Hello everybody and welcome to another episode of Vet Chat. Today I'm very excited to be joined by Pam Mosdale, who's gonna be talking to us about quality improvements in practise. Pam is quality improvement clinical lead at the RCVS Knowledge and chair of the RCVS Knowledge Quality Improvement Advisory Board.
Pam was formerly lead assessor for the RCVS practise Standards scheme, and she has also worked in first opinion practise for most of her career. Pam has been heavily involved in establishing quality improvement resources for the veterinary practise team, and she is passionate about quality improvements becoming part of the normal working day for veterinary teams and contributing to a just learning culture in practise. So welcome Pam, thanks so much for joining me today.
Thanks Catherine, lovely, thank you for giving me the chance to talk to you today. So quality improvement, what is it all about in practise? Right.
Well, I think most people know that it's in the code of conduct for vets and veterinary nurses that we have to Take part in clinical governance, and clinical governance I think is something we've always done. It's just about thinking about what we do and seeing if we can do it any better, really. And we've always done it and I've been qualified a long time, we've always done it in an informal way, maybe around coffee breaks and things, but, clinical governance asks you to have a framework to do it regularly and act on the what you've talked about.
So that's the kind of framework, but quality improvement is giving you the tools to do it. It actually is about giving you the systems and tools to actually make these improvements. So there is a definition which I like, which is one from Batton and David in human healthcare, which is quality improvement, is the combined and unceasing efforts of everyone to make changes that lead to better outcomes and better care for our patients and better team development and Learning.
And to me, that's what we all go to work for, to have better outcomes, to have, be giving really good care, and, and for our team to learn as we go along. So, I think quality improvement just, encompasses all those things and, and gives you some tools to help to do them. Yeah.
Brilliant, absolutely. How did you get involved with it and, you know, to start with? Have you've been involved with it for a long time, I believe?
Yes, it was, it is a long time, yes. When I was involved in BVHA veterinary hospitals, a long time ago, we were trying to think of How could we actually, look at outcomes from practise from practises rather than look at just buildings and, and bits of kit, which is what practise standards schemes, quality assurance schemes tend to do. So we started looking at clinical audit, which, of course, they do a lot in, in the NHS.
So that's why when I got interested in clinical audit. And then later when I was involved in the practise Standards scheme as the assessor, we brought some of the clinical governance stuff into the practise Standards scheme, and I wanted to have, produced some really practical resources so that practises could pick them up free today and do it tomorrow. And that's, that's what the resources are aimed at, that you can actually start to do it straight away.
You know, that's the important thing, I think, in, in small bite size pieces, but, but start straight away. Brilliant, that sounds good. So what sort of things can practises do to achieve quality improvement?
Do you have any examples for people listening? Yes, there's loads of things I can talk. Talk about that all day, but, basically, I think a good place to start, well, a really good place to start is having practise meetings and communicating really well with your team and making sure those practise meetings discuss clinical cases, and you follow them up.
And, you know, if you say you're going to make a change, you follow up the change and see whether it's had the desired effect. But also things like clinical audit, as I say, that was involved in earlier on, clinical audit is, just about measuring what you do and seeing if you can do it any better. And people tend to think that clinical audit is great massive projects and get it a bit mixed up with research.
But actually, it's just can be very small projects, it can be. You can measure outcomes, so it can be the outcomes of, of surgery. So, you know, if practises are measuring the outcomes of neutering of, for dogs and cats and rabbits, not only can they measure it for themselves, but if they use the same form of scoring the, the, the, the wounds after the, after the operation, they can actually benchmark them.
And we have a national benchmarking, so you can say, oh yeah, our practise is, is great, we've, our results for the . For surgical complications are really, really low, but our medical complications are a little bit high here and maybe it's antibiotics we use, so let's look at our infection control. Those are outcome audits which you can do for any kind of surgical procedure, but there's also process audits which are about how you follow guidelines, and having guidelines is an important thing in in quality improvement.
But how you follow guidelines or even protocols. So you might might, for instance, have a protocol for how animals are admitted for their procedures. And you might, be able to do a quick little audit of the consent forms.
So you could say, what we'd like on the consent forms is that they are signed and that they, have, a contact phone number and have an estimate that there could be a three criteria. And then you could go back for a month, look at them all, and then go to your team meeting with, well, we've done really great here. You You know, they're all signed, 100%.
And 95% have got a contact email, or, or phone number. But only 75% or have got an estimate. So then the thing to do then is talk to the team.
Talk to the people who actually do it. No good, the practise manager or the clinical director or anybody saying, we think this is what's wrong. You talk to the team, and they'll explain.
That's you've got a new practise management system, and they don't know how to generate an estimate, or the receptionist who usually check it last thing, but at last thing, there's no vets around to ask if there's no estimate on there. So then, once you know what the barriers and problems are, then the team can think about, well, what could we do to make knows better and make the changes, and then measure again and, and see whether the changes have made a difference. See if now it's 90%, not 75%.
So those are such short little audits, and I think they're great because you can get the results so quickly, and then it motivates your team if you get your results quickly. I mean, the other kind of things are used in checklists. I mean, we all have, well, I certainly, at my age, have problems in my memory.
But, yeah, checklists are definitely are a really good thing when you've got something safety critical. There's certain steps you have to do to have a checklist to remind you. Things like discussing things that don't go so well, things that go wrong or near misses in a significant event audit where if you look at one.
One occurrence from beginning to end, but not in a way to blame people, in a way to improve systems. A lot of this is about systems. OK, brilliant.
No, that's great. I'm the same. I love a good checklist as well whenever I'm doing anything.
And so you touched upon the barriers, there. Are there any other barriers, to QI within practise? Well, when, at our best knowledge, we, instead of just guessing, or saying that you talk to the people on the ground and find out.
So instead of just guessing, we actually did a survey. And the results we got back were the three main barriers were, time. And I think that's a really big barrier at the moment, because practises are so overstretched with, you know, after COVID and with all the new pets and everything.
Not knowing where to start, is another big barrier, and hopefully, at our CS knowledge, we are addressing that, because as I said, we've got over 75 hours now of, of, of CPD and resources. We've got downloadable templates that you can start doing your audit and all that kind of thing, as I say, all free. All we'd like is people to just acknowledge where it was from, that's all.
. So, yeah, time and, and, I'm not going to start, and the other barrier I think is organisational support, really, because I think it's got to come from two directions. It's got to come from above as well. The, the, the practise or the group I've got to realise that this is important to Give people time and give people a bit of backup to do it.
But also, the team on the ground have got to do it. It's no good just being imposed from above. It's got to come from the team on the ground.
They've got to know what the important things are to them, but they've got to get some organisational support. So, those were the three main barriers we found. OK, brilliant.
So that's all on the our CVS knowledge website, is it? It's OK. So we can give you some links to those afterwards if anybody wants them.
Yeah, absolutely, that'd be brilliant. We can, we can put them on the blog. That's great.
So we did a couple of Instagram Q&As with our community and we've had some questions that have come in, so I'll just share them with you now Pam, if that's OK. So we've got one question. I'm a practise manager, what advice would you give me to get started with this?
I think, talk to your team. That's the most important thing of all this is talk to your team and listen to your team, listening to them is a really important bit and try and find out what, if you improved it would make the day, their day so much better, easier, you know, . You know, save time in the end or whatever.
So yeah, I, I think you need to involve the team from the beginning. This is not something you do in the background and they don't know, because then they'll get a bit paranoid that somebody's checking on them if they think somebody's measuring things and not telling them, so. Be really open with the team from the start, have that chat if you can about what's the thing that's bothering us in the practise and what could we improve that would really help.
And start with something small, like I said before, something bite size and small, and do that, and then you'll learn from doing that. You, you, you, you know, it doesn't matter how much somebody like me tells you these are the things that might happen or might go wrong. When you actually do it yourself, you'll, you'll find out and learn from it.
And the other thing is involve the whole team. That, that would be my other thing, and I mean the whole team. Not, not just the vets and nurses.
Everybody else, the student nurses, any animal nursing assistants, and the reception team, because they're really important. For instance, if you were talking about, the significant event of a rabbit dying under an anaesthetic, if just the vets and nurses talk about it, yes, they can talk about all the clinical stuff that's gone on, and that's really important. But if they don't include a reception team, they won't know that that rabbit was sat with the owner of that rabbit was sat waiting for 20 minutes right next to a barking dog in the waiting room.
So the rabbit was so stressed and had so much adrenaline when it came in. So I don't think you get a holistic picture of any of these things unless you have the whole team. OK, brilliant, no, that's really good advice, really good advice, thank you.
And we've got another question. So what steps should be taken by my team if we want to generate a quality improvement plan? Well, have a look at the resources, I said, ask your team what's important to them and then think what's what you can actually do, you know, what's sensible for you to do, because what's right for one practise might not be right for another.
So if, for instance, you're going to have, introduced some guidelines, then don't, you don't have to reinvent the wheel. You can look at some consensus guidelines that are already there from people like, you know, International cat care and things, and then make them specific to your practise. But see what your priorities are, and, and, but, and also, I think QI champions within the practise is a good idea if you've got people who are keen, so you could have a, an overall QI champion, or you could have people championing different bits, like somebody.
You know, is the one who's going to be, not the only person who's going to be running the audit, but who's going to be encouraging everybody to do the audit, and another person might be the one who's going to take it on themselves that they're going to try and introduce a surgical safety checklist in into the theatre for people to use. So, build on your team's strengths, I think, but, but choose from those QI tools, have a look at which ones. Apply to you and which ones you want to use first.
Don't try and do it all in one go, but, but I think the regular meetings, whatever you do, the regular team meetings where QI is always an item on the agenda are really important. OK, brilliant. That's a really nice idea to involve the whole team and.
OK, so then we have another question. Do you think blame culture inhibits QI? That's a really good question.
And it's $64,000 question really, is it? Well, I think it, there's two things really. I think if you do.
Get perhaps get involved in significant event audits, and if they can make it really clear to their team right from the start, that this is not, we're not doing this to blame people. We're doing this to improve systems. And you have to have that.
You have to have that safety, if you like, . For people to be able to speak up. So, you have to have a, some sort of safer culture, but then I think it improves your culture by actually doing it.
So I think it's hard to start that sometimes. And, and a good way to start it can be to use a near miss, because we have lots of near miss in practise. They're usually, it might, to do with dispensary.
They're usually to do with, medicine that nearly went to the wrong client, but the eagle-eyed receptionist spots it at the very last second. . And those kind of things, if you keep a little book in in the dispensary or somewhere, a kind of, you know, near miss book or whoops, that nearly happened book, and pop all these things in, and then discuss those because then you haven't got the sort of stigma of something having gone wrong.
So it's easier to discuss in that way. Also, if a, a senior leader in the team has made mistakes, be it the head nurse or the clinical director, if they want, we'll have their mistake discussed for, you know, again, that's a way of letting the team know that it's safe to do this. Mhm.
But it is really important that those ground, and it's important that during the meeting there is somebody there who keeps an eye on things and makes sure it doesn't slide into any kind of blame. Yeah, it's all around communication again, isn't it? It sounds like.
Everything is, isn't it? Yeah. And it's irrelevant to all practises, no matter how big or small.
Absolutely. I think it absolutely is. I mean, you know, in a, in a one person practise, well, it's maybe some of it seems a bit bureaucratic.
It, but it's still the same thing. You may not have, may not, document it as much if there's just one vet, one nurse, one receptionist, but you still need to do it. In a bigger practise, that obviously, it's important things the document has shared with everybody, because it's hard to involve the whole team.
But yeah, I think all practises, whatever size, whatever species, whether they're small animal practises or referral practises, or farm more equine practises, the principles apply exactly the same. And, as I say, whole team, that's the other thing. OK, wonderful.
And final question for our community is what advantages will practises see after implementing QI? Well, I hope that what practises we'll see is better communication, this listening to team members, which I think is so important and speaking to the people that actually do things and not making assumptions. Having the no blame meetings, being open to making changes, admitting that what we do, while we're doing our very best might not be, you know, there might be room for improvement.
So let's see. Because sometimes when you do audits, you find you're doing great. So even better, you can celebrate.
But yeah, I think being prepared to make changes and then either adopting those changes if they're good, or adapting them if they're good, but they have Bit of a knock-on effect. I may say, maybe like the thing I said about the receptionist, maybe, with the consent, maybe the receptionist was supposed to be doing something else at that time. So, the other job then suffers.
So, you know, you have to adapt them if they're going to have that effect. And if they had no effect, abandon them, you've tried. It doesn't work.
But if, I think perhaps it'll do that, that'll communicate, listen, make changes, and talk about errors in a no blame. Way. I think it, it all contributes to better practise culture.
And we all say these things, don't we? Practise culture. We need to change practise culture.
But it's too big, isn't it? It's massive. How on earth do you go in, go in and go, Oh, tomorrow we'll change practise culture.
It's just a, a massive thing. But I think by doing all these QI things, it kind of nibbles away at the edge of it and starts to gradually improve it. That's my hope anyway.
OK, brilliant, that's great. And have you, have you sort of noticed a change in perception of QI over recent years? It feels like a lot more people are talking about it now, is it something you've, you've noticed as well?
Yes, definitely. I think it's something that you know, I've probably gone on about in the past and and it's kind of not not just me, lot of other people as well, we, we've talked about it and maybe it hasn't been perceived as being that relevant, you know, cos practises so I spent a lot of money on clinical CPD. And they spent a lot of money on lovely shiny bits of kit.
But if you look, you know, for instance, at checklists, surgical safety checklists, you know, in the, in the, trial for that, those, the human ones, they reduce deaths by 48%. And that's a piece of paper and a way of communicating. You know, so I think people are suddenly realising that it's not just all about clinical things.
It's about those other non-technical skills that we have of communication and. And thinking about the situation and what what we can do and so on. So yes, I'm, I'm pleased to say that I do think it's, it's becoming a little bit more mainstream, which is great.
And, and you talking to me today is really helpful for that as well, so thank you. Oh, no problem at all. It's great to find out more, and I think we are, would you believe, out of time already nearly.
But is there anything else, Pam, that you'd like to, tell our listeners about if we covered everything, or is there anything final that you'd like to leave them with? I think we've covered most of it quite quickly. So, but I think what I'd just say is, if you're not doing it in your practise, just have a go.
Go and have a look, get the resources, have a look, and then just have a go, and, you know, you'll be surprised at, once you get into it, veterinary nurses, especially, if they get into doing audit, get really, really motivated by it. So, yeah, just, just, just try it and see. It's, it doesn't have to be these great big projects.
It can be quite small things as long as it's relevant to your particular practise. OK, lovely, that's great. Oh well, thanks so much Pam and yes we will put all the information on the webinar vet blog as well, so if anybody listening does want to find out more, then they'll be able to go to the webinar vet blog and find the resources there.
Thanks so much Catherine, that's been lovely. Thank you. Oh no, great to chat.
Thanks Pam. Take care, bye, bye.
