QUALITY

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