Why bother? – reflections on aspiring to quality in a busy world

Professor Amanda Howe

President, World Organization of Family Doctors

&Professor of Primary Care, Norwich Medical School, University of East

Anglia, U.K.

WONCA – a global organization

www.globalfamilydoctor.com

• 7 regions

• 150 countries

• NGO registered with World Health Organisation

• Academic members

• Growing all the time!

NORWICH MEDICALSCHOOL, 2002-2018

Whāia te iti kahurangi ki te tūohu koe, me he maunga teitei

Barriers to quality improvement

• Knowledge and competencies

• Human resource – time, expertise

• Value – productivity, impact

• Threat – criticism, blame

• Financial implications

• Loss of autonomy / choice

AAFP report 1998

Positives re. Quality Outcomes Framework (U.K)

• Increased practice income and (*temporarily) improved recruitment to general practice

• Stimulated further developments in electronic records and team skill set

• Initially aligned with evidence

• Reinforced much good professional practice (which most practices were doing anyway)

• Led to modest improvements in quality, and some reductions in variation in the delivery of care

Less positive

• Increasing trend to new indicators with little professional support / evidence

• Introduction of indicators which addressed a managerial rather than a clinical agenda

• Increasingly irrelevant to the main workload (and quality) problems which are in those with multiple complex problems (social / elders…)

• No financial incentive for community outreach / working with vulnerable groups

• …supplemented by the Care Quality Commission …

Why bother?

• Professional ‘duty’

• Patient need

• Leading and educating others

• Making a difference

Why bother? – professional motivation domains

• MASTERY – attaining and being recognised for competence

• AUTONOMY / CONTROL – making a difference

• RELATIONSHIPS – motivated by the culture / needs / wishes of others

• SOCIAL PURPOSE – driven by need to see an impact for others

• SELFCARE – avoiding demotivation by self protection / productive work environment, attention to capacity..

• FINANCIAL INCENTIVES

• Also NB resilience literature – persistence in meaningful action

More Than Money: Motivating Physician Behavior Change in Accountable Care Organizations Milbank Q. 2016; 94(4): 832–861.

The Habits of An Improver

• 5 domains recognisable in people who routinely activate QI• Learning

• Influencing

• Resilience

• Creativity

• Systems level thinking

Bill Lucas and Hadjer Nacer 2015

So how do we get those ‘habits’?

• Intellectual knowledge – the QI process, change management

• Application of knowledge – in formal training, and in CPD

• Prioritising real needs – evidence base for choices

• CAPACITY – team leads, team time, expertise

• Creating the context – community stakeholder groups, project partners, professional recognition …

• Small is beautiful – experiments, early wins, ‘nudge’….

• Cultural emphasis – improvement becomes routine …

Examples of QI approaches that can motivate and build morale• Community oriented primary care ‘COPC’ - https://www.graham-

center.org/rgc/maps-data-tools/tools/copc.html

• ‘Plan-Do-Study-Act’ – IHI http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

• QI Ready – Royal College GPs U.K. http://www.rcgp.org.uk/clinical-and-research/our-programmes/quality-improvement/qi-ready.aspx

• Undergraduate involvement in QI projects (learning and health service impacts! - King’s UK, South Africa, Australia, Canada….)

- https://www.bmj.com/content/361/bmj.k2602/rr-0

- https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-016-0694-1

- Cornerstone?!

Advocating for quality in resource constrained settings

• IHI ‘Triple Aim’ – better care, better outcomes, better resource use

• QI can reduce waste and improve efficiency – evidence based practice, more targeted use of tests and medications …

• Equity – ‘poor care for the poor’ cannot be justified

• Effective health system design can produce cost effective care

• Make incremental changes – learn and roll out…

• Do not oversimplify – health is a complex system and change is nonlinear: important to create a stable framework and allow - but analyse - variation

• Recognise achievement and share good practice

And what of WONCA?!• Family medicine workforce as a central element of highquality care

• Championing academic primary care research and researchers

• Networking of professionals for advocacy and sharing good practice

• Models of postgraduate curriculum and CPD standards

• Accreditation systems for educational and clinical providers

• Awards for recognition of achievement

• Priority areas – Working Parties Research, Education, Quality & Safety

• Work on accurate data and indicators – WICC (ICPC), OECD, PHCPI…

• Support for those in early careers (Young Doctor Movements)

• Advice and support for new members / family medicine development

Aspiring to quality in a busy world- yes, let’s do it!

Professor Amanda Howe

President, World Organization of Family Doctors

&Professor of Primary Care, Norwich Medical School, University of East Anglia,

U.K.