Sunday, 5 April 2009

What matters?

I've been to a number of meetings and conferences committees that have left me thoughtfully confused. As I've said before, I invest time in this malarky because if someone doesn't we'll get sold down the river, so it's best to at least chip in to have a voice in the process.

I think the GMC expect us to, aren't they about protecting patients? Ah no, their tag line now summaries that they too now are focussed on, "Regulating doctors, ensuring good medical practce." Well, they used to care about protecting patients. I'm sure as a doctor we're still obliged to protect patients from malign care. Thus, if managers are having a brainstorming session and generate what I would charitably call "idiosyncratic ideas" that will affect clinical practice unhelpfully, I like to be able to interject a bit of common sense and pragmatism in to the deliberations.

Mostly this works, which is why I keep doing it. I'm over stating it a bit, since in my corner the managers are actually pretty sensible and clever and helpful folk. The problems mostly involve evidencing something or doing something that we all know is nonsense but, for mind numbingly frustratingly incomprehensible and labyrinthine reasons just, "has to be done." So we get around a table and mull over how we do something we mostly agree doesn't truly need doing, and think of how it can have the least hassle for staff and least nuisance for patients.

Meetings with the SHA and PCT and partner organisations have been more . . . curious.

There's an enthusiasm to measure things. Evidence things. Prove things. Monitor things. Manage things.

This has lead to me knowing far too much about "things" which no sane man should know. Things like "quality metrics" which I won't sully your pure and beautiful minds with; enjoy the innocence, unfettered with such nonsense.

The notion proposed in my corner is that "quality" and "outcomes" are measured. Along with the work done (the content of a service line, i.e. the staff and resources). And the activity undertaken. And, for this work, the cost to our Trust for this. Anyone flirting with management will recognise this unholity trinity of Service Line Reporting (SLR) there, which is then fused with quality and outcomes and Payment By Results (PbR) and Quality Outcomes into some hideously ghastly abomination.

Zarathustra will love this. H P Lovecraft couldn't craft a finer tale of complexity, understated malevolence, despair and of something slumbering, quiescent, about to errupt causing "much badness." Reality is indeed more curious than fiction.

For now, within our corner, we're having to report to the SHA on quality. And report on Service Line Reporting to entertain Monitor.

So, over to you. What do you think will be looked at, when considering quality? For a patient, going through our service, what things matter? What is quality, what things should be recorded and reported and publically shared, to reflect whether we're doing well or not? I've my views, which I'll whitter on about another time, but for now, have a blank bit of paper. Add what so ever you will. If you're interested in a quality mental health care from our Trust, what would you be wanting to know about? What's on your list? What matters?


Milk and Two Sugars said...

In my experience, patients in psychiatric care are most concerned with being treated with respect. Treated well, obviously, but mostly treated with compassion and consultation. I doubt any HR representative will be able to craft a survey that adequately measures those very subjective preferences. But they should try.

Anonymous said...

As a patient I am in agreement with Milk and Two sugars. Some respect would be nice.

Some compassion would be even nicer. I've felt times when I have gone to an appointment, which inevitably means going over lots of unpleasant details, only to find the person was only interested in ticking the boxes on their form to get me off their list asap. It's a pretty cold experience, and not one which helps someone in a crisis. In that sort of situation a little reassurance works wonders. It's scary being mentally ill, this fact seems to have escaped a few professionals who I've come across.

Consistancy too. Not an endless stream of referrals, a single point of contact, a system which is simple to navigate. Simple to people who are already struggling, not just those working in it.

I could go on.

Lola x

Cat said...

I'm possibly too entrenched in 'the system' to think much outside the box - perhaps it's been trained out of it. I obviously agree with the above comments - Care, Compassion, Competence is a mantra than could be extended were care is widely determined. And the other 'c' which probably has a lot of relevance in my own role is carer involvement. Of course not all users want that and it needs to be respected, but carer support and information and feedback is an area that at present in our service, remains for the most part unmeasured and I think a poorer service and poorer outcomes are the result.

Anonymous said...

I don't have an answer. Just a comment.

I've mulled this question myself recently - and repeatedly. How do you objectively measure efficacy or outcomes? Esp. in community MH care?
What is a good measure?
What are the tangible measures?

I can't help but feel I'm cheating a little if I reference the recent KCL document on "state of the art metrics in nursing" - but they've gone a few steps further than identifiying pt outcomes alone. And as much as I hate 'new ways' I think it's more bringing together old knowledge in a new structure, format and purpose.

They propose that measurement of a good service is not just about direct patient care outcomes - but also about the framework around patient care - measuring complaints is a favourite of course; but also job vacancies, staff development plans, sickness levels, and so forth.
A bit ripped off/duplicated from "magnet hospitals" methinks but doesn't make it bad.

Differently Sane said...

The compassion and respect sound nice...

But I'd also like some understanding that my goals aren't necessarily the same as the MHP's goals. They always want to rush to the bottom line - gain weight, stop cutting, yep specific, measurable and look nice on the audit report. But when all I want is to stop feeling cr@ppy about myself, then it feels like I'm being pushed through, propelled to discharge from the service, so that my feelings will become 'somebody else's problem.'

Those things are measurable because they are external, a reflection of what's going on, not the original problem, so they're taken away, but the problems remain.

I'd like to believe that me as a person is more important than efficacy data - just doesn't seem to fit in with all the obligatory measuring things...

Sometimes the whole concept of measuring outcome data annoys me, because they seem to be measuring the wrong things, I guess because you can't really measure the important stuff like respect, empathy and not looking like a kicked puppy when I talk about my past. I worry that those things will get overlooked in the drive for efficiency.

And how do you measure something as subjective as quality anyway...?


Anonymous said...


"And how do you measure something as subjective as quality anyway...?"

I'm edging towards an external patient feedback service, which results in a McDonald's style star system. If you see a Doctor edging towards you with just one itty bitty plastic star on their name tag, run.

sw2be said...

As has all ready been said, care, compassion, respect are automatic expectations. Also, in a MH service, being listened to rates pretty highly on my wishlist!
I also think a mark of a quality service is one in which you see the same shrink more than once (or twice, if you're lucky), before they have either left or the service has been reorganised (yet again) by management who think it will offer patients more continuity of care (I've never yet worked that logic out).
Oh and also one where my shrink realises that I am a human being, of equal worth as him/her, and the right to disagree with his choice of drugs for me if the side effects are not bearable/ conducive to me having a normal life. In other words, a service in which 'partnership working' also includes the patients as partners in their own care, where possible.

There and Back said...

I'm with Lola Snow... consistency.

That's not my name! said...

I think, and I can understand why it isn't more so the case, that patients should be the ones evaluating the services they get.

The reason why patient feedback is only a very small part of the quality review and improvement process is because, historically, patients have not been respected enough to be given such responsibility as evaluating their care.

Granted there are now patient surveys (with forms being sent out to a selection (be that randomised or not) of people who use the services but it is small fry.

It is having an impact on The Healthcare Commission's way of reporting and giving gold stars (or withholding them) but my view is that much more patient feedback should be taken on board.

I agree with Lola that some independant patient monitoring should be going on but don't know who would be given the funding for that (am wary of 'usual suspects' currying favour). Independant should mean exactly that but, again historically, that has not been the case. Hmmm