An Uncertain Future by Ken Donaldson

Well, that’s been an interesting few months, hasn’t it!! We all watched with fascination as Covid spread across the Globe – China first then Italy and Spain – before it hit our shores and started creeping towards Dumfries and Galloway.  Everything changed. We were told to stay at home, avoid loved ones we didn’t live with, only go out if necessary and our work was transformed. Many people had to ‘Shield’ at home and could no longer work. Those still coming in found their working day turned on its head; perhaps completely new duties or sitting in front of a screen all day. But there was one thing I am pretty sure was felt by everyone; fear.

I was terrified. Terrified of how many people were going to get sick, terrified of how many may die, terrified for our frontline staff who were putting their lives at risk. I was also terrified for my own family and loved ones and, whilst this may sound selfish, I was terrified that I would fail in my job. This felt like a big test of leadership. Was I up to the task? Was D&G at risk because I was about to fail.  Many sleepless nights followed.

However it all looks different now. We have survived the first peak of Covid and, in general, we have gotten off fairly lightly. Our colleagues in the Critical Care Unit and Care Homes may disagree as those two areas have experienced a significant impact from the disease but, as a region, the numbers were nowhere near what we expected and whilst this may be down to our rurality it also reflects how all of us have adhered to social distancing and isolation and stopped the spread.

So what happens now? Lockdown restrictions will start to ease, people will be out an about and there is the strong possibility of a second wave. However there is no doubt that we are much more prepared for that and have systems in place to deal with it should it come. But social distancing is here for some time and we all need to think how we are going to deliver our services for the people of D&G in this uncertain future.

Things have changed and one message I would like to share today is that we cannot go back to what we had before. It quite simply wasn’t working and if we have demonstrated anything in the past 3 months it is that we can deliver healthcare in 2020 in a very different and more efficient way. We don’t need face to face consultations all the time, we don’t need to admit so many people to hospital, we don’t need lots of different steps before a patient interacts with the professional they need to.

There was one other noticeable change when all this kicked off; we all pulled together like never before. Many petty differences which had prevented progress vanished. People reached out to help each other (virtually or 2m apart, of course!) and it was obvious that we genuinely cared about our colleagues. There was really no need to use the phrase ‘We are all in this together’ because we all inherently knew that was the case.

So while the dust settles and we look around at the ‘New Normal’ let us not go back to what we did before. Let us embrace new ways of working and talk to our colleagues about how we do it together. Let us do the right thing for our population.

“A crisis can create an opportunity to learn and build a better way forward. The system that will emerge on the other side of the crisis is shaped by those leaders who are able to harness the potential in the moment and galvanise others to act.”

John Sturrock 2019

Ken Donaldson is Executive Board Medical Director for NHS Dumfries and Galloway

With thanks to Charles Mackesy for the image.

 

 

 

Innovation through Compassion by Ken Donaldson

Last week Jeff Ace introduced us to SAM, the Sustainability and Modernisation Programme, that NHS D&G are launching to address the complex and challenging landscape that faces the NHS today; increasing demand, reducing workforce and financial constraint. We started touring the region this week, meeting with teams to discuss these issues and ask them for their thoughts and ideas. It has been energising to hear from you all, there are lots of really good and simple ideas as to how we can change, but it is also apparent that there are many significant obstacles that it will take time to overcome. 

Lets be honest, working in healthcare today is really tough. We all know ‘winter is coming’  when in reality it never went away. Our recruitment challenges extend well beyond medics now with difficulty filling nursing, AHP and other professional posts. Beds are blocked, shifts cant be filled, and so on. What do we do? 

The following is a quote from a Kings Fund paper titled “Caring to Change’. 

“Only innovation can enable modern health care organisations and systems to meet the radically changing needs and expectations of the communities they serve. While adequate financial support is a necessary precondition, it is clear that more money on its own, without transformative change, will not be enough.”

Two words stick out to me, Innovation and Transformation. Both are necessary, both are hard, especially when we are busy, but both can be fun if we work together and support each other to deliver them. Done well they can make our lives less busy and our patients care safer and more person centred. But how can we achieve this? I know many people reading this will be thinking ‘Well, fill all our vacant posts and that will solve the problem’ and they may be right, but we know that is not easy and, whilst we cannot take our eye off the recruitment challenge, we need to do something else. 

There is a growing body of evidence showing that a different form of leadership can achieve cultural change and provide the environment that can lead to innovation and transformation. This leadership focuses on compassion. By compassion I don’t just mean Kindness and being nicer to each other (although I will come back to that at the end). So what do I mean?

Compassion can be understood as having four components: attending, understanding, empathising and helping.

Attending

If I am going to lead with compassion then first I must be present with you, pay attention, I have to Listen with Fascination. This may sound obvious but is not as easy or common as it may sound. Too often people listen with minimal interest. They clearly are waiting for the talker to stop so they can get their point across. Listening with fascination means giving your all to the person you are attending. Really hearing what they are saying so that you can fully understand their point of view. 

Understanding

If we truly listen to others then we can start to understand their point of view, what is causing this persons distress, angst or worry? It is only by fully understanding that you can apply the third aspect; empathy. 

Empathy

I have heard several people say that it is impossible to truly empathise, how can we feel what others feel when they are a complex mix of experiences and values that differ from our own. This may be true but if we listen and understand their problem then, at some emotional level, we can feel their distress and share their feelings. Then we will be driven to the fourth aspect, the motivation to help. 

Helping

Wishing to help doesn’t have to mean ‘give me your problem and I will sort it’ but thoughtful and intelligent action to address the individual or teams issues. More  ‘what can I do to support you, what do you need or who do you need to talk to to solve this problem?’ Providing reassurance that different ways of working, innovation & transformation, are welcome and will not be criticised and blocked or, if things don’t work, there will be no accusation or blame. 

To create a compassionate culture, one in which we can thrive and transform our services, then we all need to demonstrate these simple behaviours. I urge you to ‘Hold the Mirror up’ to yourself and consider your behaviours not others. What can you do to improve your service, not what others can do to improve theirs. 

Every interaction, every day, shapes our culture. The ‘leaders’, and by that I don’t just mean ‘management’ but all in senior positions, have a particularly powerful role in this. What they say, pay attention to, monitor and reward communicates what is valued by our organisation. As leaders if we pay attention to our teams, listen, understand,  empathise and seek to help then we are a step closer to the high performing, innovative and transformative teams that we need to get us through the difficult times. 

To quote Michael West, a founder of Compassionate Leadership….

“Virtually all NHS staff are committed to providing high quality and compassionate care. They represent probably the most motivated and skilled workforce in the whole of industry. However, we impose on them a dominant command and control style that has the effect of silencing their voices, suppressing their ideas for new and better ways of delivering patient care and suffocating their intrinsic motivation and fundamental altruism. Released, their motivation and creativity will ensure commitment to purpose and performance. 

Compassionate leadership means creating the conditions – through consistently listening, understanding, empathising and helping – to make it possible to have tough performance management and tough conversations when needed. Staff complain they only see their leaders when something goes wrong and that even if they do listen, nothing changes after the conversation. Compassionate leadership ensures a collective focus and a greater likelihood of collective responsibility for ensuring high-quality care.”

There is a lot more to Compassionate Leadership. Figures 1 and 2 demonstrate some of this which I will explore in a future blog. If you wish to find out more of this yourself you can listen to a presentation from Michael West here or read the Kings Fund paper ‘Caring to Change’ here. 

Just before I finish I would like to return to Kindness, which I mentioned earlier. Whilst Compassionate Leadership has many facets and some different ways of thinking, Kindness is at its core. If we are going to survive the next few years then we need to transform and adapt but we must not forget to be kind to each other. In the NHS we often discuss Kindness to patients but rarely do we discuss Kindness as a leadership behaviour. I am not saying that any of this is easy and I am certainly not saying that I have demonstrated Compassionate Leadership over the years, far from it. I am however willing to put my money where my mouth is and practice this way from now on. I would ask you all to do likewise.

Ken Donaldson is the Board Medical Director at NHS Dumfries and Galloway

Summer of Celebrations Part 1 by the SPSP Team

Reflections from Improvement Advisor, Paul Sammons

As an improvement advisor with no clinical background, I work closely with people who want to change things for the better, and who know their teams and roles well, but who don’t always have the skills to structure improvement work.  They may not have the capability to use the ‘model for improvement’ – a proven methodology that helps focus aims, identify change ideas and to measure what difference if any, a change actually makes.  Having completed the Scottish Improvement Leader programme (ScIL) in 2015/16 I do have that capability which, when brought together with practitioners who have a will and an urgency to change things for the better, can be very powerful.   I enjoy the privilege of working alongside, enabling, and learning from some fantastic individuals and teams who strive to improve services of their patients and service users.

Some of these moments will be with me forever – I recall working with Dr. Grecy Bell to motivate and enthuse a group of primary care staff about Medicines Reconciliation – not the most lively of topics, but Grecy created the ‘med rec fairy’ concept – a local champion in each GP practice who would carry the ‘wand’ to ensure their team saw med rec as a vital part of their work.

Another great memory for me was working alongside Dr. Mark Colwell – we teamed up to lead a local dental improvement collaborative, creating a structure around better decision making and treatment planning for patients on high risk medication.  Mark showed me how ceding power to his team enabled a flat hierarchy where all team members were able to critically observe each other’s practices, and contribute towards a more collaborative approach to patient care.   With the practices involved we improved much – starting even before patients arrived for their appointments – maximising the use of text messaging, moving through the patient’s journey. The work involved reception staff to engage with patients to obtain highest quality patient histories, and enabling dental nurses to observe and to prompt their bosses into even better patient conversations.

I have observed people in health and social care who once invigorated with a little QI magic, will stop at nothing to deliver better care, and who seem to have the energy to drive improvement forward in the most unlikely circumstances.  I spend time with Julia Hutchison in DG Smile dental practice, and I leave with a real spring in my step.  What is it about these people and all of the others that I get to support that is courageous, different and special?  I do reflect on a wee video that helps me answer that question.  You might like it too.  It is available on YouTube and can be viewed here.

I believe that attention to QI capability and capacity is key to improving services, and that we will see this develop through our local ever-expanding network of QI capable practitioners.  In the near future we will expand our practitioner level QI education and training – to ensure managers and leaders are well equipped to support, coach and supervise improvement projects.  In 2018/19 I plan to focus improvement efforts into the Women’s and Children’s teams as they settle into their new DGRI home.  I contribute to the improvement force field that is growing stronger across Dumfries and Galloway in health care and in social care.  I work as part of a small but wonderful team of hand-picked curious and quirky individuals – who quietly and tirelessly support each other, creating a synergy of support to our customers.  Perhaps you are close to that growing network of improvers – perhaps you feel the force like I do?  Well I do, and as I work with a widening spectrum of fabulous people I can honestly say that there is much joy in my work.  Long may it continue…

 

The QI Hub by Wendy Chambers

 

 

 

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.

The 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.

Building 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!

Being 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”.

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.

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!

 

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

QI Hub Development Team

Can I make a difference? by Paul Gray

It’s a big question – can I make a difference?  How does it feel to ask yourself that?  For some of us, the answer will be different on different days.  My experience suggests that your answer depends much less on what you do, than it does on how you feel.  In this blog, I’d like to offer some thoughts on making a difference.

However, some context first.  I fully recognise the challenges we face.  Health budgets are going up – but pressures on recruitment, and the demands of an aging population, are also very real.  There is also still much to do in tackling inequalities, and improving the health of the population, which NHS Scotland can’t do on its own.  And we do know that people have the best outcomes when they are treated and cared for at home, or in a homely setting.  So our current models of care are transforming to meet these demands, and to provide the most appropriate care and treatment for people, when they need it, and change brings its own challenges.

So my first suggestion is to turn the question, “Can I make a difference?” into a statement – I can make a difference.  If you start from that standpoint, you’re much more likely to succeed.  It’s easy to become pre-occupied with the things we can’t change, and the barriers and problems – I know that I fall into that trap from time to time.  But wherever I go, I see people throughout the NHS, and in our partner organisations, making a difference every day.  So ask yourself, what is the one thing I can do today that would make a difference?  And then do it!

Now, give yourself some credit – think of an example where you did something that was appreciated.  Write it down and remember it.  If you’re having a team meeting, take time to share examples of things that the team did, that were appreciated by others.  Sharing these examples will give you a bank of ideas about simple things that matter to other people.  And it also gives you something to fall back on, if times are tough.

Next – think of an example when someone did something for you, which you appreciated.  Find a way to share these examples too – if it worked for you, it might work for someone else as well.  Ask yourself when you last thanked someone for something they did well, or something you appreciated.  It’s easier to go on making a difference if others notice what you’re doing!

If you’re leading or managing a team, ask yourself how much time the team spends discussing what went well.  It’s essential to be open and transparent about problems and adverse events, but if that’s the whole focus of team discussions, we overlook a huge pool of learning, resources and ideas from all the positive actions and outcomes.  And we risk an atmosphere where making a difference is only about fixing problems, rather than about improvement.  So, as yourself and your team, what proportion of time should be spent on what went well?

Remember to ask “What Matters to You?”.  I know that the focus of this question is on patients, and that’s right because they are our priority, but it’s a good question to ask our colleagues and our teams as well.  Just asking the question makes a difference – it gives you access to someone else’s thoughts and perspectives, and is likely to lead to better outcomes.

Will any of this change the world?  Not on its own, of course.  But you could change one person’s world, by a simple act of kindness, or listening, or a word of thanks.  You can make difference!

Paul Gray is the Chief Executive Officer for NHS Scotland and the Director General for Health and Social Care at the Scottish Government

Speaking out: A Student’s Perspective by Ren Forteath

I was recently asked to speak at a conference organised by our consultant midwife on the topic of Person Centred Care. She wanted to hear thoughts on the topic of ‘Speaking Out’ from a variety of perspectives and asked me as a midwifery student on placement. I was delighted to be asked to present, perhaps the first indication that speaking out may not be something I find overly daunting! Having a background in amateur dramatics gives me an advantage when it comes to assessed presentations or even leading parentcraft classes when on community placement. The same could not be said of everyone in my class. Even approaching the end of our final year, many of my peers quake with nerves when asked to give a presentation. This fact caused me to consider ‘speaking out’ not only from my point of view, but from that of other students who might be younger and less outgoing than myself. (As a mature student I have quite a few years on some of my class!) The topic encompasses a variety of scenarios, and I tried to think of personal experiences that illustrated my feelings.

On a shift to shift basis we speak to women we care for, other students, midwives and doctors – and sometimes that is no less nerve racking than giving a presentation! Naturally as we progress through our course we become more confident, we gain more knowledge and our comfort zone broadens. But inside there is always a kernel of fear that we’ll say the wrong thing – or not say the right thing. Personally, I’ve had a couple of experiences that spring to mind.

In first year I was with a woman who had written in her birth plan that if things didn’t go as expected and she needed help, she would rather have a kiwi delivery than forceps. I thought no more about it until we reached that point. The reg was called in to do an assisted delivery – and he immediately went for forceps. The woman was fairly out of it on diamorphine and becoming distressed. She couldn’t speak up for herself.  So, I swallowed my fear, took a deep breath and said…’eep’. Then I took another deep breath and said “Doctor, um , she’d really prefer the kiwi, if you don’t mind, please, thank you very much”.  And he did it! She got her kiwi delivery and she was so happy. And I was absolutely on top of this world! It was so exhilarating. I had been an advocate for my woman. I had spoken up to a doctor – and he hadn’t bitten my head off! And then second year happened.

I was on shift and we heard an emergency buzzer, so we all ran to room 7: and it was a shoulder dystocia skills drill. Well, really, what were we expecting? There was only one woman in labour that day and she was in room 3! So one person took charge and started working through the HELPERR mnemonic and I thought “hey, I remember this, I know this stuff”. Then the consultant walked in, made a quick assessment of the situation and said “O.K. with a little fundal pressure, I think we can get this baby delivered.” Everyone else just looked at each other and I was thinking “that’s not right  – I know that’s not right – it’s suprapubic pressure.” And then someone suggested doing exactly that but the consultant said again “Come on now,  a bit of fundal pressure! Please, will someone put their hand on the fundus?” And I thought “it’s not right, is it?” And as if of its own accord, my hand started to move. Well, his voice was just so hypnotically consultanty. Then my mentor shot me such a daggers glance that, seriously, if looks could kill, that midwife would be in prison today! My hand shot back down, but not before at least two other people had seen it. So that sparked a useful discussion on listening to your inner voice and always speaking up, diplomatically, if your knowledge of evidence based practice tells you something is wrong. It also sparked a debate on whether it’s appropriate to use ‘making the student feel like a prize turnip’ as a teaching technique. And I wished the floor would open up and swallow me whole.

And now I’m in third year. There is light at the end of the tunnel and I’m beginning to believe it is not an oncoming train. I still have a lot to learn but I’m really starting to feel like part of the team. I suggest things and people listen. I coach women through fear and panic to relief and joy. I hold my own.

A large part of how easy or difficult it is to speak out is the people you are surrounded by. In my clinical area we have great teams, both in hospital and on the community. My classmates who have been here on rural placement always say how much they enjoy it; the working environment, the attitude, the team. People are encouraging, patient, willing to listen and keen to teach. They are inclusive and welcoming. I have rarely been berated for starting to do something the way I was shown at Uni rather than the way the midwife I was working with that day would normally do it. Not never, unfortunately, but rarely and never by a mentor.

Having my student placements there has made my own experience a hugely positive one and has equipped me to find my voice and to know how and when to use it. I know that many in my class feel the same way about their mentors in their own areas. Speaking up and speaking out are still not always easy…. but we’re learning, and as we complete our degree programmes and step out into the wards as shiny new midwives, we will find the strength to speak for our women, and for ourselves.

• Trust your learning – if your evidence base tells you it isn’t right, say something (even to a consultant)
• You are her advocate – if she can’t speak for herself, it’s your job to speak for her
• Be diplomatic – just because you need to say it, that doesn’t mean you have to upset anyone
• Find your voice – you can have a positive impact by saying the right thing at the right time

Ren Forteath is a Student Midwife

Cutting the Sugar…. by Fiona Green

Over the last 2 years NHS DG have been offering a structured programme of work experience to young people in their final years at school thinking about a career in medicine. This has been very well received by the young people who attend and the success of the programme is largely down to excellent organisation and communication skills of Anne-Marie Coxon and her team in the education centre who arrange tasters in various areas of medicine including medical admissions, theatre, surgery and A&E along with some time with me in the diabetes centre

Linocut by Hugh Bryden Crichton Hall- home to the Dumfries Galloway Diabetes centre

As a clinician it has been really interesting to spend time with these young people who have yet to develop preconceived ideas about healthcare and for me to try and understand what it is that excites them about spending a lifetime in medicine and to try and remember what it was that motivated me to apply for medicine and ultimately what made me move into Diabetes and Endocrinology.

For those of you who know me you will have heard me say that it is diabetes that excites me rather than the rare and esoteric conditions that I deal with in the endocrine service but I recognise that despite my real enthusiasm and commitment to improving care in diabetes that when these young work experience students come to diabetes clinic I sometimes find myself apologising to them that I don’t have any exciting procedures to show them, or new diagnoses to make; in fact in diabetes clinic I rarely examine people and I spend my time just listening to things that seem unrelated to sugar levels and talking…..

Just Listening and Talking…

The fact that I feel the need to apologise about the nature of diabetes clinic being  “just listening and talking” has made me realise  how little value we as hospital healthcare professionals place on these core skills that we all use every day. We are required to do mandatory training in many important areas such managing the deteriorating patient, infection control, awareness and fairness to name a few- yet it is possible for a healthcare professional to go through their in working career without any update, assessment or post graduate training in the core communication skills that we use every day. This lack of post graduate training in clinical communication skills is particularly apparent in the acute hospital setting compared to our colleagues in general practice and psychiatry where advanced post graduate training in consultation skills is the norm. Despite the seemingly acute nature of a hospital environment many of us spend a large part of our working week in clinics working with people to try and improve their health and wellbeing but what are we doing to ensure that these interactions are effective and meet the patient’s agenda?  Do we find it easier and quicker to pursue our own agendas and default into education mode rather that hearing about what is really important?  Several research studies have shown that by exploring a person’s background, worries and their understanding of their condition can help to avoid unnecessary investigations or anxiety for the patient as well as reduce the strain on resources[i][ii]

The success of the late Dr Kate Granger’s “Hello my name is …” movement and the “What Matters to Me” campaign show that in acute setting healthcare teams are beginning to contemplate a change to a more patient centred rather than the traditional paternalistic, didactic approach to our interactions with patients but this change is slow and these important initiatives are only an entry level to improving our communication with the people we see in clinic and reaching a shared agenda.

Locally Jean Robson and her colleagues from psychology, human resources and other interested clinicians have recently worked hard to put together a directory of diverse courses and programmes which are delivered locally by NHS Dumfries and Galloway aimed at improving advanced communication skills including sessions on communication skills which allow individuals to film and review their performance in real life clinic setting (been there and done that -daunting but very helpful), communicating with people with existing communication difficulties, human factors training and sessions on communicating with colleagues in meetings to name a few

So, back to the title of “cutting the sugar”. The discovery of insulin almost 100 years ago is one of medicine’s most remarkable discoveries changing the outcomes for people diagnosed with type 1 immeasurably as the before and after pictures below poignantly demonstrate

December 1922

February 1923

 

 

 

 

 

 

 

 

 

“Child 3” before and 3 months after insulin treatment

There is of course a but; insulin is not a cure for type 1 diabetes just a treatment and Insulin treatment brings with it a huge burden for the person with type 1 diabetes- blood testing more than 4 times a day, injecting insulin at least 5 times a day, assessing the carbohydrate content of foods are all required to achieve the tight blood sugar targets required to maintain health and wellbeing. This all needs to be balanced against activity levels and avoidance of hypoglycaemia. People with diabetes can never have a day off.  They become experts in managing their blood sugar levels and this brings me to the “just listening and talking bit”. Listening to what’s important to people when I’m clinic seemed more time-consuming in the beginning but by encouraging this shared understanding I have come to recognise that almost universally people with type 1 diabetes want to be healthy and that they fully understand the importance of controlling blood glucose but what I also now appreciate more clearly is that there are many other things that get in the way of achieving this goal. Some of these barriers to change seem obvious e.g. fear of hypoglycaemia, fear of injections but others may take gentle probing to identify e.g. the young woman who removed her insulin pump because she had a new boyfriend who didn’t know she had diabetes, the young mum on her own putting her own health after the needs of her family. Through training, practice and reflection I have come to learn is that each person is different and whilst a particular solution may work for one person it might not work for the next and whilst the temptation is for me to offer the solutions that I think will work by practicing the skills I have learnt at various communication skills sessions I now recognise that solutions generated by the person with diabetes are far more likely to be successful that anything that I may suggest. Of course very few consultations are perfect and like every skill we use practice, reflection and additional training can help us to improve which is why I believe that consultation and communication skills shouldn’t be seen as just “the icing on the cake” but more of the “meat on the bones” of our daily work.

Dr Fiona Green is a Consultant in Diabetes and Endocrinology at NHS Dumfries and Galloway

[i] Heisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA (April 2002). “The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management”. J Gen Intern Med. 17 (4): 243–52. doi:10.1046/j.1525-1497.2002.

[ii] eisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA (April 2002). “The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management”. J Gen Intern Med. 17 (4): 243–52. doi:10.1046/j.1525-1497.2002.

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

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

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…

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

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?

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.

 

In Memory of Kate by @kendonaldson

Over the years compassion and kindness have been common themes on this blog and nobody encompassed them more than Kate Granger.

Kate was many things; Consultant geriatrician, campaigner, wife, aunty, MBE and patient. She was born and raised in Yorkshire and after qualifying in medicine from Edinburgh University returned there to complete her training in medicine for the elderly. She married the love of her life, Chris Pointon, in 2005 and then in 2011, at the age of 29, everything changed. After falling ill whilst on holiday in California she was diagnosed with a Sarcoma and given 12 – 18 months to live. Characteristically she decided to defy the odds and do something meaningful with the short time she had left.

I think it would be fair to say that prior to her illness Kate was a compassionate, caring and person centred clinician who inspired those around her. However her illness gave her a unique insight into how we deliver healthcare, in particular the ‘small things’ which we often forget – like introducing ourselves. It was during a hospital admission in 2013 that Kate noticed that none of the healthcare professionals dealing with her told her their names. The first person to do so, and show real care and compassion, was a porter. She reflected (and raged a little) about this and from that experience the #hellomynameis campaign was born.

#hellomynameis is a great example of a very simple idea which has the power to make a difference. It started on twitter and progressed to name badges, internet memes and finally circled the globe. During the Ebola outbreak in Western Africa those caring for the afflicted could write their name on a #hellomynameis sticker and attach it to their protective suit and thus patients would at least know the name of those tending them. Many politicians and celebrities have endorsed the project and it has been adopted in many countries around the world. I for one continue to wear my badge with pride.

We were very fortunate that Kate wrote for this blog in 2014 just prior to her visit to NHS D&G. Her blog can be read here.

Since Kate died I have read many obituaries and blogs which are far more thoughtful, and certainly more eloquent, than anything I can hope to write. I would like to quote a few of them here.

Ali Cracknell, a fellow Geriatrician and friend had this to say on the British Geriatrics Society blog:

“I always thought we would work together long term, and the thing that makes me really smile is Kate is with me more than any other person at work. Every encounter with a patient “hello my name is …”, every MDT, every meeting with a new member of the team and every morning I put on my “hello my name is” badge, she is with me, she is behind every little thing I do every day, that just makes such a difference. How could one person make a difference like that?  “#hello my name is”, is so much more than those 4 words, Kate knew that and felt it, and we all do, it is the person behind the words, the hierarchy that melts away, the patient:professional barrier that is lowered, the compassion and warmth of those words.”

Just Giving, the website through which Kate raised over £250,000, described 5 Lessons they learned from Kate. You can read them in depth here but the 5 lessons are:

1) We need to communicate
2) Always rebel
3) Remember romance
4) Make goals
5) It’s ok to talk about down days

A little more about number 3, Remember romance. Just giving had this to say about that…

“Kate and her husband Chris have set the bar high when it comes to romance. Throughout Kate’s journey, she never forgot to mention how important her partner is to her and how lucky she feels to have met her soulmate. After the diagnosis, the couple recreated their wedding day and renewed their vows. They even did their first ever date in Leeds all over again.
The duo did absolutely everything together, including competing in fundraising events.
Seeing Kate and Chris wine, dine and care for one another teaches us to never take our loved ones for granted, and to remember romance. The couple remained incredibly close and strong for the duration of Kate’s illness, and managed to maintain an amazing sense of humour in the darkest of
times. It reminds us all to reflect on how we treat our partners.”

The BMJ published a particularly touching obituary which can be read here.

I will end with a quote from Macleans, a Canadian weekly magazine…

“Jeremy, Jackie, Tasha, Lucy, Pam—Kate’s doctors and nurses had names in her blogs and Twitter feeds. Outliving expectations by three and a half years, she met her fundraising goal of £250,000 for Yorkshire Cancer Charity, encouraging doctors worldwide to say hello, as she herself said goodbye.
On July 23, 2016, on her 11th wedding anniversary, three days after meeting her fundraising target, Kate was lying in her hospice room, no longer able to swallow. Christopher opened a bottle of champagne and placed drops on Kate’s lips. Caretakers called in her other family members. At 3:50pm, after Adam and Christopher’s mother had arrived at her bedside, Kate stopped breathing. She was 34.”

 

 

Ken Donaldson is Deputy Medical Director (Acute Services) at NHS Dumfries and Galloway

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