END OF LI FE CAR E
deeply committed to improving care of the dying and confident having discussions with patients. Others are deeply committed to enabling diagnosis and offering treatment. A minority are worried that by discussing dying that confidence in the hospital will be undermined. Hospital managers and executives will also hold a diverse range of views. A range of reactions were prompted by the quality improvement project. The issues and the systems involved in caring for the dying are complex. There is a complex interdependent need for knowledge, skills, equipment, medications, data, strategy and continuous review. This skillset is larger than any one person can possess. Furthermore, care of the dying is one aspect of a large and complex hospital. Then there is the knotty problem that ill people surprise staff, recovering unexpectedly or deteriorating rapidly, exposing the fact that prognostication is an inaccurate skill.
The purpose of the quality improvement project was clear, to improve care of the dying in the hospital, but where and how to start in a large and complex system was less clear. Senior executive and non-executive leadership and support would not be sufficient in itself to deliver change in the departments or at patient level.
The human in HLS
When working with complexity Lowe and Plimmer describe ‘being human’ as meaning that the variety of human need, experience and strengths is recognised, empathy is built between people and trust is deliberately fostered. Sobell Foundation funded the project in our hospital. There is a long and trusting relationship between the hospice (department of palliative care which is part of the hospital) and the Foundation. The project was liberated by that trust, reporting requirements were loose and the only requirement was to improve care of the dying. The purpose of the funders and that of the project was identical.
The hospital executives trust the care that is delivered by the palliative care department and by extension trusted the project leads who work in the hospice. At the start of the
Figure 1
project narrative feedback was requested building to more quantitative feedback as the project progressed. The executive team supported the project leads providing bespoke support, for example helping write the end of life care strategy for the hospital and coaching to help address points of conflict. The goals of the hospital and the project team were aligned.
The staff knew why it was difficult to provide good care at the end of life, where the blocks were and often knew how to set about improving care. The project team launched the project by inviting staff to identify difficulties and suggest improvements. The project team gathered concerns and addressed the urgent quick wins, helped staff develop and implement their solutions and supported the staff. That support took the form of teaching new skills such as speaking in public, developing critical thinking including the need to ask questions, mentoring staff helping them gain confidence and many varied other approaches. The
project team gave staff permission to change the way they practised and trusted them to improve the care of the dying in their area of the hospital. Minimal reporting was required.
The learning in HLS Lowe and Plimmer’s research found that humans working successfully in complex systems do not deliver a standardised single type of approach but rather adapt to the particular context in which they find themselves. An individualised approach is of critical importance in healthcare and essential at the end of life when dying is a unique family event informed by the experience and values of the dying person set in the context of their relationships. A family sitting with their dying relative were upset that a tray of food was brought to the room as their relative was unconscious and therefore unable to eat. One member of the staff took note and co-designed possible solutions with the family. With the help of the project team a notice system on the door was developed that would signal to the myriad staff working on a ward that the person was dying – indicating that all should stop and think before entering the room, ask before cleaning the room and ask before offering food. In rolling out the solution in the hospital it became clear that some people disliked the idea of being labelled and the risk of isolation. Now staff offer this solution to people and some will adopt it. That cycle of learning, reflection and redesign is described in Figure 1.
An annual symposium offered an
opportunity for staff to showcase their work, disseminate ideas and inspire others. At any one time there were more than 50 ‘project
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