Burnout is a popular topic of discussion in health care.
Recently, I was asked how I address burnout in the form of what you could call “initiative fatigue.” That is, how do I — both as a frontline leader at the Royal Alexandra Hospital in Paisley, Scotland, and on the national level for Healthcare Improvement Scotland — help my teams avoid being overwhelmed by the many patient safety initiatives that come our way.
My answer is fairly simple. Talk less, listen more.
Instead of just telling clinicians about QI or patient safety initiatives, projects, or campaigns we need their participation in, let’s find out what they care about.
Instead of asking, “How can we engage clinicians in the organization’s quality and safety agenda?” let’s reframe the question to ask clinicians, “What is your quality and safety agenda?”
Scotland’s National Patient Safety Improvements
Engaging clinicians in work that is meaningful to them and their patients is an important element for sustainable improvement, particularly for large-scale improvement such as the Scottish Patient Safety Programme.
Scotland’s HSMR [hospital standardized mortality ratio] is currently at its lowest level since records began. Through my work, I have been fortunate to contribute to this reduction. I led the Scottish Patient Safety Programme (SPSP) multidisciplinary ICU team within my own organization, the Royal Alexandra Hospital. The team, which consisted of physicians, nurses, managers, and other allied health professionals, became the first team in Scotland to reliably implement all eight elements of the SPSP critical care change package.
Within the hospital’s ICU, the SPSP work resulted in significant reductions in healthcare-associated infections (e.g., ventilator-associated pneumonia and catheter-related bloodstream infection), a reduction in average length of stay, and a reduction in ICU standardized mortality ratio. We are especially proud of our latest milestone, the longest ever period of time without a catheter-related bloodstream infection.
Our sepsis collaborative has undoubtedly had the greatest impact on patient safety, delivering a sustained relative risk reduction in mortality from sepsis across Scotland. Working closely with staff within Healthcare Improvement Scotland and other frontline health care professionals, we developed this effort from the initial concept (using driver diagrams and change packages) through to the successful delivery of a Breakthrough Series Collaborative.
The work has focused on the 4 “R’s” of the deteriorating patient with sepsis, namely reliable:
Each part of the process is crucial and interdependent. Far more complex than the implementation of a simple care bundle, the 4 “R’s” process is a combination of behavioral change and a systems-thinking approach.
Taking Pride in Scotland’s Dramatic Results
Everyone engaged in SPSP is quite rightly proud of all of these improvements in patient care. SPSP as a national strategy to address patient safety has had a twofold effect on many of us:
- Increased joy in the work: Frontline clinicians owned the work, the responsibility, and the measurement of their processes. This gave clinicians opportunities to fully engage in the work and take deep satisfaction from the progress they made. In my own organization, I’ve found that keeping our workforce happy and engaged has also aided staff recruitment and retention.
For me, this work has been a reminder of the reasons I went to university to study medicine. Being involved in Scotland’s national safety strategy has helped fulfill my ambition to help people as much as being a practicing critical care physician.
- Satisfaction in making improvements during challenging times: As the lead clinician for critical care in Scotland’s largest health board, it was part of my responsibility to help deliver high-quality care for all patients in Greater Glasgow and Clyde while also making cost efficiency savings in a difficult economic climate.
Using the skills we learned and the relationships we built during SPSP, we reduced waste, harm, and unnecessary variation within our health care system. Saving money and freeing up time to care for, listen to, and comfort patients helped ensure that providing the best and safest care for our patients is (and remains) what we are all about.
How did Scotland make dramatic improvements in patient safety throughout the country, particularly during such challenging economic times in Europe?
There are many ways to answer that question, but for me there is one key answer: quality, patient safety, and SPSP aren’t initiatives. Our patient safety work hasn’t stopped just because we reached the end of our official campaign and achieved our high-level aims. Providing the highest quality care to every patient, every time, is who we are, what we aspire to deliver, and how we practice medicine.
The Key to Clinician Engagement
My pediatric colleagues in Paisley, and now throughout Scotland, have made it standard practice to ask patients, “What matters to you?”
We should also ask clinicians in every setting the same question. Or, phrased another way, we can ask, “What keeps you up at night?” Sustainable improvement is about focusing on what matters to clinicians. If you want to know how to engage clinicians, find out what gets in the way of providing the best care possible for their patients.
In my experience, clinicians aren’t afraid of hard work, but they probably have a long list of things that make their work harder than it needs to be. Managers and leaders need to make it easier for clinicians closest to the point of care to do the right thing for patients.
Kevin Rooney, MBChB, FRCA, is Professor of Care Improvement, University of the West of Scotland, and a consultant in Intensive Care and Anaesthesia at the Royal Alexandra Hospital in Paisley, Scotland.
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