July 12, 2017

Working together means you should never worry alone

...and other lessons from NHS Scotland’s transformation journey


“Out of small conferences come mighty things,” was how moderator Kay Lewis kicked off this year’s Atlantic Learning Exchange (ALE) conference in late May. “Canada’s first leaders met here in 1864 and that small conference led to the creation of our great country.”

Held every two years and always in an Atlantic province, the Atlantic Learning Exchange builds knowledge, awareness and a shared mission to make positive change in our healthcare system. It’s a full and stimulating two days hearing the local perspective as well as speakers from across the country and around the world.

The catchword rippling through this year’s proceedings was culture – how do we change it? What role does it play? When is it working for us...and against us? There is definitely a new consciousness about the importance of mobilizing culture in order to effect change in quality and safety. But beware – several speakers warned that changing the culture is “messy, muddy and full of failure.” And don’t let that stop you.

“Working together means that you should never worry alone,” was how Healthcare Improvement Scotland Medical Director Dr. Brian Robson set the tone for his story about the cultural transformation of NHS Scotland. An astute observer of the transformation process and the elements that contribute to its success, Robson sees the lessons everywhere. Like in the airport on his way to Canada.

“He wanted to get us to our destination as quickly and safely as possible”

“I am your captain and I would like to explain why we are so delayed and what is going to happen next,” was what Robson and his fellow passengers heard on a windy Monday morning as they settled in for a long wait at Glasgow Airport. What the captain said next was unusual. “He asked us all to get on the plane so when we do get the all-clear, we’ll be the first to take off,” said Robson. “We listened to him and got on the plane, even as we saw passengers from other flights dispersing to wait out the delay in the airport shops and bars.”

It worked out exactly as the pilot predicted, an outcome that Robson says is just as relevant to hospital leadership. “He wanted to get us to our destination as quickly and safely as possible and he knew that we needed to work together to make it happen.”

Back in 2008 the leaders of NHS Scotland were in agreement with the Scottish Government that something needed to change, but were unsure of where to start. “We admitted to ourselves that we were killing 200 people a year through medication errors in hospitals in Scotland,” says Robson. Mistakes were happening and it was clear they needed a new vision.

Many hours of discussion, soul-searching and meetings with stakeholders led to the creation of the national Scottish Patient Safety Programme (SPSP).

The future will focus on patient safety and reducing harm

They knew a new strategy built around quality improvement was going to be “messy and muddy”, but it was time to break with the past. “We have had five decades of clinical audit and 10 years of clinical governance,” said Professor Sir Graham Teasdale, the inventor of the world-wide Glasgow Coma Scale. “The future will focus on patient safety and reducing harm.”

Shifting course and embarking on a large-scale quality journey would never have gotten off the ground without the buy-in of clinicians – and they got it. “The doctors loved it and the staff loved it!” says Robson. “People were most energized by the potential to positively influence the culture through shared decision-making.”

From that point on, everyone at NHS Scotland knew they had two jobs when they came to work every day: to do their work and to improve it.

Almost 10 years later this call to action continues to come from healthcare leadership in Scotland with the national Chief Medical Officer, Dr. Catherine Calderwood, asking doctors across the country to ponder some pivotal questions:

  • Can we produce a personalized approach?
  • Can we manage risk?
  • Can we become improvers and innovators?
  • Can we reduce waste, variation and harm?
  • Can we move towards shared decision-making?

A big part of Realising Realistic Medicine – the name of Calderwood’s Annual Report – is a personalized approached that puts the person receiving care at the centre of decision-making.

Blow your socks off speakers

Getting clinicians engaged and keeping them engaged was the tricky part. Robson and his colleagues at Healthcare Improvement Scotland developed an ambitious program that includes large-scale training programs in quality improvement as well as simple, inexpensive, accessible and fun learning opportunities. They launched QI Connect, monthly webinars focused on innovation and integration. “The main requirement is ‘blow your socks off’ speakers,” says Robson, of the international experts on quality improvement who deliver short and succinct talks for free.

As of May this year, more than 600 organizations in 51 countries are tuning in to QI Connect including more than 40 universities.

Another of their tools is a relentless focus on measurement. On this subject Robson can’t resist a quote by W. Edwards Deming, “In God we trust...all others bring data.” This data is definitely something to smile about...and share; it’s now posted on every ward for the public to see:

  • 16.5% reduction in the Hospital Standardised Mortality Ratio between October 2006 – December 2015
  • 71% reduction in the Pressure Ulcer Count between November 2010 – May 2015
  • 5% reduction in the Total Falls Rate for 7 Scottish Boards between January 2014 – June 2015
  • 21% reduction in deaths from sepsis

Surgeons across the country rarely operate without having a morning safety brief and since 2008 more than 2,500 leadership walkarounds have been conducted in Scotland.

The story wouldn’t have quite the same impact if it wasn’t delivered with the Scots’ characteristic wit and humour. Nothing is so serious – even a complete cultural transformation – that you can’t joke about it. “Would you want Dr. House – from the TV show House– on your team?!” Robson dares the audience. “Of course not! He’s not a team player.”

The new culture is thriving because it focuses on humility, discipline and teamwork. “We’re driven by people, community and purpose,” says Robson.

Learning together...again and again is leading to better conversations and a higher profile for patient safety at NHS Scotland. For the good-humoured doctor in the plaid shirt, the plaque on his desk with a quote from Bob Berwick asks the critical question he and his colleagues know they must never lose sight of – How will it help the patient?