Approaches that worked well within the MAGIC programme were:
Getting the team to draw ‘their’ driver diagram
This clarified aims, roles and measures. Teams were often not as prepared for change as they imagined, both in terms of their own dynamics or a consensus about what they wanted to change and why – clarifying roles and building agreement was often needed as a precursor to introducing change
Team involvement and working throughout
On MAGIC, the team worked together to develop brief decision support tools and this created a shared commitment to using the tools within the consultation and sharing the subsequent learning. The process of agreeing the clinical area, reviewing the evidence, developing the tool and deciding how to measure the impact of the intervention motivated and engaged front-line staff and in turn created enthusiasm and further momentum. For some individuals and teams this work had the effect of changing sceptics into champions.
Allowing teams to identify ‘what’s best for them’
When trying to implement the Ask 3 Questions survey in the primary care teams, we encouraged the teams to conduct PDSA cycles to test the survey. The use of this methodology, and an emphasis on flexibility in the use of the survey, ensured the practices could find out ‘what’s best for them’ through a process of involvement. Subsequently, each team found different ways to use the survey to meet their own needs. If they hadn’t been able to adapt the way in which the survey was used independently after the ‘doing’ phase, it is likely that they would have discontinued use of the survey altogether. Emphasising flexibility in use and involvement in the testing phase through quality improvement methods has proven very important for maintaining motivation and promoting sustainability.
Helping teams understand how to do work on improving systems and processes
Quality improvement was introduced within learning sets through a short presentation followed by teams working on practical tasks such as defining aims and measures. All teams appreciated the relevance of the approach and felt it helped them to see change in terms of small practical steps. Practice managers were particularly receptive: they readily understood the methodology and found it easily applicable to the individual change activities that they are doing. ‘Late starter’s and smaller practices struggled at first to identify the team: these tasks helped them to clarify who should do what and the importance of having a lead team identified to drive this work forward.
Testing changes on a small scale
Because it’s small scale, it doesn’t hurt to go back to the drawing board and restart.
Understanding that data for improvement is different
Not only did this legitimate the focus on small changes, but where people were sometimes initially reluctant to be involved in general data collection this was not the case when the information collected was the basis of specific feedback which could be used to improve clinical practice
Completing a PDSA form
This wasn’t difficult and had the benefits of providing a standard reporting and recording method and a reminder of aims and measures, as well as providing evidence to show to sometimes sceptical audiences. Additionally, having systematically collected data via PDSA cycles, it was much easier to transform it into readily understood visual formats such as data charts showing change over time/test sequence compared with baseline or trend data.
Learning sets within primary care
The learning sets provided a forum for teams from individual practices to learn about and spread different implementation strategies. Participants benefited from honest discussion of barriers to shared decision making and being able to work flexibly on solutions.
Using coding to change clinical behaviour
Whilst working on the Health Foundation’s MAGIC programme to implement shared decision making, Collingwood and Central surgeries in Newcastle decided they wanted to explore different ways to remind clinicians about shared decision making, to encourage more activity. The initial approach was to code consultation behaviour and then feed this back to clinicians on a regular basis.
Collingwood opted to use a single code that reflected when a clinician had tried to engage a patient in shared decision making. While there were positive early results, the practice felt the code was too broad.
Central surgery developed three codes, recording partial shared decision making, full shared decision making and shared decision making including use of decision support tools. They introduced a competitive element to encourage more shared decision making. Codes were searched and winners awarded weekly with a ‘MAGIC cup’. This regularly reminded clinicians about shared decision making, incentivising activity in a playfully competitive culture, while demonstrating that shared decision making was taking place.
The MAGIC team has negotiated to add these three codes to the EMIS system, and they are therefore available to around 50% of primary care practices nationally.
Testing changes to the Ask 3 Questions campaign
In Newcastle, there were concerns from primary care clinicians and the Patient and Public Involvement Panel about the wording for the ‘Ask 3 Questions’ campaign, encouraging patients to ask their health professional 3 questions during their consultation.
The debate centred around the use of the original third question: ‘How likely are the benefits and risks of each option to occur?’ which was felt to be ‘clumsy and not well understood’. The word ‘harms’ had already been changed to ‘risks’ on the advice of both Cardiff and Newcastle PPI panels, while the Newcastle panel wanted the words ‘to occur’ to be removed.
Next, two other possible third questions were examined:
- ‘And how does this fit with what is right for me?’ (See example below) and
- ‘How can we make a decision together that is right for me?’
A survey of patients in waiting rooms showed that the ‘decision together’ version was preferred. The strap line below the three questions was removed – as teams found patients did not ‘see’ it and focused on just the three highlighted questions in boxes.
As a result of the team-based process there was more ownership of the final products.
Raising patient awareness through ‘walkabouts’
Recognising that it is sometimes difficult for clinical teams to understand information requirements from the patients’ perspective, the MAGIC Patient and Public Involvement (PPI) Panel proposed a series of ‘walkabouts’ around those clinical environments involved with the shared decision making initiative.
As a result, a ‘walkabout’ observational exercise has been introduced into the outpatient clinics where shared decision making is being implemented, based on a similar model, where members of the medical directors’ team undertake ‘leadership walkabouts’ with executive and non-executive members of the Trust Board. The walkabout focuses on how information about shared decision making can be better promoted within the environment.
Representatives from the clinical teams met with the PPI Panel members and ‘walked’ the patient pathway through the outpatient clinics, particularly regarding the patient’s views and perspective of the information displayed in waiting areas and consulting rooms.
A number of actions have been agreed as a result:
- Rearrange the furniture in one of the consulting rooms for the breast care clinic, so that the patient was facing the information leaflet display rack during discussions.
- Display the Ask 3 questions posters on the wall immediately behind the clinician in several consulting rooms.
- Pursue the use of the TV screens for shared decision making awareness-raising material.
- Make shared decision making patient information leaflets available in waiting areas.
- Display Ask 3 questions information in the general waiting areas.
- Provide business card-size information for collection at reception desk.
The process has also helped clinical teams and PPI representatives to engage and learn from each other and to facilitate discussion within clinical teams, as part of understanding information needs from the patient’s perspective.