“We need to change the concept of professionalism, to really keep moving in the right direction.”
Professor Ben Bridgewater; Consultant Cardiac Surgeon at University Hospital of South Manchester, discusses how he uses Individual Clinician Feedback as a day-to-day practice measure, to improve patient experience.
What do you think it means to be a doctor in 2014?
People ultimately go to medical school because they have a desire to use their education to benefit others. The Medical School experience is based on acquiring knowledge and assessing that knowledge so you can use it. Qualified doctors then leave medical school and go to work for various areas of the service (GP, Surgeon, Urologist etc.) and set to work using that knowledge. Somewhere along the way, between the pressures of the job, meeting unrealistic targets, and adjusting to putting the skills into practice on a mass scale, the primary mission of why we all become a doctor; looking after people, caring for people, delivering quality care, gets forgotten and loses priority.
I think being a good doctor in 2014 should mean that you are able to keep the core principles that were central to your professional choices when you were 18, and never forget them. Between navigating targets and challenges, always keep those principles at the heart of the care you give.
Why is Individual Clinician Feedback (ICF) such an important consideration in being a good doctor?
When you interview people for jobs and ask the question; “are you a good doctor?” you get a resounding “yes”. But when you then ask “how do you know?” you find that people give anecdotes of good experience; letters or cards from patients post-care, success with exams, or a general ability to jump through hoops or manoeuvre multiple areas, and another popular answer – a lack of complaints. But in reality you have to actively seek feedback from your patients, since they are the people who really make that judgement, to see if they actually do have any complaints, and if so, why. In other areas of service, customer feedback is always seen as the steer to give you an understanding of the job being done, whether or not it is being done well, and to what level.
To me constantly requesting and responding to this patient feedback is what makes a good doctor. With every request there will be a degree of shortcoming revealed and this shortcoming will have to be acknowledged and improved upon to show the said patient that you have heard and understood their feedback. That their opinion of the service you provide really does matter to you.
How do you integrate ICF into your day-to-day practice?
We conducted a pilot at the University Hospital of South Manchester, where every time we saw a patient or performed a consultation the internal administration system would automatically identify that patient by name and address and send them a questionnaire inviting them to share comments and feedback on their experience.
For us as doctors all we really had to do was our jobs, but because of the systems in place we also got the feedback we needed, to get better at our jobs. The feedback service helped us to see that we could do a better job for patients and that we could give them the care they wanted and deserve. This automatic feedback system allows for the opportunity to take doctors who are essentially good at what they do, and make them even better!
Are there any other ICF practitioners you admire?
I can think of a few approaches to measuring ICF that I don’t admire. The GMC approach is good in that it puts measuring patient experience as a tool for improving care on the agenda. It is also good in the way that you have to seek out some evidence that you are doing a decent job as a doctor, but I am disappointed that it is not more robust.
To me the idea that you would only proactively conduct feedback research every five years, and draw from only a small sample just does not allow you the opportunity to improve or get a true reflection of the experience that patients are really having. Proactive feedback research should be ubiquitous and carried out on an appropriately sized sample – continually. That way, you will be able to extract a summary of that data and learn from it in terms of best practice, and it will still feed into annual appraisal and five yearly revalidation.
I think it is excellent that NHS England now accept that measuring quality of care is important. I do not discount the value of this, getting measurement on the agenda is the first hurdle. But next we have to get better at using that measurement – how we do it, how frequently we do it and whether we are asking the right questions? Which is why I think Picker are such a fantastic organisation, and why I think they are playing a key role in transforming the healthcare service available, through measurement. They understand that patients should be at the heart of everything a doctor does, and deliver the materials and programmes to get that understanding back at the top of the priority list.
I also think that Sir Donald Irvine has been absolutely instrumental in getting ICF the recognition it deserves. Although no longer in practice, he has campaigned and worked tirelessly to get the initiative acknowledged and improve understanding of just why it is so important.
Other than him and Professor Bruce Keogh, I am not really aware of many people who have gone to the lengths we have to embed this initiative into practice.
In your opinion what are the main flaws in the NHS in general?
Obviously we are up against very challenging cost constraints, but we are also living in transformative times and as a health service going through a significant transition phase. As a service we have gone from a system of complete non-management, where doctors can almost do exactly as they chose, to one that is now very actively and heavily managed, in terms of both individual and organisational performance. This dramatic shift inevitably creates difficulties, as we are seeing now.
I also think that as a result of this ‘active-management’ culture, some of the targets and priorities that have been put into place and interpreted as being in the patients’ interest, are actually not necessarily, and they are to a degreedistorting our view of the profession and the service we give.
The acknowledgement that being a good doctor starts with core professionalism, and the desire to provide a good service that puts the patients’ needs first – making for quality care – has actually been lost.
This lack of individual ownership, a reluctance to be the advocate of patient quality, while being the interface with patients and ensuring high quality performance, is a real problem. If you look at the Mid Staffordshire Report, it lists the failings that were uncovered as being caused by organisational problems. But there is another side to that argument, doctors did not do their part. They forgot the medical motivation that so inspired them as a teenager and therefore failed to keep the organisation honest and to deliver.
Through your eyes, what would real change look like?
early in the day as possible. Sophisticated operational management and systems would ensure that we could do that and that the care we gave was continually good.I think it is GOOD that annual appraisals are now essential. I also think it is GOOD that professional revalidation is now essential every five years’ to stay in practice. However I think it is disappointing that the current processes for appraisal are not significantly robust to allow for real, long term improvement.
Every time I receive my patient experience feedback and measurement I pick up a different area where I am perhaps not scoring as highly as I want to be. The feedback has never been awful, but each time it gives me a steer for improvement. It means that I never get complacent. As a doctor you say, “I didn’t get the grade I wanted, how can I be better – deliver better care and improve that grade?” Sometimes that is by speaking more clearly or providing more emotional support, but whatever the improvement measure needed is, it gives you a direction for how to deliver a better consultation to your next patient.
I think it is GOOD that annual appraisals are now essential. I also think it is GOOD that professional revalidation is now essential every five years’ to stay in practice. However I think it is disappointing that the current processes for appraisal are not significantly robust to allow for real, long term improvement.
For this to happen there needs to be a cultural change, not just a compulsory test every few years. This change would allow for problems in clinical performance to be identified early on and sorted out as quickly as possible.
In my opinion we have the concepts right, but real progress would come if the systems evolved to allow for continual measurement, so that all patients could be assured of high quality care, and that any shortcomings would be identified and addressed quickly.
There seems to be a culture where the people dealing with potential problems in the quality of care have to believe beyond reasonable doubt that there is a need to act before any action can be taken. In reality this belief is totally out of sync with patient reality. Patients need any shortcomings or concerns to be picked up quickly and as
The granularity of feedback drives the ongoing quality of improvement and ensures it is a continuous consideration not a one-off to appease the management. The motivation for measurement should be that you want the feedback to do a better job, not because if you don’t do it every five years you won’t get that revalidation you need to practice.
We need to change the concept of professionalism to really go and keep moving in the right direction.
To see more of Ben’s approach to Individual Clinician Feedback, in practice, click here.