Whats the difference between change and improvement in general practice?

#GPFUQ 17 Why does so much change in NHS cause worse care? It creates a constant struggle against difficulties which would not exist without the change.

#GPFUQ 18 Whats the difference between change and improvement in general practice? Quality. If you want to improve, not just makes changes you must ask and answer the basic quality questions before you plan any change.

This is  ‘continuous quality improvement’. The five basic questions you need to ask (and answer) when you try to improve something are: 

1.            What are you trying to achieve?

2.            What do you currently know about the subject?

3.            How will you know if you have been successful? i.e What are the success criteria?

4.            What can you actually do (with the resources you've got) ?

5.            How and when will you continue this cycle of action, question and feedback?

#GPFUQ 19 What do you need in a good health service? Easy access, low cost and high quality

#GPFUQ 20  What should GPs trying to achieve?  Make your organisation provide higher quality at lower cost and make the practice systems better and easier to use. 

#GPFUQ 21 Who achieves high quality GP? The best practices usually have a mix of one or more of three cultures.  

1. The enthusiasts are the early adopters of new ways to practice. They are technophiles. There is usually a GP who looks for high quality care and efficiency. These enthusiasts find new ways to practice and often speak in terms of the time it takes to get something done. They are innovators and can change practice quickly and easily and stimulate practice wide improvement as change champions. 

2. The motivators put extra effort into motivating and enabling staff to play important roles in improvement efforts. Strategies include a GP promoting importance of new activities in conversations and behaviour, meetings to check feedback, progress and make plans, work with practice staff to select indicators for improvement and designed activities to achieve improvement, and quarterly half day meetings when the practice was closed dedicated to making improvements. These practices have more mixed feelings about software than the technophiles. 

3. Lastly there are the businessmen – practices take a business approach shaped by customer services and risk management. They organize special service in the form of focused management clinics, hiring staff as needed. Problem-focused clinics (e.g. diabetes, hypertension) are designed to provide comprehensive, competitive, guideline-adherent care convenient for the patient and ensure that the doctor has done everything possible to manage care. Lead doctors delegate care management responsibilities to staff and provide regular supervision, such as weekly care coordination meetings between nurses and doctors. They redesign delivery systems to support the special services. They conduct point of care tests and use in house lab so that test are available for the patient when they attend. 

A mix of all three works best.

#GPFUQ 22  Why do we need bad GPs? Look around if you can’t see any bad GPs maybe its you.

See also https://www.bmj.com/content/370/bmj.m3415/rr-2

#GPFUQ 23 How to make quality GP?  Improve all the time, define the problems, challenge others, share knowledge, respect others opinions.

These are the Toyota principles for creating  a high quality organisation? The culture needed promotes the organisation to:

Improve all the time; improvement is a continuous process, it's never complete. 
Define the problem rather than produce solutions; go to the source or find the facts. 
Challenge others; problems create the need to improve. 
Share knowledge; teamwork makes improvement more efficient and effective 
Respect other opinions; if two people always agree, one of them is superfluous.

#GPFUQ 24 Whats the reality of quality improvement? Constant effort with occasional success and frequent failure. 

Andrew Perrin summed up the reality of quality improvement when he was quoted in the New York Times talking about how his University planned to reverse grade inflation and make grades more meaningful.  ‘Its going to be modest and nowhere near enough to correct the problems, but its our judgment that it’s the best we can do now’.