My year as a Quality Improvement Fellow

Dr Jonathon Gray, director of health improvement at the Wales Centre for Health, talks about his year as a Quality Improvement Fellow

Through the Quality Improvement Fellowships scheme, delivered in partnership with the US-based Institute for Healthcare Improvement, senior clinical leaders are learning the tools and techniques of quality improvement.

Dr Jonathon Gray was a consultant and senior lecturer in medical genetics at Cardiff and Vale NHS Trust before he was awarded a Quality Improvement Fellowship. He explains what he did during his transformative year in the USA.

How did you spend your time on the fellowship?

I spent the first nine months based in the offices of the Institute for Healthcare Improvement (IHI), near Boston. It’s a small, flexible and energetic organisation with a real ‘can do, will do’ attitude. The time I spent there was inspirational – full of things they should have taught us at medical school. It was hands-on and pragmatic, using IHI methodologies for quality improvement. It was fantastic to be able to spend time with people who have the personalities and experience that allow them to influence change.

During the final three months, I was taught in a more traditional academic way at Harvard School of Public Health. The programme included a seven-week intensive clinical effectiveness course which was of immense value.

You learnt a lot about quality improvement – why was this so important?

In the past, even though I recognised quality when I saw it, I was unable to define it. Now I have been able to create a framework in which to understand and discuss it and this has given me a strong sense of what makes a quality healthcare system. I have learnt that an important aspect of quality improvement is about making small changes – if you see a problem make a small change and, if it brings benefits, make another and build on it. It is what is called a PDSA cycle – plan, do, study, act. I have also learnt from IHI that to live and work in the world of quality improvement means talking about the psychological aspects of change – some might say the softer elements of team, individual and organisational change.

Has being exposed to the US healthcare system brought you any new perspectives about the NHS?

Now that I have a strong sense of what makes a quality healthcare system, it makes me even more proud of the NHS. But I am aware that while we have people working incredibly hard, we do not give them a framework to understand what they do really well and the areas in which they can improve. For me, quality is about a framework that resonates at the front line and with the patient.

My ambition is to bring a more rounded picture of quality, identify ways of measuring it and help clinical staff understand that recognising there is room for improvement is not a bad thing.

Which key elements of learning have you brought back to the UK?

I came away with two simple rules which I am trying to follow. The first is to maintain enthusiasm in myself and bring it to others, despite the difficulties when daily problems hit you, particularly at the front line. Keeping in regular contact with the inspirational people I met in the USA is really useful for helping refuel my enthusiasm when I need it. The second rule is to take risks and chances, to step outside your comfort zone, as so many people at IHI do. So while I aim to maintain some clinical practice, I also want to introduce successful systems from industry, whether it be from the aircraft industry or Toyota production systems, and to advocate for these in healthcare.

What are your aims for the future?

In the short term I want to show that we can make a positive difference in the small but very important healthcare system for three million people in Wales. I am currently on secondment to the government in Wales to try to influence change centrally by identifying a high-level system to measure quality. In five to ten years’ time I would love my career to be driven by the continued learning from North America and Europe, bringing their strengths into the UK healthcare system.