What’s super about quality conversations?

This month’s blog is by Brian Liszewski, a radiation therapist at Sunnybrook Health Sciences Centre’s Odette Cancer Centre. He is the Quality Assurance Coordinator for the Radiation Therapy Program as well as a Practice-Based Researcher at the Sunnybrook Research Institute and Lecturer, Department of Radiation Oncology, University of Toronto.

I must make a disclosure prior to delving into this month’s journal article. I do have a vested interest in the Quality Conversations (QCs) described in the article. Being involved in the large scale roll out of QCs across all of Sunnybrook Health Sciences Centre, frankly I think they’re just super. But what I think is anecdotal. What’s so super about them? Is my opinion based on experience, observation, what is the evidence that QCs are a benefit to the organization? More importantly, what is the evidence that they should be adopted by other units or considered by you, the reader? This is the burning platform that helped fan the fire of QCs. Quality conversations help reframe how we respond to anecdotal observations into evidence based quality improvement approaches, to address programmatic performance.

Team huddles have existed for in both healthcare and industry for a while, and have been a real success. They have a demonstrated benefit for the staff involved, improving communication and teamwork. But, these huddles tend to focus only on the “flavour of the day”. These discussions solve the problem facing the team that day, but often do not address the underlying causes that may be contributing to that “flavour of the day”. That being said I don’t want to detract from the benefits of huddles; shown to improve information sharing, accountability and staff growth they are an excellent addition to a department. The question remains how do you identify if you simply have that problem in your program that bugs everyone and can be an easy fix or is it something that needs a deeper dive? This is where Continuous quality improvement (CQI) comes in. CQI is one of those buzzwords that captures a whole host of tools, but simply boils down to the concept of looking at a problem, trying to understand it better, coming up with a fix and seeing if you made it better and hopefully not worse. It gives a program the chance to see it can cut down on waste, do things more efficiently, and make staff and its customers happier. The key message is whatever changes you make are informed by some evidence and that you keep an eye on your changes and redirect your course if things aren’t quite going as you predicted.

Now that we have an idea of what tools are out there to make improvements and keep them going. How do we start putting them into place? We’ve probably all heard of some really great ideas that came from some senior leadership or corporate level that went over like a lead apron (see what I did there, I made the analogy radiation related). What might be a reason for these failures? For initiatives to be successful it’s important to recognize you need staff buy-in. A grassroots approach, helping staff understand “What’s in it for me?” is integral to success.  Not only, do you need staff buy-in for the success of a team based initiative, but also you need to work with the team to transform them into one that is highly effective. There’s another buzzword and how do you transform your team? Well, let’s look at a team in medical radiation technology setting. We work with so many others in the healthcare system to succeed in our jobs as well as each other.  As we discussed early team huddles help us communicate better and grow. But we also need to start breaking down those barriers among the other professions. I can think of an instance working on a CQI project with an inter-professional team in which each profession thought the other was responsible for the task we were trying to solve… Smashing down those silos we work in, improving communication, clarifying our roles, and resilience in the face of challenges and change result in a highly effective team.

 Putting it all together:

We’ve touched on some quality improvement topics and how they relate to team dynamics. Team huddles are a pretty good approach, but tackle problems with a more ad-hoc basis. They are more effective at improving communication and accountability. CQI is the powerhouse tool a program needs in order to fully understand, address and follow-up on recurring issues. Finally, huddles, CQI or any other initiative cannot succeed unless you can get your front-line staff on the trolley. How do these relate to this month’s journal club paper? Well, I’ll tell you; those super QCs feature elements of all of these concepts.

By marrying those nuggets of traditional team huddles with a heaping spoonful of CQI theory the authors discovered that their QCs increased awareness of best practices suggesting that QCs are a good forum to discuss ideas for change, implement new processes, monitor progress, and evaluate outcomes. In addition, providing participants the opportunity to provide feedback, validate that feedback and participate in change the authors noted a positive response perception that regular conversations with the team will improve quality and safety. Finally, the embedding inter-professional elements into QCs was expressed as a future direction “being able to contribute ideas with other colleagues from different teams that would help with patient safety and efficiency and seeing it play out and what results/outcomes come out of it’’ which has subsequently been regularly integrated into QCs.

In Summary:

When it comes to assessment that QCs are super, is my opinion based on experience, observation? What’s so super about them? Not only are QCs an excellent to integrate CQI into practice, it is evidenced that they also instill CQI into the attitudes and perceptions of those whom participate. Finally, as evidenced that this paper is even written, QCs are CQIs themselves, constantly being reassessed for opportunities for improvement. In conclusion, QCs are just super… so what are you waiting for? Go get one started!

Further Reading

  1. Gillan et al. The Quest for Quality: Principles to Guide Medical Radiation Technology Practice. JMIRS. 2015. 46(4); 427–434
  2. Goldenhar, L. M., Brady, P. W., Sutcliffe, K. M., & Muething, S. E. (2013). Huddling for high reliability and situation awareness. BMJ Quality & Safety, 22(11), 899-906.
  3. Liszewski, B., Angers, C., & Kildea, J. (2017). Mitigating the Barriers to a Culture of Quality and Safety in Radiation Oncology. Clinical Oncology, 29(10), 676-679.

Protons, Protons, Protons!

This month’s blogger is James Donnelly, a Proton Gantry Superintendent in the Radiotherapy team of the Christie NHS Foundation Trust, Manchester. 

My learning and development in Proton beam therapy (PBT)

My role

My name is James Donnelly and I am therapeutic radiographer living in Manchester and have been for almost 8 years now during this time, I have trained and worked at The Christie NHS Foundation Trust. I fondly remember starting work here back in 2010 new qualified proudly thinking I could really make a career here.

The majority of my career I have been working on a linear accelerator (Linac). I have seen the Linac technology evolve very quickly over a very short period time, one reason why I have remained at The Christie. It has always been a leader in using innovative technologies to benefit patients. Over my career, alone I have been able to deliver a vast array of advanced treatment techniques such as IGRT, IMRT, VMAT and SABR.

Building relationships with patients is the most enjoyable part of my role. This allows I have the opportunity to build an excellent rapport will patients, with conversations ranging from the managing of side effects to discussing the football scores.

In 2012, The Christie was successful in its bid alongside UCLH to be the locations for the first NHS funded National Proton service. Over the next few years, I saw the proton build took shape I wanted to be part this new ground breaking project.

In July 2016, I moved to the role of treatment superintendent, leading a small team across two Linacs. This role involved a lot of problem solving with my team of radiographers and wider members of the multidisciplinary team.

Finally, in February 2018 became directly involved with PBT by starting as Gantry Superintendent.

My journey

Before starting my new role, I completed some research in proton beam therapy. I would recommend   Proton Beam Therapy by Harald Paganetti to any reader to gain a basic understanding of proton physics and delivery principles. I refer back to this text all the time when delivering training.

Maryland USA

When I started in the proton team in February 2018, I was whisked off to The Maryland Proton Treatment Centre (MPTC) Baltimore USA.I was sent on fact-finding mission to see what the delivery of protons entailed. The MPTC uses Varian equipment to deliver the proton therapy, the same equipment The Christie will use so it was helpful to see it in action. The trip lasted one week and my colleagues and I had the opportunity to work alongside the therapists (radiographers). This allowed me to interact with patients who are receiving PBT meaning I was able to discuss treatment side effects and their management. I am very kinaesthetic learner and the hands on experience was invaluable. The trip opened my eyes to the workload that is required to treat patients accurately with protons. It is more than you can imagine. The trip was very informative and it was an excellent foundation to build on my knowledge. I would recommend to anyone setting up a proton centre to send a selection of radiographers, clinicians, physicist and dosimetrists to an operational proton centre to learn its ins and outs. I hope once the proton centre at The Christie is operational we can receive visitors to impart our knowledge to them.

On returning to the UK, I have worked alongside my colleagues and the educational team to develop a series of training packages for proton treatment delivery and verification for newly recruited radiographers.

PTCOG 57th Annual conference

In May 2018, I had the opportunity to attend PTCOG 57 in Cincinnati Ohio USA. This was my second trip to the US in a year so I felt quite the jet setter. PTCOG stands for Particle Therapy Co-operative Group. I attended a series of educational lectures delivered from leading clinicians, physicists and dosimetrists in the proton field. The lectures highlighted the clinical application of proton beam therapy for different disease sites and the associated complexities of treatment planning and verification. The lectures highlighted the evolution of PBT from passive scattering delivery to the more modern pencil beam delivery. I attended the conference alongside a clinical oncologist and dosimetrist from The Christie, with this varied staff mix sparking discussion among us. The conference also hosted a cocktail reception in evening. This was an excellent opportunity to mix with peers in the proton field from around the world. Due to the small nature of the proton world, I managed to meet up with therapists from the MTPC again. This was a delightful catch up where we discussed the progress of the PBT back home. Next year PTCOG 58 will be held Manchester; it celebrates the centenary of Ernest Rutherford’s publication of the scientific paper confirming the discovery of the proton.

Further development

The proton therapy centre at The Christie endeavours to treat its first patient by October 2018.

I have applications training to be delivered by Varian in September 2018 building upon my knowledge of the ProBeam system and preparing my team for the first patient. I have completed additional courses through the NHS leadership academy to help guide my team when October 2018 comes around.

Looking back at the last 6 months it has been a whirlwind! I have had the opportunity to complete tasks that I thought I would never complete. Each day at work has been entirely different and outside of the norm. I will never get this opportunity again. I can honestly say the setting up of the new service is hard work but it will be worth it once we treat the first proton patient at The Christie.