This is the 136th #WILTW

Please read this with the Christmas spirit it was intended 🙂

In 2004 Fred Lee published “If Disney ran your hospital: 9½ Things you would do differently“.  His observations, as an American hospital executive who went on to work for Disney, are technically more pertinent to “pay-as-you-go” systems but remain relevant to all healthcare providers. His key idea is that customer experience is paramount and being obsessive about it will improve quality across an organisation. The famous example from the book highlights that healthcare professionals never say why they are drawing curtains around patients. He argues just explaining it is for the patient’s own privacy would be a small but tangible approach that would improve experience.

Having taken my daughters to Disneyland Paris this week I can vouch that the ‘Disney’ experience is certainly something special. The attention to detail in the Sleeping Beauty castle, the brilliance of the Buzz Lighter Laser Blast and the charm of the Dumbo flying ride all definitely have a ‘wow’ factor. However having completely  immersed ourselves over a couple of days I do think there are areas where the NHS might just have an edge over the corporate machine that is Disney.

1. Waiting Experience – In both the NHS and Disneyland you need to be patient and wait in line. However while waiting in an Emergency Department to have your broken arm mended is not the same as waiting to fly through the sky with Peter Pan you can pretty much guarantee in the NHS there will be toys in the waiting room. The interaction during queues was surprisingly sparse in Disney, perhaps they need to employ some Play Specialists..
2. Waiting Times – While a matter of great political and clinical debate the NHS does have standards it aspires to. Are there waiting time for rides that Disney wouldn’t publically be prepared to publish? What percentage of visitors get to ride Big Thunder Mountain having had to use a significant proportion of their total visit time for the privilege? The 4 hour target is a cause of great controversy but at least it’s a matter of public record.
3. Prioritising Services – In order to maintain flow for emergencies the NHS may chose to delay elective surgical procedures. While this is clearly frustrating for some it maintains the service within a finite resource envelope. Disney doesn’t have the ability to sacrifice Mad Hatter’s Tea Cups to improve access to Pirates of the Caribbean.
4. Managing demand – The services the NHS can provide do not match the need for care it wishes to provide. Therefore prioritisation decisions need to be made. These are difficult, and sometimes very unpopular, but aim to ensure treatments are given to those most in need of help or most likely to benefit from it. In Disney however it is possible for a group of adults to decide they’d like to have their pictures taken with Mickey over breakfast denying a couple of toddlers the chance.
5. Knowing your environment – while many hospitals are like mazes at least NHS staff will be honest if they don’t know where ‘Clinic 23’ is. To the Disney staff member who looked like they weren’t sure where we wanted to go, but still cheerfully sent us completely in the wrong direction, we forgive you.

Have a good holiday period – whatever you maybe doing.

What have you learnt this week? #WILTW

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This is the 135th #WILTW

Dependant on your source Jugaad is a colloquial Hindi word which implies a work-a-round solution to a problem. Its direct translation is ‘machinery’ but in management vocabulary it describes cheap resources which solve complicated issues. It was used in the context of ‘frugal innovation’ in a blog linked to by Roy Lilley this week. The Jugaad approach cited as a mechanism to help the NHS in this difficult period.

No immediate cash injection into the healthcare system looks likely at present. An even if it was suddenly to occur it wouldn’t solve those inefficiencies, bureaucracies and productivity challenges which are not directly amenable to financial resolution.

It is very easy to develop learnt helplessness during these challenging times:

“There is nothing that can be done, or nothing I can do, so I will continue to do nothing.”

I think this phenomena plagues healthcare more than we care to admit. Having said we have strong notions of productivity and I think pride ourselves on attempting frugal innovation where possible.

There is a delicate balance here – the concept of Jugaad could easily become part of management ‘bingo’ and certainly won’t solve some of the more wicked problems we have in healthcare. Conversely falling into a cycle of despair helps no one.

I have tried where possible with #WILTW to reflect and learn with tangible solutions. I have no immediate answers this week however if there is one thing that may well keep the  balance, it is the healthcare staff themselves…. (click here if video below doesn’t play)

The chart-topping @Choir_NHS are here to help everyone to #StayWellThisWinter – show your support and share their song! pic.twitter.com/VHlwVJR49R

— NHS (@NHSuk) December 5, 2016

What have you learnt this week? #WILTW

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This is the 134th #WILTW

There are very few completely original ideas.

Someone, somewhere is always likely to have thought of something before you have. Genius more in being credited for the idea rather than having it!

Andrew Tagg released a great blog post this week. He muses on there “never being enough hours in the day“. I am often challenged on how I find the time to do so much; especially considering that I am “always tweeting”.  My stock response to this is “well how do you know I am tweeting so much if you aren’t on twitter too?”

Seriously though, like Andrew, I am relatively regimented about out-of-work routines and there are somethings I treat as a hobby rather than a chore. I do appreciate this is a fine line and it is important to take stock and be honest with yourself about why you are doing what you are doing (especially with social media). I share with Andrew a general aversion (or maybe more correctly an avoidance) of television and video games and also see so much kinship with this:

“I currently have ideas for about 20 blog posts in slow Brownian motion inside my head.” 

One of my greatest faults is to not always be present. My colleagues do very well to tolerate this in me. It is often because an idea or thought from 2 weeks ago  re-surfaces with a progression or solution. I am not knowingly mulling things over but somewhere in my brain synapses are firing away.

Having read the post I coined the term “multi-thinking”. I am not efficient because I am multi-tasking, it’s because my brain is simultaneously working on lots of projects in the background. Sadly after googling multi-thinking I realised I wasn’t the first person to coin this. There is actually science behind it; the more precise term probably being a variant of integrative thinking.

“..the predisposition and capacity to hold two diametrically opposing ideas in their heads. And then, without panicking or simply settling for one alternative or the other, they’re able to produce a synthesis that is superior to either opposing idea…”

The ability to multi-think is, I’m sure, impacted by state of mind or other external factors, but it’s a pretty reliable component of my productivity, especially what I learnt this week!

What have you learnt this week? #WILTW

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In googling for multi-thinking I found this post on procrastination which while not directly related is quite fun….

This is the 133rd #WILTW

While delivering a presentation at #MedX a member of the audience was taking notes in a different format than usual.

https://twitter.com/jamesturnerux/status/777545688368283649

James is a healthcare designer and his visual note taking really appealed to me. He recently visited our children’s Emergency Department and had some amazing insights, both from a design point of view, but also because of his perspective from outside of the healthcare profession

One of his comments:

Kneeling down and reducing your physical size is so important. Witnessing situations where adults didn’t match the child’s eye level made it even more obvious of its importance.

Those working in paediatrics have an instinctive desire to kneel down. Jame’s statement stood out, not because it was new to me, but from his observation how obvious it is when you don’t do it.

While the message in this picture is self-evident

I think this is perhaps more powerful..

The point is maybe obvious but I am struck that it is perhaps easier to recognise when something’s wrong rather than when it is right. We are observed constantly in healthcare; what might have you been remembered for on your last shift?

What have you learnt this week? #WILTW

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This is the 132nd #WILTW

It is late at night but the waiting room is full. There are parents and children everywhere. Prams provide an obstacle course for waddling toddlers, crying babies don’t quite succeed in drowning out the irritating background disney song and there is a palpable tension in the air.

You need to walk through the waiting room. Some have been there for hours; anxious for their children, tired and probably hungry. You know they will be looking at you with a mixture of expectation, despair and perhaps even anger.

In all walks of life eye contact is required as a fundamental part of communication. Accidentally or deliberately not maintaining it creates  unease and mistrust and can infer anything from undue deference to deliberate defiance. In a small glance you can recognise a huge variety of emotions; there don’t need to be words or body movements, the posture of a person’s body tells you much about them.

And that is why that walk is so difficult. Do you acknowledge each and every person who looks at you? See their frustration and sit with it. Even though, because you’ve been called to see a very unwell child, you know there wait is going to be that much longer?

Or do you put your head down and walk at pace. Ignore the stares piercing your back hoping they understand you are as conflicted as they are frustrated. Wanting to reassure all; but knowing there isn’t the capacity or time to do so.

The ‘look’ from waiting room is a huge cognitive distraction – it weighs on you even when you are not subject to its glare. It is not the fault of the parents or carers that this pressure exists nor is it callous of health care professionals to feel it. It is symptom of health care demand and a testament to the fact that health care professionals maintain that essence of respect and dignity in their practice. Do I wish I could keep my head down? Yes I do. But to not feel this discomfort would be a far greater cause for concern.

What did you learn this week? #WILTW

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This is the 131st #WILTW

I remember being distinctly disappointed in my dad when he told me:

“The day we stopped having lunch together as consultants was the day when healthcare got worse in the NHS”

As a medical student I felt this comment seemed to belong to the era of Sir Lancelott Spratt where the rigid hierarchies of medicine encouraged Consultants to play golf on a Friday afternoon. To spend time in the company of colleagues not actively working was indulgent and would be better spent with patients.

Time has moved on, and although I am still of the opinion that a free lunch for a certain professional group in a separate area of the canteen is a distinctly backward step, I finally understand what my dad was saying. Commensality is essentially the act of eating and drinking at the same table. It is a widely studied phenomena and was discussed this week in a blog by Chris Ham of the King’s Fund.  His argument was that creating time for people to get together helps build relationships and therefore trust. This trust helps to heal some of the fractures that are dividing healthcare at present. Apparently (and this isn’t referenced unfortunately) the Mayo Clinic have undertaken a randomised clinical trial to demonstrate the benefits of staff sharing meals together.

There is inherent face validity in this. But commensality is probably more than a word that would not be out of place on a management bulls**t bingo game. As winter takes its toll on the health economy and individuals are pushed the limit a coping strategy used effectively by our team is to spend time having small coffee breaks together. Some organised, but most spontaneous, with no real agenda other than to offload, vent and chat. I wish I could do this with people outside of my team, with those colleagues of different specialities or areas I see less regularly. These are the people I will end up needing to work with when clinical situations are at their most challenging.

Chris suggests “Creating time for staff to meet, and to do so in a spirit of collegiality and fellowship, could be part of the solution“. This could easily be dismissed as another mundane attempt by a non-clinical professional to ‘improve’ things. However the discussions that have kept me sane and given me perspective have always been over a coffee rather than at a formal meeting though.

Dad, you may have been, in a small way, right.

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This is the 130th #WILTW

Have you ever accidentally left something in a bag or pocket when you went through airport security that you meant to remove?

The alarm either pings as you walk through the frame or the security guard announces to everyone in the room; “whose is this bag…?”

It’s a simple mistake, a bottle of water at the bottom of a rucksack, a metallic belt buckle you forgot you were even wearing. Frustrating, but at least it shows the system works. But what if you ‘smuggle’ something through that isn’t picked up?

In a side pocket of my rucksack I have a portable tool kit. I can’t remember when I put it there but it has a spanner attachment for my foldable bike.  I don’t think it could be used as a dangerous weapon (although one of the screw-driver attachments is quite sharp). I must have been through at least 3 airport security checks without realising it was there.

That’s why when the security guard pulled my bag out of the x-ray machine and did the ‘show of shame‘ I had a panicked moment someone may have placed some illicit substances in it. What would make them want to check?

Having pulled all the objects out and hung the bag upside down I eventually saw the pocket at the side. I was relieved when the guard looked at the tool kit and appeared to indicate this was the offending item.

“I’m not sure you can take this with you sir.”

[Brief conversation in my head – it’s been through 3 airports and no one else seemed to care – it would actually be really useful should I need it, it’s probably not inexpensive and it was a present – basically I don’t really want to give it up. Can I say I didn’t know it was there? Did I say at check-in that I declared I knew all contents of my bag?]

“Errr. Can you check that?”

The guard wonders off to chat to another officer. I have that sense that people are watching me and judging. Similar to when I take my children to the supermarket.

“It’s ok, sir. My captain has said you can keep it”

Relief was quickly followed by a sense of annoyance. Is there not an international object recognition standard? Were the other airports lax or was this one over the top? What is the point of variability of approach when lives at are risk?

It is easy to get frustrated. But this is probably the frustration experienced everyday by patients, or their carers, when they receive, or perceive they receive, different advice or management about their conditions. Medicine obviously does not operate by algorithm. There are reasons why conditions are treated differently and why patients are not all managed in the same way. But you can see why it might be confusing to take your hot, unwell toddler to one doctor and be given antibiotics and then later, with what is apparently the same problem, to a different doctor to be given nothing at all.

Variation is practice is huge but I’d never been on the receiving end of it before.  In the future, if you see your patients or parents face fall when suggesting a management plan, don’t assume it’s because they don’t like your suggestion.  This is maybe the first time they have had an ‘alarm’ and are victims of the system rather than their own health care beliefs.

What have you learnt this week? #WILTW

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This is the 129^th #WILTW

“The declining level of performance in A&E is a marker of stress across the whole system of health and social care. But performance standards or targets for A&E should not only be viewed as the ‘canary in the mine’ for system-wide pressures. They matter primarily because long waits in A&E affect patient safety and patients’ experience of care.”

• House of Commons Health Committee Winter Pressure in Emergency Department report

The Health Committee report into Emergency Department performance is a no nonsense pragmatic review highlighting safety concerns due to unmet demand, underfunding in social care and too much variation between systems. It highlights the persistent and worsening decline in the four hour target

While some will bemoan the creation of the standard, with the resulting gamesmanship and tension between clinicians & managers it produced, it did serve to drive forward changes in staffing and process in Emergency Care. Either way a fall to 85% is uncomfortable and knowing that patients are waiting for prolonged periods is an additional stress for staff in an already demanding environment. There is a feeling that things are getting progressively worse with an associated despair that improvements are not around the corner.

But what if 85% was something to aspire to? I was in Canada this week and delegates at the conference I was speaking at were kind enough to give me a tour around the Toronto Hospital for Sick Children (Sickkids) Emergency Department. I noticed some of the waiting times and found this monthly update from the Ontario Health Ministry.

Note the average time spent in the department. There weren’t any recent comparative target figures available but in 2010-11, 45% patients were admitted from the Sickkids ED with a wait time of less than eight hours, a significant improvement from the 36% recorded the year before (there have not be significant changes in last five years). A consultant recollected they have come onto night shifts with 85 patients still waiting to be seen. For those used to working to a 4 hour target, which Canada does not have, these figures are astounding.

It must be noted Toronto Sickkids is a very busy metropolitan children’s ED. It sees over 75000 patients a year and unlike many UK departments there is no assessment unit to send patients prior to formal admission to the wards; so it is not completely fair to directly compare admission waiting times.

However the perspective this has given me can’t be understated. I must be clear, it is not a case of, “well we’re ok because there is someone much worse..” From what I observed I have no reason to believe the quality of care provided, as measured by other metrics, is no worse than  the UK. In fact the huge numbers of consultants providing on site 24 care with exceptional levels of supervision to junior staff is something to aspire to. They undertake world class research, have a number of extremely impressive training programmes (including  point of care ultrasound) and there is a clear sense of camaraderie between staff.

The dissonance between the waiting times is accentuated by the fact if just children and young persons data is used the average 4 hour target is often 95% or above in the UK. So whatever we may feel about the challenges currently being faced in relation to time based measures these pale into insignificance compared to our North American colleagues. We should continue to strive to improve patient experience by investing appropriately and continually re-examine our approaches to providing emergency care. But we should also be proud of the services we offer. A perspective it is all too easy to lose sight of.

What did you learn this week? #WILTW

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This is the 128th #WILTW

I suspect there are very few lectures in the first week of Medical School that discuss not treating patients. You expect to ‘do’ things: perform life saving surgery, manipulate fractures, counsel families and treat infections. Being told you’re not to provide any treatment for some conditions would be a bit of dampener during fresher’s week.

However there are lots of treatments that are ineffective and might actually do harm. This week the Academy of Medical Royal Colleges (the collective body of all the Medical Specialities in the UK) announced a list of 40 treatments and procedures that were of little or no benefit to patients.

You can search the list via each speciality. Below are 2 relevant to children.

1. Children with small fractures on one side of the wrist, ‘buckle fractures’ do not usually need a plaster cast. They can be treated with a removable splint and written information. There is usually no need to put a plaster cast on, or follow these children up in fracture clinic as they will get better just as quickly without this.
2. Bronchodilators should not be used in the treatment of mild or moderate presentations of acute bronchiolitis in children without any underlying conditions.

Bronchiolitis is a very common winter virus with essentially no treatment other than to support the infant through the illness with tender loving care. Children may need to come into hospital to support their breathing, or keep them hydrated, but most are easily managed at home.

It is a disease with frustrating symptoms though. Babies will be difficult to feed and keep their parents up all night either coughing, or just needing constant physical contact to settle. The symptoms peak around day 3-5 of the illness which is when parents and carers tend to seek medical attention as they feel things are getting worse.

A common question they will ask: “Is there anything I can do?“.

It is truly sad that there isn’t anything that is going to alter the course of illness. The issue is further complicated by the similarity of bronchiolitis to another condition called ‘viral wheeze’ which older pre-school children suffer from. Please read this excellent post by Dr. Edward Snelson which eloquently describes the difference and if you’d like to see some videos click here. Viral wheeze is treated with inhalers which have no effect on the outcome of bronchiolitis. However because inhalers in some small children (who have bronchiolitis not viral wheeze) can result in the appearance of a transient benefit the term “a trial of inhalers” is used.  It has no evidence base in bronchiolitis but I am guilty of having done it myself (I am not proud).

The problem had persisted, not only because it appears to work, but also because it allows you to give families a treatment. Unlike for the common cold which everyone, medical or non-medical, views as a self-limiting illness there is real sympathy on the part of the practitioner for the challenge the parents face. The more experienced clinician will have a well rehearsed narrative which empathises with the infant’s illnesses impact on the family. They will suggest feeding and sleeping regimes which might at least allow parents some rest and reassures them, with clear safety netting advice, that they are not simply being dismissed. This  is not something that can be credibly wrote learnt on day one by doctors or advanced care practitioners and hence the ‘crutch’ of a treatment is offered.

It took me 13 years of training to work out that my greatest contribution as a consultant was not my knowledge or practical skills but my ability to suggest doing nothing without it appearing that there is nothing to do.

What have you learnt this week? #WILTW

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This is the 127th #WILTW

This tweet came out of a meeting of the  Q community.

The pre-mortem is a psychological approach popularised by Gary Klein and embraced by the business community as a methodology to avoid project management failures. Essentially it demands you imagine why your improvement or business plan has utterly failed and consider the events that might have led to its demise, such as overlooking critical factors like indonesia eor implementation or underestimating local regulations. You can then aim to ensure these don’t occur. There is nothing clever about this technique and it’s a wonder so many people end up learning through hindsight rather than this approach.

I’d not heard of it before but it was a welcome validation of a process I use on a regular basis.

It is indeed morbid. It is important to remember that Emergency Medicine is not black and white. Illnesses fluctuate and children I discharge may become more unwell and develop disease processes which were only in the early stages of evolution when I saw them. The key role I must perform is to ensure I’m making decisions based on the best available information & evidence and justify them. The “Brought Back Dead Test” forces me to re-read my notes to ensure my decisions makes sense.

On reflection there is another pre-mortem technique I use. It is at the early stages of managing a critically unwell child. Fortunately most practice in the resuscitation room is relatively perfunctory i.e. there is a standard way of doing things and your intervention as a consultant is to deliver these as efficiently and effectively as possible. In fact the major issues with delivering consistently high quality care tend to be with team work and interactions between staff  rather than the severity of illness of the patients.

With experience you build an increasing “curve ball” library. This is a repository of situations in which there are difficult to predict system failures, human factor errors  or an unexpected cause to an illness. It allows you to have a quick run though of a number of “ok, what if this happens?” scenarios and refresh your memory of the particular solution. It’s about thinking – in children I’ve seen like this before who have had a bad outcome, why was that and how can I try and prevent it?

A pre-mortem to prevent a post-mortem. An uncomfortable but important process…

What have you learnt this week? #WILTW

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