Category Archives: General

Utilising the improvement from healthcare social movement #MedX

I am pretty sure it is impossible to change the world alone. You may be innovative, provocative, and inspirational. But even our greatest leaders will cite key influencers to their success

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Hello – My name is Damian. I am a paediatrician. I am also a father and when my second daughter was 8 weeks old she was admitted to hospital with suspected meningitis. I saw the best that healthcare has to offer patients and their families during that worrying time. Compassion, dedication and great skill. To the colleague who expertly performed procedures on Bella’s delicate veins I will always be grateful.

But I also saw the worst of healthcare. A failure of senior staff to introduce themselves, the neglect of staff not washing their hands and the public display of hierarchy for the benefit of an individual needing to assert their authority.

There are many things I wish I could change about Bella’s stay in hospital. What would you change in healthcare? If you are a patient what frustrates you most? As a health care professional, how would you like your service to be run? Sadly change can become somewhat of a dirty word.

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Max Davie, a paediatrician, once said to me, “we are fed up of change, but not of improvement

There are many things we can improve with robust research and the scientific method. The dose of chemotherapy, the type of surgery or the treatment of infections with new generation of antibiotics. But what of personal change, system change, cultural change? For these we need movements.

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Social Movements are collective actions by large, but sometimes informal, groups of individuals or organisations to carry out, resist, or undo a social change. When we think about resources for change we tend to think about economic resources (budgets, technology, individuals etc). These resources are limited and finite whereas social movements can release resources in the form of social capital which is vital in environments where monetary intervention is not possible.

Within healthcare there are many shared values, both for patients and professionals, so achieving common goals through a movement has an obvious appeal. For example, the Institute for Health Care Improvement’s (IHI) “5 million lives” campaign aimed to reduce medical harm in American hospitals. The movement generated considerable publicity and the IHI claimed they surpassed their target.

Social Movements are not a new idea. They have been occurring for centuries. However in the last decade there has been a seismic change though the accessibility and reach of social media.

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Social media is increasingly seen as credible and accepted medium by which to disseminate information, decrease the knowledge translation gap and allow professional and patient engagement in a meaningful way. It has hugely increased the momentum and motivation behind social movements. I’d like to discuss some social media derived movements I have been involved in, or aware of, and share some learning.

NHS Change Day was about harnessing the power of collective action. It was a grass roots frontline movement for improvement in health and care and 98% of the activity was undertaken by volunteers. It asked for a simple action. To pledge to perform a healthcare intervention on a single day (March 13th 2013). It became single biggest day of collective action for improvement in the history of the NHS with 189000 pledges made. Change Day has been replicated across the world and is now in its 4th year.

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Change day started with a tweet that enable a first conversation between junior doctors and an improvement leader. From that first conversation a timeline can be drawn that resulted in a national event that impacted on the lives of patients.

Change day taught me about the power of stories. My pledge in the first year to try some of the medications that I prescribe to children. One, an antibiotic, was absolutely vile. It was truly disgusting. It made me realise that this wasn’t something you could give to parents and expect them to religiously give to their child. I realised you need to provide clear guidance on how to hide the taste and encourage adherence.

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Importantly the process created a story of my experiences. The staff in my department know about my pledge. They have seen the video of the odd contortions my face made when I tried to swallow it. The narrative a powerful back drop in promoting change in others.

This year Kate Granger, a doctor, passed away having been diagnosed with a rare form of cancer. She was responsible for #hellomynameis. A social movement that clearly begins with her encapsulation of how frustrating it is when health care staff don’t introduce themselves. Her campaign started on twitter and with now 1300 million impressions continues to spread throughout the world. A powerful personal narrative with meaning for others.

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Free Open Access Medical Education (FOAM) is an international movement that has brought together people from many backgrounds and specialties. It describes the production of educational materials in a variety of forms that are openly accessible. The concept of FOAM started in a pub (much like all great innovations!). Mike Cadogan coining the term during an international emergency medicine conference. It has come to represent a focus point for critical care and emergency medicine communities in particular. The term encompassing not just the materials produced but the bringing together of enthusiasts who design and digest them. It has developed into a true digital community of practice as demonstrated by examination of the hashtag #FOAMed. FOAM, along with patient derived digital communities such as #chroniclife, are social movements almost entirely derived within social media yet have all the attributes of a community of practice with the potential benefits they confer on professional and patient outcomes.

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We are now at the beginning of a new approach to social movements. One in which anyone: pubic, patient or professional can contribute to the challenge that is change.

A very public social movement can inspire others to feel passionate about what they are doing. To do this we must:

  • Learn to tell and share stories, always keeping in mind the event(s) that prompted the initial story
  • Let these stories build communities

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I am sure it is impossible to change the world alone. But with others we can achieve great things. The 21st century social media enhanced social movement will continue to teach us about connectivity and community. I for one am very glad to be part of it.

Huge thanks to Helen Bevan, Jackie Lynton, Daniel Cabrera, Jesse Spur, Chris Nickson, Mike Cadogan and many others who have impacted on my thinking in some way. 

This is a shortened version of my presentation at #MedX 2016

What I learnt this week: Whose ‘change’ is it anyway? #WILTW

This is the 42nd WILTW

The main dangers in this life are the people who want to change everything… or nothing.

 

In late summer 2012 a small group of junior doctors, nurses and graduate management trainees met to discuss a methodology of engaging other health care professionals in innovation and improvement. Follows is a quote from my call to action:

But like others in the NHS I have a sense of belonging, anyone who has been on a department night out will note the sense of commoradie amongst us. Despite this sense of belonging the NHS, much like a steam roller, is a machine that does not move quickly. It eventually gets to its destination and achieves its goals but the journey is slow and often painful for those at the bottom.

I was a junior doctor at the time and was really excited to be part of a project which I believed may help others make changes, however small, to their practice. Our aim, born out of a few hours discussion, was to model the Earth Hour social movement and create a day in which any health care professional would be asked to pledge a health care action. It wouldn’t be defined or mandated but could be shared and copied. In the room at the time were no government representatives, regional strategic directors, presidents of Royal Colleges or BMA representatives. There was a group of (relatively) young people connected by various leadership and improvement networks and brought toghether by Helen Bevan, then of the NHS Institute for innovation and improvement. At that meeting we set the day for early March 2013. I make this point because on the 6 February 2013 the Francis report was released. The date of release had fluxuated for some time but even given my health service naivety I was unprepared for how this would affect our project. Let me be clear first. The Francis report was a defining point in the history of the NHS. The underlying issues affecting not only Mid Staffs but other hospitals are clearly fundamental problems that need to change.

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However NHS Change Day was not a response to the Francis report. It has been, and still is, very difficult to convince people of this. The timing too ‘co-incidental‘, the concept clearly ‘from government‘, the ethos ‘reactionary rather than visionary‘. I will accept much criticism of change day (I am not an evangelist and continue to ponder whether we got the name right) but I do get upset, and I’ll be honest angry, when this particular charge is laid at my door.

From then on I have become very aware of the differences in the way people value what is important and right to do. Motivations to change (either yourself, organisation or system) are in part dependant on the values that you hold. I would have thought that many people would have had a shared vision of what change day was trying to achieve. But that in itself is a false and arrogant premise. It is not for me to decide what other peoples values are. So while thousands of people join a pledge on smiling at work, others lambast this as weak and something that should already occur. While we aim to bring discussions together on various social media channels, others see this as talk rather than action.

And no one is ‘right’. The Change Day team have aimed to move from pledge to actions, remove the emphasis on ‘totals and targets’, increasingly get involved at a local level, facilitate discussion with more patients and create more space to engage with all those interested. But we are always going to rub someone up the wrong way. We are also not homogenous in our own values. I personally can not promise that enthusiasm and passion haven’t over-run. I apologise to those who believe they are excluded and am honestly very upset to hear stories of where people have felt affronted during conversations.

But in return when I have been contacted with concerns about these events I find it increasingly difficult to arbitrate. The rapid nature of conversations that take place on social media does no-one any favours (believe me I know the Daily Mail have taken hold of an ill-phrased tweet of mine). When you combine limited characters with a topic such as ‘change’, in an organisation as emotional as the NHS, friction is likely. A simple question is perceived as antoginism resulting in an overly defensive response and there begins a spiral in which both sides feel aggrieved.

And there we have it: ‘sides’. An outcome that was never intended or desired but the ‘change’ those of us at the outset wished to take place is not the change others wish to see. It’s a shame it’s developed into ‘sides’ especially as I am sure my ‘change’, and I use this term of any methodology I might use to improve myself or others,  is no better than anyone else’s ‘change’. In fact I agree there are some fundamental issues in the NHS that are going to need a lot more than NHS Change Day to alter. And these changes are certainly not going to happen through change processes I use…

It’s my change though and I am passionate about it. My action, is neither evidence based or groundbreaking. But it’s something different, outside of my comfort zone and it creates a conversation which previously didn’t exist.

If you have something you would like to act on or join, please do and if not, I certainly think no less of you. And if I am not offering the change that you would like to see, I’m sorry, but I’m sure or hope someone else is!

Whose change is it anyway? #WILTW

Compassion in Emergency Care: More than a cup of coffee?

As part of series of interviews with my consultant colleagues I have been chatting to Dr. Pro Mukherjee. Pro is an avid advocate of compassion in healthcare and shared with me a great example of how powerful re-framing your view of something can be.

“Compassion” is a word of the movement. But do we really understand its context in healthcare?

 

And an audio file

Click here to get an audio download

What I learnt this week: Balancing proper procedure with paediatric passion #WILTW

This is the tweentieth #WILTW

In my humble opinion the Royal College of Paediatrics and Child Health have been very lucky. On Tuesday an Extraordinary General Meeting took place in regard to the governance and trustee structure which would lead to an opening up an arm of the RCPCH to all child health professionals. Details on the proposals can be found here

The outcome of the EGM was that the Foundation of Child Health was rejected. This is a great shame but I say the college has been lucky as I had half expected to see a Daily Mail headline:

Paediatric doctors feel they are more important than other health care professionals“.

Fortunately this angle was not taken, in fact there was virtually no media coverage. Those opposed cited a potential conflict if the paediatric ‘medical’ lead for the college and a non medical lead for the Foundation disagreed with each other which would be bad for public relations. Given the lack of interest in the event I’d be more worried that we have any paediatric voice at all!

My position was clear (from a previous Running Horse Group blog)

“This junior paediatrician  feels the concept of not moving in a direction that makes us multi-professional is almost absurd. I work on a daily basis with nurses, nurse practitioners, health care assistants and play specialists. I have also been part of a college structure which is bureaucratic, hierarchical and slow to react.”

Having passionate views about something makes you very dangerous. The moment you are not willing to pause and reflect is the moment you no longer have sound judgement. I therefore always make a big effort to step into other peoples shoes and aim to see things from their stand point.

Boat Land

 

cartoon courtesy of Dr. Hilary Cass

So, to be fair to those against the motion, there were some issues with the approach the College had taken. Changes to the governance structure were/are independent of the need for a Foundation of Child Health. Placing them together did cause confusion and potentially gave the impression of rail-roading the policy. The hosting of a significant event on a lunchtime, on a weekday, in London, did not invite a high turnout (to be fair the rules governing the college’s charitable status dictated that the vote needed to be in person). Finally at the hustings stage it would have been preferable to have an ‘against’ speaker as well as those ‘for’.

Adesthepoet

 

During the hustings the chair of the parent and carer’s group gave a emotional talk about her experiences of being a parent. She showed pictures of the twitter celebrity that is Adam Bojelian and the multiple interactions with doctors, nurses and therapists he has:

no child has ever died of too much communication between health and social care professionals

Her talk, followed by a focused argument from Dan Lumsden, the chair of the Trainees Committee, set out I think an unintentional confrontation between ‘procedure’ and ‘passion’. On one side, yes, there were some governance and policy issues at stake. Things could have been done differently in a very systematic fashion with extreme attention to detail. One the other we were deciding on a tone for the future. If the college of Paediatrics and Child Health are unable to embrace their fellow professionals and create a unified organisation to improve outcomes who else will?

I therefore found it very unnerving when the following was quoted as an argument AGAINST the changes…

“Management is doing things right; leadership is doing the right things.”

― Peter F. DruckerEssential Drucker: Management, the Individual and Society

A further speaker then worried that the potential non-elected nature of some of the trustees would risk a situation that is currently occurring in Hong Kong.

I spoke up in support of the motion but emotions are a strange thing. I have been more confident in a crowd of 1500+ than I was in front of the 100 or so in the audience. This was due to the fact, and I said this at the time, I was speaking against people who have mentored and supported me in the past. But it was also because I felt an overwhelming surge of righteousness about the motion; inflamed by an argument that the previous consultation was invalid due to its low turnout. This seems ridiculous given the equally poor responses rates for the Health and Social Care Act debate (context of table):

Voting in Health and Social Care Act

But also on reflection I was perhaps not as charitable as I should have been in regards to the comment comparing the college to the Chinese government.

Only time will tell as to the long term impact of this EGM. Many of the those voting no said they were voting against the lack of information  or “devil in the detail” provided. They weren’t against the Foundation in principle. Was this simply a case of the right thing to do but at the wrong time? I remain to be convinced. I worry that if the chance is to come again some equally obscure bye-law will be raised. If we are to be a multi-professional organisation then there will come a point that hierarchy and power is shared. That is unavoidable and no amount of procedure can bypass it.

Or maybe I just can’t see past my passion….

What did you learn this week? #WILTW

Additional Entry 11th October 2014

Please see the comments section. There has been some confusion I think about the Foundation being more important than the RCPCH. This is not the intention or the proposal. This diagram clarifies I hope:

Integrated College of Child Health

The Challenge of Change

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. 

 

Just who or what am I evaluating? Learning from #SMACCGold

Many thanks to the St.Emlyn’s team for the idea for blogging on the background to SMACCGold talks..

Very rarely do I get an e-mail that makes me instantly smile but receiving a request from Chris Nickson to speak at #SMACCGold was one of those occasions. I felt in someways like an imposter but also, if I am honest, some degree of validation. The input and impact of the smacc team into the #FOAMed community is something I am hugely respectful of. Surely, whatever the reasons for my invite, it must have meant some of the things I had been blogging/publishing on were being well received? (If I lack insight in this regard please be kind with feedback….!)

Regardless of my initial surprise though, how to go about constructing a SMACCesque talk that could possibly come even close to Victoria Brazil’s or Cliff Reid’s? I’d like to share a mistake I made early in the development of my talk. I do this firstly because I try to be a reflective learner but also because it has had quite a profound effect on me. The big mistake was that I spent far too long thinking the talk was about me rather than a talk about evaluating education. Obviously the talk wasn’t about ‘me‘ but I had noticed from the previous SMACC that people talked about Levitan’s “airway” or Weingart’s “resuscitation”. What could I bring to the talk that would encapsulate the essence of me? I was partly relieved to hear both Victoria Brail and Simon Carley say they had had weeks of sleepless nights before their talks due to their own internal pressures to perform well. This I suspect was a measure of anxiety to maintain high standards not because they were interested in showing off prowess of their subject. Ultimately once I realised the material could speak for itself, and I just needed to be an effective conduit, things started falling into shape.

To be clear that I don’t think I only made one mistake (!) other errors I made were embarrassingly predictable:

Changing material at the eleventh hour – don’t do this. None of the last minute changes I made in the conference centre lobby on the day of may talk added anything useful. In fact they just resulted in me forgetting to say things that would have been beneficial information!

Not practicing what you preach – specifically to practice, practice and practice and then practice again (preferably in front of someone else)

The talk itself was based on my PhD work and my experiences with trying to bridge the chasm between educational theory and the clinician with an interest but no such background. I am a firm believer in the power of face validity – therefore educational models need creating which are well researched but also easy to explain to those not interested in complex theorem. Given one of my research interests is validity in medical education this all starts to get a bit ‘meta’. I wrestled for some time with putting a run of slides in explaining different types of validity. I went for this in the end, also choosing to deliberately include a ‘bad slide’. I had been emboldened to do this  after trying the same in the education workshop (particularly Chris Nickson mouthing ‘so glad he said that!’ when I explained that the slide I was showing was intentionally dreadful)

One of the challenges in medical education is the interplay between the educator and the subject of the ‘education’. What is the impact of a great speaker in terms of knowledge acquisition? Knowing the importance of this effect weighed heavily on me. Reflections after the event have resulted in a very critical evaluation of myself as a speaker but if I have learnt anything from the experience it is this self-evaluation is a useful process. Fascinating this didn’t occur to me at the time…

 

Tips on chairing webexes and conference calls

Inspired by this tweet I set about collating some of my experiences of conference calls and webexes.

I recommend watching this video first to set the scene

The summary of my video cast is distilled into these six points

1. Practicalities – a reminder of difference between calls that are simply multi-person phone conversations and those that are facilitated online conversations including ability to see presentations and documents.

2. Preparation – as with all meetings setting an agenda is key but also remember to confirm functionality of dial-in numbers.

3. Participants – be aware of the ‘newbie’ and provide as much pre-event advice as possible.

4. Procedures – be as clear as possible about the structure of meeting at the outset.

5. Punctuality – you may need to more directive than is normal as this is an environment where body language is impossible to read.

6. Pitfalls – make sure everyone is muted –  but remind them to unmute when speaking!

I recorded in one take so it’s not amazingly fluid but I would really welcome feedback on all the points I have missed!