A version of this blog originally appeared on Joy Furnival: Striving to improve healthcare quality.
Last week (end of March 2020), I was privileged enough to join a Zoom call with a group of improvement leaders in healthcare in England convened by the SABP improvement team, many of whom are members of the Q Community. I say privileged deliberately: we were all healthy enough to join the call; we had the time and tech too; I’m gearing up to return to the NHS, leading an improvement function and so I felt lucky to join and be able to contribute; and fabulously these leaders were so impressive and welcoming, it was a pleasure to talk together.
Our call was to discuss the role of quality improvement (QI) within this current crisis and to share and learn from each other. Some learning has already begun to be captured in an excellent blog from Q Initiative Director, Penny Pereira. We considered this in our discussion, and our discussion did not disappoint. As I’m still in a role where disseminating knowledge is my day job, I volunteered to write up our discussion, to capture the conversation and to share our thoughts with those unable to make it – hopefully as something helpful. Any errors, omissions and misrepresentations are my errors, apologies in advance if needed.
To write this, I have structured this blog into four parts:
- Priorities, processes and redesign
- Taking care, learning and sharing
- The improvement positive mindset
- (And finally, and more hopefully) Thinking about improvement after the crisis.
Priorities, processes and redesign
As a group we discussed many of the imminent decisions needed or already enacted, building on previous learning from QI during Swine flu and other experiences. These decisions include: the re-prioritisation of improvement work, the need to ‘hibernate’ some existing improvement work building on the guidance shared by the iHub in Scotland. The need and argument to keep going with safety-related improvement work as much as possible, moving improvement development and training online, perhaps building on pre-existing online QI training from IHI Open School, NHS England and mass open online courses (MOOCs) many from universities, the enactment and value of virtual QI coaching, workshops and meetings, and the need to try to keep some data collection going where possible.
Cheerleading is one of our best assets. We discussed the role of general motivators, critical friends, fresh eyes and ‘enthuser extraordinaires’ that QI teams often take.
Many of these reprioritisation activities are being done to ensure that QI capacity can be redeployed where needed, be that in clinical practice, operations, elsewhere or in establishing new processes (such as staff testing) or redesigning existing ones, (such as virtual corporate induction for new starters), or elsewhere. In these examples, laying out processes, protocols and procedures clearly using QI tools such as value stream mapping helps to identify new obstacles and hand-offs in these processes to communicate and test new ways of working speedily. QI approaches can be of benefit for (re)designing such processes, and establishing new ways of managing workloads for virtual teams (perhaps Kanban might help), or conducting handover, huddles and visual management differently with social distancing. For me, and those of us on the call, this is where previous investment in QI can come into its own, right now. Rapid PDSA if you like; as many PDSAs as you can do, as quickly as you can learn, to reduce errors, harm and delay in the new processes in this crisis. Using PDSAs and scientific thinking rigorously and robustly will help us to learn quickly and effectively. (The Toyota Kata practice is designed for this level of complexity, speed and uncertainty IMHO).
Taking care, learning and sharing
Another theme in the call was that of looking out for each other and remaining connected, learning and sharing together. How can we deploy virtual team huddles for mutual support, communication and ongoing access to asynchronous QI training and knowledge systems? How can we continue to involve patients and service users in redesign and safety efforts with social distancing in place? (There are some good ideas from academic colleagues on this). How do we keep building creativity into the work that we do even when distanced? Some of the ideas from Liberating Structures may help here.
We also talked about looking after mental health, whether that be ours, our families or our colleagues, working at the coal face or behind the scenes. We recognised the risks and effort all staff are taking and giving regardless of role and noted a number of support offers from free apps and other support now being published. We also noted the non-intentional, but possible ‘othering’ risk arising from some of the ‘essential/non-essential’ language being used in the re-prioritisation processes. We took care to note that all staff and supporting teams are essential, even as priorities change and programmes become hibernated and teams redirected. Thank you so much to all, it is so appreciated, (and thank you to all those at home too, keeping households safe and running, and for grocery shopping and for childcare and so on etc). The phrase ‘one big team’ has never felt so true.
Finally, we dared to dream a little, what might all this mean ‘afterwards’? So many changes happening so quickly demonstrates what the NHS is capable of when priorities become aligned and simplified, when much preparation, testing and technology is ready (eg. e-consultations) and when the challenge stirs our core values and purpose.
The improvement positive mindset
Cheerleading is one of our best assets. We discussed the role of general motivators, critical friends, fresh eyes and ‘enthuser extraordinaires’ that QI teams often take. ‘Cheerleaders’ you could say, spotting great ideas and sharing them widely, appreciatively and optimistically. In our call, we strongly see a continued role for improvers here. Maintaining a positive narrative of what has been achieved so far and what will be achieved and learnt. Of continuing to create spaces, (mindful of the limited time people now have, not overloading and the need for virtual), for people to connect, and share obstacles, learning and solutions quickly. Facilitating good ideas such as new protocols, layouts, etc to spread quickly and ensuring that wheels don’t need to be reinvented, just adapted and evaluated locally, for context. We recognised a role to reconstitute virtual spaces for COVID and pre-COVID improvement learning so it is not lost and efforts don’t go forgotten. And a role in reminding everyone of small, yet important, wins each day.
Thinking about improvement after the crisis
Finally, we dared to dream a little, what might all this mean ‘afterwards’? So many changes happening so quickly demonstrates what the NHS is capable of when priorities become aligned and simplified, when much preparation, testing and technology is ready (e.g. e-consultations) and when the challenge stirs our core values and purpose.
There will be much to keep improving ‘after COVID’ especially related to the paused elective waiting list, new long term needs, in evaluating and sustaining valued newer ways of working, (eg. e-prescriptions), and more redesign, reconfiguration and newer safety approaches for these will be required, alongside a presumed return to policy imperatives of new hospital building and ‘the people plan’ (we might all deserve a little time for a break first tho’).
The learning we are generating now about rapid change in healthcare will be of so much value and is appreciated. QI capability, QI folk and QI skills in health and care have never been more needed. Thank you all.
This little group plans to meet again online and more sharing spaces for learning, sharing and connecting are being planned by others including the Q Community. If you can spare a moment, hope to ‘see’ you there too – you can get involved by contacting me via my Q profile.