Category Archives: Innovation

The Star Wars guide to Quality Improvement

Despite being a galaxy far, far away the principles of quality improvement still hold. Here is what we can learn from some of the main Star Wars protagonists…

Yoda (The Improvement Guru)

Yoda

Yoda knows every improvement methodology in the book. Sadly like many experts his explanation of it doesn’t always  go down well with his disciples. Especially novices who often get bored and run off to try it their own way. Perhaps Yoda should read Demystifying Theory and its use in improvement. To be fair he has some great stories to tell though…

R2-D2 (Data)

R2D2As Deming said, “In god we trust, all others bring data“. The problem R2-D2 has is despite being full of information very few people are willing to listen, or even when they do, understand him. Whether a brilliant shot with a blaster, handy with a light sabre or a fantastic pilot if you don’t understand data you will never find the solution (map) to the really big problems (death stars)

 

Han Solo (The Charmer) 

Han SoloYou have read the latest improvement science literature. You have run through your model of improvement. Your PDSA templates are ready to go. And two weeks later you are still waiting for someone, anyone, to complete your new  proforma. Just as you are about to give up, Han Solo wonders into cantina, picks up a dog-eared form used by someone to doodle on and says, “this looks ok kid“. Suddenly, everyone, is using the form.

Finn (The convert)

FinnHaving  just read “Don’t just do another audit” Finn has had something of an epiphany. Jumping ship from his organisation’s normal way of doing things he finds things are a little tougher than he expected. Improvement is really hard but it’s a lot more beneficial in the long run…

Darth Vader (The Strangler)

Darth Vader

All good improvement projects meet a brick wall. Darth Vader is an especially tall and strong one. Able to silence any new innovation without even speaking Darth knows it is going to be his way.

Or his way. Or someone is going to suffer.

 

 

The above were the first 5 which I have subsequently added to. Always keen to hear more suggestions!

Rey (The learner)

Rey_Star_Wars

Very rarely do health care professionals lack passion. However like Rey you sometimes don’t realise what your actual talents are. A small improvement project can be the first realisation that you really can make a difference and not just talk or dream about it. And even more like Rey learning is pretty exponential when it begins.

Thanks to Helen Bevan for suggesting Rey

C-3PO (The sceptic)

C-3POTo some people the status quo is simply the safest place to be and trying anything new is never going to be successful.

The odds of successfully surviving an attack on an Imperial Star Destroyer are approximately…

However sceptics are often predictable and can be inquisitive enough that with a bit of persistence you may find they join for the ride (only to find something else to complain about…)

Tie-Fighters and X-wings (Design) 

tie_fighter_x_wingThere is an inherent attraction to things that look good. Great visual design is always going to improve the chance of a successful project. From observations charts to surgical checklists you want something that looks streamlined and efficient.

Lando Calrissian (The inconsistent supporter)

Lando Calrissian

A improvement project is failing when you find unexpected support from someone who comes out the woodwork to provide additional help and resources when they are most needed. Then just as you think things are back on track they side with the stranglers and the project is stopped dead. Building a team is vital but understanding their allegiances even more important. Remember though not everyone who sides with the Empire does it for ever…       (thanks to  for suggesting Lando)

Boba Fett (the mercenary) 

Boba FettHard working, resourceful and clever but really only in it for the reputation or an award. Always delivers but only at a price. Watch out for short terms allegiances with Stranglers and inconsistent supporters

(Thanks to Ross Fisher for suggesting Boba Fett)

 

Princess Leia (the deliverer)

With a determined, pragmatic and no-nonense approach to getting the job done all improvement projects need a Leia. Equally at home dealing with high level hierarchy as she is with front line staff; Leia makes sure the right processes happen at the right time. Not afraid to express her opinions but always willing to recognise the skills of others.

Galen Erso – The Saboteur

When you’re putting together a new idea or initiative, it is helpful to have a team with you helping to troubleshoot problems and brainstorm ideas. Whilst heterogeneity in the team prevents a series of “yes-men” mindlessly agreeing, be wary of those taking part against their will.

The Saboteur may appear to want the same as everyone else, but if they don’t believe in the project they may deliberately overlook flaws, or even introduce some. This could result in your world changing plan being blown apart by troublesome rebels before it can ever make a difference. Conversely it may be your original plan was actually the wrong solution to the wrong problem and some would consider Galen a hero. Sometimes improvement and change is a matter of perspective. To paraphrase the saying, “..one man’s freedom fighter, is another man’s terrorist.” (Thanks to James Nurse for suggesting Galen Erso)

We must never forget what we have failed to do.

Last week I attended the latest King’s Fund Medical Leadership Network/Development event. These bring together a number of clinicians and managers of varying degrees of experience. There is a focus on outcome, rather than just being talking shops, and there is a clear aim to increase the number of those attending who are early in their careers.

One of the talks was from Prof. Rory Shaw, the Medical Director of Health Care UK. This organisation aims to bring NHS healthcare expertise to the world and establish partnerships that will be beneficial for the UK economy. Prof Shaw was quite open about the questions this raises and some of the challenges to be faced. My interest peaked however in respect of NHS expertise in digital healthcare. It is an interesting paradox that many worldwide healthcare services don’t have access to, or any clear plan to develop, some of the initiatives and expertise which exist here. The concept of a universal number, for example,  is something that is taken for granted in the UK but is not present at all in many other healthcare systems. However from my point of view, a young (but potentially naive and impatient) junior doctor, there is nothing particularly brilliant about our digital systems. Very recently I was involved in a case where the failure to have access to the healthcare information of a patient presenting to a paediatric emergency department may well have resulted in harm to the patient. This was not an individuals fault, it was the fault of the absence of an electronic system that can share information about patients throughout the country.

I was pretty vitriolic about this at the conference, and despite furtive glances and frowns from some members of the audience, will remain so about this. It is not an excuse to say we tried that and it didn’t work. The simple fact remains that most members of the public remain extremely surprised that we are unable to access electronic records in one vicinity but not another. Even worse it remains a cause for concern patients can frequent numerous different health care providers  without any of them knowing anything about these visits. This isn’t about being a ‘big brother’; it’s about managing risk for vulnerable patients and ensuring patient safety in a system which harm if often to easy to come by.

What then are we to make of the failure of the National Programme for IT in the NHS? One argument is that we have moved on, the initiative for local solutions and then joined up working more pragmatic and ultimately more achievable. There are still large costs involved though as the governments recent announcement of a £1Billion fund for Emergency Departments emphasises. Appreciating it’s sometimes easier to judge rather than action, I have been working hard locally towards an electronic integrated illness identification system for children (POPS)  which is now used in other centres and could ultimately be used to compare acuity rates between emergency centres. This solution had to bypass NHS IT and is not the safeguarding safety net that is desperately needed.

It is vital that we remember where we have been in the past and what we haven’t achieved. There are many people and organisations passionate about improving the digital infrastructure of the NHS, and Tim Kelsey is clearly keen on making progress. It is likely solutions will eventually been found but we must honest about our past failures. It would be equally disastrous, probably more so,  should further Berwick and Francis reports be needed, but unfortunately history demonstrates we often fail to learn.

Extolling our strengths is fine, acknowledging our failings much the braver thing to do.

7 breaths is launched

Respiratory rate needs to be measured over one minute

A fundamental part of medical practice is the measurement of primary physiology. For centuries heart and respiratory rates have been calculated to help identify disease and demonstrate response to treatment. However Confidential Enquiries, internal reviews and other studies frequently show that observations are poorly taken. This in part has lead to an inexorable rise in early warning scores and system to identify acute illness. A potential barrier to the recording of observations, whether by doctor, nurse or other health professional is the time taken to measure them. Traditionally a minute has been the gold standard in order to ensure reliability. Studies have supported the 60s approach (Simoes 1999) but with increasing pressures on health services and rapid advances in easy to access technologies the time has come for a review. Can you help?

Take part in a large scale observational trial using your smartphone

This idea was first outlined here, tweeted and published on the NHS Hackday googlegroup. This idea was very quickly picked up by Neville Dastur, a consultant vascular surgeon, software developer and owner of Clinical Software Solutions and 7breaths was born.

What are we going to do with the data?

The data will be openly available to data analysts and mathematicians to attempt to generate an algorithm that can be used in future version of 7breaths that will automatically report the respiratory rate once the software is ‘confident’ that it is able to predict within set level of confidence what the respiratory would be at 1 min.

 We envision that this will take into consideration

  • Inter-breath duration

  • Variability and pattern of the Inter-breath duration

Why bother with this?

Ultimately this is a demonstration of the power of open source, collaborative healthcare innovation. While it is a bit of fun there is a real possibility that new methods to improve the accuracy of RR measurement and that can also save time could transpire. It’s also a demonstration that a simple piece of software may enable an economical way of gathering data at the point of care that does not require any form of duplication of efforts.

 Want to take part?

Download the App

App Store  

Google Play

Register

When you first download the app, you have the option of registering the software. We would encourage this as it would allow us to acknowledge your contribution and also provides a degree of provenance for the data collected.

Start collecting data

When you are next counting a patient’s respiratory rate, use our app instead. At the end of one minute it will report the respiratory rate and it will give you an option of sending the data to us. That’s it!

Please spread the word….

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Who’s behind 7 breaths?

Wai Keong Keong – Haematology Registrar (@wai2k)

Neville Dastur – Vascular Surgeon (Clinical Software Solutions)  (He built the app > Sourcecode on GitHub)

Damian Roland – Paediatrican (@damian_roland)

Simultaneous Safety: Purposeful Physiological Detection

The Million Pound Challenge was a new event at the International Forum of Quality and Safety in Healthcare #Quality2013. Judges included Donald M. Berwick, Fiona Moss, Helen Bevan, ‘e-patient’ Dave deBronkart and JoInge Myhre.

The challenge: Junior health care staff to pitch an idea for what they would do with One Million Pounds to transform healthcare. Four finalists were shortlisted for presentation. The video of my presentation is here:

I was very humbled to be not only shortlisted but win the award with my idea for a multi-purpose saturation probe. In  summary the technology exists to not only calculate oxygen saturations and heart rate, but also temperature and respiratory rate from the same device. These four measurements together, adjusted by an internal microcomputer for a designated age range, could be used to simply display a green, amber or red light to given an impression of the patients health. This would NOT replace clinicians judgement but would support health care professionals and potentially those without significant medical training to make decisions on patient care. The probe would be powered by a small solar panel enabling its use in the developed and the developing world.

My presentation is attached. I am not a big fan of bullet points but the general sense is there.

A picture of my mock of what the device would look like is below (click on it to expand):

Annotated Picture of Monitor

So what turned out to be a ‘back of packet’ scribbling seems to have caught peoples attention. Could this really be taken forward?

To do this I need the help of the world-wide health community.

Do you work in medical technology industry?

Do you have a friend who is expert in solar panels?

Can you program algorithms into motherboards?

Would you like to just simply help!

Please get in touch by commenting on this blog. This is a real opportunity to change the world. Don’t just believe me. Donald Berwick said so….

A number counter that works within Powerpoint

This great little customisable presentation was put together by Craig Sayers in response to a request I had put out via twitter

(it did help he also happened to be my best man)

The presentation is need for something I am doing to feedback on NHS Change Day  but I suspect a counter mechanism may be useful for other presenters. Just to note it won’t work in Powerpoint for Mac 2008 (I’m trying to find out if it works in 2011!)

If you want to change any of the settings you need to go into Visual Basic from within Powerpoint.  Do this either by pressing F11 or double clicking on the Start Counter button on Slide 1 when editing it (not from within the slideshow).  You should then see a text editor-type box with the code in it.  I’ve added little comments (in green) to show which numbers need changing to do different things.  Just alter a number then close the Visual Basic window.  Next time you start the slideshow it should make the alterations.”

A huge thanks to Craig Sayers for putting this together (and providing the editing instructions)

Please send any feedback to @damian_roland or @tonythepianoguy

The presentation can be found here: Powerpoint Counter

Presentation to TASME (Leicester) 19th January 2013

I was due to given a talk to the Trainee section of ASME (TASME) on the 19th January 2013. Unfortunately the event was cancelled due to the weather  conditions. I therefore recorded a practice run through (or at least a portion of it).

It is a bit rough and ready and maybe missing an introduction about the aims (which were to talk about my experience of research, leadership and entrepreneurship).  I will probably update it at a later date and the presentation at this stage is just about the research element.

Hope it gives you at least food for thought and I have certainly learnt a great deal about narrating over powerpoint presentations! The lack of interactivity or audio-visual cues from the audience was quite disconcerting! Also on play back its amazing to hear how many unnecessary words I use so a learning experience all round….

A related resource is a storify of a question I had asked on Twitter prior to the event – click here

Am I productive? A triad of system barriers

A recent twitter posting prompted a discussion which took on a number of directions

The resulting discussion can be found here. The concept of productivity caused me reflection during and after the twitter chat; in particular on the theme of individual performance.

Obviously in the big scheme of things the number of patients I see on any given shift has absolutely no bearing on the overall productivity of the NHS. But is my own work rate or output in any way correlated? And more importantly are the metrics themselves even comparable?

What is productivity? Wikipedia describes it as thus:

Productivity is a measure of the efficiency of production. Productivity is a ratio of production output to what is required to produce it (inputs). The measure of productivity is defined as a total output per one unit of a total input.

Is this in anyway meaningful for the health sector? The Kings Fund (@thekingsfund) give a range of possibilities but I am still left asking: Am I productive?

I think back to my last weekend shift. I work in a busy Paediatric Emergency Department which links to a tertiary children’s hospital. I think of myself as having been productive if I see x number of patients (for me x is 20 but I am not sure the number is transferrable as a comparison measure). Although the actual case-mix is very variable virtually every weekend contains a number of specific events/presentations which has a large bearing on my self-productive rating (and sense of achievement by the end of the shift).

  • The state of the department prior to my arrival. A weekend shift runs from 12pm-10pm and there is a back log of reviews to clear (I am a relatively senior registrar) even before I can see new patients. Any productivity I bring in respect of patient decisions or interventions is not additional benefit it is based on prior inputs (or patient presentations in a health care sense) to my arrival. Is it efficient to potentially reduce my de novo productivity at the outset of my shift? 
  • The number of emergency cases (defined as patients requiring immediate, potentially life saving, intervention). A prolonged resuscitation requires multiple resources and, regardless of the efficiency of the team, drains time from seeing other patients.
  • The number of complex non-emergency dischargeable (CoNED) cases (bear with me on this…). Appreciating the subjective nature of ‘complex’ these are cases which do not immediately  fit a pattern which an experienced health care professional would recognise.  I suppose it is self evident that lots of complex cases will require more time and therefore less patient turnover per clinician. However in an emergency department once it is clear a patient needs to be admitted you become less productive if you spend effort utilising resources that could be done by the inpatient team. Conversely from a patient perspective there are some investigations or managements if commenced early save time later in the patient journey. So there is a balance between ‘fast tracking’ and the overall length of stay. Additionally you must also have insight that this is a complex case; often reviews on patients on behalf of juniors reveal patients who were thought not be complex but in fact are (and vice-versa!). Ultimately the ability to manage a complex case requiring admission is a skill which improves with experience and I am not sure affects my overall productivity . However if a complex patient does not need to be in hospital this may be particular time leeching. From a 4 hour target perspective (see @drmarknewbold‘s brilliant blog on this) it may well be easier to admit but this is not always in the patients best interest. The number of CoNEDs is in part a function of the success of modern medicine and the ability of health services to provide effective and prompt follow-up.

I am very happy to concede that the number of patients seen is not a brilliant metric for productivity and that emergency medicine is only a small part of the NHS workload. I believe, the triad of, the current capacity of system, the number of serious cases and the number of complex cases not requiring referral to another provider is an important factor in determining productivity. The solution therefore may not depend on the individual. That will certainly not stop me working very hard to get x as high as it safely can be.