required.

There was non-significant event, a few days ago, which got me thinking. To cut a long story short, I was dashing about in my usual style trying to juggle various bits and pieces all at once when I found a gentleman wandering down the Admin Corridor looking lost, so I stopped and asked if he needed help. Basically, he was in a dilemma about not making visiting time to see a relative. I sat in the front foyer with the gentlemen and his wife and took 5 mins out of my day to listen to their story. I was able to source the relevant information for them and found a solution to their dilemma. They were very grateful for my help.

The easiest thing would have been for me to make my excuses and run. After all, I had another 101 things to be getting on with. However, common sense prevailed, I lent a helping hand when needed, for the greater good. This resulted in a positive experience for the couple’s encounter with NHS D&G and a positive experience for myself in the form of the words “thank you”.

This in itself is by no means transformational, radical, innovative or even dynamic. However, imagine if every single encounter people had with NHS D&G provided a positive experience for patients and staff alike, now that definitely would be transformational change!

What I am really trying to say is don’t get baffled by management speak and this year’s trend and play on words. It’s not always the big things that will deliver the changes but the little things like a smile, a helping hand, a friendly ear.

Going forward into the “new world” we need to acknowledge that change is inevitable, it is coming to a place near you pretty soon. However, don’t fret, applying good old fashioned common sense to help where we can and when we can will allow us to take the steps towards the transformational, radical change that is required.

After all, it is you and me that are tomorrow’s patients and how satisfying will it be knowing that we have contributed to the transformation of the NHS…

Stephanie Mottram is a Service Development Manager for Acute and Diagnostics at NHS Dumfries and Galloway

Woman Interrupted by Penny Halliday

October 2006, after nearly twenty years as a teacher, I had started my own business and it was booming, so much so I decided not to bother with the routine mammogram appointment for that day. However, my last client of the day cancelled so I decided to keep the screening appointment. I was breast aware and knew there was nothing to worry about, it would only take a few minutes.

 

A few weeks later I arrived home to find a letter asking me to attend for further screening as the first one was inconclusive. Being a positive person I saw this as an opportunity to make sure everything was okay. After a variety of tests and a week’s wait my husband, daughter and I returned for the results. Within the first few minutes I was being told that I had Ductal Carcinoma In Situ or Pre-Cancerous Cells and would need a mastectomy. It was all very clinical and cold but we left there feeling grateful that the doctors had found this ticking time bomb which has no visible signs. The next day we travelled to see the surgeon who assured us that a mastectomy would be “all that was needed” and how I should think about breast reconstruction – I couldn’t take it all in and was beginning to feel a bit scared as reconstruction would mean a 6 hour operation instead of the mastectomy which was about an hour.

 

We found ourselves travelling again in the January cold and dark to visit the surgeon for a follow up after my breast had been removed a couple of weeks earlier. The surgeon came into the waiting room and called my husband and I into her room where there was a student, a psychologist, a breast nurse and her. She asked if I minded and of course I said no – I was feeling intimidated. She announced that I did not have DCIS but indeed had Breast Cancer and proceeded to talk about Chemotherapy, Radiotherapy, Drug Therapy – I looked at my poor husbands face we both said very little out loud we were in shock and just wanted to get out – there were 6 people including us in that room when we received this life changing news.

Two weeks later my daughter and I attended the hospital at 10am to start chemotherapy. I was told by a new doctor that it would not go ahead because there was something suspicious on my chest x ray and that I would need an urgent CT Scan – I asked what time I would have the scan and was told there were no slots available. After a very emotional reaction to this I was told they could offer me one at 8pm that evening – we travelled 210 miles that day so that this could happen and waited a week before returning to the hospital for the results. That week was never ending as I imagined all sorts of scenarios, at the same time being aware of precious time slipping by and wondering what opportunity this was giving the cancer to do further damage. The day finally came when my daughter and I returned to the hospital where the news was positive. Soon the nurse appeared and took us to another little room. He told me that I would need a line inserted into my chest as the veins in my hand were “useless” for inserting the type of needles necessary to administer chemotherapy and that it had to be done with a local anaesthetic. He thought it would help if I spoke to someone who had a Hickman Line and took us to another part of the hospital to speak to a young girl. I can’t remember her name but I will never forget her, she told us she was 32 years old and was undergoing treatment for secondary breast cancer which was in her bones and her liver – she talked about her little boy. We left the hospital and went home having still had no chemo.

 

I can’t describe the hopelessness and despair I felt after seeing that young girl. We didn’t talk much on the way home but I had made a decision – I was never going back to that hospital and would not have any further treatment I had decided to give up.

 

I was in the sitting room the next morning when my community nurse arrived smiling. She was like a breath of fresh air and asked how things went. I told her my decision that I had had enough. She held my hand and spoke to me quietly and asked if I would tell her what had happened. It was the first time someone had listened to me and was genuine, that someone had called me by my first name, she let me talk without looking at the clock without using clinical language, and she let me tell my story. In less than a week I was admitted to another hospital had the line inserted under general anaesthetic and had my first chemotherapy treatment, I never looked back after that.

That community nurse saved my life for without her compassion, patience and respect I would not have changed my mind. She gave me back control and confidence.

Penny Halliday is a Non-Executive Director for NHS Dumfries and Galloway.