Appreciative inquiry in practice: working with local teams to improve palliative care

Charles Campion-Smith. GP & Primary Care Educator, Institute of Health and

Community Studies, Bournemouth University

Some ideas

Adult Learners Working in a complex world –

uncertainty Appreciative Inquiry Significant Event Analysis Continuous Quality Improvement

Group activity 1

In pairs or threes think about the characteristics of the learners you work with in practices - for about 3-4 minutes

Adult learners Are not beginners but are in a continuing process of

growth Bring a wealth of experiences and values Come to education with intentions Already have set patterns of learning Need to know why they need to learn something Need to learn experientially Approach learning as problem-solving Learn best when the topic is of immediate value. Have competing interests –the realities of their lives(Knowles & Brookfield)

Exploring problems together

Improvement is part of life…… When a group of

optimistic and motivated people ask the same questions they become part of a dynamic curious team, exploring ways of working together and bringing them home to test them out. There is a special synergy in the collective energy of people working together to explore a question.

Berwick D, 2002

Complexity and CPD

Primary care is world of uncertainty Feelings, values and beliefs matter

greatly Critical judgement is important We deal with individuals not

populations We can be informed by evidence but

not dictated to by it Shared decision making is vital –

“Evidence based patient choice”

Learning & complexity

Learning takes place in the zone of complexity where relationships between items of knowledge are not predictable or linear, but neither are they chaotic

Learning builds a capability to enable people to work effectively in unfamiliar contexts, but this cannot be taught or gained passively

Capability is more than competence Competence – what individuals

know or are able to do in terms of knowledge, skills, attitude

Capability – extent to which individuals can adapt to change, generate new knowledge and continue to improve their performanceFraser & Greenhalgh BMJ 2001

Appreciative Inquiry ~ 1 the search for the best in people, their

organisations and the world around them. looking at a system when it is functioning

at its best, most effective and capable in human, ecological and economic terms

better to seek out what goes well and do more of it, than seeking what does not work and doing it less.

Appreciative Inquiry ~ 2

“human systems move in the direction of what we most persistently ask questions about” – Cooperider

A shift of focus from deficiencies to resources, from failures to successes and from shortcomings to competence and capacity.

Group task 2

In twos or threes each describe a learning experience in which you have been involved as a teacher or learner, in medicine or elsewhere, that has gone really well.

What happened, how did it feel? Can you think of good metaphor

for the teacher/ leader / facilitator’s role

Improving community palliative care in Dorset UK

30+ GP Practices

300,000 Patients

6 community hospitals

The Challenge

…there is a strong impression that many people die badly. People do not die in the place they wish or in the peace they desire….. Too many die alone, in pain, terrified, mentally unaware, without dignity…BMJ 26 July 2003

The process Welcome Group agreement – to allow all to contribute Shared understanding about what we mean

by ‘palliative care’ Shared vision of what team aspires to Review of current situation – recent cases Tension for change Do-able next steps

Brainstorm 1: Clarification

What do we mean by palliative care?

Who are we talking about?

Palliative care:

is active care offered to a patient with a progressive illness, and their family when it is recognised that the illness is no longer curable, in order to concentrate on the quality of life and the alleviation of symptoms within the framework of a coordinated service. Palliative care neither hastens nor postpones death; it provides relief from pain and other distressing symptoms, integrates the psychological and spiritual aspects of care. In addition it offers a support system to help relations and friends cope during the patient’s illness and in bereavement, and furthermore supports the professional staff involve in the care of patients.

  WHO 1989

Brainstorm 2: Creating a vision (Appreciative Inquiry)

If your team were to be really successful what would be the characteristics of the care you give?

How would it feel for patients, carers and professionals?

Recurring themes Excellent teamworking and

communication Good clinical care and symptom

control Respect for the individual and their

personal dignity Care for the family and relatives Care for each other as team members Choice and control

A Good Death ~ 1 to know when death is coming, and to

understand what can be expected to be able to retain control of what

happens to be afforded dignity and privacy to have control over pain relief and other

symptom control to have choice and control over where

death occurs (at home or elsewhere) to have access to information and

expertise of whatever kind is necessary to have access to any spiritual or

emotional support required

A Good Death ~ 2 to have access to hospice care in any

location, not only in hospital to have control over who present and

who shares the end to be able to issue advance directives

which ensure wishes are respected to have time to say goodbye, and control

over other aspects of timing to be able to leave when it is time to go,

and not have live prolonged pointlessly.

Debate of the age health and care study group. The future of health and care of older people: the best is yet to come London, Age Concern 1999

Brainstorm 3: The current situation

Discussion of recent cases known to the team.

Celebration of the successes Description of where the care fell

short of the standards the team would wish

Discussion of the barriers to best possible care

Significant Event Review No blame – it’s about learning and

improvement Looks at the bits that went well Look at what got in the way of the

team doing as well as they wanted Generate ideas for change Plan to try one or two out – PDSA

cycles

Creative Tension Describe the ideal of care the team

aspires to. Look at current reality – based on

recent cases MIND THE GAP – compare the two

and look at the differences. Understand what is getting in the way

Generate ideas for change

Continuous Quality Improvement

Takes a patient / user focus Views care as the product of a complex

system comprising a number of inter-related processes

Has clear aims Uses balanced sets of outcome measures Encourages serial experimentation and

measurement

Access System

Assess Diagnose Treat

Follow-up

Patient with need

Clinical Out-

comes

Functional Health Status

Total Costs

Satis-faction against need

(Nelson G., Batalden P. et al, 1996)

The model for providing care that underpins our work

What are we tryingto accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in

improvement?

ACT PLAN

STUDY DO

CYCLE forLearning and Improvement

CURRENT KNOWLEDGE

AIM

Model for Improvement

(Langley G.J., Nolan K.M. et al, 1996)

Final Thoughts ~ 1

No individual knows the whole picture but together teams have great breadth of knowledge about their patients / users of the service and about the system of care

Taking a user’s view of the service can be illuminating

Team members often undervalue their worth and contribution

The process needs to support the contribution of all

Final thoughts ~ 2

Teams will readily see how the service can be improved

People like to improve the service users receive

Learning together to improve something they care about is fun

The teacher is not the expert – the role is to harness and direct the knowledge and enthusiasm of the team – gardener not engineer!

A philosophy

Improvement is. I believe, an inborn human endeavour…….And so, it is my premise that almost all human organisations contain in their workforce an internal demand to improve their work. It saddens me how few organisations seem to know this and fewer still act on it. Improvement is not forcing something; it is releasing something.

Berwick D, BMJ 8 May 2004.