NHS ICT cuts

Oh dear! Or is it an opportunity?

Better and Escape Fire

Still reading Better by Atul Gawande about quality improvement in healthcare, by a surgeon I believe partly responsible for the preoperative check list which received so much publicity a year or two ago.

Three main sections:

1. Diligence; devil in the detail?
2. Doing right; good rather than harm, or nothing
3. Ingenuity; thinking and doing differently to what has been thought and done before (Change?)

Finishes with some recommendations for being a 'positive deviant'

1. Ask an unscripted question
2. Don't complain
3. Count something
4. Write something (in a blog perhaps)
5. Change

The person who recommended it to me, a Patient Safety expert, recommended Escape Fire by Donald Berwick to read next....a collection of speeches

From the introduction to Donald Berwick's Escape Fire (by Frank Davidoff MD);

Donald Berwick's revolutionary posture;

1. Positive (as opposed to negative, must be a good thing)
2. Recognition of medicine as a social act (as a team we can be more effective than as a collection of individuals)
3. Action orientated, expects performance and provides the tools

Some of the (more noteworthy) tools

• Name the problem
• Build on success
• Take leaps of faith
• Look outside medicine
• Set aims and show constancy of purpose
• Understand systems
• Make action lists
• Never - ever - lose sight of the patient as the central figure

Why publish as speeches?... Why speeches don't make good reading first:

1. The speaker's need to underscore key points by repetition can get in the way of written text
2. Speakers are real time social events in which the speaker connects with his audience...print is passive, generic, non-living, puts distance between author and reader (which can drain the life out of a speech)
3. Each speech has to stand on its own; publishing several related speeches has unintended redundancy

But:

1. These speeches have coherence and energy
2. Feedback was that copies of the speeches would be valuable to the audience
3. Speeches over a time could show change..make it possible to 'illustrate the trajectory of movement in medicine'...allow 'the intrinsic synergy among the speeches to emerge'...'not all redundancy is bad'

The speeches don't deal with:

1. Clinical work
2. The reality of individuals not up to the job
3. The dark side of improvement work (watch this space, more to come, I anticipate, if the dark side doesn't win me over)

One of the most important messages:

• Dependence on collective wisdom. But be inspired to mount the improvement barricades.

Themes

Flow...

Response to surges in demand

Patient orientation

Leadership

Teamwork

Value of blogging

Discussion about value to blogger versus value to audience.

Back to first blog; why?

Not necessary but let's do it anyway.

Need to make it interesting for audience

Discharge from triage

 Better to stream elsewhere, to an alternative service, where available.

Separation of work from life or combine the two?

The Emergency Care System

Pre-hospital: self care, GPs, Ambulance service and other emergency services (Fire...Police) other primary care/community services (intermediate care...)

EDs.

Other hospital specialists.

Education

Fast track education and training or take your time?

Stress and burnout

Stress has various definitions (my preferred: when demands outstrip resources).

Burn out: Emotional exhaustion, depersonalisation, low sense of personal accomplishment.

Most doctors (everyone?) will experience these.

Complications include poor performance at work and home and probably physical ill health.

What should be done by others? Supervision, psychological support and feedback?

By oneself, when stressed or identifying onset of stress reaction?

Will vary from person to person....

Worthy goals

Being committed (and, maybe passionate).

Being thoughtful.

Being positive.

Systems thinking

Worthy of an essay, but, for now, the thinking about one's impact beyond one's immediate zone of influence, and of course it's impact on you...

The interfaces if you like.

Quality in an Emergency Department

I've found it helpful to separate, at least mentally, service delivery, service quality and service strategy:

1. The main aim of service delivery is to be safe
2. Quality care is STEEEP care (safe, timely, effective, efficient, equitable and patient orientated) supported by strong clinical governance mechanisms and
3. Strategy determines trust and department policies.

The Bigger Picture

Making mind map of the bigger picture...

The reduction.

The epoché...

Postivity

Telling a team to 'have some spirit' fails unfailingly.

Can one generate 'spirit'?

I suspect not directly.

It emerges.

It is a function of leaders and team.

Branding

It's all part of the brand.

Diary keeping

I have to create/produce evidence of experience and performance.

A diary of activity.

Or outcomes.

I have done this with PDAs electronically before, not sure how best to go about it this time.

Keep a note book and scan it in? 

Get a PDA I can scribble on...?

Or a combination.

Let's tweet and blog as well to utilise these resources.

Keepy uppy

Decided: No need. But let's do it anyway.

Got to avoid entering a virtual world and not engaging with the real one.

Beware anti-social media.

I don't think I will be anti-social but I might be wrong.

I don't want to be a victim either.

Why?

Blogging, Facebook, Twitter...

What's the risk benefit analysis?

Beginnings

Blogging, Facebook, Twitter...

December 2009