Improvement goggles

What follows are three slides taken from a talk given by Dr Brian Robson, Executive Clinical Director, Healthcare Improvement Scotland and IHI Fellow, given at the Edinburgh International Conference of Medicine in September 2016:



 

I most certainly agree that culture is important. But what kind of culture? Is it healthy just to follow one? In this case the Institute of Healthcare Improvement, Boston.

The “Improvement Goggles”, it would seem, come as part of the “toolkit”?

As a doctor who is passionate about improving care it matters to me that I follow science that does not risk being pre-determined.

It is important that there is philosophical depth to the approaches that we take to healthcare.

I understand the overwhelmingly good intentions of all those involved in “improvement science”, however I would suggest that we should carefully consider the potential benefits and harms of a most determined “one organisation” approach that starts and ends with reductionist and mechanical algorithms.

 

 

‘How to Improve’

The Nuffield Trust has recently published “Learning from Scotland’s NHS”. This report was based on a select group of “30 senior leaders and experts from Scottish health and care”.

One of the primary “learning points” of this report was that Scotland should be considered as “the model of how to improve healthcare across the British isles”. What is not made clear in this report is that the improvement methodology that Scotland has embraced was introduced from the USA not by “30 senior leaders” but by three:

  1. Derek Feeley, President of the Institute for Healthcare Improvement (IHI) and former Director General for NHS Scotland
  2. Professor Jason Leitch, who is a Dental practitioner, IHI Fellow and National Clinical Director of Healthcare Quality and Strategy (Scottish Government)
  3. Dr Brian RobsonIHI Fellow and Clinical Director of Healthcare Improvement Scotland

The “30 senior leaders and experts” would seem to be “marking their own homework”.

A few personal thoughts:

I am a passionate about science but am of the view that passion should not pre-determine scientific method and process.

I have previously argued why it is unhelpful to pre-determine science as “improvement”.

I fully welcome a coordinated approach to improving healthcare.

I worry about the inherent reductionism that is the basis of IHI “improvement science”

IHI promotes learning to healthcare based upon the experience of Industry (mechanical engineering). This may work well for less complex interactional processes, such as Hospital Acquired Infection. However healthcare is rarely linear (it is more often Bayesian) and reductionist interventions (however well intentioned) can cause harm.

I have found that Healthcare Improvement Scotland (IHI) does not routinely include ethical considerations in its approach to “improvement science”.

In summary:

I would suggest that it would have been more accurate (evidence based) for the Nuffield Trust report to have been titled: “Learning from the USA”.

I welcome all learning and from all reaches of the globe. I also seek improvement. But as a philosopher and NHS doctor (of 25 years) I worry about any one-system approach.

Science needs to consider culture, ethics, narrative, and the experience of being.

“How to Improve” needs to consider the voices of people and place. It should not just be the voices of the “senior leaders and experts from Scottish health and care”.

 

 

 

 

The contributions of those “retired” often prove invaluable

The contributions of those “retired” often prove invaluable

BMJ submission by Dr Peter J Gordon.

2nd September 2015

Yesterday I was at a consultation event held by Healthcare Improvement Scotland which sought wider views on a proposed national approach to “Scrutiny” of health and social care in Scotland. At the meeting I met a number of individuals who had been designated “retired” on their name badge. I was not surprised to find that during the course of the consultation event, the contributions of those “retired” proved to be invaluable.

Returning home on the train I thought about this a little more. Names like J K Anand, L Sam Lewis and Susanne Stevens, all regular submitters to the BMJ rapid responses came into my mind. All describe themselves as “retired” and one happily calls himself “an old man”. The contributions by retired folk have always struck me as having a different quality to those by people who are still employees of today’s NHS. In “retirement” there may be a greater freedom to ask questions of prevailing approaches. Our older generation also has great experience which should be considered as “evidence” in itself.

Yet in my job as a doctor for older adults, I see the world around me as seeming to do its best to reduce our elders. The language used in discussing our elders commonly denotes some sort of loss. For example the “guru” of Healthcare Improvement Don Berwick talks about the “Silver Tsunami”. Other healthcare leaders talk of “epidemics” and “challenges”, implying that our elders are a burden to younger generations. To address these “challenges” the healthcare improvers, it seems to me, are devising shortcuts. Today these are often termed “tools” and may be part of “toolkits”.  I have even heard healthcare improvers discussing the need to “invent” a “tool” for patient centredness. I think our elders, or those “retired”, might consider this to be particularly ridiculous.

So I would like to say three cheers for the “retired” folk. To discourse they bring wisdom, to the prevailing methodologies they are more willing to ask critical questions, and when it comes to cutting through to what matters, being true to oneself, our elders are superior to many, if not most, policy makers.

       The following are quotes by Raymond Tallis:

Raymond-Tallis-(30)

Raymond-Tallis-(32)

Unpacking the miracle of everyday life (parcel 2) from omphalos on Vimeo.