Leading positive change in practice

Hi everyone and welcome to this session for this afternoon, so this is the RCVS Knowledge QI Champion session which is about leading positive change in practice. So this is a session where we’ll be looking at how we can encourage veterinary nurses to really take leadership over quality improvement in their practice and also how they can break down some of the barriers in getting there.

So I’m delighted to be joined this afternoon by Amelia Poole from RCVS Knowledge. So Amelia has been an RVN since 2011 and has worked in a variety of practices including hospitals, out-of-hours, and charity. Since 2019, Amelia has worked at RCVS Knowledge promoting quality improvement to the profession, in order to help others provide the best possible care. I’m also joined by Helen, so Helen Silver MacMahon. Helen gained her RCVS veterinary nursing qualification in 2000 and then went on to gain her diploma in advanced surgical nursing in 2005. Helen also holds a certificate in small animal nutrition and a certificate in emergency and critical care. Helen is currently studying for a master’s in patient safety and clinical human factors, so welcome to Helen.

And then finally Kelly Tillett, after qualifying as an RVN in 1997, Kelly worked at Belle Equine Veterinary Clinic which is a large equine referral practice in Kent. she qualified as an EVN in 2001. In 2013, Kelly sidestepped into human medicine and commenced a degree in midwifery which she completed in 2016. Kelly continued to combine both veterinary nursing and midwifery until 2018 and then she returned solely to equine nursing then.

So during this session we’d love for the audience to get involved and we’d really like to make this as interactive as possible so please pop your thoughts, comments, any queries questions at all into the chat box throughout the discussion and Amelia will be visiting these throughout the session. We’ve also got a thread for this session over on the BVNA forum so I’ll pop the link to this in the chat box at the end of the session and then we can continue these conversations over there so I’ll now hand it over to Amelia, I think you’ve got a presentation to bring up on your screen haven’t you Amelia.

Yes I do so bear with me while I try and find the right buttons. I am presuming that everyone can see this, yeah yeah we’re all there, brilliant.

Okay, sorry it’s all getting a bit confusing now and so as said before I’m Amelia, I’m an RVN from RCVS Knowledge and I’m joined here by Helen and Kelly. So, you’ve heard our intros and we’re going to be talking about leading positive change in practice and so I was going to do a bit of an introduction for everyone but you’ve kind of already heard us so I will introduce RCVS Knowledge. We are the charity partner of RCVS, but we are a separate organisation and our mission is to advance the quality of veterinary care for the benefit of animals the public and society. So, we meet this mission by championing evidence-based approach to veterinary medicine, inspiring a culture of continuous quality improvement and making our resources available to the profession and wider public. And all of our quality improvement resources are free.

And so as said I’m joined by Kelly and Helen. Helen and her team who worked at the Animal Health Trust were RCVS Knowledge QI champions this year for their work on implementing a just safe patient culture with their surgical safety checklist. And Kelly and her team at Newnham Court Equine were highly commended runners-up in the new category of ones to watch for the implementation of their surgical safety checklist in an equine practice.
So one thing I’d like you to think about while I figure out how to bring up the chat box is how do you identify things that need improvement either within practice or within your workplace?

I think congress is a fantastic place to get ideas for things to improve on don’t you Amelia and Kelly. Absolutely. Yeah absolutely, I’ve got loads of ideas written down just from today actually. I think that’s often the start of something isn’t it, you come back and you’re full of energy and excitement about what you’ve listened to or what you’ve what you’ve seen somebody talk about and you go back and go right I’m gonna put this into practice, how do I do that? How do I get things moving? And certainly that’s one of the big ways that I’ve been inspired to implement new things in practice. I think if you have an idea, but you don’t think that it’s a big enough idea, even the smallest things matter and if you’re talking to your colleagues, that’s a really good starting point to get that going.

Definitely. Yeah so I just want to say that for some reason I can’t open the chat so that if you do have anything can you stick it in the question and answer because i definitely have that box open and even if it’s just chatter that’s fine. yeah I’ll keep an eye on the chat box as well so… That’ll be brilliant because that box has completely disappeared. Emma Foreman’s just put something on the chat actually that I can see, that she suggested a continuous improvement board at work and they post suggestions and then they have a discussion with their team and implement if they’re agreed upon which I think is a brilliant idea. I love that idea yeah.

I think the other way of finding things that need to change are things like maybe critical incident reports or when things don’t go so well and that might bring to the fore… ideas that might need changing and looking at. Do you guys do that – Kelly you do that at Newnham Court, do you use critical incident reporting and things like that?

We do, we’re kind of evolving from our practice meetings so you identify an incident then we’ll have a debrief and then look at it in more detail. We kind of have a whole team approach to that so that is it’s nice and transparent and open, and everybody can sort of can be in an area where it’s a nice and safe feeling, and their thoughts on the subject. yeah I think that’s really important isn’t it, that people feel like they can talk about stuff and it is a safe environment to come up with these ideas and they’re not going to shoot you down and tell them oh we’ve tried that before it didn’t work or, you know, at least people keep an open mind and they at least explore the ideas with you and go from there. One of the things, like you said I like about congress and that improvement board is also thinking about why you want to improve it, because you could come back from you know this event and think oh there’s so many things that I want to try and I want to do but it, I don’t know, that may not be relevant to what you’re doing in practice so just think about why. Do you want to do it to improve your patient safety or do you want to do it because it’s something cool that you just heard about, so also talking about that as well might win some people around.

Yeah definitely, I think that’s it, having a reason behind it and having a little bit of evidence sometimes help to sway the people that you need for the buy-in, so one of the most important things is getting, when you’ve spoken to your colleagues you’ve come back from congress where you’re bubbling over with excitement and then having a chat not only with your colleagues but having a chat with the people who can make the changes in the practice. And certainly for us at the Animal Health Trust, when we implemented the surgical safety checklist it was really important to get the buy-in of the surgeons, so because obviously we needed to stop the surgery and sort of fractionally delay it, to have this sign-in part of the checklist and then the time out part just before the surgery. And without their buy-in you’re going to get a few funny looks and a bit of huffing and all the rest of it and that could really make it quite tricky for nurses to run the checklists, so making sure the nurses are and consultants are on board with it so that they can help you and get behind you and then talk to their colleagues and spread the word of something that’s a really good change idea is really really important as well. Absolutely, I think it’s like, being able to stop a surgeon from getting on with their job is quite an intimidating thing and it’s a real culture change to have to sort of empower your staff and be able to stand up and say could everyone listen to me please, can we do this part of the safety, so you know there’s lots of barriers to overcome and it’s thinking of ways of dealing with how to overcome those barriers which is all part of the planning and implementation of these sort of QI initiatives. I think is really important, it does take a lot of coordination, engagement and sort of help from your colleagues to get the ball rolling.

So just had a great question come in from Amanda, so she says she struggles because she works nights, all been there on the night shifts, and she wants to implement QI into her practice but she has little influence of what happens during the day and no one on the days seems to be that interested. Do we have any tips to pique colleagues interest in QI? The evidence behind the implementation is really important and you know we’re taking, we’re a bit behind the human medical field so we’ve there’s a lot of evidence in the human medical field and sort of aviation, of these small changes can make a massive difference and so I think to look at evidence and be able to present that at practice meetings is a really good way of doing that, even if you’re on the night if you can get your head nurse or practice manager to put that idea forward for you can add little bit more weight to the initial idea. I think that probably one [unintelligible] for you.

I think as well and if you are on nights I don’t know what sort of nights you do whether it’s just you and the vet or whether it’s a bigger team, but leading by example so perhaps have a chat with the vet that you work with and maybe start by implementing some surgical safety checklists on night time, because the patients that you have will still be there during the day and if people see that you’re doing these surgical safety checklists or some IV checklists, that might just be the spark that they need to think oh you know if they’re doing that at night that that would be a really good idea to do kind of during the day. And especially at night time it’s really important anyway, I used to hit the wall at three in the morning and honestly I was useless to anyone for about an hour and a half and so checklists were a real lifesaver with that. So that might be worth doing.

Yeah definitely, I think also you know making sure that even though you’re on nights, you’re invited to team meetings and you still have your appraisals perhaps with your line manager and and bring it up then and asking them if there’s been any other nurses that have kind of shown an interest in it and collaborate to make sure that they feel like that’s the the best way to get forward. Yeah I think another simple sort of way of implementing thing is to put posters up around so outside of theatre, have you started your surgical safety checklist and or put them in sort of areas[unintelligible] so there are a visible trigger for people to start thinking about it even if it’s not necessarily flowing immediately but it sort of it starts to seep into the mind.

Ashley from RCVS has also just come up with a really fantastic idea about auditing your performance before you try to implement the change and then make the change and then audit again and share your results with the day team so they can kind of go forward with that. Yeah definitely. Yeah absolutely because we’re all a bit we love a bit of competition and especially the vets and you know if you almost pit them against each other, not in a bad way because this is all about creating a good team but they’ll love to compete against it as well. Yeah. Definitely. So, here’s a little slide of our practice and it’s a little bit on how I kind of put our QI into practice in an equine environment and this image shows us in surgery, with the surgeon and one of our lovely technicians Paige, who is diligently filling out the safe surgery checklist. We were lucky, all of our team were on board immediately with the idea, the culture in our practice is pretty sort of innovative anyway so people want to get on with new ideas but that as I said before changing the culture can be a bit of a problem sometimes, but so we were really lucky that we were able to get this going sort of fairly well fairly quickly. And we noticed sort of changes immediately with us, just sort of taking a breath, pausing, looking at what we were doing and at the same time giving sort of the nursing staff a bit of more confidence to be able to speak up in that environment so it’s a really good use in our practice.

I think that’s it, when you get started doing checklists actually it is a rolling thing because then when you’ve got a few people who are championing it and they are, started doing them when you’re training other people, you can train them in feeling a little bit more positive and a little bit more bold in being able to stop the theatre and say hey we’ve got to do this first and it’s kind of a rolling thing until you’ve got the whole team engaged and it just runs really smoothly. That’s how we had it at the trust, that it was just the culture of the theatre that this is what happened and you were going to get stern looks off me if you’re… or one of the other nurses if anybody started surgery or talking or anything like that whilst you’re supposed to be doing the checklist so it’s, it becomes easier once you get into the throw of it definitely.

Yeah you might find that if you’re in an emergency situation that you’re wasting their time, but emergency situations are the times when you really need to be focused and think about what’s happening because they’re the times when people are going to sort of divert off of the checklist almost and big important steps might be missed because it’s a high-stress situation. So you know even in in a time where you think [unintelligible] people up, it’s actually the most important time to be able to complete all your checks.

Definitely and I always bang on about the fact that, right when I started this journey learning about stuff like patient safety, and quality improvement, somebody said to me that you can only keep seven things on your mental scratch pad. I was quite relieved because I wondered why I couldn’t remember everything, but this is what checklists are all about, we can’t possibly remember everything so it’s having a piece of paper, a checklist there in front of you so that in the emergency situation we absolutely don’t forget anything vital and our patient receives really excellent care. Yeah just obviously you say about the, kind of the mental scratch pad in an emergency situation, I’ve worked in emergency for a long time and actually it was only when I started doing routine things again that I used to forget things. So you see checklists and things not just for emergencies and that is when it’s most important but I found that I just could not prep for a bitch spay because I just would forget it immediately. Ask me to prep for a GDV, I’ve got everything. But anything routine I just used to forget and checklist really used to just, save a lot of brain ache as well and feeling like I was just a bit rubbish because I couldn’t remember laryngoscope or something like that.

So the idea of obviously, quality improvement in practice is fantastic and you two both come from places where the culture has been really good and where your team has really been engaged with it. But have you ever worked for people that haven’t been engaged with it or have been less than enthusiastic, for example you know don’t have time or something like that far too busy or anything that other people might come across that might make things difficult in practice?

I think there’s always a situation where you kind of have that we’ve already done it that way around here, or we like to make our own decisions about that and that’s really tricky to get around. And that’s where making sure that you start off with somebody who’s really good at, who has massive buy-in who’s a really good stakeholder, to help engage the rest of the team is important and making sure that you listen to everybody’s opinions and don’t… be flexible and work so that the whatever you design is fit for purpose for your environment. So if parts of the checklist that you’ve downloaded off the website or seen at congress don’t work for your practice… say to people it’s a working document we can make it our own we can we can change parts of it. Or you know be understanding and flexible and kind of just look for different solutions, don’t give up.

Yeah I’ve been lucky, I’ve been… the culture in our practice as I say is very good, but in the NHS when I was training there, you know it was quite a pretty intimidating environment and there were some staff that would be more resistant to sort of getting on board with the checklist but more from juniors. So the senior staff were pretty much well reversed because it’s been happening in the NHS for a long time, but as a student I know it was… I was quite, when someone hands me a checklist and said right stand in front of a whole obstetric theatre with an emergency c-section just about to happen let’s read that list out, it’s quite, you’ve got like 30 seconds to do, it’s quite intimidating. But I think that one of the barriers that probably people might meet in in their practices is a little bit resistance sometimes from staff and that would be where you need to really sort of have done your homework and got your evidence and this is what happens as I mentioned before how it’s working in other fields but I think, you know, it does sort of filter down and it might take a little longer for some operations than others but it does filter down and once the outcome the noted to improve or people just get more confident then it’s definitely beneficial all round really.

Definitely, definitely. Emma asked a question a little bit a while ago that I’ve just noticed on the chat, do we keep the checklist to allow for reflection and evidence in case of any post-op complications? Yes definitely, at the Trust they formed the document that was the theatre note so they would have all the instruments and swap counts on as well so you’d have the patient details on the front and then the middle section would be swab counts and instrument labels and stuff like that and then the back cover of it was the checklist. So it formed part of a document that was scanned into the patient’s electronic file or went into their paper file and depending on you where you’re at with electronic stuff.

I was also going to say Kelly that you know when you’re talking about evidence and making sure you’ve done your homework is that that’s really where RCVS Knowledge can help because if you go to their website there’s loads and loads of tools on there as to the evidence behind everything so if you go into the checklist manuals and what have you then you’ll find all of the bits and bobs you need to know behind that to really make a convincing argument for checklists and similarly for other improvement methods as well.

Yeah. We keep our checklists with our clinical notes, we scan them on and I also made like a product code so I put it into the practice management system onto the client record that one has been completed so when I go back to audit the information I can find the information really quickly so it’s good to put into a system into place where you can extract your data as well for your continuous audit cycle. So I think that’s, sort of thinking ahead like that’s a good idea. Yeah that’s a really good idea and then sorry I thought you’d frozen then, and I really like this slide that you put together which is small changes can have big impacts. So, especially after weekends like this it’s really easy to go back to practice and just bombard them with everything that you would like changed, but it’s not always the best way to go and not always the best way to convince people either so changing just very small things like for example if you have a lot of people not wanting to fill out surgical safety checklists then start them small on other checklists.

In my last practice, we basically started them on kind of induction checklists we would go through and tick if everything was ready for induction and the vet would check and that was kind of their introduction to checklists so that they were already used to doing that before we then went full hog and went in with the surgical safety checklist. So it’s kind of a little a little tester checklist and before the real one that we wanted to put in. Yeah definitely. I think also for trainees it’s really helpful as well because you know OSCE tasks, stuff like that, where you’ve got to demonstrate you can check an anesthetic machine, if you’ve got a checklist for checking an anaesthetic machine and you’re using that checklist every day and then that’s going to make life a lot easier as well. And you get into the habit of it and here are some lovely examples of what we’ve been talking about.

Speaking of! And so we do have a surgical safety checklist manual that basically has all the evidence you would need to convince people in surgical safety checklists and loads of examples, templates from RCVS Knowledge and also examples from assortment of small animal and equine and farm practices and so if you don’t really know where to start just steal one of theirs and you know have a play with it and see how it goes. But the evidence behind surgical checklists is a 47% reduction in deaths which is a massive amount and a 36% reduction in post-op complications and so I think even for the most hardened of people that evidence alone would be enough to convince them.

Definitely, we’ve got another question from Amanda, thank you Amanda, formal training in QI. I’m doing a masters in patient safety and clinical human factors which is, QI is heavily embedded in that but I also use a lot of the RCVS Knowledge courses and resources that are online because they are absolutely fantastic for veterinary stuff in our field and quality improvement in veterinary healthcare is an emerging subject where we’ve got lots of people who are interested and please join us but it’s really just evolving and getting started.

And yeah I’m about the same, I live, breathe, research everything QI so and obviously in my role at the RCVS Knowledge, every day is QI day for me and we have a Quality Improvement Advisory Board who are the fount of knowledge on so many things, so picking their brain as well is really great. I know some practices pre-COVID did do some kind of QI training sessions with their teams but I think that’s potentially stopped now because of COVID. I don’t know if people are still doing it online,but RCVS Knowledge are also developing more courses on QI which hopefully will be coming in the next month or so, so definitely keep your eyes peeled on our social media for that announcement. And if you want some, another little shameless plug for RCVS Knowledge, you guys are going to have to pay me! We are, just started doing a blog on QI which is taking sort of a bite-sized approach to different subjects and then Amelia is very kindly helping us I know as well in linking all of the RCVS Knowledge resources to the blogs so if you just want to sort of more passively learn a bit about QI there’s some things that you can be reading there and following the links to RCVS so it makes it a bit more approachable and bite-sized like I say.

So I can talk about… well we’ve touched on it slightly with Kelly and her audit… auditing – that’s fabulous isn’t it, about measuring the impact of your change so if you’ve introduced some change in practice, your team you think are getting on board with it but how do you really know. Yes sorry I’m just aware that i think we’ve run out of time! Nearly there – I think if we could wind up using this point that would be great, sorry guys! Sorry I could talk forever!

So I think we were just going to say that this is a continuous cycle so as you start then don’t be afraid to use your PDSA cycles so plan, do, study, act and keep it going. Your first idea doesn’t have to be your last idea, keep revisiting what you wanted to change make sure you’re getting there and asking the same questions and auditing to check that you are getting the outcomes that you’d like to have. Was that what you’re going to say Kelly?

Yeah then when you’re along this journey you might identify other areas that like you want to research into so extra other little parts that have come out of your to-do list or what you’ve been reading about and then you’re going to be able to identify other areas in practice that you could improve upon as well, so it’s continuous. Fantastic okay.

Do I have time to touch on one slide? If you’re quick! I’m super quick! Yeah, also if you really just aren’t sure where to start or where to go with improvement, then if you have a look on our website we’ve got a couple of kind of processes that you can use that if something happens you can identify the team factors and the proper root cause of what’s going on so that that will lead you as to where you can go and what changes you might need.

Was that quick enough? That’s super thank you so much everyone that was pretty much bang on time and so thank you again Amelia, Helen and Kelly for joining us this afternoon and given us some really useful points so hopefully that’s encouraged a few nurses who are online at the moment to really get involved in QI it’s so important so thank you so much for your time everyone.