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QUIPP (Quality Innovation Productivity and Prevention) was the buzz acronym in 2012. Personally, I was very excited because I felt for the first time in my career in the NHS that doctors and managers alike would put QUALITY before anything else. I thought this would be the first time we would be sharing the same language and singing from the same hymn sheet. Well, that was until I heard our then divisional manager talk about QUIPP as a mechanism for cutting the number of theatres and saving money. I felt that this was putting the cart before the horse. Indeed that may be a conclusion after addressing all the aspects of QUIPP, but QUALITY comes first. That means getting it right first time and every time. The literature is unequivocal; quality drives a reduction in costs.
We are all guilty of jargon. It is widespread in the vernacular of all the professionals in the NHS. FBC (full blood count), U&E’s (urea and electrolytes) and CXR (chest X-ray) roll off the tongues of the clinical staff just as easily as FCE (finished consultant episode), HRG (Healthcare resource groups) and SPELLS (total continuous stay of a patient in a hospital bed) drip from the mouths of the managers. I sat in self learning group on a leadership program and it appeared to me my colleagues revelled in the NHS management dialect and loved to ‘SHMI’ (summary hospital-level mortality index) their way through conversations with these acronyms. Now FCE, HRG and SPELLS are the currency terms for the income generation of a hospital but when I surveyed 173 consultant staff, not one of them could accurately define all the acronyms used by the NHS to realise income and define quality. It strikes me as very strange that the end users and prescribers of health care and technology are totally removed from the decision making and excluded by the language used to define our business. Why can’t clinicians and managers share the same language of quality and waste? It should be very easy to examine the time intervals in the patient pathway and record the consumables. I could look at the top ten drugs spend of the unit and the use of antibiotics does correlate with a cluster of wound infections. The clinical and operational elements of health care do go hand in hand.
I was excited by QUIPP and quality first because I believe that doctors, managers and patients would have no problem defining and agreeing what good quality looks and feels like. Indeed, we are all customers in our everyday lives and we all experience service. There is no hesitation by many walking away from an encounter and complaining, often on social media, but how often do we take time to feedback the good and bad of that encounter – it is not really English? The only way to improve quality in a service encounter is to ask for feedback and act on it! We are in general very poor at this in healthcare. Patients are too grateful and often feel disempowered.
People who are intent on improving their service only score the 5/5 encounters that are defined by an exceptional experience and a highly likely recommendation and return. I was briefly hesitant to ask my own patients in my own satisfaction questionnaires that are handed out by the outpatient clerks – ‘Mr O’Regan treated me with dignity and respect’ and ‘Mr O’Regan listened to my concerns’. I am pleased to record a >95% 5/5 satisfaction but I can tell you it does make you think about your encounter with the patient in each and every clinic. We are there to attend to our patient needs in the best and most efficient manner possible – your own discomfort and distress is of no concern to the patient.
The other altruism of good service is that you never get a second chance to make a first impression. The outcomes of health care are defined by what we say as individuals and do as a team. Many service organisations offer training and scripts to ensure that the first encounter with the customer is good. This is not obvious in the NHS and teams are often not valued for their identity nor are they given discretion to design their own services.
There is another problem. I am disappointed to have to point my finger at the consultants. The vast majority of consultants deliver a high quality, personalised and effective service but that is just it. They have many years of experience but practice an individual art. The science of quality demands that teams adhere to Standards Operating Protocols (SOPs) and they are audited and refreshed according to best evidence and practice. Unfortunately, this is often construed as an affront to well earnt professional autonomy. Institutions like Intermountain Health Care expect everyone adhere to all SOPs but do not necessarily compliance. Clinical acumen can override a SOP but it has to be documented. I have yet to see a scientific approach to QUALITY applied by any team or hospital in the UK. Unfortunately, it really is like herding cats. MY hope and observations lead me to think that this is a generational thing. I enjoy the insight and enthusiasm of the medical students. Perhaps we should teach the science of quality in the undergraduate curriculum.
Lastly, you cannot inspect in QUALITY. Quality assurance more often than not is a process of ticking the box. This does not result is sustainable improvement. QUALITY has to be designed and incorporated into our everyday work. QUALITY improvement and QUALITY science are the tools that are needed.
Good healthcare needs to be SAFE and FLOW with QUALITY
David J. O’Regan
MBA (Distinction) MD BM FRCSEd (C-Th) FFSTEd
Thesis –‘Why can’t Dinosaurs Boogie?’
Network Q – Health Foundation
We are seeing increasing reports of the lack of engagement and recruitment of new graduates to the surgical disciplines. There is a dearth of training courses available for aspiring surgical trainees. It may take up to three years for newly qualified doctors and aspiring surgeon to get to theatre and actually handle surgical instruments. This is perhaps too late to realise that surgery may not be for you or frustrating that you have not been able to handle instruments before being expected to perform in theatre. Trainees are getting less and less time in the operating theatre to learn basic surgical skills. Wetlabs and simulators are not widely available and paradoxically, according to the literature, the most high fidelity labs are under lock and key and under used. We need a system of training and practice that can be achieved under supervision but carried out at home.
The profession would further benefit from identifying and encouraging surgeons early in their careers: many medical schools have Surgical Societies and many aspiring surgeons were drawn to the profession at school. It is never too early to start: looking at the age most our champion sports men and women started to acquire their skills.
Many consultants of today learnt their skills by volume by ‘practicing’ on patients. Basic Surgical Skills were acquired and rarely taught. Many a trainer, when asked how they executed a specific task will not be able to deconstruct the actions into set up, posture, instrument handling, angles etc. They will when it is explained i.e. the tacit is made explicit. Surgery is a motor skill that has to be learnt through practice. The acquisition of motor skills and the principles are well documented especially in sport. The theory and practice of coaching all athletes at every level involves an understanding of the fundamentals of movement and ergonomics.
The handling of instruments and the passage of the needle through the tissue can be explained in a similar way – this theory has been published and the success of this teaching is realised over sixteen years delivering critically acclaimed courses – PAR Excellence and PAR Aorta courses. The feedback from trainees includes “I wish I was taught this earlier!” and “why hasn’t anyone explained this to me before!”
The time it takes an expert surgeon and a trainee to deliver a needle through the tissue is the same for a single pass “systole”– but the difference between the expert and the trainees becomes obvious when examining the time it takes to set up to take the second stitch “diastole”. The diastolic time is reliant on the ergonomics of the setup, posture, positioning and handling of the instruments – these skills are tacit for the expert surgeon and have been honed by volume and time. For the trainee, this aspect can be explained and taught in educational terms as largely due to ‘Negative Passive behaviours’ of ‘not doing what should be done’. Have you ever wondered why a good operation appears as smooth; it because the diastolic period is minimized and the surgeon makes it look easy because they have attended to the setup, their posture, address to the table and angles i.e. all the negative-passive behaviours. These are poorly explained, taught or realised by the trainee or trainer alike but can be understood and more importantly practiced and rehearsed on low fidelity systems at home.
You will observe that most skills workshops have trainees seated on fixed chairs operating at tables – this is not optimising the functional anatomy of the upper limb and cannot be further from the movements and understanding of the ergonomics required to effect a smooth action at the operating table where we are standing. Those disciplines that do sit to operate undoubtedly have a stool that is on wheels and goes up and down. The stools can move through three dimensions. It is not fixed. We are training our surgeons incorrectly. Moreover, we do not offer a framework of understanding or provide models for deliberate practice.
The practice of surgery like all sports requires the application of the same principles. It is important to deconstruct the movements and explain ergonomics required to achieve the action. It is this understanding and rehearsal or these movements that will cultivate and reinforce a motor memory resulting in a reduction in the diastolic time of an operation and a smooth transition between actions.
The 10 000 hours needed to become an expert can be helped in the early stages of training with deliberate practice and observation by a skilled trainer.
These simple principles have been employed in the instruction of the martial arts for thousands of years. The power and flow is achieved with an attention to the practice of the deconstructed movements; the first skill is to master correctness.
This proposal is based on the observations and interviews of sixteen years of Silver Scalpel Award Winners and the learning achieved through the critically acclaimed PAR Excellence and PAR Aortic courses. We have demonstrated remarkable improvements in basic skills teaching over 190 students on potatoes, bananas and poached eggs! The video evidence of improving skills is compelling.
Laparoscopic surgery has an advantage as most the movements and be captured digitally for analysis – there are a plethora of models a available for practice but this luxury has not been afford the simple skills of
- Knife and scissor skills
- Knot tying skills
- Non dominant hand skills
- Assisting skills
With advise from educationalists, we have come up with a technique based assessment of these skills. The skills are analysed in three domains
Negative passive Behaviours
Each of the five skills is deconstructed. The focus is on the ergonomics of the action.
The theory and the models have been scrutinised by educational academics. The models meet the requirements for deliberately feedback and can be used at home. The result of practice has been be captured, coded and scored digitally. They are reproducible.
Mastery comes through practice
“The more I practice the luckier I get”
This has been successfully introduced to local and national level in Surgical Student societies and as well as foundation years. It has even been met with enthusiasm at a school careers fare.
The art of surgery starts with an understanding of the instruments, soft hands, respect of the tissues and coordinated movement. Deliberately practice requires models that offer feedback: the low fidelity model we use fulfill this need.
The learning needs to be overseen by an expert. Progression is dependent on mastering the basic steps and understanding the ‘Why’ of what we are doing. This is realizing the tacit knowledge of the expert surgeon and making it explicit.
Surgeons are very goal orientated and respond accordingly especially if there is a perceived reward.
The acquisition of these skills has been from the format used in martial arts. The progress and mastery of the basic movement will result in improved flow and accuracy. The first skill to master is correctness.
The concept of the Black Belt Academy of Surgical Skills is offered.Â This addresses many surgical concerns. The concept of diastolic learning focuses on basic techniques for the early surgeon:
- The tacit is now explicit and can be taught
- The practice is deliberate
- The models are available all the time at home
- It offers a clear syllabus
- It is not a one off
The benefits are clear. The training surgeon has a framework to practice and understand their skills. There are assessed at regular intervals and progression is documented. The aspiring surgeon and their trainers, as well as the patient, will see and feel the benefit of honed skills when they eventually get to theatre.
This offers the surgical profession an opportunity to instill enthusiasm and pride in the skills of surgery are very early age. There is no reason why it should not open to A level and medical students: many surgeons knew the wanted a career in surgery at an early age. We will able to identify the rising stars.
We can make this fun and a powerful attractor for our profession. The aspiring surgeon registers their intent to improve their skills and over a minimum of eighteen months attend skills workshops and grades. The registration and management is set up on a smart phone app.
A registration fee £50 entitles the trainee to a eighteen months tuition and a basic set of instruments with which high to practice
This Academy is to run as a franchise. It can be set up with minimal expense in any room by an enthusiastic trainer anywhere in the country.
I am inviting any consultant surgeon who sees this as an opportunity to shape the future of surgical training to contact me via twitter, LinkedIn or Facebook or email email@example.com.
I will be delighted to discuss this further.
David J. O’Regan
MBA (Distinction) MD BM FRCSEd (C-Th) FFSTEd
First Dan in Wado Ryu Shotokan Karate