Dan Tipney, our Head of Evidence and Insights, gives the low-down on quality improvement following a day at the RCVS Knowledge Skills Day.
Back in November 2017, some of our VetLed team attended the RCVS Knowledge Skills Day. Here, I give my thoughts, reflections and personal insights from the day.
The RCVS Knowledge Skills Day focussed on Quality Improvement, or QI. As the VetLed areas of focus (culture, wellbeing, human factors and performance) are fundamentally aligned with QI, we were looking forward to connecting with industry professionals who share our goal of improving patient safety.
Needless to say, the term ‘Quality Improvement’ and what it means was discussed in some detail. The first talk of the day came from Dr Bradley Viner who explained the significance of semantics, his belief that QI sounds more inspiring than clinical governance, and the necessary focus on ‘improvement’. The message was clear that the process must be evidence-based but that the data is all but irrelevant if it doesn’t result in positive change. The second speaker of the day, Dr William Taylor, clarified the difference between Quality Control and Quality Improvement and commented that while there will always be a need for some control, too much can stifle improvement. I think this is a great perspective because it emphasises a growth over a fixed mindset.
Encouragingly, workplace culture was also discussed. Culture in this sense relates to the shared attitudes and go-to behaviours of all those involved in the practices, departments or groups in which improvement is sought. We believe that workplace culture affects how people think, act and feel more than anything else. A consistent example used was that of reporting error – if a blame culture (or a culture where it is the norm for blame to be apportioned to an individual) exists, the likelihood of team members sharing incidents/near misses is almost zero and the QI process stalls. What I would have been interested to hear more about was ‘feeling’. The word feeling was seldom used, but I feel that when it comes to inspiring a group of people to be an integral part of this kind of process, then how they feel matters more than anything.
Teamwork was widely discussed, with the importance of involving the entire team (vets, vet nurses, practice manager, reception) in the QI process being recognised. Encouragingly, this was often linked to empowerment (another key criteria for positive culture) and flattening hierarchy. From a human factors perspective this is crucial. If there is one thing that we have identified from human factors training in aviation and healthcare, it is that of helping to ensure that everyone’s voice is heard when it needs to be, regardless of seniority.
Unsurprisingly leadership was mentioned a few times! However, there wasn’t as much focus on leadership as I expected there to be, although it was indirectly referred to in other ways. For example, inspiring all members of a team to speak up, voice concerns and play their part in continual improvement (or during clinical situations) is a vital aspect of leadership, which can be demonstrated at all levels.
When discussing error, it was great to see that the emphasis was on normalising human error. This is a big challenge when dealing with high achieving professionals and was a huge step when Crew Resource Management training was introduced in aviation in the 90s. The vital take-away is that one of the first steps towards achieving a just culture (a culture which does not apportion blame or punish errors, but where reckless behaviour or wilful sabotage are not tolerated) is reducing the stigma surrounding mistakes, although arguably one of the hardest steps too.
Data was also discussed in detail and for good reason; it’s not possible to improve anything until you know what is going on! Compared to professions such as healthcare and aviation, the veterinary world is in its infancy when it comes to data. The focus on gathering data in practice was mostly based around clinical audit and significant event audit. I agree that collecting data is absolutely essential to seek positive change. I question, however, why there wasn’t more discussion on developing open reporting systems? If veterinary professionals could report positive events, near miss events and incidents, in a just culture without fear, where such reporting was encouraged daily, then I believe it would provide a great deal of insight. This method of data collection wouldn’t then rely solely on lengthy audits, and trends would be continually identified without an environment in which people know they are being ‘audited’. I wholeheartedly agree in audit processes, but I think open reporting would well compliment current and future audit systems.
Celebrate success! We enjoyed this message from several speakers throughout the day and it’s easy when discussing error and mistakes to become overly focussed on the negatives. I interpreted ‘celebrating success’ in two ways; firstly, most of the time things are being done really well and it’s important to recognise this. I likened this to a sports coach, whose job is as much about helping the athlete to know and continue what they’re doing correctly as it is about pointing out weaknesses. Secondly, when positive change is made, we need to celebrate it so that we are motivated to keep up with the QI process, and also to share with the wider profession.
The day closed with a focus on patient safety, and specifically the use of checklists. I applauded the sentiment from Matt McMillan who delivered this talk, when he pointed out that checklists don’t take away professional freedom or autonomy, they actually enhance it by freeing up critical mental capacity to focus on more complicated tasks. One thing I would have liked to hear more about with regards to checklists is the training and associated culture that is required for checklist implementation to work reliably. Atul Gawande demonstrated that major surgery complications dropped by 36% and deaths plunged by 47% following his introduction of checklists in 8 hospitals around the world. However, replicating these results on a wider scale has proved challenging. Two of the crucial elements are effective education and getting the buy-in to ensure conscious attention on the process as opposed to automatically ticking boxes. As such I would have been really interested to hear more about the training processes involved when such checklists have been introduced at various practices, so that we can all learn about what works and what doesn’t.
QI, by its very nature is an ever-evolving and forever-developing concept, and I am sure that much more will be discussed, reported and written about in time. It was great to connect with people who share our vision and we look forward to being part of the ongoing QI conversations in the weeks, months and years to come.
Dan Tipney is Head of Evidence and Insights at VetLed. Dan’s role at VetLed primarily involves providing insights into human performance gained from his perspective across multiple fields; formally as a semi-professional athlete, sports coach, pilot instructor, cabin crew member and currently as a commercial pilot and human factors trainer.