Feature

posted 2 May 2006 in Volume 9 Issue 8

Swatting superbugs – and tabloid newspapers

A ‘peer assist’ is helping the NHS to overcome patient fears of so-called superbugs.

By Julie Wells, Gillian Granville and Chris Collison

The UK’s National Health Service (NHS) is one of the largest employers in the world, staffed by some 1.3 million doctors, nurses and, inevitably, administrators and managers. The NHS dominates healthcare in the UK, providing services to all citizens, free at the point of delivery, funded out of general taxation and accounting for nine-tenths of all healthcare spending in the UK.

But it is far from monolithic. While the Department of Health is responsible for overall administration, management of the delivery of healthcare to patients is devolved to semi-autonomous trusts, which are responsible for delivering those services to people within their geographic areas and, of course, within their budgets.

The minister for health, however, remains ultimately responsible for everything that goes right – and wrong – in the NHS.

Meeting such acute challenges as those posed by the so-called superbug MRSA and other healthcare-acquired infections (HCAIs) has been made all the more acute by the widespread tabloid newspaper coverage in recent years.

This case study examines just one facet of the NHS’s fight against HCAIs – the bid to put the risks into proper perspective following a decade of health scares in the UK, from the epidemic of Creutzfeldt-Jakob Disease (CJD) that was supposed to follow as a result of Bovine Spongiform Encephalopathy or ‘mad cow disease’, to the so-called flesh-eating bug Necrotising Fasciitis, which was popular in the press in the 1990s.

Beneath the simplicity of the tabloid headlines lies a deeply complex problem, one that requires an understanding of how patients, carers, clinical professionals, community health workers and the general public each contribute to the problem and can also help contribute to the solution as well. HCAIs challenge us to re-think our approaches to change.

The NHS Institute for Innovation and Improvement was created in July 2005 to help the NHS to device strategies to address such challenges on a nationwide basis. Indeed, the creation of an MRSA reduction strategy was the first of its four priority programmes established when it was set-up, to support the government’s commitment to cut by half the number of hospital acquired MRSA infections by 2008.

Comprising about 100 health professionals, the NHS Institute is a special health authority based on the campus of the University of Warwick in Coventry, England. Its purpose is to develop solutions that address key NHS problems with a focus on developing the capabilities for service transformation, technology and product innovation, leadership development and learning in the NHS.

Identifying the problem

So how could ‘learning’ be linked to the reduction in MRSA? What analogous situations existed from which lessons could be drawn? To help answer these opening questions, Julie Wells and Gillian Granville from the NHS Institute asked consultant Chris Collison to work with them and facilitate a ‘peer assist’ meeting.

Collison worked with the peer assist concept while part of oil giant BP's knowledge management (KM) team, a concept that was explored in depth in Inside Knowledge (then called Knowledge Management magazine) in June 2001. The purpose of peer assist is to enable staff to "learn before doing", says Collison.

Key to KM, of course, is to learn from the experience of others. The NHS Institute therefore brainstormed around some previous public health challenges in the UK to find out what they could learn from how they had been handled:

What about the foot and mouth outbreak in 2001?
What about the BSE (mad cow disease) outbreak of the 1980s and 1990s?
Was there anything that could be learned from the response to the 7th July terrorist attacks in London?

For the NHS team, the particular topic that they wanted to explore was the role that public perception and public confidence play in infection control:

How could they keep the general public aware of the part they play in the spread of infection, and therefore to be vigilant in the way they act, without spreading fear and fuelling further doom-laden headlines?
What was the optimal approach towards communication?

This was the basis for the peer assist held in December 2005, when representatives from the Department for the Environment, Food and Rural Affairs (DEFRA), the City of London Police, the Home Office, the Food Standards Agency and, of course, the Department of Health joined six participants from the NHS Institute to help them ‘learn before doing’.

What is involved in a peer assist?

Originally developed in BP in the 1990’s, a peer assist is simply a facilitated meeting or workshop where people at a peer level are invited from other teams to share their experience, insights and knowledge with a team that has requested some help. A peer assist is all about a team asking for help at an early stage in a project. It is for their benefit, although during the process, everyone can learn something new.

The concept of peer assist is fairly simple and is more than just an exercise in ‘sharing good practice’. Experience and knowledge is gained in a particular situation or context. Knowledge is context dependent and does not always transfer easily to a different context.

Key learning for the NHS

As the participants from the non-NHS organisations shared their stories and examples, a wide range of lessons and insights bubbled to the surface and a number of valuable lessons were learned.

We should:

Drip-feed repetitive messages, proactively tackle misinformation, ‘horizon-scan’ for future issues (City of London Police);
State the levels of uncertainty together with the scientific facts, tackle Google-ranking to ensure that messages are easily found (Food Standards Agency);
Maintain a database of current stakeholders to enable rapid, targeted communication, looking beyond national media. For example, local radio stations (DEFRA);
Address head and heart in communications – explain the impact of infection in human terms (Department of Health).

As a consequence of this peer assist meeting, the NHS Institute team made a number of recommendations to the Department of Health for improving public confidence.

These include:

Developing a web portal with various levels of information and interactive methods for signposting;
Developing local and national media strategies, which create a more direct and proactive approach to the complexity of the issues;
Working with a range of audiences to understand the roles that different groups can play in reducing HCAIs.

These recommendations resonated well with thinking in the Department of Health’s MRSA programme-communication team. In addition, the institute ‘re-framed’ the way they think about the divide between medical professionals and the public/patients. For an organisation of the size of the NHS, staff are also a significant part of the public (and they can also become patients).

The peer assist also helped participants to develop their own ‘knowledge networks’. Several of them are still in regular communication with the NHS Institute staff whom they met at the workshop and continue to exchange learning and ideas between their respective departments.

The next step for the NHS Institute is to accelerate the spread and adoption of the learning and good practices across the organisation – no easy task when there are 1.3 million staff, but success here will put the NHS on course to meet and beat the Department of Health’s MRSA targets. n

Chris Collison was part of oil company BP’s KM team and director of change and knowledge management at Centrica.

He now works as an independent consultant and can be contacted via his website, www.knowledgeableltd.com, or e-mail chris@collison.com.

Julie Wells is Priority Programme Head at the NHS Institute for Innovation and Improvement and was formerly Head of Improvement Knowledge for the NHS Modernisation Agency Julie can be contacted at Julie.wells@institute.nhs.uk

Gillian Granville is a former specialist associate at the NHS Institute for Innovation and Improvement and now an independent consultant. gillian@gilliangranville.com

Twelve steps to holding a peer assist

Step 1 – Clarify the purpose

Peer assists work well when the purpose is clear and you can communicate that purpose to participants. Define the specific problem you are trying to get help with, consider whether a peer assist is the most appropriate process, then write a terms of reference.

Facilitator’s notes: If you are the facilitator, be totally clear on the purpose of the peer assist and be sure that the person holding it genuinely wants to learn something. Ideally they are targeting the peer assist to address one of the key business risks. If the stated purpose is to gain endorsement or to get others to use "my" method, then advise them that they require some other sort of meeting.

Step 2 - Check whether someone has already solved the problem

Consider whether someone else has already solved the problem. Have a look at the corporate knowledge base – if you have one – to find out what others have already learned. Share your peer assist plans with others. They may have similar needs. For example, several oil refineries at BP held peer assists to improve efficiency. This involved some people repeating the exercise at many refineries in different parts of the world. A more efficient way might have been to hold a peer assist at a single refinery and extract the common lessons for all refineries to adopt.

Step 3 - Identify a facilitator

Identify an external facilitator. Their role is to ensure that by managing the process the meeting participants reach the desired outcome. The facilitator may or may not record the event; make sure you agree roles beforehand. Plan the details of the peer assist in conjunction with the facilitator. Clarify the purpose and the desired outcome, and then plan the time to achieve that.

Step 4 - Consider the timing and schedule a date

Schedule a date for the peer assist. Plan it early. People frequently hold them too close to the decision date to make a real impact. Ask yourself, ‘If I get a result we do not expect, will I have time to do anything about it?’ Give yourself time to apply the knowledge and be prepared for the unexpected. After all you didn’t invite people just to endorse your ideas, did you? Consider, also, the timing. Who is available on your selected dates and when are the holidays? How long does a peer assist last? This depends on the complexity of the problem and the familiarity of the team with the context. In our experience the majority of peer assists total between one and a half and two days long, though something useful can be exchanged in half a day.

Step 5 – Select a diverse group of participants

Once the purpose is clear, develop a list of potential participants who have the diversity of skills, competencies and experience needed for the peer assist. Six to eight people is ideal. Sometimes we observe that the same people turn up again and again. Avoid ‘the usual suspects’ and bring some fresh ideas into the discussion.

Facilitator’s notes: Watch for the balance between the visitors and the home team. Avoid the urge to invite the whole project team into the meeting. It’s easy to overwhelm the visitors and stifle new thinking.

Step 6 – Be clear on the desired deliverables and how to achieve them

What are the desired deliverables of the peer assist? Plan the time to achieve that. Prepare carefully; optimise the time spent together and make use of the knowledge gained. The deliverables should comprise options and insights rather than the answer. It is up to the person who asked for the assistance to decide upon the actions. Give them the benefit of your experience and allow them to decide whether to follow your advice. Provide the participants with any briefing materials early enough for them to review them prior to the actual event. Be clear in articulating both the objective of the peer assist and the business problem or challenge for which you are asking the group to provide input. Be prepared for these to be "re-framed" in the course of the challenge.

Step 7 – Plan time for socialising

Allow time in the agenda for the team to get to know one another. The team needs to socialise; this may be a dinner the night before or, at the very least, half an hour over coffee at the start of the day; something to start building rapport. Remember, this is a temporary but newly formed team. For the group to work openly together, to make and receive challenge, to have your pet project put under the microscope, it is important that you get to know each other. If you cannot manage this, plan dinner for the evening between the two days. It is amazing how much knowledge is transferred over a glass of wine and a good meal. One team started by sharing a communal Japanese bath together, but this is not absolutely essential to ensure a successful peer assist…

Step 8 - Spend some time setting the environment

Spend time setting the environment and stating expected behaviours. If it is useful, deploy the matrix diagram to explain the sharing of knowledge. Brief the host team to listen for opportunities. A defensive reaction will deter the visitors from offering their insights. Design the day ensuring plenty of opportunity to reflect. Chris Collison achieves this by asking a few simple questions. The role of the participants is to offer help, know-how and experience to resolve the challenge without adding to the workload. However, some contention will raise the level of discussion. This will not occur if the group is too polite.

Facilitator’s notes: Ensure that the contention is focused on the activity rather than the person and encourage people to consider alternative ways of completing the action.

Step 9 - Divide the time into four parts

Most peer assists last up to two days. Divide the time into four roughly equal parts. Clearly articulate the purpose of bringing the team together and make a clear request of them. During the first quarter get the resident team to present the context, the history and the plans for the future. Resist the temptation of having too many from the home team and telling too much. You want only to say enough to get the peer assist team started in the right direction. They can ask questions if they want to know more. The visitors have travelled and have given up some of their precious time to help. Ensure they are listened to. There was one peer assist in London to which an engineer from Trinidad had been invited. He had travelled overnight for ten hours to help, but despite efforts to involve him he wasn’t given the space to say what he thought of their plans.

Facilitator’s notes: Keep context presentations short and sharp. There is a noticeable tendency for any information presented to become the focus of discussion. Avoid this by finding out what the visitors want or need to know.

Step 10 - Encourage the visitors to ask what they need to know

In the second part the visitors take up the baton. Their role is to consider what they have heard and to discuss what they have learned that has surprised them and, what they haven’t heard that they expected to. The home team should take a back seat at this stage – maybe even exit the room. The peer assist team then decide on their course of action. What else do they need to know and who do they know who knows? It may be that you want to talk to others to get their viewpoints at this stage, to talk to operational people or experts, customers or government officials. Set up some interviews, or make telephone or videoconference calls. Get views from contractors, external bodies and/or local staff, if relevant. Request data and reports. What do you need to know to address the problem at hand? Remember, it’s not the job of the peer-assist team to solve it, but to offer some options and insights based on their unique experiences.

Facilitator’s notes: Feedback is an essential part of the learning process. Allow time at the end of each day for feedback. Use an after-action review, if appropriate, to help set the direction for the following day.

Step 11 - Analyse what you have heard

The third part of the meeting is for analysing and reflecting. By all means involve a couple of the home team, but make sure they do not close off options too quickly or drive towards their preferred outcome. They should be there to listen and learn. At this stage you are examining options. Towards the end of this phase create a presentation to give to the wider home team. What have you learned, what options do you see and what has worked elsewhere? Tell the story of how it has worked elsewhere rather than telling them what they ought to do.

Step 12 - Present feedback, consider what each has learned and who else might benefit. Agree actions and report progress.

The last step for the visitors is to present their feedback and to answer questions. Avoid getting into debate at this stage. As in all feedback start with what has been done well and then what options there are to do things differently. Focus on the activity rather than the people. Finish with a general positive statement. On the receiving end, don’t expect a silver bullet, a single solution to all of your challenges. Frequently the home team feel nothing new has come up. Remember the visitors are reflecting what they have been told, coupled with what they know in their context. Often they confirm what you are doing is right, but may set priorities somewhat differently. The peer assist may increase your confidence to do something that is a difficult decision to take. The person who set up the peer assist should acknowledge the help and the time people have given up. They should also commit to when they will get back with an action list of what the team are going to do differently. They may decide to invite the peer assist team back for future help. The benefit of this would be that they would not need to learn the context again and the peers can gain satisfaction from remaining connected with the project.

Next have the visitors reflect for five minutes then say what they have learned that they will take away and apply. Learning is never one-way, although the peer assist may start out along those lines. Offer what you learn to others and provide a contact name for follow-up discussions.

At the end, have each participant consider what they have learned and will apply from the Peer Assist.

Consider who else might benefit from the lessons learned and the best way of doing that. Share the lessons learned with these individuals. Provide contact names for follow up discussions and progress reports. Re-using knowledge is a smart way to avoid duplicate effort. Finally carry out an After Action review. Did the Peer Assist go according to plan? What was different and why was there a difference? And what can you learn from that?