It has to be… perfect

360 degree appraisals are often held up to be one of the most useful tools when seeking and obtaining feedback to inform personal development, and the appraisal process.

Their strength lies in them being a forum where peers, direct reports (juniors), members of the wider team, secretarial staff and other clinicians get to highlight not the clinical knowledge, but the day to day working of an individual.

These forms are usually anonymous, collated by a third party and then discussed with an educational supervisor who reveals some or all of the comments received.

As I understand it, 360s allow individuals to appreciate their impact on others, how they influence and work in a team, and provide a substrate to enhance reflection, and from there, personal development.

In true edu-babble speak, 360s help to “open your Johari window.”

Over the last few years I have heard several stories of people who have been pulled up in ARCP and RITA interviews for marginally negative comments in the free text of the 360s. Some have even been told that to have a less than perfect record on the 360 exercise is a threat to future employment.

I have a few difficulties accepting that this is the right approach to helping people develop.

Firstly, trainees are people, they are human and have human attributes. The people they work with are also humans and where there are lots of personalities, ambitions, emotions and stress, people will occasionally have differences of opinion and disagree with each other. To expect that trainees will go through life as perfect automatons with little in the way of character which will challenge those they work with is, I feel to be exceedingly naive. When I look at the people who I have worked with who are successful, are pushing boundaries, innovating and progressing medical science, I don’t see timid individuals who will simply get on with people for an easy life; I see ambitious, driven individuals who are not afraid of ruffling a few feathers to ensure that they get the resources they need, the access to services, or the time of others. Medical science would not be what it is today without the innovators and positive deviants. As Aristotle said: to avoid criticism,  say nothing, do nothing – be nothing.

Secondly, the idea that the 360 exercises should all be perfect is to deny the trainees the opportunity to explore how they affect those around them, their impact on other team members, and how they appear to the outside world. Instead of being a tool for revealing attributes which might require consideration, reflection and development, the tool becomes one which reinforces the status quo and fails to fulfil its intended role. Instead of being a tool for revealing aspects of ones personality and behaviour, it becomes a whitewash, masquerading as a genuine assessment, but in truth being only a paper exercise.  ( and to keep on with the greek quotes – Socrates pointed out that “The unexamined life is not worth living”)

In addition, the feedback given is often in a poor format. There are usually general statements, covering a broad sweep of behaviours and impresions, rather than being issue-specific.  Worse still, feedback can focus on who the person is, rather than the actions they have taken.  Feedback should try to concentrate on actual events, not inference and speculation.  The general comments often offered are not always helpful for a trainee to think about.  More helpful, and a better substrate for examining ones behaviour, are examples of specific situations where a behaviour has influenced others – either for better or for worse. Even better if the impact of the behaviour can be explained.  eg. when X said this after it happened, it made me feel Y, because of Z.  (This article and this pdf have some interesting ideas and principles for good feedback)

So – next time you are filling out a 360 form, be honest, but give real feedback that will help  the person receiving it – preferably with a specific example of when a behaviour resulted in a particular outcome.

If you are giving out the forms – be bold, discover something about yourself and don’t just ask your mates to be “nice” to you.

Finally, if you are reviewing the 360 appraisal of a trainee, please don’t tell them it must be perfect – it is unrealistic, unreasonable, and results in a charade which helps no-one.

Institutional Memory

Junior doctors are great at seeing problems, but often struggle with implementing solutions.

They move jobs every few months, and see new problems, inefficiencies, and defects in systems – and either quietly get on and reform things, or, if the problems are out of their power or scope to change, make suggestions, and then, before they can get up momentum – move on.

The peripatetic nature of our junior medical workforce is one of the major reasons why juniors sometimes seem to be seen as a problem to be dealt with, rather than valuable members of a highly qualified workforce.

Institutional memory is something which is built up over time, and is often held within the memories of the longer-standing members of the workforce, rather than written down and archived for future reference.  When key members of staff move on, or retire – that valuable resource is often lost.

In the case of junior doctors, it is more the handy hints which a shadowing period can help to transfer to the new crew which get lost in the transition – who to ask for for an urgent ultrasound, which secretary is best at passing messages to the boss when he is on study leave, which ward is most likely to look after certain types of patient better than others.

At a recent learning event, we had a discussion about how to combat this loss of ‘institutional memory’ within the junior doctor grades.

I’m not entirely convinced of the full answer – but for a start, wouldn’t it be great if those juniors who are due to move on after only a few weeks could write down their observations, maybe even with a little bit of data – and then next bunch could pick them up – analyse the problems, and implement the solutions.

A team file of ideas, trials of solutions and successful innovations could hold the history of improvement efforts of the team – and who knows – that part of the organisation may truly become a ‘learning team’

So – before I leave my current post – it seems I have just given myself a task – to record the handy hints and attempted improvements which were made throughout my year there, and I’ll pass it on to whoever comes next.  Hopefully they will see through some of my ideas and develop them to improve things further – and if they pass the baton on, who knows, in time things might just improve.


Value and Carbon


Value is a concept which is making waves in the management / leadership / policy world of medicine at the moment.  It is not an entirely new concept, but has been worked on and promoted as an approach to the management of healthcare which will unite providers, commissioners, and payers in healthcare economies across the globe.

Michael E Porter has been looking at this area for some time, and has defined value as:

outcomes / $ spent

This deceptively simple equation helpfully focuses the mind on the numerator of outcomes – specifically those important to the patient – and cannot only be improved only by cutting at the denominator.

A recent seminar at City Hall in London (see here for slides from the talks) explored this idea further, highlighting to a number of prominent leaders from the world of medicine how this concept of value unites different actors in the system around the thing which matters – outcomes for patients.

Porter gave six steps in a strategy to realign objectives along the value agenda:

1.  Organise into Integrated Practice Units around patient medical conditions

2. Measure outcomes and cost for every patient

3. Reimburse through bundled prices for care cycles

4. Integrate care across separate facilities

5. Expand areas of excellence across geography

6. Build an enabling Information Technology platform

Of these 6 steps – one of the most complex is probably the costing of care.  This is not simply the tariff, or the invoiced cost,  but the true costs of each care cycle (this may be a short emergency admission, or a year of chronic condition care – depending on how the care is bundled up)

One cost of healthcare which at present is often hidden away, and not really counted in business cases, service proposals etc is the carbon cost of care.  Carbon useage has been estimated for the whole of the NHS (with updates regularly – here is the 2012 update– one of the first healthcare systems in the world to take this important step to understanging the impact of care on the environment.   It is not so simple to find out what the carbon costs of individual episodes or cycles of care – or what the solutions might be.

Understanding this aspect of care cycles is going to be increasingly important with the introduction of league tables of carbon useage (find your organisation on the current table here)  and with the UK having legally binding targets for reducing carbon consumption ( we  have a target to reduce CO2 emissions by 80% from 1990 levels by 2050 – and in the meantime need to get down to 34% of 1990 levels by 2020 – not that far away)

Simple efficiencies are not likely to make huge differences to the overall footprint – but re-examining the way we ‘do’ medicine could – building use makes up 19% of the current footprint, whilst procurement still makes up 65% – and pharmaceuticals making up the lions shar of this.  Frances Mortimer explored this in an opinion piece published in 2010 – and there remains considerable doubt about what could be done.

Respiratory disease is a major burden to the NHS (pdf), and the UK economy – £6.6 billion pounds spent on it in 2006, and around 1 in 5 people dying of respiratory disease (more than ischaemic heart disease for example)  The chronic nature of many respiratory diseases, characterised by periods of stability, punctuated by dramatic episodes of illness make it a complex care model to decipher.  However, the fact that respiratory disease – and in particular COPD can be both prevented, and ameliorated by non-pharmacological means, improved self-managment and better organised care make this area one of huge importance if we are to understand and control the carbon costs of the NHS.

I am pleased to be working with the Centre for Sustainable Healthcare on a project to determine what the carbon costs of different care models are for COPD, and use this to help focus the minds of commissioners when it comes to defining high value treatments and strategies for addressing respiratory disease.

It would be great to have your opinions and ideas about how respiratory care could be made more efficient, or if you think that counting carbon could help to discriminate between care models, and help us to improve not only the quality of respiratory care in the UK, but also enhance the value we can offer patients through smart commissioning.

Please visit the Centre for Sustainable Healthcare and sign up to the networks they have there to get the latest news and resources to inform your practice, and see how you can help to improve the services we offer – in terms of value, quality and carbon.

Competition 2.0, high tech and low tech

Cohort Review

Technology is a great thing, and has advanced the human race at an almost unimaginable pace over the last few years.  I love being almost a native when it comes to IT and technology.  I am not overly confused when a new technology comes out, can sort of understand the way the web works, and don’t completely lose it when it comes to cloud computing ( something my parents don’t really feel comfortable with)

But, I am also a bit of a Luddite, and find pleasures in timeless pursuits, like walking up hills, camping, sitting by a fire, reading from paper (although the majority of my reading is now on a screen of one sort or another)

When it comes to healthcare, I have pretty similar views, and appreciate all of the advances that can be made with our new technologies, but also find fascination in the seemingly simpler, but often more complex interactions between individuals, especially patients and doctors.

This week I got to see all of the things I find interesting rolled into one.  The meeting I went to was the North Central London cohort review.  Cohort review is a method of rolling audit if you like, in which a service reviews it’s most recent cases, checks on performance and outcome, and tries to lear lessons along the way.  Each case seen by a service is presented by the case manager to a panel of experts, with an audience of their peers from their own, and other services.  Various essential pieces of data are presented, including detailed information on outcomes of treatment, adverse events, and the results of contact tracing. the presentation is made to a panel consisting of an independent chair, senior case managers, an epidemiologist, a microbiologist with access to a vast array of lab data, and public health representatives.  In future editions, local primary care physicians will be invited.

The Cohort Review process was used in New York in the 1990’s to reverse a trend of increasing TB incidence, and is credited, along with other changes in management as one of the main reasons incidence of TB in NYC is falling, rather than rising as it is in most major capitals. (see here for more information)

So, what is so special and why did I get so excited.

#1. Cohort review is not an audit in the sense of a junior doctor clinical audit, but falls more in the category of continuous quality improvement, with lessons learned on the hoof, solutions thought of and shared by those on the ground ( the TB case managers) and a process of rolling review to see how improvements have impacted on the outcomes achieved.

#2. Cohort review is a public test of how well you are performing as a service, with your peers scrutinising your practice, and competition between services being very much on outcomes and reputation (see Muir Gray’s blog for more on this). It is slightly unusual in the health service to hold people to account in a robust way, but this meeting made that possible, and clearly drove people onwards to achieve higher standards.  The fact that this meeting covered a number of neighbouring services, but remained local enhanced this sense of being held to account, but by those who understand and sympathise with the local context.  An independent, respected, and expert chair helped to keep this a robust, but fair process.

#3. Cohort review combined the latest in technology with something very basic, and this brought out amazing opportunities to fight a disease.  TB is caused by a mycobacterium, and each of these can be strained by analysing it’s ‘fingerprint’. When this fingerprint data is added to the clinical, and demographic data, it is possible to see clusters forming, and data from the ground can highlight areas of social interaction, which in turn allow targeted efforts at controlling the spread of the disease.

So the strain typing is the high tech bit, but the simply all getting together in a room, not with just the directors if each service, but the foot soldiers, allowed the tacit knowledge from the front line to inform those with a high level overview ( an epidemiologist and public health doctor attend the cohort review) and create strategies for investigation in real time. (an example was a cluster of 17 cases presenting to a large number of services, but with common geographical and epidemiological data, highlighting a very specific area of high transmission – a charity mission as it happened)

#4. This is scaleable.  Solutions to problems are often very situation specific, and transplanting one solution into another context can rob it of any chance of working, but the principles which make the CR process so effective, in my mind, can be applied to many different fields, especially where we are moving to distributed networks of practice.

So, competition between services, but experienced in a meaningful forum (not just a league table produced every few years), a continuous process of improvement, with accountability for performance being felt at the front line, along with a blending of high tech, and simple communication between those looking at a problem from different perspectives.

All these ingredients made me more excited about this process, and brightened up my Thursday morning more than I could have hoped for.  Now I need to look at where else this could be applied, and see if I can sow the seeds. Get in touch if you would like more info.