This is the 126th #WILTW

When starting a new job in a senior position, for a (short) period of time you are blessed with a relatively free diary, defined workload and a bit of breathing space. To make the most of this period, check out BizJetJobs.com for tailored Pilot Jobs that match your career goals and help you plan your next steps.

This does not last long.

Time management is a skill and an art. Some are better at it than others. However anyone who claims not to have some time management problems aren’t busy enough.

I have a sinusoidal pattern of time pressure. This fluctuates from being on top of e-mails, ahead of deadlines and having spare capacity to being in a nadir of behind on just about everything and needing to persistently sprint to keep up. Things reach a head when every meeting becomes a heart sink moment as you know you have a thousand other things to be done. And then just at the point I tend to get on top of things, and claim I’ll never let this happen again, the pattern seems to repeat with a metronomic frequency.

I was prompted to question my very involvement in a meeting this week as I realised despite being physically present; I mentally wasn’t. In writing this blog I thought I’d been unique in coining the term ‘meeting mindset.’ It appears this is not a new phenomena.

Apparently there are 4 meeting mindsets:

Vacationer (using the meeting to get out of what they should be doing)

Hostage (doesn’t want to be there)

Expert (feels they will learn nothing new)

and Explorer (keen to solve a new challenge)

I relate to the first three on a far too frequent a basis. But whose fault is that? Your mindset before entering a meeting must have a huge impact on your participation in it. I suspect just checking your own state of mind in the preceding couple of minutes may be beneficial. It is not going to make you any less busy but it might stop the meeting being an utter waste of time.

What did you learn this week? #WILTW

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This is the 125th #WILTW

“Paediatricians often think of themselves as clinicians who are always willing to go that extra mile for their patients and that no child will receive less than the best care on offer. Unfortunately, looking at the wider healthcare system, evidence does not bear this out, in terms of overall mortality rates, variance in care and patient experience….[1]”

Prof. Mary Dixon-Woods and Prof. Graham Martin published an article this week entitled “Does Quality Improvement improve Quality“. It is a sobering read and explores the mis-conceptions and mistakes made with the deployment of ‘Quality Improvement‘ techniques in clinical environments. It certainly puts into perspective a passionate, but well meaning piece, I wrote with a colleague Bob Klaber 3 years ago “Quality Improvement: The need to believe it is necessary”

“….It may well be that the term ‘quality improvement’ is misunderstood or mistrusted. The concept of evidence-based medicine (EBM) took years to be accepted by the medical profession and it seems likely QI may suffer from similar resistance.”

Dixon-Woods and Martin aren’t belittling Quality Improvement’s ability to reverse some of the endemic problems in health systems but pointing out the poor use of methodologies and inadequate reporting of outcomes. The quote that particularly stands out:

“The NHS continually loses learning, and this is an urgent problem [2]”

They suggest four ways to improve Quality in Quality Improvement

My interpretation of these suggestions:

i) It is too easy to act in isolation and “allow a thousand flowers of QI interventions to bloom [2]” rather than deliver improvements across ‘sectors’ in a standardised and methodologically robust fashion.

ii) Too often an initiative with some appealing face validity will be picked up and rolled out without any understanding of the environment it was originally developed in.  An intervention may work because of the ethos of the institution it is practiced in not necessarily because of the intervention itself.

iii) Too little time, and resource, is spent understanding the (ii). Monies are directed towards providing quick fixes rather than detailed evaluations involving different specialties and disciplines.

iv) A model has evolved, particularly in education, that rewards involvement in ‘micro’-QI projects delivered over short time periods. Larger programmes, which by their very nature are more likely to fail but provide better learning, are not seen as beneficial for or by trainees.

The challenge is that significant senior leadership will be needed to make these changes happen. What of the healthcare professional wanting to make a difference now? How do we maintain enthusiasm and passion in an increasingly disillusioned workforce when a more organised, and therefore potentially more bureaucratic, improvement strategy may be needed. Healthcare training, particular in medicine, is increasingly dependant on the micro-QI project to develop creativity and provide team work and leadership skills. We may still need a thousand flowers of QI interventions to provide these insights even if they don’t provide improvement.

What have you learnt this week? #WILTW

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[1] Klaber R and Roland D. Delivering quality improvement: the need to believe it is necessary. Arch Dis Child 2014;99:175-179

[2] Dixon-Woods M and Martin G. Does quality improvement improve quality? Future Hospital Journal 2016 doi: 10.7861/futurehosp.3-3-191           

 

This is the 124th #WILTW

The person in front of you pulls, instead of pushes, the door they are trying to get though. How long do you leave them trying to heave open something that just needs a gentle nudge forward? Probably not long and it wouldn’t bother many people (even if they are British) to intervene and witness their awkward embarrassment.

But what if you are at the resuscitation of a seriously unwell child? The mechanistics of hospital staffing with many different specialties mean you may not know all the people around the bed.

This can raise problems if someone does something out of keeping with normal practice or hasn’t noticed that the child’s condition has changed. This may mean what they are currently doing might be making things worse. Although it may be assumed any health care professional would intervene, sadly, time an again, hierachies in medicine conspire against this (please click here if video doesn’t play)

A mechanism I was reviewing this week is the ‘CUSS’ method. CUSS stands for Concern, Uncomfortable, unSafe, Stop (there are slightly different versions out there). The aim of CUSS is to give any individual an approach to becoming more assertive. The standardisation of this approach has two benefits.

i) It is empowering to the individual using it

ii) It might prompt the recipient to become an aware that the tool is being used on them. Ideally this may trigger them to reflect on their own practice.

So if you are ever in a high stakes situation and someone is going in the wrong direction maybe a chance for a good CUSS.

What have you learnt this week? #WILTW

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Details on CUSS and other situational awareness tools are available from the RCPCH Safe Programme.

 

 

 

This is the 123rd #WILTW

In the last 100m of the final race of the World Triathlon series  Alastair Brownlee gave up his own position to help his brother Jonny complete the race 

Alastair acted on instinct. He doesn’t look around to see if anyone is catching him, he doesn’t pause and think, he just supports his brother and walks him across the line.  The reaction of some was to declare Alastair’s actions outwith the spirit of sport, ‘competitors shouldn’t help each other‘, but what would the reaction have been if Alastair had carried on to leave his brother to collapse to the floor?

Alastair said it was a natural human reaction to help his brother (although he did add he “… wished the flipping’ idiot had paced it right and crossed the finish line first..” )

Even with a number of different options available to you, acting on instinct is relatively easy if the outcomes of your actions can be easily ranked. Alastair’s love for his brother outweighing his desire to win the race.

What if your instinct to do something is challenged because undertaking it may have adverse consequences. This may seem like a ridiculous scenario but it is not uncommon in busy Emergency Departments, or other areas, managing unwell and sometimes critically unwell patients. As we approach winter in the United Kingdom we will be faced with increasing volumes of children, generally with respiratory disease, who become ill extremely quickly. At any given time you could be managing a baby, a  toddler and a teenager all with signs and symptoms requiring experienced input and intensive treatments.

…and then another patient can arrive looking blue, fatigued and close to collapse. The instinct to run to them and help impossible to ignore. And receive care this patient must – primum non nocere.  But doctors and nurses in charge of clinical areas have additional responsibilities. Not all resources can be directed at one patient. The most appropriate staff, with the most appropriate skills, must be re-directed to the most appropriate patients. Continually robbing Peter to pay Paul as more and more patients arrive over the course of an evening steadily increases cognitive load and stress on those running the department.

If the newly arrived patient is unwell, but not critically so, this creates the greatest instinct versus ‘other action’ challenge. There are no correct answers to maintaining the right balance between being appropriately involved a few patients care and ensuring situational awareness for all patients.  Time spent evaluating extent of illness and redeploying resources appropriately takes senior staff away from managing and treating patients directly.  Healthcare systems appreciate and plan for this; overall leadership of a department one of the core skills of an Emergency Department Consultant.

I wish though, like Alastair Brownlee, acting on instinct had no real consequence, but I am also very glad that this instinct exists and I hope it always will.

What did you learn this week? #WILTW

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This is the 122nd #WILTW

I am currently in San Francisco at #MedX. The conference looks at new technologies and innovations, keeping the concepts grounded in good design and patient applicability. The team have developed a process called Everyone Included™ which aims to ensure ‘expertise’ is defined by what people can contribute rather than a strict notional concept of what they know. It aims to ensure that all potential participants have been considered. Below is some of the criteria that are required for the highest level of integration.

Medical conferences in the United Kingdom don’t have a strong track record of patient involvement. To be blunt there remains a strong paternalistic attitude that there is little patients would contribute to medical debate. Some of this is based on the correct notion that an academic conference is not a suitable venue for individuals to be seeking resolution of a complaint. Sadly there have been occasions where the boundary between patients telling stories to aid learning and to vent their grief have become blurred. This is neither fair on the delegates or the patient. However these are rare, and are over played as a reason to not allow patients to contribute.

At the first day of the conference Michael Seres spoke eloquently on patients and their role in research (click on this link to play)

and Lucy Kalanithi spoke movingly on the concept of suffering (click here for the video)

There will be some who will say the ‘expert’ patient is not representative of the general population. There will be those who feel that certain conversations would be restrained. And there will be those who cite tokenism.  But we don’t really know what the outcomes will be because we have yet to start trying. #MedX has proved it is possible to integrate what should be a unified population  of patients and providers. It is up to other conferences to start following suit.

What have you learnt this week? #WILTW

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This is the 121st #WILTW

The concept of collective competence came under my radar this week (click here if the video by Dr. Lorelei Lingard doesn’t play)

While the slide below probably dumbs down the theory it is a very good introduction to the concept (and is used by Dr. Lorelie Lingard herself):

Competence is an education buzzword which goes in and out of vogue. It is almost always used in respect of the individual, a mindset that Dr. Lingard is trying to change. Consider the child with a severe head injury, non-withstanding the need to have recognised they are seriously unwell, a number of individuals need skill sets (competencies) to ensure the child gets the best possible care. Observations need to be recorded reliably, medications need to be given precisely, intubation needs to occur safety and leadership of the team needs to occur robustly. Not all of these things are performed by an individual; so the outcome of the child is dependant on the collective competence of the professionals in attendance.

Being a big fan of the conscious competency model (or more precisely 2×2 matrices generally) I couldn’t help thinking there are insights needed to ensure the group as a whole doesn’t go off track.

Groupthink, the plague of many teams, committees and organisations perhaps a consequence of collective incompetency? Are you as an individual aware of the mistakes your group might be making?

What have you learnt this week? #WILTW

For some further thoughts by Dr. Lingard please click here

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This is the 120th #WILTW

I did a double take on an e-mail I received this week. It was from a sales agent who had been chasing up confirmation of a booking I’d cancelled due to a change of plans.

“Ok shame but thanks for letting know.

Noticing your email signature….keep up the valuable good work!”

The cynical might suggest this was good business practice. Saying something positive to the customer in the hope of future sales. If this was the case – fair play – but I’ve never had this happen before and I’m hoping it was genuinely felt.

Doctors often rank as the most trusted of the professions. 

This holds true in many other countries, although it is of note a similar survey in Australia ranked nurses top (92% – unchanged from 2015 and the 22nd year in a row they have come first)

Does this support matter? It is topical as the recent announcement of further strikes by Junior Doctors in the UK is likely to push public support to the limit. It is a challenging debate – one in which truths are hard to come by. Ultimately the junior doctors are taking on a wider challenge – what can, and should be, delivered by the NHS? This is as much a question of political ideology as it is one of economics. The Junior Doctors the first victims of a desire to provide a greater spread of services in the same cost envelope. Others will follow and in some case already have (although to much less fanfare). Sadly for the junior doctors their services are in between the government and the patient. They will be seen as arbiter of the disruption that is caused.  They are in a trap. It will be Junior Doctors that the media will see as the problem. However eloquent their arguments the narrative can always be brought back to their withdrawal of work.

It may well be remembered the medical profession let the juniors down. Long term flat growth in the NHS is not sustainable and the system will fail. This is the unified argument that needs to be moved forward by professionals to the politicians. The doctor’s strike perhaps a welcome distraction for the government.

But what of the public and the patients who need the NHS? What argument should they make? This open letter from a group of patients to both Jeremy Hunt and British Medical Association may provide the answer:

“If this dispute is strictly about pay, then fine. The two of you should be able to sort it. But if it is about pay AND conditions, then it is about patient safety. And if this is about patient safety (and both sides say it is), then enough is enough—patients need to have a say.”

The medical profession has been blessed with strong public support for a considerable period of time. If we think it matters what the public think of us then perhaps considering how they can be practically involved in aiding this dispute would be a good way of repaying the respect.

What have you learnt this week? #WILTW

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This is the 119th #WILTW

“Hospital Doctors miss signs of illness because of chronic staff shortages”

This headline played across news outlets and social media this week.  Based on the results from a doctors survey it encapsulated the pressure currently felt by many health care professionals. Politics aside there remains increasing demand for services with a relative fixed amount of staff to deal with it. Additional challenges were revealed by the extent of General Medical Council training concerns at over 70 hospitals in the United Kingdom.

Regardless of the underlying reasons; patients expect not to have signs of illness missed which in retrospect should have been detected. This is not saying all diagnoses should be be correct or timely. Some conditions are difficult to detect in their early stages and some require extensive work up to define the extent of illness. However even with an increasingly litigious society a large amount of NHS funding is expending settling complaints which could have been avoided had appropriate initial interventions occurred. Why does this happen? Why do healthcare professionals miss seemingly obvious signs and symptoms? Obviously the reasons are multi-factorial. External pressures as noted in the doctor’s survey will play a part. However there are some intrinsic factors in the way that doctors make decisions that often cause problems.

Some of these Diagnostic Reasoning errors were reviewed in a blog published this week  summarising a lecture delivered by Jonathan Sherbino. Jonathan works in an Emergency Medicine Department in Canada and has a research interest in decision making processes. System 1 (fast) versus System 2  (slow) thinking was reviewed along with some myth busting of how diagnostic errors occur.

One of these was speed of diagnosis. Evidence suggests that going slower makes you slow, not better. This isn’t saying going faster makes your more accurate but that you often gain little in the way of accuracy by spending more time thinking about a problem. Even more interesting was the fact in some studies interruptions, which would seem an inherently bad thing when you are busy cogitating a problem, didn’t seem to make diagnostic accuracy any worse. The final take home message was that reflection, in this case a cognitive forcing strategy of structuring a second review of your decision, only really benefited those with prior experience.  Experience coming up again and again as the best way of avoiding diagnostic error.

This then asks some difficult questions of how we should best structure our healthcare service. Having more senior staff is something many Royal Colleges have been calling for for some time. But those senior staff need to gain their experience from somewhere which resonates with the blog’s author Jesse Leontowicz closing point to ensure that learners get experience in the Emergency Department and not just hope it happens. I’d add something else as well.  Health care professionals, especially doctors, need to understand why they make mistakes rather than hope they don’t happen and be chastised when they do.

Learning the processes that facilitate making mistakes makes it much easier to avoid getting caught up in them.

What have you learnt this week? #WILTW

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This blog co-incides with the release of the summary of my induction lecture to our Emergency Department new starters (click here if video doesn’t play).

A previous WILTW has also covered cognitive error:

What I learnt this week: Avoid a confirmation cock-up this Christmas #WILTW

This is the 118th #WILTW

A last minute victory in a sporting event is always exciting to watch. Whether it be a perfect two and a half back-somersaults with two and a half twists in the final round of the diving or a dive across the line to win the 400m it’s brilliant to see years of hard graft coming to fruition.

I always experience a pang of guilt during the Olympics having chosen medicine and a social life at University rather than medicine and steeplechasing. I have huge respect for the sacrifices made by sports men and women in dedicating their lives to, what in some cases, is less than 10s of action. I have also watched with interest the increasing public awareness of marginal gains. Concentrating on ensuring every part of your performance is as good as it can be is something I discussed in reviewing Leicester City’s football success. 

Marginal gains are not a new concept in healthcare so it is easy to see why people wonder if we can transform the NHS in the same way British sport has radically altered since the nadir of Atlanta 1996. Huge financial investment, £5 million (Atlanta) to £350 million (Rio), has resulted in a 2000% increase in gold medals compared to those 20 years ago. Trying to make a comparison with healthcare is patently silly and also quite difficult as direct funding figures are hard to come by (although I was surprised to find between 1999/00 and 2009/10, NHS real-terms expenditure rose by 92%). However it does seem odd that while we are happy to expand funding to reward olympic sporting success we are not happy to expand NHS funding despite relatively high performance compared to other international comparators. The figure below shows flat expenditure growth in the last 5 years.

 

One thing that doesn’t happen in healthcare compared to sport is penalisation of failing to succeed. This is not something that would benefit patients or staff. You do wonder though if the NHS is such a national treasure we should support its success in the same way we do for our Olympians.

What have you learnt this week? #WILTW

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This is the 117th #WILTW

John has been admitted to hospital with pneumonia. He is on a bed near the nursing station on ward 22A. Around the station are a couple of doctors and nurses looking through the notes trolley. He watches the ward clerk stand up and walk off the ward to find some stationery. 

The phone at the desk starts to ring. The doctors and nurses on the ward round continue their discussions.

The phone continues to ring. John watches a doctor walk past the station, look at the phone, look around the room and then continue to walk up the corridor.

The phone continues to ring. A nurse arrives at the station. She looks stressed. She sits next to the ringing phone, pulls out a diary, opens it, rolls her eyes and then walks away. 

The phone continues to ring. Through the doors to the ward a consultant arrives with some medical students. They all look at the ringing phone. They look at doctors and nurses around the notes trolley and look back at the phone. They then move off to examine the patient next to John. 

One of the doctors at the notes trolley then moves round to sit next to the ringing phone. He starts writing in the notes. He looks at the phone. The phone keeps ringing. He looks up at the remaining team around the notes trolley. He then continues to write in the notes.

The stressed nurse comes back to the nursing station, mutters something under her breath and then leaves the ward. The doctors and nurses around the notes trolley push it towards the patient opposite John. They are joined by the note writing doctor. 

The phone continues to ring .

The ward clerk returns to the ward.

The phone stops ringing.  

I had to call out our staff this week for leaving the phone ringing despite a number of people being quite capable of answering it. The act of picking up a phone seems an inherently simple task. Certainly to an external observer like John there seems no reason for someone not to do it. The assumption is staff are lazy, rude or completely uncompassionate. Imagine if John had been waiting for a phone call from a loved one with some important family news or maybe about his transfer home.

Some of the reasons are more complex than the assumptions though. A honest junior said to me once, “The problem with answering the phone is that the majority of the time you can’t help at all and get dragged into a situation where you become responsible for the problems/issues/concerns of the person on the other end of the line.” This doesn’t excuse not answering the phone but if you knew you could always respond with a yes or no I suspect answering times would decrease significantly.

The prompt for this muse comes from a powerful article by Dr. Ranjana Srivastava on professionalism and responsibilities in medicine. She questions why health care professionals ‘overlook’ potential poor or harmful practice by colleagues or in systems:

“So, while professional integrity is necessary, I think the question we ought to periodically ask all doctors is actually a far simpler one. “What kind of a person do you want to be?”

I want to be the consultant that sets a good example to the medical students. I want my juniors to understand how to prioritise tasks and I want nurses and doctors to realise that some jobs can be done by either professional.

This is really easy to say but much more difficult to put into practice. Maybe answering the phone is one place to start.

What have you learnt this week? #WILTW

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Post release note:

#WILTW rarely produces responses and it is even less common for people to disagree (please see comments below). The topic of discussion is definitely in the grey zone though and I think it was a justified challenge. The tweet below perhaps was something I should have included within the blog.

Is the message here: never walk past an unanswered phone?

— Mat (@MatSilk) August 11, 2016

Fair Question

Answer: No e.g. emergency

But if you, or someone else could. Why don’t you? https://t.co/6YLNIitUST https://t.co/IsFEolOMDn

— Damian Roland (@Damian_Roland) August 11, 2016