Ten Things I Have Learned About Governance by @craigwhitephd

“Everybody involved in overseeing, planning, delivering and supporting healthcare services in Scotland has a role to play in ensuring that our governance procedures improve, assure and result in necessary remediation to drive the quality of our healthcare services” 

Extracted from ‘Governance for Quality Healthcare in Scotland – An Agreement’, Scottish Government Health and Social Care Directorates, NHSScotland. Available at: http://tinyurl.com/qualitygovernance (Accessed 17^th December 2013)

From 2010-2013 I worked as Assistant Director in the Medical and Nurse Directorates of NHS Ayrshire and Arran, supporting and advising on the Board’s Clinical and Healthcare Governance activity.   A significant amount of time (as you would expect given the role) was spent in dialogue regarding ideas and requirements for changes in systems and processes – a common thread across all governance, learning and improvement work.

I quickly realised that there were many different views and experiences in respect of how governance and improvement work had been experienced, understood, discussed and approached.

I was recently asked by colleagues in NHS Ayrshire and Arran’s Mental Health Services Directorate to speak at their annual clinical governance and improvement symposium.  My talk focused on ‘ten things that I have learned about governance’.

These are outlined below:

1 – What have you done about it?

Governance is about being able to identify what action is required and demonstrate that this has been effectively implemented.

 2- Adopt an open ‘questioning’ mindset

Engage and support questions that drive forward a focus on understanding systems, making sense of contributors and understanding relationships between people, processes and wider organisational climate and culture.

 3- It’s not about you

Systems, processes, organisational climate and cultures are more powerful than any one individual.  It’s not personal, even though there may be many who think it is and try to make it so.  Stay focused on the people who we are employed ‘to serve’ – this is the ‘key’ unifying factor in terms of focusing on what matters to the people that use services being provided.

4- Defensiveness is dangerous

Defensive and dismissive reactions can significantly weaken good governance – energy is taken away from learning, dialogue, and the generation of ideas for change, development and, most importantly, the implementation of plans for improvement.

5-That’s not your job/that’s my job

There needs to be clear, shared and accepted understanding of what individual roles and responsibilities are. Delivery of ‘best in class’ governance practices is always more effective when roles and responsibilities were clear and understood in practice.

6-Clarify your intentions

Personal and organisational custom and practice can mean that intention/personal meaning that is attached to actions is incorrect.  I quickly learned that if colleagues had not had the opportunity to consider the same theoretical models of healthcare governance as I had, they would sometimes attach meanings about intent of my actions that then became unproductive. 

This could lead to perceptions of unjustified interference, thankfully often addressed by making sure intent was clarified – for example, saying ‘My intent in asking about how this action has been progressed is to provide an update to Mr Jones’ widow who is frightened to come into hospital herself now in case we have not improved the systems’ would often help focus action around what mattered. 

7-It’s all about measurement and change

Governance, improvement and performance have more in common than people think or believe that they have.  Data for dialogue – to understand systems, inform ideas for change and examine whether changes have resulted in improvements or delivery of a stated aim is what matters.

8-Some people don’t “get it”

A well-developed understanding of the legal, professional, moral and policy imperatives regarding governance does not always seem to have been an essential recruitment criterion. It’s insufficient to issue policies and guidance and hope that actions will be effectively taken as a result.  Good governance also depends on a grounded and comprehensive understanding of what matters most to the people using services.

 9-Impact is everything

The impact of getting it right (even after getting it horribly wrong) can be profound for everyone involved.  Trust can be restored when there is an authentic and honest ‘reaching out’ to connect with the lived experience of all who are touched by the encounters that are reflected in governance and improvement conversations.  

10-Did I say impact is everything? – I meant transparency is everything

People who use services, people who might need to use them and the staff who work within them have a fundamental right to know what is happening – what is going well, what hasn’t gone well, what has been done, whether it worked and how they can become involved with efforts to continuously improve service quality.

Some closing remarks…..

Governance and assurance doesn’t need to stifle improvement activity.  The following simple model for healthcare governance process was based on the work of the late Avis Donabedian and, I believe, demonstrates how governance process can be entirely resonant with improvement focused thinking and action.

• Information on the quality of care is collected (through a range of sources)
• Information is then interpreted to identify what action is needed
• Agreed actions are then documented
• The impact of taking these actions is then monitored through agreed measurement and reporting processes
• The information on this impact is then considered against agreed aims, this in turn again provides information for further interpretation:      
  • Has this made a difference? 
  • Are things better?
  • What have we learned?
  • What do we need to next to make this more reliable?

Good governance consists of a set of simple steps. Although they are often difficult to implement consistently and reliably they can be powerful enablers to support a learning and improvement focused approach to governance and accountability.

Footnote

The views outlined in this blog are personal views based on professional experience while Assistant Director (Healthcare Governance and Assurance), NHS Ayrshire and Arran 2010-2013.

 About the Author

Professor Craig White is now Divisional Clinical Lead (Quality and Planning), The Quality Unit, Health and Social Care Directorates, Scottish Government.   

Email: craig.white@scotland.gsi.gov.uk Twitter: @craigwhitephd

 

The Christmas Card by Mike McMahon

She wasn’t my Auntie, in case you wondered.

A little before Christmas a patient gave me a red envelope. She smiled as she handed it to me, her manner suggesting she was perhaps a little embarrassed. I can’t pretend to be Sherlock Holmes, but I was pretty sure it contained a Christmas card. I thanked her for it. I don’t remember if I mentioned to her that I presumed it to be a Christmas card, but I set it on the desk and said I would open it later if that was alright with her.

 A clinical consultation followed. Then she left the room leaving the envelope behind.

 That afternoon, in my office, which was quiet enough to bring my tinnitus to notice, I read then deleted several emails, each deletion a small victory swelling my soul, then corrected and verified some letters, a slow process of  removing or inserting apostrophes which sapped my soul back to normal size, all the while glancing occasionally at the envelope.

 I have always recognised that I have a slightly atrophied curiosity, but perhaps it is just slow to awaken, since eventually I found myself reaching for the envelope.

 A Christmas card. Just as I thought. A smiling snowman and a large star. “Merry Christmas”.  “Thank you for all your help” written inside. No “X”, thankfully, since that would be particularly awkward.

 But the card was not alone in the envelope. There was also a five pound note. Not a crisp new one, but a much folded one that had obviously had a story of its own.

 

 Perhaps you should know that she was not a wealthy woman by any stretch of the imagination.

 What should I do with the five pound note?

1. Give it back?
2. Write to ask what she would like me to do with it?
3. Write a letter of thanks?
4. Write a letter of thanks but hint that it was too much?
5. Write a letter of thanks and enclose the trust guidance on gratuities?
6. Donate it to charity?
7. Put it towards biscuits/chocolates for the clinic staff?
8. Place it in the endowment fund?
9. Have it framed and hung on my wall?
10. Disclose it, and my response, at my next appraisal?

Mike McMahon is a Consultant Physician and Rheumatologist for NHS Dumfries and Galloway

“Learn a single trick” by @personcntrd_DG

On November 21 -22 2013 a delegation from NHS Dumfries and Galloway attended the third Learning session on People at the Centre of Health and Care at the SECC in Glasgow.

This blog is an amalgamation of thoughts and experiences from that group of nurses, managers, doctors, carers and social and third sector workers who attended the two days and hopefully will provide you with some insight into what proved to be a very interesting and thought provoking learning session.

One of the themes of the two days was #hellomynameis. For those of you not familiar with Twitter the # sets a trend and this particular one was started by a young doctor called Kate Granger.  Along with being a junior doctor and accomplished author Kate has terminal cancer and writes eloquently about her disease and experiences on her blog and twitter. Earlier this year Kate was admitted to hospital and she noticed that not everybody introduced themselves. She writes about this on her blog and we would recommend reading it here. The upshot was her campaign to ensure that every encounter between healthcare professional and service user started with ‘hello my name is…’  and this quote, complete with #, was put on every delegates name badge – along with the request to take ‘selfies’ (a picture of oneself taken with a smartphone)and post them on twitter. Some examples can be seen here.

Although the title of the event suggests a focus on patients and service users we would like to stress that staff experience, staff support and staff values are recognised as being equally important and there were several workshops to this effect. If your workforce are unhappy and feel poorly supported then your patients experience will consequently suffer.

At the core of the Person Centred Collaborative are the 5 “Must do with me” elements. These are:

1. What matters to you?
2. Who matters to you?
3. What information do you need?
4. Nothing about me without me
5. Personalised contact

Throughout the two days we were asked to focus on these elements and consider improvement plans to take back to our workplace based upon them. We shall list a few from Dumfries and Galloway later in this blog but for now here are some of the highlights…..

Tommy Whitelaw – Tommys mother died following a 6 year fight against progressive dementia and throughout this time he was her main carer. Tommy delivered an extremely moving speech highlighting how some small acts of kindness can make all the difference and unfortunately that lack of kindness can have such a negative impact. He speaks best for himself and his videos can (and should) be viewed here. There not many events like this where a speaker gets a 5 minute standing ovation.

‘F for frailty’ – a workshop focusing on the Comprehensive Geriatric Assessment (CGA). This tool is used in the Emergency Department and has proved very successful in reducing elderly care admissions. One hospital reported a reduction of admission by one third using this tool, which has a very person centred approach.

Staff experience – a number of workshops focused on this. Supporting our staff to ensure they can come to work safe, confident and able to offer care compassion and respect to their patients and then go home with a sense of worth and value is vital to ensuring that we are delivering person centred care. One tool to support this is Values Based Reflective Practice (VBRP). VBRP offers a safe environment for a team to discuss difficult cases in a non-judgemental or accusatory way. No blame is apportioned and no ‘solution’ expected. This is evidence based and can significantly improve staff well-being and morale. We will be starting a course of VBRP training sessions in the New Year so watch out for adverts and emails offering places.

Visiting – this is a controversial area. Strict visiting hours are not always in the patient or families best interests but are felt historically necessary to protect them. There were two lively debates around relaxing visiting hours and moving to more person centred visiting ‘contract’ which felt very positive. If we wish to deliver this in DGRI then we need to involve staff in its implementation and we plan to do so early next year.

Teachback – This is a tool which is used to ensure that a patient has understood what you have been telling them. Some concerns were raised that doing this with every patient would make clinics unbearably long. However the counter argument was that taking 2 minutes to ensure understanding would save time in the future when it became clear that patients didn’t understand and required a further clinic appointment etc. In this workshop there was also a discussion about ‘going Italian’ which essentially meant encouraging families to attend clinic appointments with loved ones to help with both understanding and difficult decision making.

Leadership – our very own Hazel Borland led a workshop where she described her experiences of putting on her nursing uniform and doing a shift ‘back at the coal-face’. Hazel does this once a month and freely admits that it is important to her but has found that it matters to the staff as well. There was quite a buzz around this workshop and I heard several clinical leaders planning to do likewise on return to work.

Another powerful moment was when we were shown a youtube video of Dartmouth Childrens Hospital performing Katy Perrys ‘Roar’. This was extremely moving and in case you are wondering why it was included its because of the the lyric  “I am the champion and you’re going to hear me Roar.” You can watch it here, which we strongly recommend.

The team returned with many plans to improve services in Dumfries and Galloway including; the use of ‘Getting to know me’ booklets for every referral to the social care hub, a change to visiting hours (from visiting to welcoming), a neonatal passport, training in VBRP,  further enhanced patient experience events and many, many more.

A final point is that we now have a Person Centred Health and Care Committee  which reports to the Board and will be the driving force behind many of the improvement plans mentioned above.

This is a brief summary of some of the excellent work experienced by the person centred team from Dumfries and Galloway. It would be an understatement to say that we all came away enthused, excited and keen to get working on improvement. The key message is that when we are considering any changes to service we need to not only think of the service user but include them in the decision and continually be asking the question “What matters to you?” We are doing some great work but more needs to done – change is clearly ahead.

“If you just learn a single trick, Scout, you’ll get along better with all kinds of folks. You never really understand a person until you consider things from his point of view. Until you climb inside of his skin and walk around in it.”

Atticus Finch (To kill a Mockingbird)

@personcntrdDG represents The Person Centred Health and Care Committee and this blog was put together using contributions from; Tricia Kirk, Muriel Malcolm, Lisa Rennie, Michaela Cannon, Gladys Haining, Jacqueline Nicholson, Kerri Van-Nuil, Caroline Sharp, Judith Proctor and Penny Halliday.