Outpatient Parenteral Antimicrobial Therapy (OPAT) – from Cellulitis to Meningioma by Audrey Morris and Shirley Buchan

OPAT as a service has been in use in many countries for the last 30 years. It is a method of delivering intra-venous antimicrobial therapy in an outpatient setting, as an alternative to remaining an inpatient.

Preparation of a typhoid shot in the medical clinicThe advantages of providing this service for the patient means that they have a reduced hospital stay and can return home and rehabilitate in their own environment. In certain cases the patient can continue to work whilst receiving IV antimicrobial therapy therefore causing them minimal disruption to their daily life. Psychologically the patient feels happier, eats better, sleeps better and is more likely to recover quicker in their own home.

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In DGRI the service started in 2012 under the “What if?” project. Its main aim at this point was treatment of non-complicated cellulitis leading to the reduction of patient admissions for short term IV antimicrobials. In the intervening years we have developed to become more involved with complicated infections requiring longer lengths of treatment i.e. up to 12 weeks of IV antimicrobials, but the patient is otherwise fit enough return home.

 
From January 2016 to the end of March 2017 we have released 1419 beds, an average of 3.2 per day. We have treated patients with Cellulitis, Osteomyelitis, Infected Joint Replacements, ESBL, UTI’s, Pseudomonas, Osteoradionecrosis, Lyme disease, Endocarditis, Discitis, Peripheral Vascular Disease, Actinomycosis, SAB, Urosepsis, E-Coli ESBL and Meningioma.

 

Why do we need OPAT?

 
In December 2015 a 30 year old man, who we will call John, was referred to us. He is a high functioning gentleman with Spina bifida who regularly competes in Shot Putt events, all over the World. He had been admitted 6 weeks previously with an infection of his hip. He was clinically improving and ready for home. His family were also keen for his discharge. On discharge John was keen to return to weekly training but due the nature of his infection this had to be put on hold. He attended the clinic daily for 12 weeks either at Dumfries or nearer his home at Castle Douglas Community Hospital, even attending on Christmas day. John had a Hickman line in-site and he decided that in order to assist us he would dress according to which lumen we were using, red top red lumen white top white lumen. He made a good recovery and was discharged from us a year ago. John still phones us now and again and had informed us he is back to full fitness, competing again and even throwing further than before. His one regret he told us, was that due to illness he was not selected for last year’s Paralympics but he is working hard to go the next event in 2020.
So why do we need OPAT? To give people like John an effective patient-focused service as good as inpatient care in an out-patient environment. Our aim is to provide patient centred care nearer to home. In some cases we train the patient or their relative/carer to administer IV antimicrobials in their own home, leading to increased independence and putting the patient at the centre of their own care.

 
Main aims of OPAT.

 
Clinical
To provide a high quality efficient clinical service using robust pathways, guidelines and protocols.
Reduce inpatient time and therefore reduce the risk of hospital acquired infections.
Develop the service to meet the changing demands on an overstretched service. With the opening of the new hospital imminent and the call for care nearer to home OPAT can help reduce demands on beds.
Patient.
image3Improved quality of life for patients. They eat better, sleep better and generally feel better in the own home environment.
Increase patient involvement in delivery of care, continuity of care and communication.
Provide ongoing support at home and utilise a pathway for re-admission if required.
Organisational.
Reduce the length of inpatient stays therefore utilising acute beds more efficiently.
Structured pathway from referral to discharge.
Staff development.

Patient journey from Inpatient to OPAT patient.

 
We aim to make the transition from inpatient to OPAT patient as quick and painless as possible but have to follow guidelines. Once a patient has been identified by their Consultant as a potential OPAT patient the first step is to complete an SBAR referral form (In Beacon use ‘search for document’ option). On receipt of this we visit the patient to assess them and their needs for OPAT. There are certain criteria which must be met but these are listed on our SBAR referral form and should be considered prior to referral.
The patient is then seen by our Consultant and the OPAT nurse team. If they are suitable and want to become an OPAT patient then the discharge process can begin.
So in summary OPAT provides patient centred care led by a small dedicated team. It clearly reduces the length of inpatient stays, which can be from 2 days to 12 weeks. Patients are very much involved in the method of delivery of their care, they can opt to be trained to do it themselves at home or we try to deliver care as near to their home as possible. We work around their commitments e.g. an elderly patient who has carers in the morning can get a later appointment or in the case of the patient who continues to work we can see them early in the morning to allow then to get to work. Patients feel better at home, they sleep better, eat better and psychologically feel better. They are more in control of their treatment and have continuity of care.

In the words of one of our patients we “made a bad situation better”.

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Audrey Morris & Shirley Buchan are Clinical Nurse Specialists in the OPAT team.

The QI Hub by Wendy Chambers

 

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Wednesday 19th of April – Marks the official launch of The Quality Improvement Hub for Dumfries and Galloway

Our vision: To support health and social care staff to design and deliver services that better meet the changing needs and aspirations of people, families and communities that access care.

The purpose: Quality is everyone’s responsibility. We aim to build a culture where continuous improvement is the norm and develop a network to share resources, learn and work together, to make it easier to do the right thing at the right time, every time.

Wendy C 2The QI Hub is a creative space where you can connect with others throughout health & social care, people with a passion to make a difference. Thinking space, away from the hustle & bustle that is daily life!! Come and find a supportive network of colleagues, share experiences and learning. Choose from a library of resources and practical tools to help structure your improvement projects and explore development and coaching opportunities.

Wendy C 3Building capability and capacity to lead improvement is vital, it empowers people and teams to own change; one resource available is a locally delivered Scottish Improvement Skills Programme. To illustrate how this is already having impact Wendy Chambers, who has recently graduated from Cohort 1, shares her reflections.

3 lessons from Scottish Improvement Skills (SIS) in D&G

Having recently completed cohort 1 of the SIS course in Dumfries, with a project that hasn’t gone quite according to plan, I thought I’d share 3 things I’ve learned along the way.

Lesson 1 – I’m not alone

I’ve always been comfortable questioning my own clinical practice; to be honest I ask “why” and “how” about most things in life; it drives my other half, and now as a parent I can appreciate must have driven my parents, mad! For me though questioning things is a reason why I get out of bed in the morning and keeps my job interesting and challenging. But in my 20 plus years of clinical practice, in many different settings, I’m acutely aware that not everyone thinks as I do…. then came SIS.

I walked into a room, filled with 30 other people, on the first day of the course and I felt like I had arrived, I’d come home! These were my people, this was my tribe – we spoke the same language, had the same fire in our bellies and were comfortable with the “what if …” questions!

Wendy C 4Being surrounded by similar and like minded people; learning from each other, sharing ideas, both the things that go well and the things that fail – I’ve come to appreciate that this support is essential to the process of implementing and testing change ideas. Because when I go back out into the real world, with all its pressures and realities, the natives won’t necessarily be as welcoming or receptive to my “bright ideas” and things won’t feel as cosy.  So now I won’t be alone, I’ve found my tribe, I’ve found support.

Lesson 2 – “Whose project is it anyway?”

The SIS course has given me an opportunity to consider and reflect on the process of implementing a change idea from conception through, in theory, to completion. And one of the fundamental pieces of learning for me has been – it’s all about the relationships; the people who I need to work with and who need to work together cohesively, in order to try things out.

None of us like, or take kindly, to being told what to do, regardless of how much positive evidence there may be that it’s the right thing to do. We all like to feel and be in control of our own destiny and decisions, try things out and discover for ourselves – and I’m no different from anyone else, in fact I’m possibly worse!

A change project idea that one person has come up with is exactly that – it’s their idea, their project.  It doesn’t, at that point, belong to the team for whom it is intended will be the “willing” guinea pigs to trial and develop the ideas. At that point it is “my project, not yours” and “your project, not mine”.

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I’ve had the opportunity to reflect on my current and also previous projects, consider and question when I’ve done this well and a team has taken on board an idea and really owned it and made it their own and when it has most definitely remained my idea and no one else has bought in.
And my reflections go back to the relationships and the time that I have spent in this part of the process as a whole. And I realise that the time spent in the planning, alongside and with the others who will be involved and affected by the change idea is essential to the process, not the icing on the cake.

This isn’t new, or rocket science, any leadership book or workshop will include this – but we rarely have the luxury of “thinking space” to reflect on our learning.  And having a space, such as the SIS course, where failure is seen as valuable a part of learning as success has been enlightening, reassuring – it feels like home.

Lesson 3 – Skills

Apart from the thinking and reflection space the SIS course has also given me an opportunity to learn some real, practical skills and to relearn some old ones. I feel as if I now have a working toolbox of things which I can use and try out next time around, and every time around, when my next bright idea pops up.  I also have access to a whole tribe of people who can help me when I get stuck – which I will.

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Old dogs, New tricks, nothing new under the sun.

But in the current health and social care climate things have never felt so uncertain, it’s all about change and innovation. We are all being expected to get comfortable in a world which is full of discomfort and will be constantly shifting. In this world my learning and reflection would be – get skilled, take time building relationships, find your tribe!

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Wendy Chambers is  a Mental Health Occupational Therapist and AHP Practice Education Lead at NHS Dumfries and Galloway

The QI Hub is for you and your team and you’re invited to actively contribute. Your ideas, knowledge and experiences are crucial to ensure the hub provides what you want!

Join us on Wednesday 19th April 2017, Conference Room, Crichton Hall. Programme and registration available by contacting Stevie.johnstone@nhs.net

QI Hub Development Team

Improving Patient Flow by Chris Isles

Dave Pedley gave an excellent talk two Wednesdays ago on Tackling Crowding in Emergency Departments, triggered no doubt by the number of times recently we have been running at 100% bed occupancy with patients sitting in chairs in the Emergency Department because there were no free cubicles.

The nightmare scenario for us all as the clock ticks inexorably towards December 2017 is that the same thing happens when our fabulous new hospital opens and the TV cameras, newspapers and journalists begin to salivate at the prospect that something goes wrong (there will be no story to report if the transition to the new hospital goes smoothly and there are no corridor patients).

The chances that something could go wrong are actually quite high and the problem is almost entirely medical by which I mean the large number of frail older people living precariously in the community who fall, become immobile, incontinent or delirious and require at least some form of assessment but often admission to hospital.

The omens are not good.  Dumfries and Galloway has the second highest proportion of people in Scotland who are aged 75+ and living alone.  Our Health Intelligence Unit have shown that despite numerous initiatives and new ways of doing things the Medical Unit would be sailing perilously close to 100% bed occupancy if we moved into the new hospital today. (See me previous blog on the new hospital here)

During his talk Dr Pedley showed a powerful 5 minute video by Musgrove Park Hospital in Somerset entitled Tackling Exit Block ie their hospital’s inability to move patients through ED because of numerous interrelated system failures.  (https://youtube/WX1YwKIkWzA).  Musgrove Park ‘s Top Ten Reasons Why People Cant Leave Hospital were as follows:

  1. Discharge delayed so patient can have lunch
  2. Carer/relative can’t pick them up till after work
  3. Nurses too busy looking after other patients to arrange discharge
  4. Waiting for transport or refusing to leave without free transport
  5. Waiting for pharmacy
  6. Waiting for ward round
  7. Waiting for blood or scan results
  8. Waiting for discharge letters
  9. Packages of care planned for late afternoon/early evening
  10. Patient doesn’t want to go to the assigned bed in community hospital

During discussion a number of solutions to our own recurrent difficulties with patient flow were proposed.  These included tackling all of the above in addition to attempting to educate the public about when and when not to attend ED.  My own view is that this might be as fruitless as King Canute sitting in his throne on the beach and attempting to stop the incoming tide on the grounds that any patient who comes up to ED and is prepared to wait up to 4 hours and possibly more to see a doctor or a nurse must feel they have a very good reason to be there (one often quoted reason being that they could not get an appointment to see their GP).

There were some illuminating moments.  We asked Patsy Pattie whether Dynamic Daily Discharge was still as effective as it had been when it was first rolled out.  She replied that some wards needed support on embedding the process.  Dr Pedley praised staff for their firefighting skills on those occasions when patients were unable to access cubicles in ED which prompted Philip Jones, our chairman, to say that a corporate rather than firefighting response was needed.  Many heads nodded in agreement.

A corporate response might mean fixing lots of little things in order to make patients flow through the system more speedily.  Dynamic Daily Discharge could then become an established part of ward routine rather than an optional extra; the paperwork in the medical assessment area might need to be simplified to allow nurses to move patients into the body of the ward more quickly; a nurse on each ward might be designated to carry the ward phone rather than allow it to ring endlessly in the hope that someone else will pick it up; clinical teams would actively consider how patients might get home;  consider community detox for alcohol withdrawal; patients earmarked for discharge might move to the dayroom unless physically unable to do so; hospital taxis might take people home if relatives or patient transport cannot do so; patients could be issued with a prescription to take to their local pharmacy if new medications are required or go home with immediate discharge letter to follow if not.

To these solutions I would add fully funded Ambulatory Emergency Care and Comprehensive Geriatric Assessment services together with more and better social care and a commitment to fill the hospital with more staff on public holidays (of which there will be four within one month of the new hospital opening).

The Chief Executive of Musgrove Hospital finished her contribution to the Exit Block video by saying ‘we need every single member of staff to understand their responsibility in ensuring patients flow through our hospital so that we can discharge them home as quickly and as safely as possible’.  Who could disagree?

Professor Chris Isles is Sub-dean for Medical Education and is a Locum Acute Physician.

To Err Is Human by Maureen Stevenson

‘To Err Is Human’, to cover it up or fail to learn unforgiveable

It is now nearly 20 years since the Institute of Medicines (IOM) seminal work ‘To Err is Human: Building a Safer Health System’, raised our collective conscience about the scale of harm in healthcare and that the majority of factors that give rise to error are systemic in nature.

maureen-1As we take our first tentative steps into 2017 and begin to think about how we might improve our work, work off those excess pounds and gain a new level of fitness and wellbeing (or maybe that’s just me!) it is important to reflect what has been achieved and what we will take forward into 2017:

  • A new Hospital
  • Integration of Health and Social Care
  • Development of a local Quality Improvement Hub

Whilst these might be strategic in nature there are many equally worthy service, team and individual achievements to be proud of, each one of them contributing to the wellbeing of many thousands of people, families and communities.

On a personal note I was very humbled to be able to accompany my Mum to an Alzheimer’s Scotland Christmas Tea Dance. In my head I had so many other callings on my time and attention, I rushed from a meeting straight into ‘the hokey cokey’ to truly learn ‘what it’s all about’ – people, compassion, caring and having fun. Wouldn’t it be lovely to retain that special feeling all year and to remember why we do the work that we do?

My blog today is about Human Factors. Human Factors (Ergonomics) i.e. the study of human activity (inside and outside of work). Its purpose as a scientific discipline is to enhance wellbeing and performance of individuals and organisations. The key principles are the interactions between you and your environment both inside and outside of work and the tools and technologies you use.

In my role as Patient Safety and Improvement Manager I have the great privilege of supporting individuals and teams to develop the capability to improve the quality, the safety and effectiveness of care. However, I also oversee our adverse event and learning systems which all too often highlight the failings in our systems and in our interactions with those sometimes very complex systems. Human Factors and ergonomics offers an opportunity for us to understand the interactions of humans working within often imperfect and messy systems. People who most of the time make the correct choices and decisions in difficult situations with incomplete information to help keep patients safe.

New thinking suggests that we should look at the actions and decisions that help keep patients safe and not only those that result in harm. If we were to support teams to understand the thinking and the behaviours that keep people safe we might enable a more resilient workforce able to vary their response to challenging situations.

Often the design inputs and processes related to the workplace fail to adequately take account of human abilities and characteristics, making it inevitable that failures will happen (and happen again). We know that many patient safety incidents across all health and social care sectors are directly related to a lack of attention to Human Factors issues such as the design of everyday work tasks, processes & procedures; equipment and technologies, organisation of work and working environments.

We would all agree that safe care delivered to a high standard is what we look for in a health and social care setting, and most of the time we achieve just that. Tremendous gains have been made in eliminating infections from our Intensive Care Units by standardising work practices and improving team communication. Improvements in Medicines Reconciliation have been seen across Primary and Secondary Care and work is currently underway to reduce pressure ulcers across our care system but how can we simultaneously improve efficiency and effectiveness and care that is delivered in a way that considers the needs of the recipient and the caregiver. Might a review of Human Factors help?

Human Factors (Ergonomics) can contribute to achieving this as it involves learning about our characteristics as humans (e.g. our physical size or strength, how we think and how we remember things), and using that understanding to improve our well-being and performance through the type of work we do, the tools and equipment we procure to do it and who we do it with.

The environment, the culture, our communication processes and leadership impact on system performance as they impact on how people perform. Understanding how improvements in one part of our system might be spread elsewhere will require careful attention to all of these factors.

To achieve a culture that is just and fair we have to take account of Human Factors, we need to understand what safe, effective person centred care looks like and be able to replicate the conditions that enable it to survive and thrive.

I’d like everyone’s Mum to experience the joy of care, apparently effortlessly given that accounted for her health, her care and her emotional needs. I’d like to extend a huge thank you to all the health and care staff and volunteers who together make that possible in very difficult circumstances.

My ambition for the year ahead is for us to become more proactive in our pursuit of safety , to understand what we might learn from when things work well and how that might impact on how we support individuals and teams to learn and continually improve. Safety II as this shift is being referred to will require a shift in our thinking and in how we behave. The table below highlights how we might begin that shift from Safety I to Safety II.

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As humans we bring our whole self to work, so let us use all of our resources and resourcefulness to enhance the safety and the experience of care. Nothing is more satisfying than bringing joy to those you work with whether they be your co workers or the patients and their families you care for.

Maureen Stevenson is the Patient Safety & Improvement Manager at NHS D&G

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Daily Dynamic Discharge (DDD) by Patsy Pattie & Carole Morton

“Daily Dynamic Discharge is to improve the timeliness and quality of patient care by planning and synchronising the day’s activities”.
(The Scottish Government, Edinburgh 2016)

The 6 Essential Actions for improving unscheduled care was launched in 2015. The 6 actions were identified as “being fundamental to improving patient care, safety and experience for the unscheduled pathways”. One of these actions is “Patient Rather Than Bed Management”. This approach requires the multi disciplinary team working together to plan and synchronise tasks required to ensure a safe dynamic discharge process, aligning medical and therapeutic care, discharge earlier in the day and transfer back to the GP in time, reducing the length of stay in hospital.

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Why do we need it?
The recent day of Care Audit in September 2016 indicated that 30.5% of patients in hospital beds did not require acute hospital care. These patients should have been transferred to another area for continued care or discharged home.
For some health professionals, too many conflicting demands on time often results in optimising work in such a way that may seem logical to the individual, especially if you are covering across wards, but may not be optimal for patient flow. This mis-synchronisation can cause delays and increase the length of stay for patients. Where there is a clear priority of order of tasks for that day, each individual team member plays their part in ensuring the priority tasks for patients is actioned or completed, which works for the patient, thus reducing delays in discharge or transferring the patient.

Who is doing it?
Ward 10 was nominated as the Exemplar ward for DGRI and implementation commenced in early September 2016. Early indications show that time of day discharges are taking place earlier in the day around mid afternoon. Prior to the introduction of DDD 27% of patients had been discharged by 4pm, in the four weeks since implementation the figure has almost doubled to 49%.

When are we doing it?
Each DDD ward huddle usually takes place at 9am each morning. Some wards have incorporated a DDD catch up meeting into their afternoon handover huddle.

What are the benefits?
The DDD approach promotes proactive patient management for today and preparing for tomorrow’s activities i.e. increase accuracy on our discharge position and increase awareness of the need to create capacity at key points throughout the day.
This is aligned to The Royal College of Physicians acute medical care “The right person, in the right setting – first time” (please see link below).
https://cdn.shopify.com/s/files/1/0924/4392/files/acute_medical_care_final_for_web.pdf?1709961806511712341
A recent quote from Vicki Nicoll, SCN ward 10:
“DDD for us has had such a positive impact on the ward as we are finding patients are being seen by all members of the Multi Disciplinary Team (MDT) in a timelier manner.  The patients are being discussed rather than going from one weekly Multi Disciplinary Team meeting to the next.  Interventions are being done more timely from all members.  We have noticed that length of stay has reduced and patients that you would normally presume would be with us for some time seem to be getting home quicker. We recently had a patient who was a complex discharge and I personally thought the patient would have passed away in the ward, but everybody pulled together and we were able to return the patient home.  Sadly, she passed away at home, where she wanted to be with her family”.

“DDD has taken away the thought that nurses should do everything when in fact it is everyone’s job to work together to ensure that the patient is on the right pathway”.

DDD is currently being rolled out to most of the acute wards in DGRI and a test of change commenced on 21st November in Annan Community Hospital. Implementation at the Galloway Community Hospital is planned for mid December.

We all have our part to play in the planning of a safe discharge for our patients, DDD enhances our current processes, promoting an MDT approach with teams working collaboratively and more robustly.

Patsy Pattie works in the Acute Services Improvement Team and Carole Morton is an Assistant General Manager Acute Services for NHS Dumfries and Galloway

Let’s insist on the possible by Valerie Douglas

Many things in life are complicated, require great debate and despite huge resources are not guaranteed to be successful in practice. There are other things which are simple to understand, can easily be implemented and immediately make a difference to improve lives or in some cases save lives. You only have to think of the meaningful campaign to change the care of people with a diagnosis of dementia led by Tommy Whitelaw (Tommy Whitelaw @tommyNTour). It makes sense and it hits you in the heart. As a professional you cannot listen to Tommy talk about caring for his mum and withhold your support for this campaign. His mum is your mum.

Another example is Kate Grainger’s inspirational campaign (#hellomynameis). This focuses right in on the doctor/patient relationship. It goes further than just making us think more about face to face contact with patients who may feel vulnerable, distressed and in alien surroundings. It asks us to look at our practice on a basic level, to say our name aloud, on every contact. At one point this patient was Kate Grainger but the patient could be any one of us.

Last November an important, widely supported campaign for the mandatory teaching of Cardiopulminory Resuscitation (CPR) to schoolchildren was unsuccessful. This Emergency Bill was opposed despite irrefutable evidence that it saves lives. In Norway it has been compulsory for schoolchildren to be taught CPR since 1961 and survival rates are double what they are in the UK. As out-of-hospital cardiac arrest is the commonest life-threatening emergency in the UK so I thought this campaign was bound to be fully supported and unchallenged. You can imagine my disappointment.

I felt at a loss about what to do next, yet felt there had to be a ‘next’. To increase survival rates of cardiac arrest the immediate action of bystanders is crucial. Personally I have carried out CPR three times, twice in a hospital setting and once at a family event. A day of laughter and pleasure turned into tragedy. Event though, as a nurse, I’m aware that the outcome from CPR is variable for a myriad of reasons, I was left affected by this last experience. Then a doctor said to me, “If I had a cardiac arrest I would want someone to have a go.” I am glad I have been taught CPR and am able to ‘have a go’, otherwise the most I could have done that night would have been to phone an ambulance instead of giving a friend a chance of life.

What could I do now? I decided to put together a resolution to RCN Congress 2016 calling on governments to mandate the teaching of CPR to schoolchildren (the remit of the Emergency Bill had been wider, encompassing all kinds of First Aid). The resolution was accepted and I presented this in June this year.

There were wide ranging contributions to the debate. Personal stories were shared about children delivering CPR successfully. A delegate told us about a situation where his 27 year old teammate collapsed during a game of football. 23 players including the referee were there and nobody knew how to do CPR; this man died. He went on to describe a more recent experience when an instructor was brought in to teach CPR to the junior football team. Within 10 minutes they were doing it perfectly.
Some delegates expressed concern about the effect on children if they delivered CPR and it was unsuccessful. Others answered this by saying: remove the fear, teach them young. The evidence is there. Someone else highlighted again that encouraging CPR lessons in schools as an add option is not enough; teaching needs to be a requirement so that there is no national disparity. Kate Ashton made a very acute observation at Congress:
“If we can educate youngsters in schools about sex education and creating life then surely we can educate them about saving lives.”

Every year an estimated 60 000 out of hospital cardiac arrests occur in the UK (BMJ 2013;347:f4800) It could happen to any one of us. What can you do?
Write to your local MP and express your support for the campaign to mandate teaching of CPR.
Become a local First Responder.
Find out if your town/village has a defibrillator and where it is kept.
Ask your school if the teaching of CPR is on the curriculum.
Let’s insist on the possible.

Valerie Douglas is a Staff Nurse in Mental Health at Midpark Hospital, NHS Dumfries and Galloway

Why wont MY ‘thing’ go viral? by Ros Gray

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Dreams are made when your great idea gets out there in this social world and goes viral. The very thought that thousands of people (likeminded as you) are looking at your good idea and thinking – “That’s a great idea, I could do that”
especially in our health and social care world when it isn’t necessarily the idea that’s new (although sometimes it is) but the ability to engage others to get them to follow your lead, for the benefit of patients and families.

So when things take off in this way, is it just good luck, or is there something we can learn? How does a good idea move from being MY great idea to something that a lot of other people want to do too?

In his New Yorker article ‘Slow ideas’ Gawande started my thinking on this topic (and a million other things!) when he discussed the evolution of surgical anaesthesia compared with the uptake of antiseptics to prevent sepsis. He described how the former spread almost worldwide in 7 years, the latter taking more than 30 years (and you might argue that the inability to clean our hands consistently even today means that we still haven’t cracked it).
It’s easy to imagine the difficulty undertaking any surgical procedure on a patient not anaesthetised (not least for the patient) – having your colleagues hold down the poor patient until such time as they (hopefully) passed out with the agony of the ordeal. Then you hear of an innovation where the patient inhales a gas and goes gently to sleep, allowing the procedure to be done with ease – a no brainer in terms of its likelihood to be adopted by others… and swiftly! The action of holding down the screaming patient and wrestling to undertake the procedure was clearly very personal and real for all those present.
However, the use of antiseptics to prevent an infection that the practitioner might never even see personally, leaves a lot to the imagination and limited personal cost, with the exception more latterly of professional reputation and in some quarters accreditation.
This situation was also exacerbated by the unpleasantness of the environment, where the practice of good antisepsis in the early days meant that theatres were gassed with antiseptics, hands scrubbed raw with early chemicals – all to prevent something that the practitioner might never witness… Perhaps, then, it’s easy to see why that adoption took longer than 30 years. Or is there more to it than that?

Gawande’s article goes much further and is very thought provoking but he fundamentally sets out how, if we want our ‘thing’ to be taken up by others at scale, then “…technology and incentive programs are not enough. “Diffusion is essentially a social process through which people talking to people spread an innovation,” wrote Everett Rogers, the great scholar of how new ideas are communicated and spread.”
He goes on to say that while our new social world can get the ideas out there
as Rogers showed, “…people follow the lead of other people they know and trust when they decide whether to take it up. Every change requires effort, and the decision to make that effort is a social process.”

I think these might be key concepts for us to consider with our personal improvement efforts. How hard do we make it to do the right thing?

Looking around at some other recent great ideas gone viral that I have become aware of – I thought it might be helpful for us to take a closer look at these and consider their spread from this perspective – I thank Delivering the Future Cohort 11 for their help with my developing thinking #DTFcohort11.

And also to consider how would the business world more broadly consider this issue?
Great marketers certainly start with two concepts that absolutely relate to our world and reflect Gawande’s thinking:
Know your audience
and
Make an emotional connection.

So looking at 3 examples of great ideas that have gone viral a little closer to home, can we identify the critical success factors that made them work so that we can apply that learning to our own work?

Case 1 – What matters to me

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Who Jennifer Rodgers @jenfrodgers Lead Nurse for Paediatrics NHS GG&C
What What Matters To Me (WMTM)

WMTM is a 3 step approach

1 Asking what matters

2 Listening to what matters

3 Doing what matters

Why “Clinicians, in turn, need to relinquish their role as the single, paternalistic authority and train to become more effective coaches or partners — learning, in other words, how to ask, ‘What matters to you?’ as well as ‘What is the matter?’”
Where Yorkhill Children’s Hospital Glasgow – global
When Last 4 years
How Originally Jens’ Quality and Safety Fellowship project, building on the concept of Lauren’s list in the USA; national and international presentations, Used the Model for Improvement as the improvement method. Started by asking one child to draw what mattered to them, and staff making every effort to include and react positively to this information –  now used routinely as part of the paediatric admission process. Spread includes other specialties such as the Care of Older People and those with Dementia.

Case 2 Hello my name is…

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Who The sadly very recently deceased Kate Granger (http://hellomynameis.org.uk @grangerkate) a young doctor battling at the time with terminal cancer, made observations about the human interactions she was struggling with at a very vulnerable time.
What Kate decided to start a campaign, primarily using social media initially, to encourage and remind healthcare staff about the importance of introductions in healthcare.
Why She made the stark observation that many staff looking after her did not introduce themselves before delivering her care. She felt it incredibly wrong that such a basic step in communication was missing. After ranting at her husband during one evening visiting time he encouraged her to “stop whinging and do something!”
Where NHS England – Global
When Last 3 years
How Twitter campaign initially – #hellomynameis has made over 1 billion impressions since its inception with an average of 6 tweets an hour.

Kate has left an incredible legacy with #hellomynameis that will continue to impact positively for patients.

Case 3 The Daily Mile

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Who Elaine Wylie – Headteacher (recently retired) St Ninian’s Primary School, Stirling

thedailymile.co.uk

What The aim of the Daily Mile is to improve the physical, emotional and social health and wellbeing of our children –regardless of age or personal circumstances.
Why It is a profoundly simple but effective concept, which any primary school or nursery can implement. Its impact can be transformational- improving not only the childrens’ fitness, but also their concentration levels, mood, behaviour and general wellbeing.
Where St Ninian’s Primary School, Stirling – global
When Last 3 years
How The Daily Mile takes place over just 15 minutes, with children averaging a mile each day.

Children run outside in the fresh air – and the weather is a benefit, not a barrier. 

There’s no set up, tidy up, or equipment required.

Children run in their uniforms so no kit or changing time is needed.

It’s social, non-competitive and fun.

It’s fully inclusive; every child succeeds, whatever their circumstances, age or ability.

Elaine demonstrated huge impact on eliminating obesity in her primary one class that had stated the Daily Mile in Nursery.

In each of the cases the idea started with one individual who had a simple, sensible, not necessarily unique idea, but certainly something that was a bit different from the status quo – perhaps even challenging and making the status quo uncomfortable.
Each leader had a degree of power and autonomy in their local context, for Kate this was as an informed patient, so some might argue her ability to influence would have been limited.
Each idea was simple and easy to try in different arenas.
Each was free or relatively low cost to implement, even at scale.
The impact on patients or children was obvious or in the course of early testing clearly demonstrated.
Each leader used social platforms as a spread mechanism.
In every case, the idea clearly feels like it was the right thing to do, or scandalous that it wasn’t happening routinely, something each of us would want to happen if we were the subjects in question. Perhaps even the standard we apply every day in our professional or personal lives and assume that everyone else does too.
So clear evidence to support Rodgers view that “Diffusion is essentially a social process through which people talking to people spread an innovation,” – Perhaps the easy access to social platforms in these cases made ‘people talking to people’ helped in these cases?
Each leader knew their audience and played to that strength – but also and perhaps most importantly in each case, the emotional connection is huge, but each from a very different perspective.
Is the emotional connection the critical success factor in these cases – and something we should consider carefully if we want our work to spread?
Which emotions might you tap in to when trying to engage folk in your great idea? Emotions described in pairs of polar opposites might give you some food for thought and a place to start with your great idea:
Joy or sadness
Anticipation or surprise
Fear or anger
Disgust or trust

You will have many more thoughts than time permits here, but I leave you with a thought of mine… perhaps we all have an opportunity to use a more considered approach to the scale up and spread of good intentions by learning from those that have done that well.
If not you, who? If not now, when?

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Simple checklist
How simple have I described my great idea – Have I got my 1-minute ‘elevator pitch’ worked out to easily influence others?
Does it feel the right thing to do?
Is it relatively cheap or free? If not who will fund the idea, now and then at scale?
Am I convinced that it isn’t happening to every patient/family every time, reliably? Do I have the data that proves that?
Do I have the power to influence, or if not, who do I have to get on board?
Do I have the data and story to describe how it works and how easy it is to adopt, including the impact?
What social platform for spread will I use?
Which emotions are triggered, or will I aim to tap in to, in order to engage people to want to do things differently?

Ros Gray recently retired from her post as National Lead for the Early Years Collaborative. Prior to that post she was Head of Patient Safety for Healthcare Improvement Scotland.