Working towards continuous improvement (and finding inspiration in unexpected places)

Today is a good improvement day. A helpful contact in St George’s clinical coding team has been able to extract some data that would have taken me weeks to find by myself. As part of emergency surgery improvements, I needed some information on our historical emergency theatre case management. I thought this would require a laborious search through hundreds of patient records, but my clever colleague in coding has shown me a better way, using routine hospital data. A breakthrough has come from a place I never thought to look. This has happened a few times now, but somehow I'm still surprised.

I learned early in my improvement training that help can come from the most unexpected places. As a Darzi Fellow, I accidentally emailed the whole emergency department about night working, instead of just my intended audience of doctors and nurses. But the insights of the receptionists (who I had not intended to ask) were unique and extremely helpful. They observe a lot of the night’s activity and no-one had asked them their views before. They were a huge source of help that I had discovered quite by accident.

In a large acute organisation like mine, it’s hard to make sense of the complex interplay of 9,000 staff and countless processes of care; so my skill as an improver isn't to know things, but to know who to ask for help. Understanding how the system actually works (as well as how it is supposed to work) is crucial. This means I make a lot of connections with people – both to help me understand what work or care is like for them, and often to ask them to help make it better. The formal and informal connections made through this kind of collaboration are invaluable. So now the more improvement I do, the more people I get to know and, in some respects, my job gets easier.

But the workload I see in my clinical time is growing almost as fast as the need for improvement capacity. This means that I can no longer rely on serendipity to oil the cogs of our improvement machine. We need to organise more formally to connect those with helpful knowledge and skills, and for organisational learning to be captured and shared more explicitly, so we aren’t all reinventing the same wheels. The Q community, which I’m part of, has an important role in helping improvers share with each other and learn. I’ve already been able to link up with improvers working on similar areas like sepsis and surgical safety, and I can see so many possibilities for similar connections in the future.

We also need to take a leaf out of our own improvement books, and not let any work be wasted. We need to be more purposeful in directing activities towards an improvement mindset; using routinely collected data more wisely and getting more improvement activity from governance and incident reporting structures.

I would love more patients and service users as partners too. I have found some great inspiration in patients and hospital staff working together as partners in planning improvement – there are so many unique skills and perspectives to share.

In a co-design group I once set up to improve a patient pathway, we were considering the ward round and the inequity of status in the consultation. As it happened, one of our patient team members was a theatre set designer and said: ‘If I was designing a set to show power over dominion, I would place my actors like a medical team looming over a recumbent patient. Let me show you how you could change the furniture to improve that’. So we bought some footstools for the consultant to sit on at the patient’s bedside. Another improvement breakthrough from a place we rarely think to look.

Finally, I think that improvement activity needs to be shared among a far greater number of people to capture the range of talents in health care, but also to help preserve the enthusiasm of frontline improvers. Leading improvement can be hard going, especially if you feel isolated. Frontline workers leading improvement are constantly, uncomfortably, reminding themselves of where their service is failing. Trying to coax behaviour change from their colleagues and peers can be an attritional endeavour.

Thankfully improvement is a team sport, and the team approach is vital for preserving a positive mindset; we can share our moans and gripes as well as the workload. Spreading improvement capability more widely throughout clinical teams would allow us to take a break and recharge when it all gets too much, knowing that there are many others who can take up the lead. This could truly enable continuous improvement, where leadership is distributed and energy levels are maintained over years of activity. I think this would encourage more people to take up improvement responsibilities, because the burden wouldn't seem so great.

Carolyn Johnston (@Drcjohn) is a member of Q, Consultant Anaesthetist at St George’s University Hospitals NHS Foundation Trust and Deputy Chair of the Royal College of Anaesthetists Quality Working Group