Astrid Atherley, a co-researcher with Q Lab, writes these updates and reflections. Co-researchers work alongside the test team to support them to distil and communicate their learning and progress.

Update about the South Docs Services test team: Engaging the stakeholders

January 2024

Those of you tracking the SDS team’s progress through this year’s Q Lab will be aware of the unique challenges this team has compared to others. Their project seeks to improve the flow of patients through the urology pathway across Birmingham. It’s a vast undertaking, spanning multiple organisations. It has been crucial for the team to nail down a representative stakeholder group early to set them up for success. These early discussions are not only important to gain the necessary buy-in, but to help in problem scoping and definition to ensure the improvement project is focused on the right issues to be sustainable long-term.

Stakeholder engagement

Since the November workshop where teams gained tips on problem definition and stakeholder engagement, the SDS team has made great strides in gaining buy-in from relevant stakeholders across their system. They have met with senior members from their Integrated Care Board, transformation colleagues, general practitioners, and others to discuss the current state of urology care in Birmingham and the opportunities for improvement. SDS team members feel this was a productive session and there was the consensus that the wider system should be on board to take a system approach to improvement.

Stakeholder buy-in and communication is an important part of any improvement project. To identify stakeholders, the SDS team had early discussions internally about key players which led to snowballing – where some of those key players identified other players or groups thought to be influential or of interest. One team member mentioned that this should be a dynamic process. As progress is made throughout the project with the scope more defined, there may be changes in the influence, impact, and importance each stakeholder or stakeholder group can bring.

Not a surprise within the NHS, a major barrier to stakeholder engagement was competing with people’s busy diaries! The team fully empathised with this, being busy NHS employees themselves. One helpful tip was to have an awareness of the different agendas of key players in an attempt to tailor conversations in a way that ensures the project aligns with their scope of work. Understanding what motivates different stakeholders is important in guiding those early conversations to gain buy-in.

Problem definition

When the team and I met at the Q lab workshop in November, we ended the day with several problem statements based on the shoes we filled with thinking about the challenges at play within the pathway. Catching up with the team in December, there were still refinements being made to their problem statement given the wider discussions across the system which were happening. Albert Einstein is thought to have said that if given an hour to solve a problem, he would spend 55 minutes thinking about the problem and the remaining 5 minutes focused on a solution. I think it is fitting for the SDS team to spend time building their wider team and hearing those voices and perspectives to pin down a suitable problem statement.

My previous notes (see below) highlighted the issue of urology patients ending up on secondary care lists. This was due to fuzzy diagnostic and there being no other place for these patients to be managed given the current service delivery set up. From where I sit, it does seem that the interface between primary and secondary care may be where the improvement opportunity lies. I am interested in seeing where discussions with the wider system leads the team to focus their efforts.

Update: Research and discovery phase

October 2023

Reflections on the first Lab workshop

During September and October, the Q Lab test teams have been busy making progress with their projects. On 21st September, all participating teams, along with co-researchers and contributors, attended the first Lab workshop. As part of the workshop, the Flow Academy delivered thought-provoking talks which helped participants consider:

• How to use data to understand service pathways.
• Ways to identify barriers causing narrowing along patient pathways, impeding patient flow
• The importance of building effective stakeholder teams to optimise buy-in to service redesign efforts.
• Problem framing vs problem-solving – emphasising the importance of spending time understanding the root cause of the issues and the perspectives of those affected before jumping to idea generation.

This insight was sure of value to all in attendance – whether a part of a Q-Lab team, a visiting collaborator, a patient partner or a co-researcher like myself – offering useful tips to anyone involved in improvement efforts.

How South Docs Services team understand the problem

It appears that this workshop has also been a source of reflection for the South Docs Services (SDS) team. Their project hopes to refine Birmingham’s urology pathway, which spans primary and secondary care across several organisations.

The team have already engaged with clinical colleagues to understand their challenges with the current pathway. A key issue is that patients who may be supported in primary care are added to hospital waiting lists due to unclear diagnostics, as there is nowhere else for these patients to be supported.

Outside of the clinical point-of-view, the team knows that there are other key players whose perspectives need to be considered when discussing challenges with the current pathway. A refined stakeholder map has allowed the team to visualise where groups impacted by this work fall on scales of influence and interest.

Most of us know how busy NHS staff are and how challenging it can be to set aside time for QI projects. Favourably, the SDS team has been able to garner support for their improvement effort and are busy scoping sessions to invite these diverse stakeholders onboard to help define the challenges with the current pathway and engage in design workshops to help craft an agreed solution.

Patient voice is equally crucial, and SDS plans to capture patient views via survey methods, a common method used in the NHS which is accessible and capable of capturing a wide range of opinions – this is particularly important given the breadth of service this project will impact.

The team is making steady progress, and I am looking forward to catching up with them at the second workshop on November 1st where we will be talking about problem framing and stakeholder engagement. Like workshop 1, I am confident this session will be another source of invigoration for the Q Lab test teams, arming them with tools to continue their improvement journeys.

Introducing South Doc Services

August 2023

As someone at the intersection of clinical care and innovation, with an interest in design thinking, I was motivated to engage with this year’s Q Lab, which seeks to address the system-wide issues with waiting times for elective hospital care. This year’s Lab kicked off on 27th of July when six teams across the U.K. introduced their ambitions to reduce delays in elective care; each with a different focus or within a different healthcare context. The Q Lab is an open, judgement-free zone which facilitates personal development for all team members as they work to tackle the problem of elective waiting times.

All teams will engage in an iterative, 9-month process inspired by the likes of the Design Council’s double diamond approach (a popular design thinking framework) to:

• Discover and understand the root causes of the issues at hand,
• Define the specific problem to be solved,
• Ideate potential prototype interventions and
• Agree a desired solution to be delivered.

Throughout these 9 months, I will recap the journey of the team from South Doc Services (referred to as SDS). This team hopes to solve challenges regarding elective waits across Birmingham’s urology services.

About the test team: 

Currently, patients in Birmingham wait around 62 weeks for an initial outpatient urology appointment, with no insight into the waiting times across urology subspecialties. As you may imagine, this leads to significant challenges for patients requiring access to hospital urology services. The team from SDS seeks to solve two unique challenges. The first, to understand how current waiting times in outpatient urology can be supported. The second is to redesign the patient pathway in collaboration with the wider system, to reduce the demand on secondary services, freeing up capacity for those who truly need it. While there are specialists able to deliver urology care within primary care, the SDS team wonders whether this expertise could be used to mitigate or relieve some of the barriers facing elective urology pathways, such as service capacity. While COVID-19 may have certainly compounded the issue, there may be other variables at play which contribute to the burden on urology’s elective services.

As SDS itself encompasses 9 primary care networks across Birmingham, there is a unique opportunity to leverage that reach to delve deep into understanding the system-wide issues. As this large network also brings with it a diverse patient base, it will be important for the team to uncover key inequalities in urology care and outcomes, to ensure the needs of the wider population are served. The team plans to engage hospital consultants, GPs, specialist nurses and patients to support in the problem definition and ideation phases, ultimately optimising the resulting solution. At the end of the 9 months, SDS hopes to have a cohesive response to how urology elective waiting lists are managed to achieve long-term improvement, beyond that of traditional approaches to waiting list management. This multidisciplinary team appears well-equipped, comprising talented members drawing from their time working with the Integrated Care Board, NHS innovation and improvement, urology clinical care and across primary, secondary and community services.

In the welcome session, I already witnessed shared learning between Q Lab groups as the SDS team admired the group from University College London Hospital (UCLH) which has begun understanding the relationship between health inequalities and young people’s attendance in rheumatology. This inequality lens is one through which the SDS team also hopes to look at their own problem, and so they may benefit from hearing more about how UCLH uncovered those relationships in order to apply similar techniques to their own root cause analysis.

Conclusion:  
I look forward to chronicling the SDS team’s path to improving the elective urology service across Birmingham. Their experience could help similar services overhaul their pathways and improve the experience and outcomes for urology patients across the country. Their plan to involve stakeholders on the ground, such as frontline urologists and GPs, is sure to add valuable insight to the project and benefit from a collective, systems thinking approach. I’m especially keen for the team to uncover how the waiting times affect different demographic groups, and what the differences in outcomes are (if any) for those groups. As the team includes patients on this journey, this lived experience should help to ensure the planned transformation is well received and acceptable to new and incoming service users.

If you have any questions or recommendations, join the conversation on the online group.