Getting started with quality improvement for practice managers, with Cath Grimsey

RCVS Knowledge:

Welcome to the Quality Improvement Boxset by RCVS Knowledge, a series of webinars, podcasts, and video interviews for practices and practitioners.

Pam:

Hi everyone. Today I’m going to talk to Cath Grimsey, a Practice Manager, about the Practice Manager’s role in Quality Improvement. Cath is the Practice Manager at Pinkham Equine in Wiltshire. Hi, Cath.

Cath Grimsey:

Hi, Pam.

Pam:

Great. Thank you so much for agreeing to do this because I think the Practice Manager’s role is very important in Quality Improvement. So, how did you get involved in Quality Improvement?

Cath Grimsey:

So, I’ve worked in veterinary practice for quite some time, Pam, most of my career in both equine and small animal practices during that time. And my interest has always been in efficiency, effectiveness, and profitability of practices. Quality Improvement as a topic seems to sit within that bracket of business optimization. And I was really delighted when I saw it as an optional module on the Veterinary Management Group Level Five Certificate in Veterinary Leadership and Management, which is a course that I’ve been studying online because I was really keen to learn more.

I was a little bit worried, I’ll be honest, that when I went into it that I thought, oh, gosh, I’m going to be behind this drag curve. I’m a more mature Practice Manager. And I thought, gosh, perhaps this is a new modern thing that I’m a little bit out of my depth with. But doing the module proved that that wasn’t the case at all and really drove home to me that this is just a formal structure around the common sense things that we do every day.

Pam:

Absolutely. I couldn’t agree with you more. It is about what we do, it’s about what we’ve always done, but just doing it in a more structured way and remembering to do it consistently and act on the results really, I think. So, that’s great. So, what kind of Quality Improvement tools, like guidelines and protocols and things, do you use any of those in your practice?

Cath Grimsey:

Yeah. Yeah, we do. So we use our CVS standards as a framework for managing and developing the practice. And we have protocols in all of the usual areas. For instance, medicines, health and safety. And we’re also building a library of how-tos within our office for the day-to-day tasks that we do in there.

That’s a great resource because it provides new team members with a source of information for how we do our tasks and the approaches that we take to ensure regulatory compliance, data protection, and client confidentiality. Like most workplaces, Pam, it’s a bit of a journey,

but we are on it and we’re very keen to improve and I’ve made completing our how-to library and revisiting our risk assessments and protocols a priority for 2024.

Pam:

Excellent. And I think for Practice Managers, protocols are a big part of what they do anyway. And I was involved in practice standards and we’re very keen on protocols and SOPs, but guidelines are a little bit more clinical. So, I don’t know if any of your vets draw up any clinical guidelines, because it’s quite useful to have a library of those too for your new vets when they come along.

Cath Grimsey:

Yeah, you’re absolutely right. And again, it’s a journey that we’re on. We are just about to employ our first equine veterinary nurse (EVN). She starts actually on Monday, which is exciting. And one of her primary roles will be to develop a set of clinical guidelines to sit alongside the nonclinical ones. And she has a mentor in place, one of the clinical directors, to help her do that.

Pam:

Wonderful. I think that’s an excellent role for an equine veterinary nurse. Really good idea. What about checklists, another Quality Improvement tool? Do you use checklists at all?

Cath Grimsey:

So, checklists have been one of the main gains since I did the Quality Improvement module as part of the course. We didn’t really use them before. We had some kind of in-our-mind checklist, but not formally written down ones. But now we have them, we are an equine-only practice, so we have them for pre-purchase examination administration. We have them for exporting of horses administration, and most recently we’ve started developing one for the thoroughbred foal registrations, because we’re just about to enter the thoroughbred breeding season and all of the foals will need registering with Weatherbys. And that’s a process that previously seemed to be a bit harum-scarum with it.

But as well as those tasks, Pam, I’ve also developed some checklists for some really day-to-day mundane tasks. So we now have a little checklist that sits in our posting tray for sending out post where we record everything and have a little crosscheck with the postage fees that we’re sending out. And it’s just tidied up a couple of those really mundane more day-to-day tasks where I think mistakes can happen because people are either new, they’re a bit tired, or they’re a bit less excited about it than they are about the grander things that go on in practice, but actually where marginal gains in efficiency and profitability can be made.

Pam:

Absolutely. And you may say they’re mundane tasks and, yes, compared to some of the others, they are, but there’s also huge implications of when those tasks don’t get done and things don’t get posted back to people that need to go out, et cetera. And I can imagine that things like your, whether it be foal registration, is absolutely fraught with areas for forgetting something and we’re all just human, aren’t we?

Cath Grimsey:

Yeah, absolutely. And you’re absolutely right. Last year drove home to us how many little tasks make up that big task, and failing to do one of them retrospectively can give you real headaches. So, the posting would be a good example. We weren’t always making a note of which samples belonging to which animal were in which package, and one went missing and we didn’t know who’s was in there. So, yeah, that won’t take place this year because I have a checklist, Pam.

Pam:

Excellent. And people sometimes say about Quality Improvement, “Oh, we haven’t got time to do that. We are so busy. We’re so busy in practice, we haven’t got time to do that.” But I think that things like you are describing can save you time, can’t they? I mean the amount of time, if something goes wrong, that you take to put it right.

Cath Grimsey:

Yeah, you’re right. And not only that, but also the questions that take… So for instance, now with that checklist, I don’t have every person doing posting coming to me every time to make sure they’ve done it correctly, which takes my time and resource. So, there are time savings all over with it.

Pam:

And so, those few minutes you save every day can be really important when they’re added up. And also, an error with something like that can affect the reputation of the practice, can’t it?

Cath Grimsey:

Yeah, yeah, that’s the main issue. So, the owners expect a good or a very high level of client service and that dents reputation when it happens.

Pam:

Particularly if it was something around your pre-purchased examination or the foal registration and those kinds of things. So, how have you got your team on board with bringing QI into the practice, would you say?

Cath Grimsey:

Okay. So this, again, is a work in progress. My own office team meets weekly on a Friday and we have a standing agenda and it includes items pertaining to personal and team wellbeing and also includes what we call WWW, which is What Went Well, where we all focus on the positive and talk about the things in our week that have gone well. And then we have EBI, which stands for Even Better If, and it’s a fun non-combative way of introducing QI ideas without some of the more fancy language. And we often implement and try out ideas that get put forward during the EBI agenda item.

A good example of this actually would be, recently we’ve introduced colour coding to all the messages that come into our combined email box. Previously, they just sat in there until somebody decided that they would take ownership of them. Now they’re allocated using colour coding to different people and that’s made that process far tighter. And I feel once people have got ownership of something, they feel responsible for doing a good job with it. So, that works brilliantly. And that was the brainchild of an office member during an EBI chat. So, that’s how I get my team involved.

The wider team, I have just introduced the ideas of Waste Team, Green Club, and Quality Club, and I use the word club because I wanted to get everybody really excited about joining these things. It mostly worked. Waste Team met twice during 2023, and the idea of that was to maximize our efficiency around the clinical and nonclinical waste that we produce in the practice and that, this year, will be incorporated into Green Club. I’m very fortunate that I’ve got two non-director clinicians who have a real keen interest in environmental impact. So, they’re going to lead on that with two meetings planned for 2024, and we’ll have some recommendations for improvement, and we’ll implement those and then we’ll review them over the course of the year and see how we get on.

I’ll head up Quality Club, and that’ll also meet twice in 2024. And that will follow the more formal process that I learned during the QI module that I studied using a couple of the method techniques, like method study and the decision matrices to look at specific areas for

improvement and provide some very simple and practical tools like checklists and job descriptions to define roles and responsibilities to really improve our quality and probably some of the bigger things that we do, the more important things that we do.

Pam:

Wow, that’s loads. Brilliant.

Cath Grimsey:

We’re very aspirational.

Pam:

No, that’s brilliant. And I think there’s a real synergy between sustainability and Quality Improvement because most of the sustainability things, or environmental sustainability require you to measure really before you start making changes to see whether the changes are working. So, I think there’s real synergy there with audit. I absolutely love your EBI, I mean you could have What Went Well, you could have WWW and WWB, couldn’t you? What Went Badly?

Cath Grimsey:

Oh, no, no, no, no.

Pam:

That would be so negative. Yeah.

Cath Grimsey:

It would be so negative. Yeah, yeah. No, we try to… I mean EBI, I do wonder sometimes whether I should flip them around and end on the positive, but actually the flow works well that way.

Pam:

Yeah. No, I love Even Better If, and everybody can input to that presumably?

Cath Grimsey:

Oh, yeah, absolutely. Our meetings are confidential within our team, but we do make notes and we do implement, have action plans to implement what comes out of them.

Pam:

Great. Wonderful. And so you follow things through because you’ve got your notes and bullet points, et cetera. That’s brilliant.

Cath Grimsey:

Exactly right.

Pam:

I just mentioned audit vaguely there with sustainability. So, have you got involved in any, I know clinical audits, I know sometimes Practice Managers worry because of the word clinical audit, but they don’t have to be exactly clinical because everything that happens in a veterinary practice impacts on clinical, I think. So, have you been involved in any audits in your practice?

Cath Grimsey:

Not really, apart from our external annual financial audit, which is a mandatory thing that all business organizations have to do. And the other regulatory compliance checks, like our VMD inspection. We are at the beginning of that journey, but it’s what I plan for Quality Club.

Pam:

Excellent, because I think there’s lots of areas, both for clinical areas within equine practice, dispensary, there can be audits around certain medicines used, all those kinds of things. And then there can be nonclinical ones around auditing, how consent is gained for procedures and consent forms, things like that. So many things that could involve the whole team. So, that’s brilliant. And we’ve got some case examples around some of those things on RCVS Knowledge Website.

Cath Grimsey:

Okay, cool.

Pam:

So what about if things aren’t going well? What about if something goes wrong in the practice? Is there any kind of Quality Improvement aspect to that?

Cath Grimsey:

Yeah. I’m really, really lucky that the practice that I work in already has a very constructive and restorative culture and QI is still new to us, but most recently we had an incident that wasn’t our finest hour and it gave me the opportunity to apply some of the basic and helpful principles that I’d learned on the QI module, including a review of the relevant job roles, responsibilities, and competencies most importantly, to develop a more robust way of performing the particular task that went wrong.

I’ve had no indication that any of the individuals concerned felt in any way blamed and that’s certainly not my take on it. It was a systems failure and the system has been analysed and improved, which is what QI is about.

Pam:

It’s absolutely what it’s about. It’s not about blaming people, it’s about improving systems. Brilliant. Do you look at near misses? If something happens in the practice and someone says, “Oh gosh, that horse nearly got that wrong medication,” or whatever, do you tend to look at near misses?

Cath Grimsey:

So, in a formal way, we look at first aid near misses or accident near misses because those are a part of your first aid protocol. I’ll be honest, beyond that, it mostly takes place in our minds, but now that I’ve done the QI module, I will be applying some more formal techniques and I’ve learned that Ishikawa thing, the fishbone diagram, I love those, Pam.

Those are great. I’ve got fish going on all over my desk. Yeah, love a fishbone diagram.

Pam:

Like an aquarium on your desk, is it?

Cath Grimsey:

Well, we don’t make that many mistakes, but yeah, there are a couple of minnows.

Pam:

Very good. So, yeah, using root cause analysis like the fishbone diagram or the contributory factors checklists are really good things to do. But getting back to those near misses, I don’t know if you do this already, but I find having a near miss book a really good idea so that anybody in the practice can just jot something in, or a ‘whoops book’, some nice bright colour book and I tend to keep them in the dispensary, because that seems to be where a lot of the near misses occur. And then people can just, as you say, they’ve got the right culture so they can learn from. They know you’re just going to learn from them, so they can just jot them in and you can discuss them at your Quality Club. That’s brilliant.

Cath Grimsey:

That’s a really-

Pam:

Have you used… No, sorry.

Cath Grimsey:

Sorry. I was just going to jump in and say, actually that’s not something that I thought of and that’s a really good piece of advice, so I’ll do that.

Pam:

Yeah. You just need a notebook, something nice bright colour or something so everybody knows it’s there and that culture which you’ve already got is that it’s not there to blame anybody. That’s the important thing. It’s just, we’re going to learn from it. It’s about learning from everything, isn’t it?

Cath Grimsey:

Absolutely. Yeah. Yeah.

Pam:

And we’ve got quite a few resources at RCVS Knowledge. Have you used any of those? Well, maybe the Ishikawa diagram, that’s on our website, but is there anything else that you’ve used?

Cath Grimsey:

No, only the ones that I learned about in the QI module, although there were a lot of them incorporated in that module, the decision matrices, the roles and responsibilities and looking at job satisfaction, job flow, those kind of things. But I’ll be really honest, I haven’t looked in there since I did the module, but I’m very aware of them and I have my login and I know, should I wish to access them, I can.

Pam:

Brilliant. That’s good. And also, if any of your team members or yourself come up with some great QI projects, we’ve got Awards that they can enter for, so do that.

Cath Grimsey:

Yeah. I’m quite keen to do something actually now I’m reasonably fired up about all of this stuff, I’m quite keen for us to enter something.

Pam:

Absolutely. So, with what you’ve said, you are early in the journey, but to me it seems like you’ve done a lot already, which is great, but would you recommend other Practice Managers get involved in quality improvement?

Cath Grimsey:

Yeah, absolutely, I would. And I think what I’d say is not to be scared of it or to think that everyone else is managing quality within their practices better than you are or that you’re a bit late to the party or lacking somehow. I think the title’s a little bit fancy and maybe a little bit off putting. It has a slightly science-y sound to it and maybe it’s not quite as grand as it sounds.

For me, it’s just a set of questions and flow charts that guide your thinking when you want to see how a task can be done better and whether that’s as a response to something that’s gone wrong or just because you think, “I’m really bothered by that. We don’t seem to get that right all the time.” It just gives you a set of tools to look at something and think about how they could be done better.

It is completely suited to very low level, everyday tasks just as much as the high ticket exciting surgical clinical stuff that goes on and it needn’t take too much time or grand planning. I think once you’ve done it a couple of times, you can filter out the bits that you find useful and the bits that you like doing and then you can build it into your existing team get-togethers and it becomes second nature and just something that you do anyway in a slightly more documented way.

Pam:

Yes, absolutely. I’m really interested in your comment about the name. I mean personally, we do also have the name Clinical Governance, which-

Cath Grimsey:

Oh, gosh.

Pam:

Clinical Governance is the kind of structure and Quality Improvement is the way to do it. And I find Clinical Governance a really off-putting name, I have to say. It sounds like Big Brother looking over your shoulder I think. Whereas I find Quality Improvement a bit more ‘Ronseal’, a bit more ‘does what it says on the tin’. But it’s interesting, isn’t it? Because words can really put people off.

I don’t know how else we would describe it. We could just describe it as continuous improvement, but that’s still, I don’t know if we’ve got any other ideas, what we could call it, just common sense maybe.

Cath Grimsey:

I’ve got Even Better If tomorrow morning, Pam, so I’ll ask my team what a fluffier title for Quality Improvement might be and we’ll come back to you if we come up with any great ideas, we’ll come back to you.

Pam:

That’s such a good idea. And it illustrates the QI principles brilliantly that you involve the whole team and you ask them what the stone in their shoe is, what it is they want to improve, and I mean for me-

Cath Grimsey:

I mean perhaps we could call it Even Better If.

Pam:

Yeah, exactly. No, I think that’s a great title. EBI instead of QI, but I mean if you look at the definition of Quality Improvement from Human Healthcare, it’s about improving outcomes, improving care for our patients, and improving learning and the atmosphere we work in for our teams. So, I think those principles, whatever we call it, are really important in practice.

Cath Grimsey:

Yeah, I would agree. Very important in practice. And we are a practice that has quite high standards. We have high expectations of ourselves as individuals and as a team. And one of our differentiating factors is that we provide excellent client service and I think that Quality Improvement just completely dovetails with all of those aspirations and it’s something that we certainly are very keen to embrace and use all the time.

Pam:

Brilliant. And the Practice Manager shouldn’t be scared of it, whatever it’s called. I don’t think they should be scared of it and shouldn’t be scared of things that say clinical at the beginning because what everybody does in a veterinary practice all contributes to the clinical outcomes at the end of the day.

Cath Grimsey:

Yeah, you are right. Absolutely. Was it the NASA thing, when they asked the cleaner what his job role was and he said, “I’m helping to put a man on the moon, sir”? So, yeah, we’re all helping to fix the pets, sir.

Pam:

Yeah, absolutely. No, that’s been brilliant talking to you. Thank you so much.

Cath Grimsey:

You’re so welcome.

Pam:

And enjoy the rest of your day.

Cath Grimsey:

Thanks, Pam.

RCVS Knowledge:

For further courses, examples, and templates for Quality Improvement, please visit our Quality Improvement pages on our website at rcvsknowledge.org.