Dr. Damian Roland (@damian_roland) - #FOAMed supporter

The Challenge of Change

In General on September 29, 2014 at 8:53 pm

Has Change Changed?

Has Change Day Changed?

Or has Change Day changed change?

At a recent strategy day for the 2015 event table ‘3’ contemplated questions that might be asked of the Change Day team in 5 years time. This simple sequence of questions raised a laugh at the time but has a serious point to make as to the challenge faced to continue the movement in a relevant way to health and social care in 2015. Change Day was envisaged as a social movement, not a solitary intervention, with a view to reaching out to staff in a way that would engage and inspire not direct and dictate. But because of this its very success became almost its worst enemy. Those who decided to pledge did so for reasons intrinsic to them and therefore the pledges were, by definition, very different. The sheer volume of pledges highlighted the fact that, while some pledges had obvious face value and clear outcomes, others did not. Quite rightly the dissonance between what, why and how pledges were being undertaken concerned those who felt uncomfortable without any tangibility in purpose.

“To the organisers of Change Day, you need a bit of cautious optimism. Don’t let the event be hijacked by people jumping on the bandwagon with pledges that raise questions along the lines of: “What have you been doing so long?” From Dr. Partha Kar: A note of caution about Change Day ” Health Service Journal March 2014

I’ll be honest – some of the pledges caused me conflict. I am a ‘quantitative’ personality.  My PhD research in medical education created measurable frameworks to bring together often qualitative attributes. Pledges such as “I will provide great care” weren’t quite what I had in mind when I first meet Stuart Sutton and Helen Bevan to discuss how Change Day would work.

But I have moved on from this state of mind. In large part due to Kate Granger  who reminded me that even the simplest thing in health and social care can be done badly. #hellomynameis a perfect of example of what some might see as a ‘quid pro quo’ in communication and yet it clearly isn’t. My own reflections on when I forgot to introduce myself made me realise it is not for me to say what others can and can’t pledge. It is their pledge. The purpose of change day was to engage in a non-hierarchical fashion. The very notion of telling people their pledges are worthless simply destroys that approach.

But what of ‘change’ itself. The term change is becoming increasingly poisonous. One delegate hit the nail on the head at an RCPCH event to assist educators in promoting and delivering change.

So a NHS Improvement Day? I feel that may well have created a similar backlash. So we decided on Change Day. But I acknowledge change is a challenging concept. Change itself is undergoing somewhat of a revolution at the moment. NHS IQ have released a white paper on the subject. It is worth a read. Some will find its ideas off putting – its use of the term ‘radical’ uncomfortable. Recent discussions on twitter and other fora have identified an important engagement principle at stake here. It is not a black and white case of bad vs good. There is a danger that camps may start: radical vs non-radical, insiders vs outsiders. George Julian recently raising the issue of Courageous Challenge versus Conformist Control. A vital theme is explored here and one we must all heed: perceptions and motivations of change are different. Health and Social care is not a homogenous beast but a vibrant mix of personalities and approaches. And this is why I see see Change Day not being the same thing to all people. We are not a small group of individuals telling people what to do but a large network of professionals and patients wanting to make a difference in their own localities. The hubbies are a fantastic example of how a shared value can bring people together – student nurses, managers, patient advocates, junior doctors – working in a capacity that wouldn’t have been plausible a decade ago. But some of those same people are enthusiastic about change in a way that is very different from others. In fact within the ‘change’ community I see grumblings about the importance, or not, of wearing public passion on your sleeve. Twitter, in particular, has enabled some people to be very openly proud about their values. Their followers applaud this public display of strength and candour and affirm it. Others can’t stand the pomposity of it all and ignore or deconstructively challenge. And some where in between a group of people who share similar passions often find themselves arguing against each other. The fast paced nature of the world we live in creating conversations and dialogues in formats not always suited to appreciate both sides of the debate. Having recognised my own passive aggression on twitter I really think we could all benefit from a look at our own approaches to the change debate and this is something the Change Day team must be very cogniscent of. We are running the risk of creating radicals within radicals if we are not careful.

Change Day Triangle

As well as determining a common language of change we are also challenged with looking at what change day has actually achieved. I was very deliberate at the start of the piece. Change Day is a social movement – it is not a medical intervention. That does not mean it is not being evaluated but it does mean that it is not a simple case of saying; “This went in and this came out”. I use the following tweet to explain the complexity of the challenge:

A learning package was created on the basis of Change Day which resulted in one doctor changing their practice for the benefit of a patient. This is a very difficult thing to record (and if I had not seen the tweet I would have missed it). But it is a very real difference for the persons involved. My own pledges have been around patient experience. Can I truly say I have changed anything. On paper – no. But around the department many know of the unpleasant nature of flucloxacillin and I’ve seen staff speed up the extraction of children from spinal boards as they have heard of my experiences. Please don’t get me wrong. I am not making excuses for why (to some) we have little definitive to show (we do have a developing, long term evaluation strategy which involves a PhD on our work). We must acknowledge this is not a Beta-Blocker trial but an ongoing complex intervention spanning years.

I think an important lesson for us all is to be  respectful of others ‘change’ journeys as everyone moves at very different speeds. The emotions and passions surrounding the NHS sometimes make it easy to forget we are all part of this great institution whether you are a health and social care professional, patient or member of the public. I personally welcome the challenge of change and hope I, and others, respond in a way that is considerate and constructive regardless of the medium used.

 

 

This blog is my personal opinion and has has not been reviewed or endorsed by other Change Day Team members. I welcome comments, critical or otherwise, from anyone with questions about Change Day. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What I learnt this week: What you see is maybe not what I see? #WILTW

In #WILTW on September 26, 2014 at 7:40 pm

This is the nineteenth #WILTW

A significant proportion of patients in health care services are seen by multiple health care professionals (excepting primary care and out-patients). Acknowledging some patients do deteriorate rapidly, generally there are the same clinical signs and symptoms to be observed regardless of the different staff seeing them. It is well recognised however that patients can have many clinical encounters before someone finally recognises they are seriously ill [1].  The fact that some clinicians see different ‘things’ in patients is not unsuprising. There are some clinical signs which are very subtle, such as work of breathing and fine movements, which require training and repeated exposure to be able to put into a context which makes pattern recognition obvious.

However others are more clear; physiological features such as heart rate and breathing rate being fixed signs which should not differ when examined by different individuals. To be clear I am not pondering over gut feeling here. The literature on the use of ‘gestalt‘ by experienced clinicians to recognise serious illness is substantial but this is not about subtle signs or intuition. How is it that in the same time span a patient who has clear features of illness may be recognised by one person but not by another? Experience and knowledge play a role but continued failure to recognise significant illness even by experienced  professionals represents a significant challenge for the health care community.

I have a research interest in the educational use of clinical video cases. This hat often collides with my clinical practice hat when system errors occur in the recoginition of illness in children. This dilemma of why a particular patient isn’t recognised as being ill (or the converse – when someone is overtreated as being very unwell when in fact they weren’t) is an important issue as is often the root cause of communication problems between departments in hospitals.

The video below was consented for general viewing by the patients’ mother (appropriate hospital and national guidance was followed). I use it (hopefully!) as a potential grey case to highlight how the same clinical features can be interpreted differently . I’m hypothesising there maybe differences in determining which are the salient clinical signs in this case. Please feel free to leave your thoughts in the comments section (appreciating previous comments may bias you so try not to look!). Regardless of whether I’m right or wrong I hopefully will learn something I can feed back on in the future!

[Oxygen Saturations 96% - Heart Rate 170 - Temperature 36.4]

What have you learnt this week? #WILTW

[1] RCP NEWS standardising assessment of acute illness severity 

What I learnt this week: Am I really learning..? #WILTW

In #WILTW on September 22, 2014 at 9:45 pm

This is the eighteenth #WILTW (and a little delayed due to working the weekend!)

How many times do you need to experience something for you to learn from that experience? In medicine health care professionals will often refer to ‘sentinel’ events. A clinical incident which has forever changed their practice:

I will never forget the patient who…. “

These events often have a patient safety element to them, with harm or near harm, unfortunately occuring. It is the seriousness of the outcome making the event the more memorable. A catalogue of these stories by senior health care professionals can be found in the handbook  “Medical Error“. It is shame that these sometimes tragic events need to occur to ingrain key actions and principles in people. But how do you make sure you don’t repeat mistakes when there isn’t a significant outcome to an error you have made? Take this example; males presenting with abdominal pain could actually have a problem with their testes. Failure to examine the scrotum may miss a testicular torsion (twisting of the testicle) resulting in the patient having to have it removed. However it would be possible to examine hundreds of patients with abdominal pain – never examining the testes – and no one ever coming to any harm because none of them had testicular torsion as the cause of their pain. If no-one ever audited your notes and fed back to you may never realise you were missing out this important part of the examination.

Medical Error

 

I am reminded of this as my second ever post on #WILTW was about the importance of clinical guidelines and how sometimes guidelines may trump gestalt. Last week I was involved in a similar case demonstrating following  a tried and tested pathway was probably better that thinking ‘I know best”. Although ultimately it wasn’t a black and white issue, and there was no harm to the patient, I was left with a real sense I hadn’t learnt my lesson. In some respects cognitive errors that involve the interplay between guidelines and gut instinct are not great examples of sentinel events.  I am though left with the feeling that despite blogging publicly about “what I had learnt this week” a couple of months ago maybe I had not learnt anything at all? Or maybe the event opened my mind to note when I am making similar errors. Maybe this post was only possible because of that previous experience? Learning might not be so concrete as to ensure when this event happens you will always do this. It’s probably a little more subtle than that. At the end of the day I hope this catalogue of reflections will always inspire me to think that little bit harder about the consequences of my actions.

What have you learnt this week? #WILTW

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