Interview with Dr. Brian Robson

Today I’m speaking to Dr. Brian Robson. Who’s the Clinical Director of Healthcare Improvement Scotland, also a part time GP and Improvement Fellow with the Institute for Healthcare Improvement. Hello, Jacqui and thank you very much for involving me in your MOOC on quality improvement. So Brian, to start off with, how do we know that improvements are needed in patient safety? Well, there’s now a well publicised and published literature on the harm and error that happens in health care, not just in Scotland, certainly not just in the UK, but across the world. So we know that there are failure rates in medications, in terms of medication error.

We know that there’s failure rates, in terms of reliability of processes that we should be carrying out regularly for patients. And these are well documented. Some of the data around that’s very interesting. In fact, we have well publicised, well published literature going back 20 years now on the literature around error in hospitals. And pretty steady now, at 10% to 15% of patients who are admitted to hospital may experience an adverse event. So there’s plenty of literature, and now an increasing body of work to try and improve the failure rates. So that’s great that there’s lots of evidence there to support the patient safety and quality improvement agenda. Can you explain to us why measurement’s important for making these improvements?

Well there are great leaders in the field of quality improvement that talk about measurement being the cornerstone of all improvement. And the basic argument there is that if you don’t know how your activities are impacting upon the system, you don’t know whether things have improved unless you measure them. So having measurement at the centre of what you do and thinking about it, even before you start, is extremely important. So what types of measures can be used to improve safety? Well, there’s all sorts of measures you can use. The main thing is to think about how simple you can keep it.

It’s important to keep measurement simple, so a small number of measures, preferably ones that are already collected or easily collected. And it’s important you can break them down and you can read more about this into process measures, outcome measures, and balancing measures, so measures of how well we do things, how reliably we do things, process measures, measures of outcome, whether we’re actually impacting upon for instance medication error, or harm to patients, and balancing measures, this concept of unintended consequences. You may improve one part of the system, but something else gets worse.

You may improve the way that you process work with patients, in terms of getting them through a system, but actually it takes much longer and cost a lot more money. Those balancing measures are important. But keeping it simple, small amount of measures, and preferably measures that are already captured.

So can you tell us what the key requirements are within a health care system, to enable improvement? Well, that’s a good question. So the key enablers, I guess there’s a model that we think about, which is do we have the will to improve, do we have the ideas, the things that might actually improve the problem that we have, and do we have the ability to actually do them, actually put those ideas into practice or execution? So we call this will, ideas, and execution. And you need to have all three of those to actually make improvement happen.

So who within a health care setting needs to be involved with this improvement work? Well, the short answer is everyone needs to be involved in improvement. In fact, we have a phrase, in health care when you come to work you have two jobs. You have the job to do, the job that you’re employed to do, but you also have the job which is to improve the job that you’re doing. So everyone should be both involved in improvement, and able to actually improve the health care system. That’s from the support staff, the clinical staff, all the way through management, and all the way up to the board.

So improvement sounds like a great idea, but what sort of methodology is available for people to get started with improvement? Well, there are so many methodologies out there. And most of those methodologies came from industries beyond health care. But the big ones for us, are model for improvement, the Plan Do Study Act cycle, associated with that. Lean improvement, which is about reducing waste and adding value. Six Sigma, which would be around reliability, and improving reliability of systems. And then you get into all mixes of those, Lean Six Sigma, you get into Vanguard. There are a whole variety. But in Scotland, we’ve made a great success out of focusing on the model for improvement.

OK, so can you describe in a single sentence how using this model for improvement has benefited the quality of health care in Scotland? Well, using the model has offered us a framework within which we improve, at scale, here in Scotland. So can you give us some examples of areas of practice that improvement has been successful? Sure. Well, the main aspect, some seven or eight years ago was looking at Intensive Care Units in hospitals and how do you make the procedures and processes in there reliable, those such as the ventilator associated pneumonia bundle, the five or six things that you should do every time for patients who are ventilated.

And that’s had a dramatic effect, in some places eradicating ventilator associated pneumonia, which is a complication of being ventilated. But all the way through to now in primary care, we get significant improvements happening in results handling, within general practice, general medical practices in the community, significant improvements happening in culture, climate, safety climate, survey tools that we’re using. So we’ve got improvements happening across hospital care and primary care, and increasingly now in social care, in terms of patients who have chronic care needs, long term conditions, and polypharmacy. OK, thanks very much, Brian, for joining the MOOC and for highlighting the importance of quality improvement in health care.

And we’ll come on to look at that in a lot more detail, and particularly focus in on measurement for improvement. Thank you very much, Jacqui.