Dominique Allwood is Assistant Director of Improvement at the Health Foundation, and was recently seconded to lead quality and learning work at the NHS Nightingale Hospital, London. We spoke to her about what learning she will bring back to her role at the Health Foundation and her NHS role.

How did your working life change as COVID-19 reached the UK?

I have worked part-time at Imperial College Healthcare NHS Trust for several years where I am Deputy Director of Strategy and Improvement and Associate Medical Director for Public Health. In March, I was seconded full-time into the NHS and an opportunity arose to help set up the Nightingale Hospital in London. 

The Nightingale took over a large conference centre in London to expand capacity for ventilated patients and I co-led the quality and learning team. Treating a new disease in a new setting, we had a duty to learn, capture and share internally and externally. We rapidly developed and implemented a learning system there: integrating and continuously analysing data, ensuring rapid decision making, implementing changes and monitoring outcomes.

In parallel, my work at Imperial was fast becoming more focused on the coronavirus pandemic. My improvement team helped in lots of ways: setting up a 24/7 clinical decision support (where ‘three wise people’ provide advice directly and rapidly to clinicians facing challenging decisions) and a staff health and wellbeing advice helpline taking hundreds of calls a day, training PPE helpers, and developing staff testing to name a few! We used improvement approaches including driver diagrams, process mapping and Plan Do Study Act cycles to problem solve and implement rapid tests of change for keeping staff and patients safe.

At some points I was doing more than 100-hour weeks but while it was really tiring, it was motivating to be part of the response in such a variety of ways. 

What did the learning system at the Nightingale Hospital London focus on?

We developed a learning system that captured data from staff, families and patient care, combining this with evidence from outside the organisation, and rapidly making improvements to the care being delivered. We developed a new role called the bedside learning coordinator. They observed and gathered direct insights from the bedside staff and we joined this with other data such as incident reporting and triaged what needed to be ‘fixed, improved, or changed’. 

We presented data at a daily forum, a place that became the rhythm of decision making where clinical and non-clinical staff met. They could feed their own insights in and be part of making decisions. Every day we would agree three key messages on safety or staff welfare and these would go out via different channels including electronic boards in the conference centre, handover notes and shift briefings. The bedside learning coordinators helped to implement the changes, for example by putting checklists in place, alongside staff who were making continuous improvements eg improving efficiency in donning and doffing PPE.

How was learning put back into the system? 

We regularly connected with other Nightingale Hospitals, colleagues in the NHS and internationally to share what we were learning and ensure we were learning from them too. In many ways it might seem different because we were starting from a blank sheet of paper and relatively few patients, and while no one would have wanted Nightingale to have been full, there is learning you can take back to the NHS for COVID-19 and non-COVID-19 times. Other NHS organisations are very interested in the staff welfare and training, the learning system approach and the role of the bedside learning coordinator and several have started to pilot this. 

The learning transfer also went both ways, and I was struck by the quantity of learning in my home NHS organisation too. I was able to take some of it to the Nightingale – setting up a clinical reference group, huddles and safety briefings and asking patients and relatives ‘what matters to you?’

What key learning will you bring back?

One of the elements I valued most during COVID-19 was the rapid and agile nature of decision making and communication. Some of the bureaucracy that can get in the way was stripped back in both places I worked. But there's a risk you become very reactive in a crisis and you don't get a chance to take a bird's eye view of what you're seeing and learning and what the themes are. In a learning system, you're not just aiming to fix an immediate problem in front of you, you need to look at the double loop of learning, looking at the system it is part of. 

The experiences of working with people on the front line and witnessing the burden they've experienced, the impacts of some of the policy decisions of the last few years and how that's influenced how the NHS has functioned under the coronavirus pandemic were brought starkly home to me. Our staff are our greatest resource and we need to support them better both physically and psychologically. NHS staff are not a homogenous group and we need to keep our focus on equity and inequality, and the differing impact that COVID-19 has had on staff, patients and communities as we move into the next phase. We need to draw out the learning from how people swung rapidly into action to make change happen, not just in our health and care institutions, but in our communities. The work I am leading on anchor institutions and staff health and wellbeing at the Health Foundation has never felt more important. 

I’ve learned a huge amount about change, improvement and most of all learned about learning. I was only away for three or four months, but it feels like a lifetime’s work. I’m even more clear on our role at the Health Foundation in supporting some of that work of understanding those insights, codifying them and helping people retain and build on improvements.

How will this experience affect your thinking about the work you lead?

I have been an improver for a while but I’ve become a real fan of the lens of learning. In the NHS, I’m seeing that people feel a real sense of responsibility to learn from this time. During COVID-19 I rarely used the term ‘improvement’ with staff and creating a culture of learning was inclusive.
People felt empowered and enabled to do new things and work collaboratively and we need to think about how we don't automatically lock in changes without understanding the bigger system that those changes are part of, what enabled those changes to be a success and ensuring that we understand the impacts they've had.

There are also some unanswered questions for me. We've not really answered the question of what does quality look like in a crisis situation in an NHS context, which will be particularly important if we have a further surge. Things like equity and inequalities have also come out much more strongly than before and I hope to focus on how we use our improvement and learning ‘muscle’ to address these big population health challenges. 

This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.

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