O1 Navigating by the starr: “black holes and revelations” on the journey of delivering quality care

Background Quality of care in the NHS is measured using audit and numerical targets. At St George’s Hospital, Tooting, collection of Safety Thermometer and RAG-rating data revealed clinical areas struggling to meet safety targets. In response, GAPS Simulation and Skills was challenged to develop targeted interventions for a ‘hot-spot’ medical ward. Thus the STARR (Safety Thermometer and RAG-risk Response) project was born. The aim was to use a theory-driven approach to bring meaning to audit data, identify and prioritise interventions and engage staff in creating a sustainable educational programme for improving quality of care. Methodology We performed a mixed-method needs analysis incorporating observations on the ward, interviews, use of a validated Staff Safety Perceptions Questionnaire, in-situ MDT simulations and an anonymous staff suggestion box. We drew on Activity Theory to give explanatory force to the data and identify themes and tensions around safety and quality. Outcomes Priority themes included ward rounds, EWS scoring, management and escalation of sick patients, team-working and communication. Different communities of practice shared a vision of effective, quality care but reported that they often worked in parallel and that information ‘fell between the cracks’. Many were unwilling to speak up with strict perceived hierarchies. Regular discussion between various stakeholders generated support and understanding at Trust level and engaged ward leaders and staff, who implemented a variety of changes independently including initiation of regular quality review meetings between the ward’s matron, manager and clinical leads. It generated new opportunities for system changes, educational design, and collaboration – simulations, new practice tools and new ways of working together on the ward and between the simulation centre, ward staff and strategic QI groups in the hospital. Conclusions Using a theory-based approach allowed the GAPS team to act as researchers investigating the intricate balance of material and social-cultural factors affecting “quality and also to intervene and participate in change. Rather than ‘delivering quality’, we found that opening channels of communication between stakeholders facilitated a collaborative approach. This promoted greater engagement and ownership of the change process than interventions that were ‘delivered’ into the target environment. Simulation, both in-situ and centre-based was utilised in project research and design and as part of the educational programme, however this formed only a small part of the whole project. We found that the Simulation Team was ideally placed to bridge the gap between ward staff, clinical and Trust leads in opening dialogue on delivering. Reference 1. Engestrom Y, Virkkunen J, Helle M, Pihlaja J, Poikela R. The change laboratory as a tool for transforming work. Lifelong Learning in Europe 1996;1(2):10–17.