Quality Improvement (QI) – Knowledge-creation, translation, and implementation
Webinar Blog and Q&A summary, 20 Jan 12:30-13:45
Connect Health “Change” brings you the seventh in a series of webinars to make and embed transformation in healthcare. Aimed at system leaders and clinicians across the NHS, the webinars provide practical solutions to the challenging issues we are all grappling with.
The need to close the gap between research and clinical practice is well considered and there have been some great steps in recent years to close this gap. One area which has shown great promise and continues to deliver positive outcomes is that of Quality Improvement (QI). Despite this, understanding of, engagement with, and benefits realised from QI is variable within healthcare. This webinar took a deep dive into QI from multiple stakeholder perspectives including clinicians, QI specialists, academics, commissioners, operations and ICS leaders with the aim to provide you with an understanding and clear direction to aid the translation of knowledge into practice to improve patient outcomes.
- “Great style of presenters”
- “Well-chaired. Good opportunity to ask questions”
- “The speakers were engaging and presented in an interesting way”
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Honorary Prof Kay Stevenson, Consultant Physiotherapist, Honorary Professor of Musculoskeletal Care and Leadership, Versus Arthritis Clinical Champion, Keele University and Midlands Partnership NHS Foundation Trust – Knowledge translation from academia to clinical practice. Translating and implementing research into practice
Question 1: What have you had to consider when involving patients in your work?
Answer: I think we very often aspire to involve patients in our work whether that’s in-service re-design or in quality improvement. We often want the playing field to be equal and level, but we know that’s not true. We’re all paid to be at work, thinking about how we improve quality but patients very often come as volunteers or give their own time and I’m very keen with our new role that we’ve just developed -Mike is a peer support worker so he’s now going to be paid to be with us in our service, attending our meetings asking questions from a patient perspective and we’re going to use this six months opportunity, to try and get some data together on the impact of this role. This needs to be a permanent role. How could we possibly live without this, so I think one of my reflections will be about how can you make sure patients are paid or given some remuneration for their time with you in your services.
One of my other reflections was thinking about when we did a project that involved people with lived experience of mental health. I set this meeting up and there was a lot to do in this meeting. I hadn’t viewed that from a patients’ perspective, with lived experience of mental health to come into this environment. They kindly fed back to me afterwards to say “you need to give a lot more thought about how your meetings are constructed and the support you might give to people given that they might have mental health issues” and so that was a real lesson for me thinking, I can’t run meetings as though I’ve got a group of very busy clinicians who can just tune into things very quickly. I’m going to have to give extra time and consideration to making sure that people are well prepared and prepared enough to contribute their opinions.
Question 2: Much like the Canadian Institute of Health Research which has different knowledge practice processes with Indigenous communities, do we have such processes as well for diverse communities. This knowledge transfer may also need to happen in multiple languages? is there a process for this?
Answer: I’ve given you thoughts about how we might involve people from maybe different backgrounds or harder to reach communities within this process, that’s really interesting only because we’ve been having a conversation about that this week and we flipped it around – It’s not that they’re hard to reach, we just haven’t put enough effort in and so I think Mike is going to help us think differently about how we might interact with our local communities. Especially if we have a community of practice, we want to make sure that we’ve got representative views, but it might mean that we have to do things differently, we might have to take the conversation to where the patients are, which could be in community groups or a group meeting in places of worship. I think perhaps we’ve just got to be a little bit more creative and think about how we interact in a meaningful way.
Question 3: When patient representatives are paid and embedded within a research or clinical team is there a risk that the authenticity of the patient voice can be lost?
Answer: We will only learn from this, we’re only three weeks into Mike’s role. I’ve already reflected that the support Mike needs will be considerable, but I don’t want to turn Mike into a sort of an NHS or a health person who speaks our language. I’ve asked him to really challenge us from the patient perspective so at every meeting to have the ‘what difference does this make to patients’ so he can hold us to account in a slightly different way. Mike is already involved in our integration work and he’s already started saying “how do patients know what’s going on… who’s communicating this… how are you communicating it?”
It might relate to having the right person who has the confidence to challenge you, which is an important thing to consider when you’re going through the selection process potentially.
Question 4: Are you able to expand upon how you see sensitive leadership to fit within that and have there been any barriers that you’ve had to overcome as part of your community and practice work?
Answer: Yeah I’ve put sensitive leadership and I kind of just invented that, because it was like you say, a penny dropping moment for me when this person with lived experience of mental health was able to say to me “you know you really didn’t get this right for me, given my difficulty being with people” and I just thought gosh, we’re used to dealing with patients with musculoskeletal disease and we perhaps these are areas that we’re not so familiar with.
We must have that perspective, but also be very willing to hear that you know we all want to do the very best don’t we? We all want to get it right, but very often we don’t, and we have to learn from that. I was very grateful for that gentleman sharing that with me, so I took from that, that I really needed to make sure that participants now whether that’s patients, clinicians or commissioners, that they have sufficient confidence to participate. I see my role creating an environment or a new structure where that is allowed, so we may have preparatory sessions where people can join to share an understanding of the context and be in that conversation. I think sometimes we’re all so busy that we rock up to our meeting thinking everybody’s happy, and they understand all issues, but maybe there’s some preparatory work for all participants to allow that to happen in a meaningful way.
Prof Chris Littlewood, Professor of Musculoskeletal Research, Manchester Metropolitan University – Research brings opportunity, not threat, so let’s embrace it
Question 1: What do you think are the take home messages for clinicians?
Answer: Let’s not see this research as a threat, there are enough patients out there and many who need our support. For example: when we’re seeing that these intensive interventions aren’t more effective than minimal or brief interventions, let’s embrace that and let’s use our resources more efficiently. For individual clinicians, what I’d really like to see is those models become commonplace across our NHS and for individual physios or groups of physios to use their own thinking to develop ideas into practice. My question really is where those gurus and experts led us to, is this where we wanted to be? So I’d like to see that more frontline clinicians have a driven approach to research and quality improvement.
Question 2: What are the barriers to “thinking physios/physios thinking”? How can we begin to overcome them?
Answer: One thing that perhaps we don’t do well is that we don’t understand what’s important from the patient’s perspective, that’s why in any research, we should work with patients not as participants in the research, but they work with us to make sure the research covers what’s actually important to your patients.
Also, in the culture of the profession, i.e. it is developed by following guru’s – research should be taught in parallel to clinical, rather than integrated. Generally there is poor research literacy also. We need to change the undergraduate curriculum so we have real integration of learning through critical appraised topics, and communities of practice with less reliance on the expert/guru-led short course model for CPD.
Now the secondary benefits of exercise. It’s a non-starter of an argument in the context of physiotherapy because for example we don’t prescribe couch to 5k for people with shoulder pain, but we might give them an elastic band or tell them to do some dumbbell exercises or some push-ups. In the kind of exercise that many physiotherapists currently prescribe, you don’t get those secondary benefits, so it isn’t an argument that holds up for me.
Question 3: Is there a limit to what RCT’s can tell us?
Answer: It is a point that’s put to me quite a lot and with respect often the points that are put to me are outdated critiques of randomised control trials, without recognising how trial methods and approaches have evolved over 20-25 years. The trials that many of us work on now are pragmatic, and they’re embedded within usual clinical services. They are probably more effective than what some outspoken voices try to suggest. Is there a better method? It always depends upon your research question, but if you’re looking to determine whether treatment is effective then at the moment, we have no better way than randomising people to different interventions otherwise the risk of bias really scuppers any potential results.
Question 4: What would your advice be for determining the quality of the evidence to appropriately direct decision making if we are broadening what we consider to be valid evidence to inform translational knowledge?
Answer: I’d probably just push back on the question and the concept of valid evidence. I wouldn’t be a strong advocate of using blogs for example or other pieces of information as valid evidence but they may be useful information that you consider. If we’re really serious about doing things as well as we can, then we think about the questions we have and match the methods to that. If we are serious about offering the best quality interventions both clinically and cost-effective interventions then we need to invest in large high-quality randomised trials. My concern is there’s an element of seduction around other sources of information and I think we need to do things bigger and better, then really focus on what is valid. That doesn’t always mean the randomised control trial but I’d be cautious.
Andrea Gibbons – @Evidence4QI Founder & Improvement Evidence Lead, Somerset NHS Foundation Trust – will talk about using evidence for quality improvement in healthcare.
Question 1: Have you got any top tips for how people can start to use evidence in their quality improvement projects?
I’d like to challenge you to ask 3 times
- Ask your library service. lit searches, they can do the heavy lifting of finding and filtering QI evidence
- Ask yourself – are you using documenting and sharing QI evidence, so you now who else is working on this
- Ask others – what’s the evidence of their decision, who have they spoken to and who else has done something similar
Links of interest
- QI monthly evidence updates: com/QImonthly
- E4QI Pinterest Boards: co.uk/E4QI
- Q Special Interest Group: https://q.health.org.uk/community/groups/evidence-4-quality-improvement/
Question 2: If we widen the scope of what can be considered valid evidence as suggested, beyond the academic literature, what advice do you have for determining the quality of that evidence to appropriately direct decision-making?
Answer: You’re absolutely right. The downside of using evidence is that as the net is drawn so widely there are no routine quality standards and so you need to use your expertise and judgement when finding and using it. How do I focus on only the relevant evidence? By deciding up front what is “in” and what’s “out”:
- Types of evidence (e.g. lessons learned)
- Organisational and geographic context
- Outcomes of interest
- Narrowing strategies
- Limit by date, publication type, source
Luke Baumber, Associate Director of Quality Improvement, Nottinghamshire Healthcare NHS Foundation Trust – Using data and KPIs to change and enhance behaviours and performance in Nottinghamshire, how to measure impact of a set intervention
Question 1: Luke, what are in your opinion, the most prevalent themes of Quality Improvement that Healthcare providers are continuously challenged with?
Answer: It’s absolutely crucial at the moment that we need to vaccinate millions of people, so the focus is on getting the right flow of patients through the door and working with them in a way that maintains quality. That’s a real challenge because of the quality risk ratio.
Throughout quality improvement, variation is a really important theme where we have unwarranted variation. We have lots of services across a particular geography but if you’re a patient who lives in this postcode or lives in that postcode you get a very different service.
Why is it that there is such a variation, and a huge amount of improvement work is about identifying where that variation is, why it’s there, and reducing it so we get a clear standardised flow. This will allow us to be really happy with the quality components of the care that we’re giving.
So in summary – flow, quality, safety and efforts towards improving variation for consistency of patient access, care and experience.
Question 2: With QI training to colleagues do you train any of them so they can deliver to their teams, or is it a central training function?
Answer: We’re in a command and control situation across the world, so in some ways you might think that’s not really in keeping with quality improvement coming out centrally from the government every single day. You can do quality improvement very rapidly because it is about iterative changes and very rapid learning, which has been a cornerstone of this programme so far.
We’ve got services all across the Nottinghamshire system who are learning to do things differently and making improvements each and every day, which is the fundamental essence of what quality improvement is all about. It is happening on a huge scale across the world in terms of the vaccination rollout. It is about adapting and learning, whilst making those changes as rapidly as we possibly can to maximize all sorts of different components of this programme.
Rob Tyer, Advanced Practice Physiotherapist (APP) and Clinical Lead, Northumberland Joint Musculoskeletal and Pain Service – Overview of the 10/10 Clinical Guidelines, how they were developed, aims and why they help knowledge translation
Question 1: Do you think if we put a group of appropriate stakeholders in a room and asked them to make some recommendations on good practice, that is would come up with a different answer to some of the guideline producing agencies?
Answer: Yes – because of the use of the term ‘appropriate stakeholders in the same room’. For me, the appropriate stakeholders in that room are the same people that should be involved in national guidelines. The big difference between the two would be the bureaucracy which is neither a positive nor a negative word, but the red tape in national guidelines can impact how long things take to publish.
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