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Healthcare Quality Improvement with Frontline Engagement: Reducing Calls Missed by a Hospital’s Telephone Exchange

**This post originally appeared on the BMJ Quality Blog

Change is always hard and most of the times we hate to change. Often, attempts to change or improve in an organization are met with resistance, making failure and frustration the common outcomes of change initiatives.

In the summer of 2012, I was two years into my new position as Quality Manager at our family-founded nonprofit hospital.  I had earlier completed the ten-month Improvement Advisor Professional Development Program of the Institute for Healthcare Improvement and become one of earliest professionals with such a certification in India.

Yet my two projects attempting to improve cleanliness of public toilets and availability of quality linen had failed.  I was beginning to question the applicability of the methods I had learnt in the Indian setting.

Triggering Incident: Changing the status quo can sometimes  begin with the most unassuming catalyst. And that’s exactly what propelled our third major improvement project at Sitaram Bhartia.

One of our consultants complained to our medical director about her patients not being able to reach her through the telephone exchange, moving us towards addressing this issue. This time, we succeeded and managed to reduce missed calls to the hospital telephone exchange from about 26% to 8%. Clearly, something was different that led to success, but what?

The Story of Our Change: Engaging Frontline Staff

As I’d mentioned earlier, success had evaded us with earlier improvement projects. However, this time, we had two major differentiating factors on our side:

  1. The quality of the department manager, and
  2. The degree of engagement of the frontline staff.

So how did we make it happen?

  1. We had good departmental leadership: Sitaram Bhartia’s telephone exchange was under Irina Sharma, a manager who had technical understanding of the job, strong people skills, and a desire to improve.  All three factors proved to be invaluable in driving success.
  2. We got organized: From the very beginning, Irina embraced the project and began by observing the staff in a non-threatening manner.  She identified system related defects – for which staff were not responsible. We collected data, created a project charter, and brainstormed for change ideas among ourselves.
  3. We began communicating more: We hear about open and transparent communication quite often, but implementing it is a different ball game altogether. At the time we began the telephone exchange project, we came across a familiar challenge.

    As was typical for our organization at the time, most discussions happened in a room away from where all the action was – between the department manager and the quality manager supported by a quality officer; an experienced telephone exchange officer was brought in occasionally.

    We changed that.

  4. We began snorkeling! Around this time I made a trip to the IHI headquarters in Cambridge, Massachusetts to help teach the Improvement Advisor program to a new cohort. I was desperate to succeed in my third project and shared details with Ron Moen and Jane Taylor, the senior faculty who I was assisting.

They suggested that I re-think how the front-line staff was being involved in the project and pointed me to “Transforming Care at the Bedside How-to Guide: Engaging Front-Line Staff in Innovation and Quality Improvement”.

This is how I got introduced to the Snorkel: a valuable process, not only for generating new ideas for testing, but also as a powerful way to engage the hearts and minds of frontline staff.

While still in the US, I spoke to my project team and requested them to ask the telephone exchange staff to help reduce the missed calls. Irina called for a meeting of all telephone exchange staff without a specific agenda.

Mid-Journey Roadblocks

The meeting was held in a typically formal manner with the manager doing most of the talking.  It failed as the staff did not participate in the discussion. This was the first time the management was asking the staff for their opinion and the staff was a bit suspicious.

We were disappointed with the initial failure but we brainstormed again and set up another meeting – this time for generating ideas for reducing missed calls at night. The project team had already come up with a list of change ideas for reducing missed calls during the day and believed that they had covered everything; moreover, they felt the frontline staff would not be able to add anything further.

Simple Fixes for Large Obstacles: A Snorkel in Action

For the next meeting, we created an informal round table set up with the manager, a quality officer, and our telephone exchange staff.

The manager started the meeting by sharing what was working well in the telephone exchange and acknowledged the defects in the present system. She assured the staff that the idea of the meeting was not to point fingers but to understand system-related issues. Tea was served. The manager acted as a facilitator and the quality officer, Zorba Bahlvi, took notes. A change in the meeting format led to the staff feeling relaxed. Once the first staff member started talking, others joined in.

Though the meeting had been called to get ideas to reduce missed calls at night, the staff became so engaged, they also offered ideas to reduce missed calls during the day with solutions that hadn’t occurred to anyone in the project team. At this point I realized the power of the frontline staff – they bring insights that nobody else can.

With the help of the frontline staff, we regenerated a list of change ideas. Some of the changes were implemented immediately – these were the “just do it” sort of ideas that required little effort and seemed like “no-brainers”. For some of the other change ideas we decided to run Plan-Do-Study-Act (PDSA) to test if the change would lead to an improvement.

Did we face any resistance this time? Unequivocally, no. Because the frontline was engaged in coming up with the list of change ideas there was no resistance in testing or implementing these new ideas.

You can read more about our project in the BMJ Quality Improvement Reports!

A Happy Ending for All

By the time we were done, we were looking at results we couldn’t have fathomed before getting started.

Morale in the department shot up.  Making a change seemed to become much easier.  I learnt that working with the right partner – an engaged department manager – was essential.  I learnt the critical role of the frontline staff. I also realized the importance of persevering through multiple failures as one tries to learn effective use of an improvement methodology.

New Beginnings

At the time of writing this post, it’s my pleasure to report to you that since the telephone exchange project, we have taken up other projects in the laboratory, emergency room, labour room, operation theatre, and outpatient department – and all are progressing satisfactorily!

Here’s to new beginnings and forging ahead! And to hearing your stories of transformation! Share with us any change initiatives that you’ve had success – or failure – with.

Telephone Exchage Success - 1

Telephone Exchage Success - 2

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Driving System-Wide Healthcare Quality Improvement at East London NHS Foundation Trust

Sixty-four different sites – many with high rates of child poverty and complex long-term conditions; high proportion of ethnic minorities; 14 care-commissioning groups who demand different quality metrics; and a focus on mental health and community care – not the most remunerative areas in healthcare.

All this complexity hasn’t prevented East London NHS Foundation Trust (ELFT) to set itself the audacious goal of becoming the highest quality provider by 2020!

I had the privilege of sitting in on a presentation being made by Dr Amar Shah, associate medical director for quality improvement (QI), and his team today (24th January, 2015) to a small group of Harvard Business School students and representatives from The Health Foundation, a charity that promotes quality and safety in healthcare in the UK.

  ELFT1

 “Application of QI to mental health hasn’t really been done anywhere as yet… so we have to be very innovative as many of the problems we face don’t have any readymade solutions” said Dr Shah as he started off the presentation.

He pointed out that there were no evidence–based bundles for improving mental health unlike many areas of acute care such as reducing central line infections.

Stable senior leadership, champions of quality at the top, and robust finances were some of the factors identified by Dr Shah for the Trust’s success in driving the quality agenda.  He pointed out that ELFT chief executive (who has been here for 7+ years) believes in quality over money and that their medical director had come from the National Patient Safety Agency (NPSA) with deep knowledge of improving quality and safety.

Five years ago their Trust had two sentinel events – an inpatient homicide (one patient killed another) and an inpatient suicide.  “This made us think… these incidents happened despite good quality assurance… we realized we had to go beyond.”

“We will have to improve quality while earning less – this isn’t possible without innovation and redesign, and eliminating waste in processes” said Dr Shah referring to the declining reimbursement for care.  He also clarified that though cost is typically lowered and quality improves when waste is removed, the QI program was not about cost-cutting but improving quality!

James Innes, the head of quality improvement, presented how ELFT hoped to achieve this audacious goal.  ELFT has identified four drivers for achieving their aim as seen in the figure below.

 ELFT2

 Image Courtesy: ELFT Quality Programme Presentation

I was impressed by how thoughtfully they are building the will for quality leadership through a new website and events showcasing their successes.

To build improvement capability they have partnered with the IHI to get strategic advice and run training programs for staff at all levels.  For example, over 500 front-line staff will be trained in 5 six-month “waves” of training and 250 clinical leaders will be given deeper understanding of the improvement methodology.

ELFT3

Image Courtesy: ELFT Quality Programme Presentation

The ELFT team is working to ensure alignment so that projects are focused on two stretch goals:

  1. Reduce harm by 30% every year, and
  2. Provide the right care, at the right place, and at the right time.

And in less than a year they already have 114+ projects going!

Dr Genevieve Holt, a QI Clinical Fellow who recently completed the prestigious Darzi Fellowship in clinical leadership, discussed an example where the Trust targeted a reduction in weight gain for patients who were hospitalized.

She shared her insight of how it was important for the team to come together to generate change ideas in order to have ownership for the project and how improvement often has to begin at the very beginning – in this case, setting standards for how patients will be weighed and how this data will be captured to enable analysis.

Tsana Rawson, another QI Clinical Fellow, related how ELFT was creating an evidence base for reducing violence on mental health wards using better communication (speaking with patients uncovered that one source of tension was a tussle over what channel would be played on TV), flattened hierarchy (often lower down staff could identify patients who were at risk of becoming violent but didn’t feel comfortable speaking up), transparency and stakeholder involvement.

She shared how ELFT was using a collaborative model wherein different adult wards working on the same problem were learning from each other and accelerating improvement.

ELFT4

In the afternoon, I also had the privilege of joining a weekly review meeting of the QI team.  I saw how Tim Gill, Programme Manager, efficiently updated progress on the various tasks while the meeting was on and learnt how Forid Alam, QI Data Analyst, was creating dashboards to increase transparency and help answer the all important question of “whether all this effort was really making a difference”!

ELFT5

Throughout this amazing morning, I was struck by the similarities with the journey in our own small nonprofit hospital in India.  We too have turned to the IHI for guidance – our head of quality is an Improvement Advisor, a number of consultants have completed the IHI Open School Basic Certificate, and we participate in a collaborative for improving perinatal care.

We pursued quality as a fundamental aspect of our nonprofit mission and are embracing transparency, such as disclosing our caesarean section rates, without any external triggers.  Even our payers don’t fully appreciate what we are trying to do and we too have to look overseas for learning!

Like ELFT, even in our case it was patient safety incidents that moved me and individual consultants to deeply reflect and commit to going down “a road less travelled”.  But unlike ELFT, we have had to sustain this journey despite financial instability – quality is our strategy for winning trust and achieving financial health!

I left East London feeling inspired and uplifted – by the excellence of the work that I had seen but even more because of the humility, helpfulness and willingness of the entire ELFT QI team to share their experience.  I learnt that in March they were hosting an associate medical director from a mental health hospital in Uganda that this Trust has an ongoing relationship with!  I too was invited to come back or send colleagues and offered copies of their reports.

“We’re only beginning” is what Dr Amar Shah and his colleagues kept repeating as I expressed my awe and appreciation for what I was seeing. “You guys are creating magic and the world will learn from you” was my response!

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Global Maternal Newborn Healthcare Conference in Mexico delivers on all counts!

“We discussed this internally but don’t feel we have the bandwidth to travel to Mexico” I wrote to Sue Gullo, director of the Institute for Healthcare Improvement, in reply to her invitation to submit an abstract for the Global Maternal and Newborn Healthcare Conference.  I also wondered if the conference would be relevant for someone like me, chief executive of a small nonprofit in India, whose target population was very different – middle-class women in Delhi subject to over-intervention in maternity care rather than the most marginalized populations dying from access to care.

My doubts were quickly put aside in the Welcome Event. Geeta Rao Gupta’s moving address taught me the importance of investing in the hardest to reach populations as it gives the highest returns.

In the opening ceremony, Melinda Gates reminded us that “collaboration is hard but you do it because of the power of collective action” and that “when health improves, lives improve by every measure”. From Babatunde Osotimehin I learned that for “adolescent girls to go and stay in school requires access to family planning”. Lastly, Hans Rosling exhorted us to have an evidence-based view of the world, give up irresponsible structural racism and celebrate the successes of countries!

 

 

In the first panel session I came across stories of how innovative organizations were leveraging mobile technologies for impact at scale. Aparna Hegde’s mMitra platform was reaching out to women in urban slums of Mumbai at a cost of only $5 for two years of antenatal and infant care!

GMNHC1

In another panel I learned how Centering Pregnancy, a form of group antenatal care, was being spread to developing countries from Malawi to Nepal – improving quality of health care, promoting interactive learning and building communities.

GMNHC2

On a panel that highlighted efforts to maintain appropriate Caesarean section rates and delivery, I presented my organization’s journey of reducing Caesarean sections. On this panel was Paulo Borem, who is currently working with 42 hospitals in Brazil to bring down the Caesarean rate from the existing level of 80% – a rate not very different from our own situation 15 years ago!

There were attendees from 75 countries and some of the most rewarding experiences came from informal interactions over meals and coffee breaks.  Hearing Dr Shershah Syed describe his hospital in Karachi as being midwife-led was a real inspiration as we look to start our own journey of training midwives in Delhi. I valued interacting with Moses Kitheka from Kenya and Cyril Dim from Nigeria, as they were both from countries that I have never visited.  I was also grateful to have the opportunity of speaking with Prof Joanna Schellenberg of the London School of Hygiene and Tropical Medicine about our interest in collaborating with them for student thesis projects based in Delhi.  Other highlights were meeting Drs Mathews Mathai of WHO and Harshad Sanghvi of JHPIIEGO and sharing the findings our maternity survey in Delhi with them.

GMNHC3

While I was appreciative of being at the meeting, there were some who complained about it being an exercise of preaching to the converted.  They had a point – many people, such as obstetricians in private and government service, who may have benefited from the meeting seemed to be underrepresented.  I wondered if future meetings could specifically target “early adopters” from such underrepresented groups and as a strategy for increasing impact?

Overall GMNHC delivered on all counts of a great meeting – I gained new knowledge, formed new relationships, and came away inspired to do my bit in making the world a better place.  Ana Langer closed the meeting saying “Next time at GMNHC we will hear how you progressed as a result of networks formed here” – I hope we will all have stories to share!

GMNHC4

Edit: This post is a slightly revised version of the original, which can be found here – Abhishek Bhartia.

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What did I as a consultant learn from a conference on healthcare quality improvement?

When I was asked to register for the IHI/BMJ International Forum on Quality & Safety in Healthcare I was a bit concerned.  Being a consultant obstetrician and gynaecologist in a small non-profit hospital in Delhi, I wondered whether the conference would be applicable for our setting because many of the topics seemed related to public health.

But Abhishek Bhartia, our director, thought differently, and soon we were in London to attend what turned out to be a bonanza of sharing, learning and interacting with over 3,000 delegates from about 80 countries!

Main auditorium at Quality 2015

A Commitment to Quality

On the day before the start of the three day conference, I attended a full-day course on patient safety.  At my table was a nurse manager from Norway, a pathologist turned manager from Kuwait, and a paediatrician from The Netherlands who headed quality in her neonatology unit.  The paediatrician described how there were regular audits against standard benchmarks for safety and quality.

I found myself thinking how different this was compared to the situation in India, where government teaching hospitals are overwhelmed with patients and struggle to provide minimal care, and private hospitals have very variable quality ranging from good to bad.  I also realised that quality improvement is an unknown science for a majority of doctors in India who mostly think that their responsibility is limited to doing their best for patients on an individual level.

Carol Haraden, a patient safety expert at the Institute for Healthcare Improvement, and one of the leaders of the course, gave a great example of an old patient who was abusive and erratic in the post-operative period following a surgical procedure.  The nursing staff thought he needed psychiatric help and in the middle of the night when a nurse suggested to the doctor that the patient likely needed an antipsychotic, the doctor agreed. When the patient died, an autopsy revealed a pulmonary embolism.

This patient was known to be at high risk of thromboembolism but there had been no risk assessment and no SBAR communication (Situation, Background, Assessment and Recommendation) between the nurse and the doctor.  And it’s not surprising that at 3 am the doctor did not question the nurse’s judgment.  Carol used this example to highlight the importance of building communication and teamwork at par with clinical skills to create a safe environment in healthcare.

The opening keynote address of the conference was by Maureen Bisognano, president and chief executive officer of the IHI.  She gave a beautiful example of an obstetrician dealing with high risk pregnancies who introspected about the reasons behind the high prevalence of preterm births and how they might be prevented – rather than only focusing on the treatment. To think differently has been the highlight of this conference and as a clinician I realised I could have a much greater impact on health by looking beyond the immediate clinical situation.

Maureen Bisognano Keynote

I was very impressed by Dr Gary Kaplan’s talk on how the Virginia Mason Medical Center in Seattle has adapted Toyota’s lean manufacturing methods to improve healthcare.  I learnt how tools like value-stream mapping can reveal waste in processes and how events like Rapid Process Improvement Workshops (RPIW) can be used to understand gaps and streamline processes.  I had previously read a book called Transforming Healthcare which told the story of Virginia Mason’s healthcare quality improvement journey but hearing about it from the CEO himself was a treat!

Sharing Hope

Patient engagement was the theme of this year’s Quality Forum.   I heard this lovely keynote address from Martine Wright who was one of the tragic victims of the London Bombings in 2005. She lost both her legs when a bomb went off in the London Underground and was in the hospital for a year.

Martine related how she got the strength to get back to her life and started flying and playing sitting volley ball – things which she had never dreamed of doing before. She even went on to become the captain of the National Sitting Volley Ball team! She called upon healthcare providers to never ever underestimate their potential to change, transform and revolutionise peoples’ lives.  I think this is the greatest gift of the medical community – to have a patient who has no hope left come out of the darkness and pay such a tribute!

Martine Wright speaking at Quality 2015

Patient Engagement – A Team Approach

But I couldn’t help thinking that patient engagement seems such a faraway thought in the Indian scenario. Trust between patients and doctors is at a low – and yet if we have to look after our patients well we have to include them in our challenges and dilemmas.

I see this in my work of reducing unnecessary interventions in maternity care and achieving a medically justifiable caesarean rate – work that I had an opportunity to present as a poster at the Forum.  Without joint decision making it would be tempting for me to practice defensive medicine and over-intervene!  Many people appreciated that a small hospital serving private patients was making an effort to tackle the caesarean epidemic in Delhi.

Poster presentation and fun in London

I did not learn clinical skills or robotic surgery in this conference but what I learnt is perhaps far more important for my patients. I learnt about systems thinking, team building and patient engagement as the building blocks of safety in health care. I came away inspired to continue my journey in making healthcare processes more reliable and fully utilizing the potential of the entire team.

We have experimented with SBAR communication in our labour room; now we need to implement it reliably and further empower our nurses by training them to interpret electronic fetal heart rate tracings.  We are working to reorganize our outpatient care so that other healthcare team members can do some of the routine tasks freeing up consultants to focus on hearing the concerns of patients.  And I am particularly excited by the prospect of involving families in sharing their experience with couples during the antenatal period and using their feedback to improve care.

At the end of the day, we’ve all walked away with insightful and actionable learnings that will help us all become better care providers. In the meantime, I’m looking forward to seeing what will emerge from the International Forum on Quality and Safety in Healthcare being held in Honk Kong this coming September. The Forum promises to “Improve, Innovate, Inspire” – values we could all certainly benefit from.

Consultants, no matter how brilliant they might be individually, will never be able to do their best for patients unless they take leadership for helping build a safer healthcare system.

 

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Ward rounds – ideas for making them better

A leader must be able to define an ideal state and get people enthused about moving towards it” said Dr Prab Prabhakar, a consultant paediatric neurologist at the Great Ormond Street Hospital (GOSH), as we sat down together in my office.  I had met Dr Prabhakar a few months ago in London and was pleased that he was taking a day out of his vacation in India to visit us.

“Would you feel comfortable raising an issue if you noticed something wasn’t quite right?  How do we, as doctors, learn to see things from the patient’s perspective?  How do you develop a culture where you feel responsible for what happens in the whole hospital, not just your unit?”  These were some of the questions he asked members of our paediatric unit before hearing a presentation on ongoing quality improvement work in the department.

Dr Prab Prabhakar with paediatric unit at Sitaram Bhartia

Before long we were in the auditorium to hear his talk on improving ward rounds.  Dr Prabhakar related examples from his actual ward rounds at GOSH.

LISTEN and SILENT have the same alphabets

“A 3.5 year old child with a serious genetic immune disease had been admitted to the hospital over the weekend and I had to see him on Monday to talk to the family about the possible causes of the current acute deterioration; the differential diagnosis included three possible reasons…. How long do you think this consultation is going to take?” asked Dr Prabhakar.

Estimates from the audience ranged from 20 minutes to a full hour.

“It took me 2 and half hours!” said Dr Prabhakar. “I thought it would take between 30-45 minutes.  But no one had told me that both parents were lawyers.  The father had a notebook and was documenting everything.  The parents had already put in a complaint against the hospital. And most importantly the father was depressed!  How can you ever prepare for this?”

“In the first one hour I hardly spoke.”

“Should I have just given them the differential diagnosis and told them about the tests that need to be done?  Is it my responsibility to listen to their complaints?  Should I have terminated this conversation and simply told them about the neurological condition of the child?”

I think the one hour I spent was the golden hour. It said to them that this doctor cares, he is willing to give his time to listen.  If I had stopped them and told them what I had to say, I bet nothing would have gone in.  Because I took 2.5 hours on Monday, it took me 15 minutes on Tuesday, 10 minutes on Wednesday, and on Friday before I left it took only 5 minutes.  By Wednesday and Thursday the writing stopped!  Not so with other specialists – writing is still going on, still having one hour conversations.”

Dr Prab Prabhakar LISTEN and SILENT are spelled using the same alphabets

What I learnt is you never know what you are going to encounter.  But by taking time to listen to the family, the narrative from their point of view, hearing their story, their anger, and their feelings, we can meet our fundamental duty of empathizing with them and clearly communicating what we were trying to say.”

You have to go where the mother is to be heard

The next case that Dr Prabhakar picked was of an 18 year old single mother with a seriously ill child in the hospital.  She sat withdrawn on her chair, unaware that her child had lost half his brain.

Dr Prabhakar demonstrates how to approach an apprehensive parent

“She is sitting in a place of safety, where she knows what is happening, she doesn’t know what is happening in the rest of the room. We can’t talk to her from this space, we have to go to her, acknowledge she is in a different place. Looking someone in the face is quite a powerful thing to do.

Taking responsibility for decisions as a team

As a third case, Dr Prabhakar discussed a 3 year old who had come in for an angiogram.  This child had an experimental treatment and now was now suffering serious side effects that had left him blind and unable to walk without help.  He was needle phobic; all he knew was that people held his hand and then there was a big poke.  The healthcare team had sited a canula after much screaming and shouting and 10 minutes later the child had pulled out.  Dr Prabhakar had to decide whether they needed to re-site the canula?

He decided that they didn’t need the canula!  And he asked why did they had put in a canula in the first place?  The decision had been taken by a colleague five months ago, in different circumstances, and this time around there was no one senior to check the plan before executing!

Prof Vinod Paul in discussion with Dr Prab Prabhakar

“How do you communicate and take responsibility for such decisions as a team?” asked Dr Prabhakar, highlighting an important problem in care delivery in hospitals.

Placing equal importance on showing respect as on making a clinical diagnosis

What struck me most about Dr Prabhakar was how he embodied the qualities of an ideal consultant – he seemed to be not just an expert clinician but also outstandingly empathetic towards the patient, family, staff, junior doctors and colleagues.  I found myself thinking that this was different from how even some of our best doctors come across in India.  While clinical skills for diagnosing diseases and performing procedures are often highly developed in our better consultants, their ability to communicate and empathize with different stakeholders often leaves much scope for improvement.  This may be because of high pressure of volumes in teaching hospitals and as Dr Rinku Sen Gupta Dhar, consultant obstetrician-gynaecoligst, pointed out, “It’s hard to display compassion when you have to see 45-50 patients in two hours in the OPD”.  But undoubtedly there are other reasons too.  Prof Vinod Paul, head of paediatrics at AIIMS said, it could be related to how we select doctors – relying on multiple-choice questions.  And Dr Prabhakar pointed out, it could be because “we have never been told that showing respect to a man from a village is as important as finding a mitral stenosis murmur.”

The dignity of the consultant that Dr Prabhakar displayed in his examples was made possible not just by his personal qualities but by being in a system that permitted such behaviours to be practised.  If medicine has to live up to the expectations of its stakeholders – patients, families, doctors, and others –senior consultants will have to provide clinical leadership that values courtesy and care as much as diagnosis and treatment.

 

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Are you inspired by Florence Nightingale this Nurses Day?

Every year we celebrate International Nurses Day on Florence Nightingale’s birthday.  In our hospital it’s a time when nurses dress up in their best, renew their pledge to serve, collect awards, and put on a cultural program.  For the third year in a row I was asked to say a few words.  Last year I had discussed how our newly introduced Training Within Industry (TWI) program had helped reduce nursing complaints, increase our Net Promoter Score and win glowing comments from patients.  But the program hadn’t been further expanded in the past year and I didn’t have anything new to say.

5-2015-05-12 Nurses Day

So I decided to learn more about Florence Nightingale and was amazed to discover how through astute observations, meticulous data collection, report writing and public effort, she created awareness of the role of hygiene in preventing infections and how her insights had transformed care of the sick in hospitals.  As I was getting inspired by her story, I was also becoming increasingly conscious of how nursing in our environment failed to achieve its potential – in our hospital and more widely in the Indian health system.

Prof Hans Rosling’s video on Florence Nightingale’s use of statistical graphics

Florence Nightingale was a “passionate statistician” and so I too began by asking  Anitha, our human resource manager, to prepare some statistics on nurse turnover at Sitaram Bhartia – a problem that all private hospitals have come to accept as inevitable.  In 2013 our hospital had 67 resignations from nurses.  Given our approved strength of 86, this meant that we had a turnover of whooping 78%.  We started 2015 with only 28 nurses who had been with us for two years or more.  In most nursing departments like adult intensive care, neonatal intensive care and ward, only about a third of nurses had been with us for longer than two years!

Reason for nurse resignations in 2013

“Nurses leave because they go to the Middle East or find a government job – we can’t compete with that!” is a common retort that I have heard all these years.  But when we looked at the reason for nurses leaving us, the biggest group emerged as absconding, a term that is used for those nurses who leave without any notice and don’t respond to any correspondence from our side (29/67 resignations in 2013).  When we compared the tenure of nurses who had absconded versus those who had left because of marriage, maternity, government jobs, or postings in the Middle East, it became clear that this was a very different group – a disproportionate number of absconding nurses had left under a year (27/29).  These nurses were either not intending to stay long with us from the beginning or left because they found us to be unsatisfactory upon joining.  Marriage and maternity were leading causes but typically these nurses had tenures of 1-3 years with us.

Coxcombs

So inspired by Nightingale, we have gotten some clues as to where our problems may lie.  Of course, we need to complete the picture by speaking to others and using common sense (which is unfortunately not so common).  Most importantly, we need to decide whether we will accept status quo as inevitable, or following Nightingale’s example commit to improving the situation through analysis and systems thinking.  Doing more of the same and expecting different results is insanity as Einstein had warned.  And Thomas Edison could have written a book on hundreds of ways of not building a light bulb.  We will have to be innovative and we will have to persevere.  Luckily we don’t have to be as brilliant as Nightingale – the tools for understanding and finding solutions are largely well described in the quality improvement literature – but we have to embrace them.

The question is are we up for it?  Individual nurses and organizations that succeed in doing so can  expect better patient care, more joy and meaning at work, and more cost-effective healthcare delivery.

It may be easier to celebrate Nightingale’s birthday than live by her principles.

 

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Should doctors embrace social media?

Yes, according to Dr. Farris Timimi , a cardiologist at Mayo Clinic who is medical director of Mayo Clinic Center for Social Media . In fact he goes as far as to say that physicians’ participation in social media is a moral imperative and part of being professional. He says that patients are spending time online seeking health information and support and that represents both an opportunity and a moral obligation for providers.

“Profound impacts can occur when we sit on the sidelines”

Dr Timimi recounts the impact of a flawed study by Wakefield that wrongly connected MMR vaccination to autism and led to a world-wide decline in vaccination rates. This decline was responsible for a major outbreak of measles in 2011. He then asks doctors to ponder the following: “There are 60,000 members in the American Association of Pediatricians; if each one put out one blog, one YouTube video, one Tweet, one Facebook post, who would have more ascendency on this issue – us or the celebrities who seem to rule the conversation?”

Dr Farris Timimi: Healthcare Social Media and Professionalism

An excellent example of how a physician, in this case a pediatrician, has used social media to connect with her patients and share opinions, new research, and controversies in parenting, is Dr Wendy Sue Swanson of Seattle Children’s Hospital. Check out her blog here.

Social media will help you get new patients
Dr Howard J Luks, an orthopedic surgeon in the New York area, gets about 7-10% of his new patients because of social media presence. He finds that these patients who see his videos and read his blog arrive far better informed and comfortable with him. He advocates using social media to present evidence-based information without any commercial hype. You can see how he has built his online presence by visiting his website here .

Online presence helps combat negative reviews
Physicians are often concerned about negative reviews posted online. Suing such sites or patients is counterproductive as it brings added negative publicity, says Dr Kevin Pho, an internal medicine physician in the US and co-author of the book, Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. The effective way for physicians to counter this is to establish their online presence by creating social profiles – these can get high rankings by Google and push down the third party sites with negative reviews. Dr Pho also points out that another counter-intuitive solution is to simply ask all patients to rate physicians online – experience shows that overwhelming majority of patients rate their doctors positively and this can drown out outlier negative reviews!

“Tip toe in to get started!”
Dr Pho recommends starting the social media journey with small steps. That might mean just a LinkedIn profile with some details on a doctor’s practice or a Facebook page (consider starting a page rather than a profile, see the difference here ), moving on to Twitter, and finally writing a blog.

Dr Kevin Pho: Physicians and Social Media

Twelve word social media policy
Often doctors stay away from social media because of the risks that it can entail. Dr Timimi has a twelve-word social media policy that you can read about more here : Don’t Lie, Don’t Pry, Don’t Cheat, Can’t Delete, Don’t Steal, Don’t Reveal. He recommends combining the policy with orientation, training and guidelines for turning social media from a potential liability to an asset.

What next?
Social media is a jungle but there are many good resources to help you learn – one of my favorites is the Social Media Examiner . If you would like to take some free courses specifically targeted at health professionals, you can register for a guest account at Mayo Clinic’s Social Media Health Network .

You can also let us know what more would you like to learn about by commenting below and we’ll do our best to respond!

If you enjoyed reading this post, consider signing up to receive email notifications for future posts and liking our Facebook page for updates on the social media journey in our organization. Also, share the post on your social media channels or via email. Thanks!

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Learning about Patient and Family Engagement at WHO Geneva

I skipped breakfast and arrived a good half-hour earlier than the scheduled start time, not wanting to risk being late for my first WHO Expert Consultation.  When I had received the invitation to participate in developing a framework for Patient and Family engagement several weeks ago, I remember feeling honored.  I was excited by the prospect of making a contribution at a global level and developing new relationships that could help our hospital continue along our journey of improving safety and transparency  (see my earlier blog posts on the start of our safety journey and on disclosing our caesarean section rate).  So there I was, in Geneva, at the famed, World Health Organization, waiting for the program to begin at 8:30 hours on 27-October-2014.

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“I work at Brigham and Women’s in Boston, a Harvard University teaching hospital” said Ronen Rozenblum, “And I am at Johns Hopkins” said Hanan Aboumatar, two of the other early arrivals in Salle D on level 7 of the Main Building.  As luck would have it I ended up sitting between these two true experts in the field who were doing projects funded by the Gordon and Betty Moore Foundation(GBMF), co-sponsors of this consultation.

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The meeting kicked off with Ed Kelly, Sir Liam Donaldson, and Dominick Frosch speaking.  The first two I had known about earlier, and both were predictably outstanding, but Dominick – the person leading this initiative in the Moore Foundation – was new to me.  He struck me as a person with great insight who was so articulate that every sentence he spoke seemed worth tweeting!  Kristin Carman, along with Dominick, presented the Patient and Family Engagement Roadmap (PFEroadmap), an action-oriented guide “targeted to those on the fence”.  Dominick pointed out that while “principles of PFE are global, implementation has to be local” and Kristin stressed the importance of pairing patients with clinicians to get clinician buy-in for change.  Their presentation provided us with a concise model for thinking about engagement along the dimensions of levels of engagement (direct care, organizational design and governance, and policy making) and continuum of engagement (consultation, involvement, and partnership and shared leadership).

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Nittita Prasopa-Plaizier, the project manager for this consultation, spoke about the interesting variation in the attitudes of patients – we learnt that many Asian patients don’t want ‘partnership’ unlike in the West!  Vivian Lin confessed that it was “much easier to talk about what than how” while Hernan Montenegro reminded us that “we have to move beyond patients… to keeping people healthy”.  Neelam Dhingra-Kumar, the new coordinator for Patient Safety and Quality Improvement at the WHO, reminded us that in many parts of the world simply getting informed consent would be a step forward.  June Bolger, an articulate healthcare leader from Ireland pointed out the importance of clarifying expectations and responsibilities before asking about patient satisfaction.  Angela Coulter from the UK spoke about the need for changing the mindset from “we’ll solve your problems… to we’ll help you solve your problems.”  Casey Quinlan, a cancer survivor and journalist representing the patient perspective, reminded us that “people served by healthcare should be involved from the beginning of redesign.”20141028_110742-c

Soon it was time for us to break up into small groups and I became part of the group discussing creating a supportive environment for meaningful and effective engagement.   As I heard the various viewpoints, what struck me is that each leader and organization would have to find their own path, but connecting with others who could provide guidance or just support could be very useful.  The first day ended with Dominick recounting that when his eye exam showed that he was free of any signs of retinopathy, 23 years after being diagnosed with type 1 diabetes, his doctor said “You must be really good at following orders!”  Dominick reminded us that the health “system responsibility should also be to acknowledge when the patient is doing well and to empower them.”

Later in the evening we caught the bus to Rive and headed over to La Brasserie Genevoise for drinks and dinner.  Here I spoke with Manvir Jesudasan, a renowned radio jock in Malaysia who became interested in patient safety and engagement after being diagnosed with end-stage renal failure and undergoing a kidney transplant.  And with Tonny Tumwesigye who was a leader in a network of faith-based hospitals in Uganda, and Nuria Toro Polanco who was from the Basque Country in Spain and had recently started working at the WHO.   It was great to share experiences, though I’m afraid, as usual, I did more talking than listening.

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Day 2 of the consultation was mostly presentations from the invited experts.   Densie Klavano of Canada, Kadar Marikar of Malaysia and Piyawan Limpunyalret of Thailand described their accomplishments and challenges in the field.   All presentations were outstanding, but one was simply mind blowing – Jonas Gonseth from Ecuador related how he took over an ailing public hospital in 2012 as “Jonas the fifth” – the fifth manager in twelve months, and within two years transformed the place with patient and community involvement.  I wouldn’t be surprised if there is a book or even a film on his feat in the future!

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Susan Frampton of Planetree reminded us that how we treat our staff trickles down to how staff treats patients and that organizations wanting to go down the route of PFE needed to make a commitment to human relations and communications skills training for their staff.  Susan said that it wasn’t enough to adhere to the Hippocratic oath of doing no harm and that providers must strive to provide the most compassionate care possible.

Sue Sheridan of Patient-Centered Outcomes Research Institute (PCORI) reminded us of Google’s principle – “Focus on the user and all else will follow” and how PCORI was funding research in which “patients plan, conduct and disseminate the research along with the researchers.”   Hanan shared her observation that utilizing patient feedback in the form of stories and data on a regular basis with providers at the bedside was critical for improvement.   Rachel Goodens, a consultant involved with the African Partnership for Patient Safety, said that perhaps community engagement should be made part of what hospitals are already doing rather than an add-on.  Ed Kelly concluded that now there was sufficient evidence that PFE was not something that was just nice to have but was something that improved health outcomes.  Sir Liam Donaldson summarized the meeting with six arguments in favor of PFE including lower harm, better research, and reconnecting professionals to the passion that originally brought them into healthcare.

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The two days flew and soon we were on the roof of the main building for a group photo.  The goal of the Global Patient and Family Engagement (GPFE) consultation was to “put together a document that serves as a jumping off point for pilot projects across the world.”  Having participated in the consultation, for me the document has already done more – it has inspired and energized!  I wish I could make a bold declaration of adopting an ambitious goal that we will achieve in our hospital.  But I’m tempered by the reality of our limited bandwidth and several competing priorities.  What I can say is that we are committed to increasing patient and family engagement and in time hope to have valuable learnings to share with others in our health system and beyond.

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To see a Storify.com summary of the event’s tweets click here.

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What you should know about safety in private Indian hospitals

“I have greater assurance about product quality and service quality when I walk into a Sagar for a snack than when I go into a hospital!” (Sagar is a chain of restaurants in Delhi best known for serving South Indian food.) I have often said this to our consultants and managers to illustrate the unacceptably low levels of reliability in most healthcare delivery encounters – including at our hospital. And despite my having this realization and my being chief executive, there has been limited progress on improving safety and reliability in our own organization. So the natural question is, Why?

There is no simple answer. It’s a bit like asking why driving on Delhi’s roads is so chaotic and unsafe despite it being the capital of the country. Safety is impacted not just by your behavior and choices but also the environment. Behind an unsafe act of someone driving in the wrong lane may lie contributory factors like poor road conditions or lack of a safety culture which in turn may reflect a governance failure. In healthcare delivery, an unsafe act may reflect poor education (the quality of graduates of India’s medical and nursing schools is very variable), lack of standardization (often different consultants within a specialty in a hospital insist on different pathways for “their” patients thus increasing complexity and the chances of error), and inadequate staffing (many hospitals face high turnover and chronic shortages in the ranks of nurses and junior doctors). But this is not the complete story.

Consider the case of an elderly patient who requires surgery and has diabetes and hypertension. Often investigation and management of pre-existing conditions in such patients is postponed until admission on the night before for surgery. Even if blood sugar or blood pressure control is found to be inadequate, the admitting surgeon feels hesitant to postpone the surgery. If post-operatively the patient develops a cardiac complication, the nurse or junior doctor may not detect the condition in time, and thus increase risk. Should the patient die, it would not be uncommon for the surgeon and hospital to engage in finger-pointing –with the hospital blaming the surgeon for proceeding without adequately controlling risk factors and the surgeon blaming the hospital for poor support. The potentially preventable nature of the complication will not likely be disclosed to the patient’s family and the hospital and surgeon will want to “move on” from the memory of the “unfortunate” event.

Let’s analyse this case from a systems perspective. Private medical practice in urban India takes place in a competitive marketplace and both consultants and hospitals don’t want to risk losing patients by demanding treatment that may increase cost, fully discussing risks of the surgery, or revealing limitations of a hospital. Hospitals rely on consultant reputation to attract work and feel compelled to defer to consultant judgement about selecting patients. When complications occur, weaknesses in the system get revealed – particularly the inadequate defences to protect the patient.

There are other challenges – such as limited requirements for transparency making it difficult for anyone to really know about the safety record of a hospital or a consultant. Most of the time, unsafe acts don’t result in serious harm and this leads providers and patients to ignore the potential for harm. An environment in which any error is seen as negligence on the part of the providers also discourages openness and thus learning. Within the medical profession, understanding of safety science and capacity for leading change is limited as these topics are not part of medical education. In summary, the framework for clinical governance is weak in most hospitals.

Beginning the journey of making our hospital safer
So what can we do other than simply raise our hands in frustration and blame the “system”? The National Patient Safety Foundation of USA has outlined five concepts for transforming healthcare safety:

  1. Transparency
  2. Integrated care platform
  3. Consumer engagement
  4. Joy and meaning in work
  5. Medical education reform

 

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We are beginning to apply this framework in our hospital. We’ve started measuring outcomes in select specialties and sharing this information internally; we’ve publicly disclosed our caesarean rate and aim to share our patient feedback data soon. We’re working to redesign our care platform to enhance reliability and are exploring adoption of group practice for maternity care and checklists for making surgery safer. We’re improving consumer engagement by empowering patients with relevant information and giving them more time for informed decision-making. We’re training our nurses one-on-one to enhance their skills and engaging the entire care team to make them feel valued. And we’re encouraging doctors and other staff to enhance their ability for leading improvement – through lectures, case discussions, and online courses such as The Science of Safety in Healthcare offered by Johns Hopkins University on Coursera and the Open School of the Institute for Healthcare Improvement. Most of all we’re trying to get everyone to reconnect with their original purpose for entering the health professions and asking ourselves how we can be more in sync with that calling.

Taking on the goal of improving safety is like committing to a marathon without a finish line – it is daunting but also exciting. Along the way we hope to enjoy the highs of running a good race and doing our best for patients!

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Why you should ask about the caesarean rate before selecting your maternity care provider

Many of us do extensive research before buying a mobile phone or a car, booking a hotel for a holiday or even selecting a new restaurant.  But when it comes to choosing a doctor, many of us do little more than get a word-of-mouth reference.  Unfortunately, what often drives patient satisfaction and thus recommendation of a practitioner to others is “bedside manners” and may not always reflect evidence-based medical practice.

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