Are you an Improver? by Paul Sammons

I caught a bug back in 2008 – the Patient Safety bug. I caught it when I became involved in the Scottish Patient Safety Programme. I have kept it and cultivated it ever since.
Before that time I thought that rapid cycle improvement was something about new carbon fibre bicycle frames!

OK so I was wrong – as an ex banking project manager, I knew loads about change, but was hit with the realisation that in the past we did things to people rather than with people, and used hierarchy to make people do as they were told. A bit like inviting folk round for dinner and telling them what they will enjoy eating. Not the best recipe for embedding change.
And so I was smitten, with the likes of Jason Leitch talking about the lens of profound knowledge, small tests of change and measurement for improvement.
After a sabbatical into NHS IT work, I became an improvement advisor, and saw that the same bug had visited Dumfries and Galloway and taken hold, with lots of measurement and improvement going on, aimed at process improvement and reducing harm to patients.
But see this Model for Improvement methodology and all that goes with it – is it portable? Can it be used where there are no doctors?
In 2016 I am lucky enough to be supporting a new improvement collaborative, working with 5 dental practices to apply the set of improvement related tools and principles to address the question – does dentistry harm patients? Well there is risk of getting it wrong in all walks of life, and dentistry is no exception. Since we are people, dealing with other people, we may be able to address unnecessary harm, reduce variation in processes and improve communication. To anybody who has teeth – this matters.
This opportunity allows me to support dental practices to identify where they want to focus their improvement efforts, apply the Model for Improvement methodology and see if the concept works.
The dentists enjoyed a learning session around improvement methodology, and collaborated to agree an aim around improving the quality and use of medical histories in dentistry. Locally we built a process map so the practices involved could see, and discuss where medical histories matter. We saw a number of areas where a medical history influences treatment planning, for example diabetes, allergies and certain medicines. Dentists, hygienists, nurses and practice managers agreed measures that we could use to track the improvement journey, and to feed into improvement conversations.
The methodology tells us that measurement should continue objectively all the while we identify and test change theories – ideas that may (or may not) result in improvement.
The theories in the model for improvement are logical and simple to use. Say for example, if we need to know if a patient takes a medicine called a bisphosphonate – and we don’t actually ask that question on the medical history form – might it be an idea to change the way we ask for the information? Well it might – but how do we know that any change actually improves anything?

The methodology suggests that we don’t waste time implementing ideas that might not work. So the practices might say, change the form for one patient, and determine if the change worked for that patient. If it did they might try with say 5 patients, redesigning and refining each time. As the theory develops the form is likely to get better, and spread to a wider group. Eventually, if the small tests of change go well, the change might be adopted across the practice. And if the collaboration aspect does its job the change would be available for other practices to try out for themselves.
So six months into this application of the Model for Improvement, I have to say I m completely convinced that it has the potential to deliver small changes that will collectively result in significant improvements, as well as developing the collaborative culture within and across practices.
OK so I am sold on the benefits of the Model for Improvement, and in my role I am lucky enough to spread its virtues daily.
But that’s me. What about you?
What I do see is that when folk are granted permission and have capacity to take part in improvement work – they love it. But rarely is it seen as part of their every day workload, and the skills that make it happen are not often embedded in the team or the individual. So as an improvement advisor it may be that when I walk away the focus on improvement activity can reduce.
So the skills, knowledge and experience needed to take part in or lead an improvement project – do you have them? Do you know what they look like? Would you have the confidence to lead an improvement project – and do you have access to the support that you might want to secure?
I truly believe that these capabilities should form part of everybody’s role. So it is with that in mind that I would love to do myself out of a job. If everybody could do this work, then I would not be needed – right?
What gives me the most pleasure is when I leave the room knowing that the people I work with no longer need an improvement advisor. That they can run small tests of change, that they can measure the effectiveness of, and the variation across processes, and use the results to discuss and promote improvement in their team, and also that they don’t rely on hierarchy to determine whose ideas are considered.
Right now the Patient Safety & Improvement team have a programme on offer called the Scottish Improvement Skills programme where many of these skills are offered. You may have seen the flyers across Dumfries and Galloway. Applications close on 30th June however, so you may need to get your skates on! This is a great way to prepare for involvement in improvement work – and to do me out of a job!
Do I not like my job I hear you ask? Well with my involvement in the dental collaboration I am lucky enough to see this cross fertilisation of capability unfolding before my eyes every day. Now that’s job satisfaction for you. Long may it continue!

Paul Sammons is an Improvement Advisor with NHS Dumfries and Galloway

Tour de Finance by Jeff Ace

This summer, unlike the many thousands of fellow Welsh folk heading south to France for one of our regular appearances in a major football tournament, I decided to head west, then east, then sort of north east. Together with our Finance Director, Katy Lewis, I recently undertook a tour of the region to try to talk directly to as many staff as possible about the challenges we were facing and to hear first hand their experiences and ideas for improvement.

In three days we travelled over 400 miles, met over 400 staff and heard from nurses, AHPs, domestics, GPs, consultants and others on issues ranging as wide as the region itself. At a number of the meetings, it was great to see social work staff in attendance, reflecting our ever closer working relationships.

I asked Katy to open each session with a presentation on the financial situation – my thinking being that pretty much anything I then said would come as light relief. The 2016/17 numbers are grim and substantially worse than anything we’ve faced up until now. In summary, we estimate our costs will increase by around £16.5M in the year (largely driven by drug cost increases and pay / price inflation) whilst the increase in our allocation for health services is around £3.6M. The gap between these figures of about £13M (or 5%ish of our running costs) will have to be found from efficiency savings. This would be a tough ask at the best of times but, as most of you will be well aware, it comes after four years of delivering large annual efficiency savings targets.
And of course the financial problem does not sit in isolation. In each of the discussions across the region we heard of pressures caused by difficulties in attracting staff or by increased service demand driven by an ageing population. At times it felt as though we were describing a perfect storm of crises in money, recruitment and demography that threatened to overwhelm us as surely as Storm Frank had submerged parts of Dumfries.

But just as the pub in this picture was open for business only two days later (it felt longer), things often brightened up pretty quickly in a lot of our discussions. The staff that we met were keen to highlight potential solutions, things that could change services for the better and stand up to our triple challenge.
We’re going to write up the key points raised and create a plan for delivery but some of the common themes were;

• The right I.T. can transform the way teams work, but we need to make it connect faster and more reliably across the region.
• We need to get far better at sharing appropriate information between health, social work and third sector colleagues.
• We need to be quicker at admitting that some vacancies won’t be filled and to redesign and retrain teams to provide services differently.
• Local teams need to be empowered to make locally appropriate decisions and as much resource as possible needs to be devolved to operational levels.
• Coordinated support to teams around improvement techniques and methodologies would be helpful.
• We need to work more closely with carers and families.
• We need to celebrate team successes and better spread their ideas and learning.

It’s also important to remember that we’re not on our own in trying to work our way through the financial, demographic and recruitment problems. In our meetings we highlighted some of the huge amount of work ongoing at national and regional level at the moment to try to identify high quality and more sustainable models of service delivery across Scotland. Two particular strands of work have the potential to help us transform the landscape;

• The National Clinical Strategy (written by Angus Cameron, our Medical Director) sets out a clear direction for closer working between Health Boards aimed at improving safety and effectiveness of care within their wider region.
• The Chief Medical Officer’s work on ‘Realistic Medicine’ points to how genuinely person centred care can lead to better patent outcomes whilst reducing waste and unnecessary expenditure.

So, both locally and nationally, there are grounds for cautious optimism that we can come through these uniquely challenging times in a way that allows our teams to continue to deliver excellent health and care services for our population. It is clear though that to succeed in this, the pace of change around redesign of service models and ways of working will have to be dramatic. Whilst there’ll be a few giant leaps (it’s just over a year until we receive the keys to our new acute hospital…) most of this change will be smaller scale and driven by the local teams that we talked with on our regional tour. Our success will depend on how well we support these teams and ensure they have the skills and confidence to adapt their services in ways that allow us to deal with the financial, demographic and recruitment complexities.
Thanks to everyone who came along to speak to us on our tour.

Jeff Ace is the Chief Executive Officer for NHS Dumfries and Galloway

Inspirational by Eddie Docherty

As the new Nursing, Midwifery and Allied Health Professions Executive Director I’ve now been in post since February 1st. As I write this blog almost exactly 4 months since starting, Id like to use this opportunity to introduce myself to as many staff as possible, and share some of my initial thoughts.

Prior to starting in NHS Dumfries and Galloway I’d worked in a number of health boards. Initially working in NHS Lanarkshire, in critical care and advanced practice, I moved to NHS Ayrshire and Arran in 2007, initially as nurse consultant for the acutely unwell adult, moving on to senior nurse consultant then associate nurse director. During this period I also worked in NHS Orkney as associate nurse director for 8 months, learning about the challenges and rewards of working in a remote and rural setting. For the year prior to commencing in D&G I worked as the lead nurse for East Ayrshire Integrated Joint Board and Associate Nurse Director for Primary care and Community Nursing. I’ve been incredibly lucky in my career, supported and developed by truly inspirational staff throughout the years, and have maintained roles which have allowed for direct patient contact through most of my time in nursing. Working with patients and staff has always been a key priority for me- its why I started nursing.

This link to inspirational staff continues as I’ve moved to NHS Dumfries and Galloway. At the last Twitter conversation held by the Chief Nursing Officer, Professor Fiona McQueen, one of the questions posed was: – What are you most proud of in your current role? I didn’t hesitate in my answer. I spoke of the compassion I see and hear about everyday from the staff in NHS D&G. The value of compassion is clearly embedded throughout our teams, from the Board to the staff directly delivering care to our patients. The key attitude of compassion in our delivery of care is reflected in the shared behaviours and attitudes I’ve seen in the last 4 months and is the springboard for the excellence in care we all strive for. Of course we aren’t perfect, but on the whole, compassion is being displayed. What I would ask everyone is this- are we compassionate to each other? Are you compassionate to yourself? The organisation is in a period of unprecedented change as we join an integrated world and build a new hospital. D&G couldn’t do just one major change at a time! The financial challenge is more acute than ever as we try to do the same, or even more, with less. If we are not compassionate towards ourselves and each other we may find ourselves overwhelmed and begin to lose touch with the reasons we all came into health care? Something to think about.

We often speak of our challenges, but clearly this period brings significant opportunities. I believe that each team hold the answers to most problems within their areas. The ability to adapt and innovate, to find solutions to complex problems, lie within the gift of all of our teams. If empowerment of staff is to truly have meaning then the staff have to feel empowered to enact change. The application of quality improvement methodology and an understanding of the theories of profound knowledge are the survival tools of the 21st century health care team. I have spoken to staff around our areas about the need for innovation and commonly say “The answer is in the room” It usually is. Someone within the area has the exact answer to the problem. If all staff members can see that improvement is something they do rather than have done to them, combined with the skills and understanding of the science of improvement, we can absolutely change the landscape we all work in.

Speaking to senior nursing, midwifery and AHP staff I have been incredibly impressed with the projects and ideas being developed, and in many areas there is great work being done in one key area: patient experience and satisfaction. For many years patient experience and satisfaction have been placed in the ‘nice to do’ category of work. As we move forward it is clear that the patient experiences of our systems are key to understanding how effective we are. There are many great local examples of this, from such areas as mental health, critical care, occupational therapy and medicine, but we haven’t yet shown our ability to do this at scale and share our learning across the entire organisation. I’m confident we will, following the discussions I’ve had with various teams, but it’s not something we can do without anymore. We look at, and report on, complaints as they come in and use them to look at individual areas of improvement, however, working in Scotland, we don’t spend any time looking at compliments and positive feedback. If we can capture the learning points from the good and bad episodes of the patient experience we can gain a better understanding of the impact we have in a balanced way.

I feel honoured to be Executive Director for Nursing, Midwifery and Allied Health Professions within NHS Dumfries and Galloway. Everywhere I look I see staff members that are committed to the care and well being of their patients and who place the person at the heart of everything they do. We have challenges and opportunities ahead of us and I’m absolutely convinced we can shape the future of our services together to meet the needs of our patients and improve the health of our communities.

Eddie Docherty is Director of Nursing at NHS Dumfries and Galloway

 

Change…. Didn’t we do that program already? by Neil Kelly

“The Only Thing That Is Constant Is Change -”
― Heraclitus

How often have we now heard that the challenges we face can only be resolved through transformational change?  It seems we are in a constant state of flux with management structure changes, team developments, policy statements and strategy.  So does it feel as though these changes are transformational? Although we have this feeling of constant reorganisation I suspect we are all still inherently conservative and hope that if everyone else changes then we can keep our own ‘show on the road’.  Our natural anxiety of change being disruptive helps us to keep our heads down and hope that the process will pass us by and things will settle down as they so often have in the past. This defence mechanism has served us well in until now but is about to be found wanting. In Primary Care (as in the whole of the public sector care giving service) we face the ‘perfect storm’ of even increasing demand, a dependence culture generated by our desire to ‘do good’, a crisis of man power with unfilled posts for GPs other clinical staff and especially carers and significant financial pressures which continue having already ‘trimmed all the fat’ over the last 4 years.

It trying to deal with the’ impending dooms day scenario’ we have been doing multiple tests of change, PDSA cycles and participating in all the latest Scottish Government and Health Board initiatives in an attempt to reshape what we do.  We have gathered a lot of information about how good some of these initiatives have proved to be.  However now we seem stuck.  How do we convert all this ‘learning’ into the transformational change we all desire? Certainly our approaches until now do not seem to have delivered for us.

At the core of what we do as a service are the people who are toiling every day to provide the care demanded and recognising the pressures trying to work harder, faster and smarter.  We are literally ‘sweating our assets’. The eternal busy-ness has resulted in silo working and fragmentation of teams.  So we now need to pick up our bits of learning, coordinate our approach to care, re-establish our community based teams and begin a very different sort of relationship with the communities we serve. In Annandale and Eskdale we will establish in the first instance 4 community groupings of health and social care staff with third sector and independent service providers. These groups will work closely with public health teams to better understand the needs, prioritise and plan services more in tune to those needs and negotiate amongst themselves how this can best be achieved.  In other words everyone involved will take a bit more responsibility for what they do.  The users of the service will be encouraged and enabled to care more for themselves, family members will take a bigger role and everyone involved will be geared to working towards those aims.

So how do we make this happen?  We need to invest in and support collective leadership and ownership, allow much more autonomous decision making and allow the team to monitor its own success. This is a change in approach which is just beginning and will be challenging and uncomfortable at times.  It may feel like just another ‘dip in the change water’ but this time it really needs to transform what we do.  This is applicable to everyone and this time there will be nowhere to hide.

“No man ever steps in the same river twice, for it’s not the same river and he’s not the same man.”
― Heraclitus

Dr Neil Kelly is a GP in Annan.