Appreciative inquiry in practice: working with local teams to improve palliative care

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Appreciative inquiry in practice working with
local teams to improve palliative care

• Charles Campion-Smith.
• GP Primary Care Educator, Institute of Health
  and Community Studies, Bournemouth University

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Some ideas

• Adult Learners
• Working in a complex world uncertainty
• Appreciative Inquiry
• Significant Event Analysis
• Continuous Quality Improvement

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Group activity 1

• In pairs or threes think about the
  characteristics of the learners you work with in
  practices - for about 3-4 minutes

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Adult learners

• Are not beginners but are in a continuing process
  of growth
• Bring a wealth of experiences and values
• Come to education with intentions
• Already have set patterns of learning
• Need to know why they need to learn something
• Need to learn experientially
• Approach learning as problem-solving
• Learn best when the topic is of immediate value.
• Have competing interests the realities of their
  lives
• (Knowles Brookfield)

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Exploring problems together

• Improvement is part of life When a group of
  optimistic and motivated people ask the same
  questions they become part of a dynamic curious
  team, exploring ways of working together and
  bringing them home to test them out. There is a
  special synergy in the collective energy of
  people working together to explore a question.
• Berwick D, 2002

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Complexity and CPD

• Primary care is world of uncertainty
• Feelings, values and beliefs matter greatly
• Critical judgement is important
• We deal with individuals not populations
• We can be informed by evidence but not dictated
  to by it
• Shared decision making is vital Evidence based
  patient choice

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Learning complexity

• Learning takes place in the zone of complexity
  where relationships between items of knowledge
  are not predictable or linear, but neither are
  they chaotic
• Learning builds a capability to enable people to
  work effectively in unfamiliar contexts, but this
  cannot be taught or gained passively

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Capability is more than competence

• Competence what individuals know or are able to
  do in terms of knowledge, skills, attitude
• Capability extent to which individuals can
  adapt to change, generate new knowledge and
  continue to improve their performance
• Fraser Greenhalgh BMJ 2001

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Appreciative Inquiry 1

• the search for the best in people, their
  organisations and the world around them.
• looking at a system when it is functioning at its
  best, most effective and capable in human,
  ecological and economic terms
• better to seek out what goes well and do more of
  it, than seeking what does not work and doing it
  less.

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Appreciative Inquiry 2

• human systems move in the direction of what we
  most persistently ask questions about
  Cooperider
• A shift of focus from deficiencies to resources,
  from failures to successes and from shortcomings
  to competence and capacity.

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Group task 2

• In twos or threes each describe a learning
  experience in which you have been involved as a
  teacher or learner, in medicine or elsewhere,
  that has gone really well.
• What happened, how did it feel?
• Can you think of good metaphor for the teacher/
  leader / facilitators role

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Improving community palliative care in Dorset UK

• 30 GP Practices
• 300,000 Patients
• 6 community hospitals

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The Challenge

• there is a strong impression that many people
  die badly. People do not die in the place they
  wish or in the peace they desire.. Too many die
  alone, in pain, terrified, mentally unaware,
  without dignity
• BMJ 26 July 2003

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The process

• Welcome
• Group agreement to allow all to contribute
• Shared understanding about what we mean by
  palliative care
• Shared vision of what team aspires to
• Review of current situation recent cases
• Tension for change
• Do-able next steps

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Brainstorm 1 Clarification

• What do we mean by palliative care?
• Who are we talking about?

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Palliative care

• is active care offered to a patient with a
  progressive illness, and their family when it is
  recognised that the illness is no longer curable,
  in order to concentrate on the quality of life
  and the alleviation of symptoms within the
  framework of a coordinated service. Palliative
  care neither hastens nor postpones death it
  provides relief from pain and other distressing
  symptoms, integrates the psychological and
  spiritual aspects of care. In addition it offers
  a support system to help relations and friends
  cope during the patients illness and in
  bereavement, and furthermore supports the
  professional staff involve in the care of
  patients.
•   WHO 1989

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Brainstorm 2 Creating a vision (Appreciative
Inquiry)

• If your team were to be really successful what
  would be the characteristics of the care you
  give?
• How would it feel for patients, carers and
  professionals?

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Recurring themes

• Excellent teamworking and communication
• Good clinical care and symptom control
• Respect for the individual and their personal
  dignity
• Care for the family and relatives
• Care for each other as team members
• Choice and control

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A Good Death 1

• to know when death is coming, and to understand
  what can be expected
• to be able to retain control of what happens
• to be afforded dignity and privacy
• to have control over pain relief and other
  symptom control
• to have choice and control over where death
  occurs (at home or elsewhere)
• to have access to information and expertise of
  whatever kind is necessary
• to have access to any spiritual or emotional
  support required

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A Good Death 2

• to have access to hospice care in any location,
  not only in hospital
• to have control over who present and who shares
  the end
• to be able to issue advance directives which
  ensure wishes are respected
• to have time to say goodbye, and control over
  other aspects of timing
• to be able to leave when it is time to go, and
  not have live prolonged pointlessly.
• Debate of the age health and care study group.
  The future of health and care of older people
  the best is yet to come London, Age Concern 1999

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Brainstorm 3 The current situation

• Discussion of recent cases known to the team.
• Celebration of the successes
• Description of where the care fell short of the
  standards the team would wish
• Discussion of the barriers to best possible care

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Significant Event Review

• No blame its about learning and improvement
• Looks at the bits that went well
• Look at what got in the way of the team doing as
  well as they wanted
• Generate ideas for change
• Plan to try one or two out PDSA cycles

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Creative Tension

• Describe the ideal of care the team aspires to.
• Look at current reality based on recent cases
• MIND THE GAP compare the two and look at the
  differences. Understand what is getting in the
  way
• Generate ideas for change

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Continuous Quality Improvement

• Takes a patient / user focus
• Views care as the product of a complex system
  comprising a number of inter-related processes
• Has clear aims
• Uses balanced sets of outcome measures
• Encourages serial experimentation and measurement

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The model for providing care that underpins our
work
Functional Health Status
Access System
Assess
Diagnose
Treat
Satis-faction against need
Clinical Out-comes
Follow-up
Total Costs
Patient with need
(Nelson G., Batalden P. et al, 1996)
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Model for Improvement
What are we trying to accomplish?
AIM
CURRENT KNOWLEDGE
How will we know that a change is an improvement?
ACT PLAN
CYCLE for Learning and Improvement
What changes can we make that will result in
improvement?
STUDY DO
(Langley G.J., Nolan K.M. et al, 1996)
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Final Thoughts 1

• No individual knows the whole picture but
  together teams have great breadth of knowledge
  about their patients / users of the service and
  about the system of care
• Taking a users view of the service can be
  illuminating
• Team members often undervalue their worth and
  contribution
• The process needs to support the contribution of
  all

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Final thoughts 2

• Teams will readily see how the service can be
  improved
• People like to improve the service users receive
• Learning together to improve something they care
  about is fun
• The teacher is not the expert the role is to
  harness and direct the knowledge and enthusiasm
  of the team gardener not engineer!

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A philosophy

• Improvement is. I believe, an inborn human
  endeavour.And so, it is my premise that almost
  all human organisations contain in their
  workforce an internal demand to improve their
  work. It saddens me how few organisations seem to
  know this and fewer still act on it. Improvement
  is not forcing something it is releasing
  something.
• Berwick D, BMJ 8 May 2004.

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