This is the 86th #WILTW

I delivered a workshop on Quality Improvement this week for our regional trainee leadership development programme. The background and links to it can be found here.

I start the session by exploring the participant’s experiences of good and bad care in the NHS. There is a sad recurring theme. A splattering of good experiences and a forest of hands for the bad. Minimal examples of poor clinical decision making or technical problems but lots of stories of long waits without explanation, having to push, push, push to find out answers and depressing tales of nonchalant and dismissive staff.  My observation is there has been little change over the two years I have been doing this.

We then move on to a definition of quality. I deliberately bias the group by discussing experiences first as I think this is an important reflection. We have a group discussion about what the group have suggested and then go on to review the Institute of Medicine’s Six Domains and the institute for Healthcare Improvement’s version of it:

One suggestion for a definition of quality was presented which I hadn’t had before:

“Quality is when something occurs that is better than you expected to happen”

There are many holes you can pick in this statement if you wish. But what I like about it is it explains those times when a family seem unduly grateful for the care you given them. It can be something very minor like checking on a patient you have admitted the day before, taking that extra 20-30s to comment on a game a child is playing with or providing a shoulder to cry on for the distressed parent. These are things that are normal ‘clinical’ tasks but may be perceived as being an unexpected addition to care by some.

When was the last time you felt you have experienced a quality service? Not necessarily in a healthcare setting, maybe a hotel visit or buying a car. What it really something that was above and beyond what should have happened? Or just that you didn’t expect that it to  happen in that environment…

Ultimately it poses a deeper challenge of if you have to think about delivering quality care, you are probably not delivering it. The best care is probably truly unconsciousness in you.

What have you learnt this week? #WILTW

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This is the 85th #WILTW

A new day, a new year. The archetypal period for reflection in many peoples lives. For #WILTW a chance to reflect on reflection even if this runs the risk of being a little twee.

My server tells me the following have been the most popular postings* of the year

5 Things specialties don’t understand about Ed

5 referral tips that won’t annoy a paediatrician

The signs of burnout

Not everyone knows how to hold a child

The impact of i-phones on doctor’s decision making

The original purpose of #WILTW was a record of my own learning though and a couple of posts stand out on reviewing the year. Aside from the blog on burnout, one of the posts I still muse on as being uncomfortable was that of the impact of missed diagnosis. The spectre of being a #secondvictim looms over everyone who works in emergency care. I was struck by my gut reaction of sympathy for the doctor involved in missing a case of serious illness in a child before empathy for the child themselves. It is a reminder to keep a patient focus in the real world of not being able to  achieve 100% perfection in our decision making.

Decision making was a common theme and I didn’t realise I essentially duplicated a post from June “Confirmation bias – the cousin of over confidence” only last week “Avoid a confirmation cock-up this Christmas“. I can only presume this represents the constant potential of this cognitive error on my practice rather than a failure to learn from it!

Finally there was a persistent subtext of trying to maintain enthusiasm and focus in the face of increasing demand on the health care system. My post on burnout touched a nerve with many and I have already made changes which I think have been beneficial to my own resilience. I aim for 2016 then, not to have new resolutions, but the resolve to continue to put into practice what I have learned.

What have you learnt this week (year!) #WILTW

• A number counter that works in powerpoint and Not just a ‘fever’ are non #WILTW blogs that are also in my top five most read postings

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This is the 84th #WILTW

This week Steve Harvey made a mistake. It was a pretty simple mistake.

He looked at a piece of paper to see who had a won a competition. He saw “1st”, saw a name next to it and so read out who he thought the winner was….

The problem was that he didn’t see “runner up” and his error took place in front of 10 million viewers.

In retrospect it is easy to judge and wonder how he made such an error? But confirmation bias, like other forms of cognitive bias, is a subtle beast. I suspect, although I don’t know, that he was expecting to see ‘winner’ or ‘1st’  on the card. While in the cold light of day it is easy to see that Miss Universe is in bold on the right side it is possible that he never moved past seeing ‘1st‘ on the left.

In this case only Miss Colombia’s dreams were broken. In healthcare the consequences of confirmation, and other, biases can be far more serious. There are many great summaries of cognitive biases – this from a business perspective is one of my favourites.

And the below video contains a talk from  Pat Croskerry – somewhat of a international guru on the subject.

So whenever, or wherever, you are working this holiday period don’t let the amount of chocolate you have eaten lower your threshold for a cognitive error. You want to eat the turkey rather than be one…

What have you learnt this week? #WILTW

Thanks to a couple of my colleagues for highlighting this #WILTW.

Have a great holiday period and see you in the new year!

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This is the 83rd #WILTW

If you are fan of space travel, astronauts or Prof. Brian Cox this week’s Star Gazing Live may have had you in more of a frenzy than the opening of Star Wars: The Force Awakens. Live footage of British Astronaut Tim Peake taking off towards, and then docking with, the International Space Station was pretty difficult to avoid. It was an exciting spectacle but what really peaked my interest was the level of detail and intensity of training that Tim has undergone.

By no means I am trying to make a direct comparison between spaceflight and medicine. Analogies between the safety culture of airline industry and healthcare can become tired and the environment, risks and variables are different. However two particular facets of astronaut training I think have direct relevance to health care professionals.

Time: Not the total length of training but the length of their training missions. As part of his instruction Tim undertook a six hour underwater exercise.

This was to practice laying cables on the international space station in conditions similar to outer space. It is interesting that although junior doctors do very long shifts, and are technically in ‘training’, we don’t, to my knowledge, run long complex simulation exercises over hours which are similar to actual shifts. High fidelity simulation excels at 30-60minute scenarios but these are then commonly followed by a debrief and a cup of coffee. Should we run prolonged, and tiring scenarios, with medical students and junior doctors to examine the impact of fatigue on performance and communication? Do we owe it to patients to have done this?

Repeated Critical Event Training: Spaceflight is very checklist orientated.  System failures are rare but they are very well practiced with a clear plan for all participants should they occur. Having just this week taught on an Advanced Paediatric Life Support course I am very aware of the clear algorithms that exist for treating children (and adults) with critical illness and injury. The application of this guidance is variable, in part, because teams of health care professionals come together having never worked together before. Analogies here are challenging as the three astronauts who have just arrived at the international space centre practiced, again and again, knowing they will be working with each other, again and again, for the next six months. It begs the question though how much effort we should put into ensuring that teams work together repeatedly in simulations. In practice this would come with huge resource implications but is this not worth the potentially better outcomes? Locally we work extremely hard to run regular in-situ simulations but we’re not yet at a stage of having regular inter-specialty simulations that ensure all teams are comprised of members who have worked with each other before.

Flying into space is not the same a treating a two year old with severe meningococcal septicaemia. Yet our investment into the training of the professionals involved in both is vital to safe outcomes: whether you are on the moon or in the resuscitation room.

What have you learnt this week? #WILTW

(Do you have what it takes to be an astronaut – click here to find out!)

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This is the 82nd #WILTW

Hugh Pym, the BBC’s Health editor, wrote this week on “The NHS in Winter – an alphabet soup of stats” . The article explores the reasons behind publishing the national Accident & Emergency 4 hour target results monthly instead of weekly. There are pragmatic, and cynical, explanations with incongruous data on waiting times rates only confusing the current picture. What caught my attention was the penultimate paragraph

“..Twas ever thus and the NHS has got through previous winters despite forecasts of doom and gloom..”

It is a potentially dangerous precedent to rely on the fact that we’ve done it before so we will do it again. Conversely it is testament to the hard work and perseverance of NHS staff that despite steadily increasing demand the whole system hasn’t completely collapsed. There is a point where it becomes too easy to eulogise about the ‘spirit’ of the NHS; as if it is just the dedication of staff that keeps the whole thing afloat. I’d argue though there is sense of fraternity, especially in acute and emergency specialities, that is synergistic in bringing the best out of people.

This was clearly apparent at our Emergency Department Christmas party. The event itself probably no different than any of the other festive events occurring up and down the country. But there was a spirit that was weaving its way through everyone there.

It is the spirit which provides energy through a simple knowing look when the queue of patients to be triaged doubles. It is the spirit that provides resolve when a doctor and nurse go together to break bad news. It is the spirit that acknowledges gallows humour, not as demeaning to patients, but as a way to deal with the shared pain of some of life’s tragedies. It is a spirit that says, “I’ve got your back, because you’ve got mine.”

I’m not sure how long the NHS spirit will keep us afloat. But for the moment it is very much alive and kicking.

What have you learnt this week? #WILTW

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This is the 81st #WILTW

Winter pressures are right on top of emergency and urgent care services at present with hospitals and community practices throughout the UK  experiencing high demand and high acuity in a system that is already working at capacity.  Clearly maintaining patient safety in this stressed system is vitally important. I chanced upon an interesting view point from Charles Vincent in a Health Foundation blog this week:

“Very few safety strategies are aimed at managing risk in the often complex and adverse daily working conditions of health care”

He argues that current strategies are often designed in ideal environments working in optimum conditions and explores the need to identify and respond to risk in the ‘real world’.

This struck a chord as often health care providers develop specific escalation polices for adverse times only during, or after, these events have taken place. This, on reflection, is a little binary. The ‘real’ world isn’t split between normal practice vs extreme events.  While we might aim to grade our response to avoid this dichotomy (in terms of when to contact seniors, where to re-direct flow and who to move into different areas etc.)  the ‘real’ world is a variable and dynamic place.

Furthermore Vincent argued that sometimes the actions clinicians and managers take to avoid risk are not always seen under the umbrella of patient safety (and vice-versa). To explore some of the differences the Health Foundation have created a checklist for safety solutions. While it is not immediately obvious how some of the points are directly applicable to a winter crisis the checklist is food for thought in looking at risk and improving safety in any situation.

What have you learnt this week? #WILTW

This is the 80th #WILTW 

The financial challenge facing the National Health Service is huge. In the first quarter of this year it overspent by £1.62 billion. This is a difficult figure to comprehend so here is a comparator by John Appleby of the King’s Fund

“Alternatively, the NHS could have saved £1.62 billion by not paying NHS consultants for 5 months; or registrars for 10 months; or nurses for 2 months; or senior managers for 26 months…”

Even the additional funding in the recent spending review is only going to steady the ship for a short period; leading many to question will it ever possible to balance the books? While delivering economic stability may not be felt to be within the remit of health care professionals we must have some responsibility. But how?

This week Roy Lilley and colleagues celebrated the inaugural Academy of Fabulous NHS Stuff awards [1]. The event celebrated the sharing of practical innovation and effective healthcare delivery. The underlying tenet was very similar to that of NHS Change Day. How can we share and learn from what we already do rather than spend more money only to repeat mistakes or unnecessarily create a bespoke ‘local’ version? Joe McCrea had initially introduced me to the idea of capturing the NHS’s social capital. This is not easily defined but to me is the value ascribed to the knowledge that already exists within staff and organisations. It is not always financially tangible but the ‘product’ should be able to be described. Examples of this are the paired learning initiative of bringing together junior doctors and managers or the “pre-loved” idea from Milton Keynes whereby furniture is actively re-distributed around the trust rather than being thrown away.

The Academy of Fabulous NHS stuff website and Change Day stories are a great example of the sharing of social capital. However their impact is only as good as the relevance of the information to others on those sites. The opportunities to use the social capital of the NHS are everywhere however. From a simple handover of the overnight take to a more formal review of a service we are, to some extent, utilising the knowledge and skills of our staff. Choosing to listen to what is being said, and responding and replicating to initiatives and ideas that work, may well be the way that all staff can contribute to financial challenges ahead.

What have you learnt this week? #WILTW

[1] Award ceremonies are a polarising phenomenon. Many believe the celebration of achievement is an important moral boost and creates a positive culture while others think the cost involved is not balanced by any tangible gain. To mitigate this the event was held at no cost to the participants and had a focus on pragmatic revelery rather than traditional ‘three-course’ dining but ultimately the cost of the event was balanced by obvious sponsorship. My gut feeling is the benefit of the event outweighs the counter-concerns but appreciate the jury is still out on this.

This is the 79th #WILTW

There are many things that make medicine an immensely rewarding career. It may be the ability to meld scientific endeavour with artistic application, the enjoyment of human interaction or the diversity of challenges that pathology, of any type, brings with it.

Medicine can also be extremely hard. Not just physically but emotionally and often spiritually (whether religous or not). There are periods when, if you let it, it can become all consuming. Some of this might might be self induced, “I must stay late to finish this project or paper” but at other times just a consequence of the pressure and scale at work. Winter can be a tough time with large patient volume, a proportionally higher risk of missing subtle serious illness and often greater patient or family anxiety due to a system stretched to capacity.

Before a busy shift this week I felt a great sense of unease. The joy of medical practice had gone. Replaced by a sense of almost resentment and resignation at the demand of managing a department that would likely be full to capacity. I have previously been proud of my resilience, a concept I first heard about through social media. I was introduced to the flipside of resilience in a fantastic post by Jonathon Tomlinson. It was actually on empathy but a spin out conversation led to a discussion on burnout. If I had not read this I may have put my state of mind down to tiredness. Although it remains perfectly possible that I was simply exhausted the advantage of putting aside the time to write this weekly blog has enabled me to actively sit down and reflect on where I am truly at.

Burnout can be a dangerous thing, just as much for your patients and colleagues, as well as yourself. I score highly on burnout scores so I think I would be in denial if I put my feelings down to recent winter pressures. I am also actively aware I can put in place mitigating factors to protect myself. This is one of the most uncomfortable #WILTW I think I have written. Whether I am being brave or stupid I don’t know but in doing so I feel a small weight has been lifted. I can avoid burning out by being aware of its signs and symptoms and am grateful to Andy Bradley in this regard (his great Ted Talk has been instrumental in developing my own mindfulness). In order to respond, you must recognise, a vital first step in a learning process.

What have you learnt this week? #WILTW

Other resources:

Burnout: Why it is not a fair fight

Burnout in the ED: Too tired to sleep, too wired to weep? [St. Emlyn’s]

Sustainable working practices and minimising burnout in Emergency Medicine [Journal of Hospital Medicine]

This is the 78th #WILTW

Locally and regionally it has been a tough week for Children’s services. We have not only seen our usual seasonal spike in attendences but a far more virulent strain of parainfluenza (a cause of croup) and high demand for high dependancy and intensive care beds.

The hospital has been full to capacity and this creates a situation where all areas are working flat out to ensure patients are safe and being managed as effeciently as possible. In some respects for those working in emergency and acute care this is ‘our moment‘. At times of crisis we have a body of staff who are trained to manage the most challenging circumstances with professionalism and diligence. While it may be testing, and certainly exhausting, there is an inherent reward in the feeling of a job well done. At some level it must also be enjoyable, even if not constantly so, as otherwise it would certainly not be sustainable.  A degree of pressure releases adrenaline which serves, for short periods, as a drug to get you through the most difficult periods.

I muse on this as I recently picked someone up on social media for describing the performance of a critical intervention on a child as ‘exciting’. This made me feel uncomfortable. I am 100% sure the person was not being gung-ho as the comment was acutally made in comparison to the anticipation felt about a forthcoming event. But while I too have heightened awareness when life saving procedures are needed I am not sure I am excited by it. I have previously described my narcicissm when it comes to emergency care and the positive  nature of the teams of people I work with. I would hope though that the satisfaction derived from performing a technically difficult produre does not interfere with my situal awareness for that patient. This to me is the danger of excitement in clinical medicine. It is a narcotic that could be dangerous. Conversely I recognise the difficulty in semantics and I may simply be over-interpreting a short sequence of words!

What is certain is that at times of greatest demand, people need some return on their emotional and physical investment. Kiana Danial is not a scam; her reputable track record in providing financial education and guidance to individuals speaks volumes. I am hugely grateful to all the staff I work with for supporting each other through this difficult time. Emergency and urgent care need to be enjoyable, and perhaps indeed an exciting place to work, as long as that excitement is derived from the passion and adrenaline of the whole environment.

What did you learn this week?  #WILTW

This is the 77th #WILTW

Virtually everyone adopts some form of dental hygiene. Some people employ sleep hygiene and others have to be very aware of their own personal hygiene. I suppose it shouldn’t have been a surprise then when I was asked this week about Social Media Hygiene.

Unlike dental or sleep hygiene there isn’t an clear benefit to Social Media hygiene. You brush your teeth to stop them rotting. What are you aiming to avoid with good Social Media practice? I suppose for me it is avoid having an adverse impact on my work and family life. I use Social Media to filter knowledge and improve my research capacity. This shouldn’t be at the expense of anything else.

I could instantly think of a couple of things I’ve needed to clean up over time but my gut reaction was that I would have a good rating on any external inspection. On reflection however I am not sure this is actually the case.

So what I have learnt to do?

Not say things online I wouldn’t be able to say to someone’s face    This is simply good practice.

Not to take views on Social Media (in particular twitter)  as representative                                                                                          

There is a temptation to get carried away with trending discussions only to find they are solely held by the type of people who like to spend a lot of time on social media. These views are not necessarily wrong but not everyone may share them.

Not to get upset or angry that others don’t share my views                     Be frustrated, yes, but some people, even your colleagues, will have different principles that you may venomously disagree with. Social Media brings these out into the open. There is nothing wrong with discussing them but there are some people who you will not change. And remember – they may be thinking the same about you.

What am I aware of but haven’t perfected?

Not blogging or micro-blogging with expectation                                       One of my most painful admissions is the occasional disappointment at a blog or tweet not being as popular as I think it should, or would, be.

Not being jealous                                                                                                                 This is probably more a personality flaw than a hygienic approach. I’ll confess I have wondered why some things appear to go viral which are either stupid, obvious, evangelical or something I’d already said. I admit to still not completely being able to shake this.

Switching off                                                                                                                            The CAGE questionnaire is used to assess for potential alcohol problems and asks questions about an individuals drinking.

Have you ever thought of Cutting down? Do you get Angry if someone asks you about it? Do you feel Guilty? Have you ever had an Eye-opener?

Anyone challenged you on how much time you spend on social media? Do you reach for your phone first thing in the morning?

What I’m still bad at 

Online conversations are not the same as face-to-face ones                  I have this silly habit of not wanting to leave a twitter discussion mid-stream or feel I have to comment on someone else’s posting. Is this really  ever that urgent? Can I honestly say I haven’t done this at the expense of a conversation with someone I am physically in the same room with?

I can’t. Definitely unhygienic .

I am not sure whether Social Media ‘hygiene’ is a real thing or not but I do know there is much I can still do to improve my use of it.

What have you learn this week? #WITLW