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amazing. Hello. So just a really quick introduction. I'm the doctor. Talk also. I was very lucky to have in today's an emergency medicine consultant on the associate medical director for Quality Management in and it just tastes like this is joining us for on Scotland on. But here's interested in a quality improvement on improving clinical outcomes. I'm unstable is the concept of realistic medicines. They were definitely heard you guys to check that out after this talk today. So you completed the Scottish quality and Safety Safety Fellowship program, and he's now the Depression. A lead for it. So again, something really interesting to look into, um, after his talk today, So I'll hand over to you. Thank you so much for being here. Uh, that's okay. Hopefully, you can. I didn't catch the be any of that. So I have to change the settings again So you can hear me now? Yeah. Okay. Good. Um, so, yeah, I had a little everybody. Um, thank you for inviting me to speak to you about the topics of getting involved in queue. I So I'm, I guess, to start off with a pill a little bit about myself. I currently work in three different jobs. So my clinical job is as a consultant in emergency medicine in case I be on within the same organization and associate medical director. The quality management, which means I kind of oversee a team, helps conditions who are trying to work on more complex is a Q. I work that kind of cross across many different clinical teams, ready to community into acute care on. But I just heard. And also the clinical leads to the stop. This quality of fellowship program, which is a which is a teaching program for conditions that aims to train them up to be leaders for quality improvement on, has not just Scottish have Scottish participants. And also, once you got married in Denmark and your weight on occasionally have had people who elsewhere, even England, but also New Zealand, Canada. So because you've been on the job title, I guess Where do I work? I work in Scotland about blue areas in the middle. There is hey, Borders. If you like it, there's a large geographical area with in Scotland, has a lot of reality that a lot of real populations but also has, um, the the major city personality within the region. But believe the major city and then the is a 50 off extremes. It has extreme issues of poverty. The drug issues has, well, the highest drug death rate. Um, in Western Europe, um, has developed a real reputation around dying the first day in a from outside or London that you see in the top left of your screen. So it's a fair bit of variation in terms of what I have around me. So your job title of a soldier wear a workout, told you much about myself again, just having her to speak about herself. That's pretty well doing a little bit about. And maybe for this audience. One of the things would be the how badly I answered my question. When I tried to get into medical school rush time around, I didn't get in first time around on that question is, why do you want to do medicine? I was 18. My hunter was awful, I think of sooner versus the interview. But anyway, moving on from that, why should have said, maybe give you a bit more insight as to where I throw them in here and So what I should have said, um, I really committed to mention, um I have what really hard overcome. They're kind of bullying that sometimes comes that still is where academic achievement isn't valued. It was unusual to go to university from school. I was in London. You have to work really hard so that you're committed to working hard when I got the job. Um, I wanted Teo. Obviously, it grows to make their parents proud. I guess that my my mom and dad pictures from the in the fifties. I reckon woman Dad came over from India in the early fifties that you may ask that he got married. My dad came over and a year later in the month came and joined him. Um, Andrea, they also instilled within the, um, a sister kind of work ethic on, you know? So the importance of the king after people around you and actually have also mentioned my uncle he was a surgeon who were in India. The urologist, um, Andi met mentioned how in the young boy I saw the power of medicine or the power it had to impact on people's lives so he would deliver three treatment to the poor and needy in in the city that he worked in. And you could see the impact of that and how much people valued that. So that's what I should have said. Hope you. It gives you a bit of an insight. My background. I didn't say that I didn't get in, but then I got in eventually. So it all in about in one about one in here. So why you question is what I want to start off. It's getting involved in Cuba. I in my mind what you should is want to be involved in She, Ryan want to be involved in to you. I really have a have a high. So why do you want to be involved in cure So, doctor, just by showing you why the Academy of Row Colleges think she should be involved in Cuba Um, it recognizes the fact that students in his junior training we really still focused on how we improve our individual skills. Our knowledge, our our ability to diagnose and choose the right tests, etcetera for an individual consultation with this patient, actually understanding how the system works and how work is done is massively important to how how effective you feel that work. Um, so actually understanding that why the system is really important. And that's where cure. I have a skill that shit's not to think about, um, and talking about the system. Healthcare is often mentioned as one of the most complex working environment anywhere. Um, is hugely complex. Put a few things on the right, but not just such a surface. Multiple different staff bruits that we have doctors nationally. HP es have paramedics. We have, um our teams of admin support. Our reception staff are domestic staff. A portrait is that one of them actually do impact on the quality of care that we deliver and all of whom actually have to come together to deliver high quality, not purely about the technical knowledge and skills other society of the other. In the wider context, we have seen science advance over the years, thanks to all of those academics, Um, we therefore seen the ability to diagnosed disease improved with also seen a number of the DJ can diagnose increase. I'm actually what you been start to see is people who are collecting conditions that they go through life and the number of conditions that you have A you get older goes up perfect 30 or 40% of those over 70 years taking 10 medicines or more. And so therefore, it's not quite the same as saying Well, you have been changed to diagnose one condition in one person and treat that in its on its own in isolation, because that person will have multiple other conditions with multiple other medicines and introducing new thing into the mix. That suddenly becomes more of a balancing act where you actually need that person to be engaged in their own healthcare and their decision. There's also the financial pressure, the political pressure on the general public expectation is healthcare. Never. We've never out of the headlines for long. That's where there's a level of pressure that comes when you try to manage that. My system on the way we developed our desire to manage care is that we have really started to increasingly think of it as a machine. Um, so by that I mean that we believe healthcare can treated in the same way as a machine where a machine is the exact some of its parts. And if you reduce it a lot down to the various processes and bits and pieces within that machine. If you made every pit of the machine working efficiently and effectively as possible, then that whole machine would work amazingly well. Well, you need to do is find you in the process, is, um, and on and possibly set targets for people to achieve. So we see that in day to day life in terms of how we manage healthcare. I guess the problem with that is, if you think about machine or a factory where you have a conveyor belt coming down the line and everybody around, that could be about a trained to do the one thing that that conveyor belt need to do. That's just unrealistic when it comes to health care, because the other basic level, the units on that production mind, are all standardized so that the people have been putting together and create get something. At the end of it was in healthcare. Our unit's a patient, Um, are you know, it's not standardized, so our unit might be somebody that is from an accident minority taking 10 different medicines or not from an ethnic minority and I've taken two different medicines, but they're very, very just not the same. And that's where we start to hit the buffers in terms of thinking of healthcare is purely a machine. So, really, if we do treat, there's a machine and we do treat humans like units, actually improve efficiency because that's what we really aim to do by treating things as a machine. And actually, no, it's a straight answer to that. If you look at studies, um, what were guilty old is over treatment, failure of care delivery, saying there's a care coordination that create harm, that we then have failure demands where we actually have to make up for the harm that we've created and that uses more resources. Um, just a couple of, um uh, deference is at the bottom of this slide, but there's there's more than that. There's also from the ECB, and the estimates are we have we here lot in the news about financial pressure in the NHS on boards or trusts would go into special measures if they're 5% over budget. Um, actually, these papers suggest anything from 20 to almost 50% of what you spent on healthcare add no value. So 25 50% of what we spend is adding no value because of in large degree that things are listed on this flight failure, delivery, failure of coordination over treatment, but not involving people in the decisions about the care. And they're not very efficient about delivering security. Improvement has a role in addressing that. And I consult you in terms of statistics on it, maybe of some level of interest. But it might know connect with why you should be involved. Why you should be interested. So let me start to talk about my why, if you like and White why this is important and try to illustrate that I want to illustrate that with that a patient story on but not some random old Asian lady that I've decided to take the extra. This is my mom. This is cancer. She's 92 years old. She's had both knees replaced. She walks with a frame on. She has high BP, so actually she takes fewer letters than 30 or 40% of people in her, um, age group. If you saw her in the past goes, you were sitting on a walking frame. She would probably have somebody with her. Just a wonder around. Test goes with her just to help out with the shopping. My sister, usually about my mom made me. In this case, since you're visiting here in hospital getting the occasional iron iron infusion because you could get it and make it times on, show these pictures to submit the students locally instead of having you characterize this person on. Do you know what we would expect is what they said frail, elderly Asian difficulty with mobility would need help with this would need help without Blakely. Have some sort of personal care on that In some ways. Start to demonstrate the problem that we're in, where we are, assuming that she is that unit that's going to come through our healthcare. There's an actual fact. She was affected by the pandemic. She similar lots of elderly people. Lots of people from the world had a stroke, Didn't leave the house. Thanks a lot down. Was nervous about leaving the house. Nervous about going out all she noticed that that was leaving for her doing more. I selected on her what we call deconditioning. Um so her UM her physical condition was becoming worse use not a strong as she used to be. So she took the choice. Teo. Then engage in the morgue. Digital world and hep contact with us. Get contact with other people in the UK and in India via What's that messaging? What's that? Videos. Ooh, coals in the middle. That that's a That's a picture of this year There on on the Left is still very good at directing the camera after self, but we'll forgive that. The MS picture in the middle is her joining her zoom group of armchair yoga enthusiast. So she took that up on our two hours a day over the past. For the last 23 years. Now she's been doing that, and she was also then inspired by captains at home, and this is her wandering around a sister's house. She chose to be as mobile as she could be, so we don't see that when we just see her sitting on a trolley or in hospital receiving treatment. We don't recognize how engaged years in her own health, how committed she is improving her own health and being a part that the decision's made about, um, so I'm gonna continue that and tell your story that she had. This is last October. Now, what's a list? That the purpose Italian. The stories really illustrate those things around over treatment. So you can't delivery etcetera. And what impact that has and how well we spend our money in the healthcare. Friday eight of October, some of them after a few more laps of the house, I suspect, because she was aiming to get the main 1000 steps a day, Um, she developed pain in her right knee. Now her right knee is her Achilles. Few. Um, she has had a replacement in that knee, and the vision is that usually the peri perspective structure and then treatment sepsis in the joint following that revision. So that was a few years ago on Ditzel. Been fairly quiet since then, but it's always been in her weak spot, So she was suddenly unable to weight bear pain in the knee, looks swollen, didn't read it wasn't hot to touch. She hadn't had an injury, didn't have a king her she wasn't unwell that such you're needing a fair, better help to get up and get to the move. My sister was at home with her, and so she managed her over the weekend because obviously healthcare isn't as easily accessible over the weekend. Come Monday, shows D P surgery on the GP uh, willing to do a home visit. But the way that things work at that point in that surgery, she had, uh, get a paramedic to come and visit their homes of their race through visit. Not that day, but the following days. On the Tuesday um, the paramedics came to see her on Be looked at her knee So that swollen that said they wanted to have a have a next Ray. Now, to get the X ray, they sent her to the emergency department of the major hospital in her region, Um, where she the e g staff saw her again, Breckin eyes that she had a swollen knee, performed an X ray and also took's, um, love. They then referred us to pedic, regulated the complexity of her knee. Um, orthopedics didn't think they have anything to do with that, and they referred that medicine on medicine, chose to admit her, um remained in the emergency department or light waiting for the bed in bed on the following morning was given a slice of toast for breakfast. So we're now into Wednesday. So Wednesday she moves from a knee, too. A medical admissions unit not seen by any medical staff for that day that is moved to a general. Medical wards haven't gone through the medical admissions units where she probably had the same blood taken again, Um, she was off of between a sandwich. Interestingly, enough hormones, even having told everybody that she was vegetarian on. So the authority in the sandwich says, I can't eat that, and so they didn't have anything else to offer. So I think eventually someone brought her complain. Boiled pastor to That was her anemia on Wednesday. So we moved Thursday, first day she has seen on the ward around, and she's told Marty really speaks to her from what she reports. But she's told that she's going to be seen by a physical therapist on doorstep edicts again, Um, so you can see, uh, strangely enough, without Thursday, That's six days after the initial issues. She's been in hospital for two days, and she's now just recovering on our own. To be honest, because nobody that you've done anything is not getting the treatment of such, um, and she's been able to wait there and with managing to walk in the frame. Um, but what? The pedic didn't come. So no other decisions you made. We had moved to Friday. Try. They want to be a bit come on, because she is now able to walk that there's nothing else I needed to do. Um, two doctors can see her right there on in the morning, Um, and said that she would be kept in the hospital without any explanation. I'm gonna come back to that conversation in a minute or so. So I became systems told that she was now going to stay in hospital and that Parliament should be in hospital A. We can. The way things work. Um, so she wasn't happy about that? I wasn't happy about that. We both wanted her home. I just was more than happy to look after her home, and she was actually able to walk several calls. So I try to speak to the consultant. They were too busy, but I asked for the doctors on the ward's. They really team meeting. It couldn't come to the court. I then I asked for them to call me back. So I have a detailed taken and nobody in the in these real cause I was making in between seeing patients in the, um so nothing really happened. And then suddenly, eventually, they having had a lot of pressure from us, they agreed the letter home. Finally, she was free with your street to go home. That was three nights in hospital, um during which is difficult to know what was actually done. So if I look at this time by of what I feel was offered, let's just say that there's a face to face a specimen CD assessments, orthopedics, met, medical physio. Nothing cares. You, um that may or may not have needed nutrition in hospital communication with her and the family and the passenger. I have to knock off the things that really I don't think I did anybody. I don't think he'd be out of any value. She's already been seen people with the new shot is for me. She didn't have an emergency. She didn't have a medical problem. She didn't need. Nursing care should not receive that much less in catfish didn't need it. She wasn't offered nutrition in the hospital. She had passed out and there was no communication of anyone. So what? They're But that is ideally, somebody should've seen her face to face at the time. So her pathway should have been radically different. Probably should have been a GP. Seeing her face to face contacting orthopedics directly may be arranging an urgent clinic. Same day critic her to maybe get an X ray at that. Same they could it be seen by orthopedics if she needed a night in hospital. Fair enough. Um, but under orthopedic care, rather than on the medical care where she received other tests that weren't necessarily so over treatment potential. And that's where Q. I start to potentially haven't impact. If you can get people together to consider these pathways and make them more streamlined, have less wasting. Then we are been starting to use our our resources more productive. And what about the usages? Let's go back to that conversation on that final day. This is interesting. So the doctor came seen on one. Well, we want to keep you in hospital. So which Mom said, Well, why would you want. But why? What you're going to do for me? Well, we just want to be careful. Really. You aren't doing anything for me. Uh, no one comes to see me. You're not giving me any treatments. If you want me to stay, you'll need to tell me why No one seems to want to do that. This is her record in about conversation comes back. And it is your son. Adults. Uh, he seems to want you to go home. So obviously a message have been passed, You know, in doing yourself now, people by then, yes. He's a specialist in any, and he knows what he's talking about on. My daughter also knows what she's talking about. And she knows what I need in terms of what I need for help. And they both look after I would like you to stay. So they doctor his name? I don't know. Still, but why? He wanted to stay. You'll have to You have to tell me why and I will consider staying. I think you want me to keep me in hospitals so that you can tell the government that your soul and cannot take any more patients. Yeah, I've read about how busy in it gestures and how difficult it is to get a bed. So I want to leave. So someone else could be treated too rich. He just left. Um, and in some ways, those final statements were about I really good indication of why we need quality improvement. And I'm not trying to be down on the people that drink after my mom because I suspect they were running around between wards between patients trying to make decisions in this ball. You know, people coming through and try not to make a mistake. I've been trying and hoping that she wasn't going to go home and fall and then injure yourself and come back in trying to do the right thing. But really, the stress probably and really running around trying to say that individual they are bad people, that the system, the system and ended up with her being a hospitalist didn't need to. What's the impact about system on the stuff for the impact That that's just working in that kind of system is that you don't actually feel like you're in control? Um, six. Don't feel like you're in control, and you feel you're overwhelmed with work and the work you're doing. I feel like the work you were trained to do. Um, you're not diagnosing people. You're just performing tests and you're trying to process people that starts to lead to people disengaging from their work. And if she's not disengaging for you, what is a high risk of burn out and you and you don't end up feeling all of these things that you see on this side But you I can help with about because you like it. I'll just get past this one. But you I can help about me this cute. I really encourages you to work together as a team that where you come come together as a team, the process project, and you engage potentially with lots of different professions with different specialists and different Eames, uh, on with patients back in the really challenging. Um, ultimately, it could be very rewarding because you can see things change, and you can feel that you've actually had an impact in that change that starts to reverse that sense of disengagement from your work. And yet and you feel valued that work again. My fly in terms of why I think why I am involved in Cuba, because I don't want to be a process of of units. I want to do the job that I trained. So I want to feel like I'm a good condition making clinically important decisions with my with with patients, Um, and in a way that that improved their outcomes. Um, and I want the people affected by the test of your values by the nature. And by that I don't just mean patients and relatives. That means we're colleagues that offends that work. So those are the reasons I think I'm engaged in cure. You'll have to find your own. But it's important that that is a question that you ask yourself before you're really getting involved. So it's like a little bit about how here I can create change what other kind of methods and some ways not gonna do a empire talk in the next 10 minutes on the methods Accu. I run a program that that spanned the year, so I'm not going to pretend that can convince the info to side um, essentially cure I attempting to improve clinical outcomes and improved clinical experience, um, patient experience on by doing so make the process of delivering healthcare more effective and more efficient. So we use our resources more or efficiently. At this point. I need to play that Q is not Hold it. Um and I will show this, which is the view that again, the Cabinet roll colleges on the stent the up until now and still now Chinese and students ah are encouraged to form critical order it even that which is not you. I even that has become a bit of a token efforts on it, simply data collection. So you are not cord it. Try to explain that using some an illustration, if you like ever of measurement. So this is, uh, a fake study to take points of order it, um on. But let's just say we recorded it at a time. One on the audit cycle time or whatever is we're testing and order thing. The cycle time. 70 minutes will be performed. Our first order. Now the gold standard is that it should be 20 minutes. So we think, Oh, that's not great. The order has shown us that we're not performing According to gold standard, we have to do something about it. So you kind of go away and you try and make a few changes. There's often more than one on. Then you and then you come back and you really it. And often as trainees on students, you only really be involved in one of those. Or if it's the only really be involved in the order that showed that the thing was 70 on then. You're really lucky if you go back and really it for another group might come back in the order. On the real. That shows you that things have improved, um, and they now 30. But that doesn't have to study what it is like. Taking a picture of that is to snapshots, either to snapshots taken at two different periods of time. So I tried to illustrate the difference between order queue in terms of measurement what you see on the right now, three grounds for a three run chart off the same three different potential stories of the same results. So going from 72 30 in the first example Unit one, what you see is that the average ahead of the change was 70. We then annotate this monthly beta collection with what changed we put in and you see that there's a step change after that introduction of that change and then after that step changed the performance has moved on, assisted and is remain around 30. So the step change here has has the results of that change that you put in an example to what we have is a unit that was generally improving, but it went from 70 to 30. It genuinely gradually improved. Your change happened here did not make any difference. So the change is not that that the improvement isn't on a result of the changes that you've tried. Something else is going on. They improve that that's improved performance. Certainly. Maybe you've gone along at 70 you've introduced your change here has been an improvement on the average. Here is 30. But actually, what I'm seeing from the trend is that things are getting worse again. So you've introduced to change the meds to an improvement, but that improvement has not been sustained. So hopefully you get feeling for that that you I actually gives you a story, not just a snapshot here. I gives you a nice idea of how your system is working, what impact your changes had on. But it's It's like a movie rather than that picture. So within a Q I project again going back to the colleges, they feel that Q Y is important. Because of this. I feel it's important because it encourages you to have a better understanding of the complexity of the health care environment. Mentioned that right in the beginning, how complex health care is. I'm on it and it gives you that through system a systematic approach with a number of different tools that you can use the ads Rebus nous to those methods on robustness to the change that you're trying to bring in. Encourages designed thinking, encourages testing, encourages the implemented Implementation has changed in a proper manner, evidence with really minor measurements, and it means to make a difference. The patient that I would add colleagues by improving faithfully effectiveness on the experience of care there are for this element I would speak about. So I guess one is that we ask people to focus on quality by using your eye and his focusing on quality, asking you to think about weight variation in your system that creates failure and create its own demand. The asking, You think in a structured manner about the aim of the project that you're working on? Um, we then giving you tools to help, not the process. Construct drive of Bagram, listen to the customer test, changes measure and then influence others. The big thing that your eye is that if you really get into it, you start not to create leaders because you have the influence. Others you have to manage change. They have to manage resistance. The time. Lots of tools to be used along the way. So a couple of examples just finish off first. Very much example of work done in collaboration with medical schools. We published recently in the BMJ about the undergraduate approach to health care improvement that we take in PE sites. So the University of Fundi and myself with it and our team within it it just tasted work closely, rip students and connecting them. Two. Q. I enthusiastic the system who then provided with real world experience through out there training from year to away through, including if I wanted to those practical experience, so an example of that within the way had a project where we brought design students together with medical students to look at the experience of care within our emergency department. So this is the emergency department pre any change. We asked them really to speak to our patients because it's difficult for us to get the pain to do this kind of work. But speech our patients and find out what their experience was of care in the department. Um, and we're expecting comments about the quality of care, the interaction with staph We didn't. We got holy positive feedback about the quality of care in the interaction of staff, the manner of people with people. The negatives was the waiting room and how boring it was weight. People understood they have to wait, but it was dull, and it didn't know what was gonna have to mix. So, actually, using the design, students on the medical students together unlocked lots of interesting thinking about how to describe what happens in our department on. So we moved on match now having a lot more interesting. That way you can go. We designed a schematic that describes the flow and the process of going through an emergency department. You can see it describes. Check in how you're going to be a test for investigations and outcomes on how what we have. Different people correcting by ambulance or walking in the different types of problem the green. So it is very minor injuries, more majors and then resuscitation even describe in the process of re directions. If you come to the evening on, we're not the best people for you able directly elsewhere. We described in uniforms people wear and what their roles are. There something to read that prepared you for the next step. And then we can color code different areas of department to match the streams. Okay, down very well on bit was done by teams of medical students of design students who engaged, and it really felt that everybody was really getting getting something positive. The other one's a bit more ward based on junior medical teams, so blood culture contamination is an issue. Three. False contamination for positive results over treatment. The antibiotics increased testing down the line on an issue international standard. The contaminant rates are acceptable contamination right to 3% River. Told by our labs that we were sitting about 6%. I think it was. So we used design thinking, which is the double diamond approach here, where you really ask people to discover what the problem is by aging. With teams we engaged with our junior medical staff to say, Well, what's the difference? What's the problem? And they said, Well, all the equipment is everywhere, but wonder around everywhere, and I've got nobody put something when I want to sit down and do the blood culture got notes, tray or anything like that? Yeah, the nurses. Why in a store? White things start the way they are. And we then brought together healthcare support workers with the junior doctor to create the puncture trolley that has everything in one place. You can real around clear instructions on the trauma as to how to do but cultures, in case you forgot, um, we saw number attack. Don't have to read the side in great detail, but there are a number of tests on the way. This is a run chart number of tests along the way. Think to this chart progress where we went from what they were 6% about 5%. All these tests change nothing. to come together. These maybe are high impact changes, and they brought the performance down. There was an occasional point out here where we found that we had and out liar that we were able to describe that in the chart that was a failure of induction. If you like, actually back into a more reliable induction process, we were, well, I'm under that 2% on target. So there's a couple of examples that how even at the level of being students or Junior Cheney's within teams, training doctors, teams, um, you could still be involved in quality improvement. Just gonna stop the wrap up now. And this is a very famous quote, Um, which is, I think, really pertinent quality improvement, Uh, which is that everybody in healthcare has two jobs. Um, when they come to work, wonders to do their job, to do their work and the other one is to improve. It's not genuine. Me feels right to me that fuels the way that people that that resident nights with how my colleagues feel you come into work and see something that's not right. You want to improve that what we need to do is to give people skills and support to be able to do that on their own and not see quality improvement of a darker that only have one or two people are qualified to, um, perform. Finally, cross improvement is about improving a lot in the lower airways. It's about reducing waste it without looking at processes of commission and say We could do this better. We could cut up, step out, get up this help. But it should also be about how you engaged with your user. That should also be about improving that journey. It should also be about not seeing somebody as someone who is, um, frail, elderly in need of support all the time, actually recognizing the person underneath that. So she asked my mom. That's the moment the last thing she went to in India for today. So we all have a character, and underneath on, we need to recognize that we need to produce processes that are standardized to a level but have the ability to recognize the unique characteristics of of the patients that we deal with. So thank you very much. Thank you for inviting me. I hope you enjoy the rest of the program. Um, Andi, I am happy if there's pain with those questions I'm happy to take. Um, now, before you see a coffee, Amazing. Thank you so so much. That was really incredibly interesting. We've got already a question in the chap. I know. I've got a few, so we'll spend a couple of minutes doing it so that we don't, uh, take your coffee break a swell on. So, um, Ali has asked on you make a strong case for doing Q. I get, perhaps not enough done in practice. What do you think of the main barrier is preventing people doing Q. I projects well sustaining changes from previous interventions. And how come you overcome them? So I think there is a bit where people within the Q. I community have been guilty, making it seem like something really sort of exclusive. Um, if the whole jargon loaded language behind it, there's really jargon. It stick on disengages people. Um, so I think we need to be careful people that are engaged in trying to be really careful not to use that in different people. Um, I don't think everyone really understands, so that the fact that you I have some fairly robust methods behind it if it's done properly, and so when we try it, we don't try it sometimes properly. And one of the key things is trying to see what's what. Pressure said. They have their own. We need to think about mentors. How do you connect with those who actually understand what you guys about? Um uh, how do you have had you therefore have someone that's going to guide these projects on once you? So there's a There's a bit within organizations where you complain people towards training so you can train yourself right? So we have three. In Scotland, there's an online portal. We can go in and do basic training within our department. We run team based training events where you come as a team, you get several sessions and you broke through a project, so that's important. But there is also this idea that those you know you should be out there coaching and should be out there mentoring others. Um, on what you find it in departments where you do have those mentors on some people with experience on came to help with that mentorship role. They tend to be the ones that have embraced Q I and there's got numerous projects running even if they're busy. So the E. D is very busy environment, but we still manage to have que i project rather wait staff engaged in the queue. I put it, um, so it is possible It's not purely just about pain. It's about it's about paper bility. Um, and it's about mentoring. Amazing. Thank you on. Got a question from gonna swell on. Thank you for the talk to you. Have any advice for identifying with a Q I project? They're likely to be tokin ist IQ or will bring about more meaningful change. Ask your team and ask your patients. Could be the thing. So you saw it briefly. I went past something called the Double Diamonds. The first part of Double Diamond, which is a design thing. Service divine to is discovery on Discovery is around really engaging with those who are affected by the process. You're looking up so initially, the problem should have come from them in the first place. You shouldn't be going down and saying I want you to so sometimes you have to, um, encourage people focus on something, but really, you have to engage with those who are closest to the problem on. Then, if you're doing that on, that's the full range people, not just the medics involved with the problem. Um, if you're doing that properly, then you will construct a project that means something to then, um and therefore no shortness time breathing. Thank you, Andre. Got another question from a new, which is a little bit similar. Um, which is, uh, sometimes in departments, there's lots of lots of things that could be improved on. It could be a bit overwhelming in terms of choosing. So how do you pick which area to improve? So sounds like we kind of answer that. But is there anything you would want to act about? Yeah. You kind of depend about that a little bit. We've answered it. So some of this about depends Accu. I links in the leadership quite a lot. I think so. Within departments there, there's lots of things that need to be improved. The leaders of that department should be taking a lead, um, and deciding which are the highest priority. Um, and there are ways of doing that. Even even if you take that to one side, she's got a number of potential problems within the department or number of potential issues. There are ways of describing what to focus on first, this ways of even using data. Um, you could use data to do what we call people goes jargon, parieto analysis or an 80 20 analysis is a lot often what we What we see is that, um, 20% of the problems in a system are causing 80% of the activity, So these 20% of things are sucking in 80% of resources on activity. So, actually, if you have a list and you can identify the top 20% these are the things to go focus on first, not to say the rest of not important, but you do have to prioritize in somewhere another so about leadership. Part of that is part of it is understanding data on understanding what it's pointing towards. Amazing. Thank you. Um, so, um, so, actually, I've got one more question on. Then we could do a break, if that's all right with you. Um, So, uh, but thank you for sharing the story of your mom. I think it was a really, really thought provoking encounter. I'm sure we've, um also seen a lot from the from the doctor side rather than the family slide on. Down on what? My question was, Have a couple, but I'll choose. One was kind of around. Um, I think minorities in academia, which is probably a little bit of interest for myself as well. Um, did you feel that there was any kind of difficulty with you getting involved with things like system change or writing papers or wanting to get involved with outside of things outside of just clinical practice? Well, in what way do you think in terms of on, perhaps to do is, uh, like ethnic minorities? Maybe not seeing a Z. Any people like yourself in those rules. Was that challenging? Ah, yeah. So I think I think it is challenge. I think so. I think you do need to see yourself in some of the people around you. You do need in a very basic human trait. So you kind of you need to see on diversity in the leadership team. Good that you look at and on those people in power. If you like someone was need to see diversity there. If you believe that, help you believe that you cannot see progress, that helps. But it's definitely to do that because I didn't see much of that managed to progress. But it does help. Um, I think, I think a kind of feel that they think some of the opportunities around academia and research in this kind of stuff, Not sure how much of that. I didn't really engage because I wasn't not interested in it. To be honest, I didn't have the activities about, or whether it was anything else and sure that it was anything else. Do you see is when you look at academia and you look at guidelines that come out and you look at even Q. I projects that we don't engage with the kind of people at. It's not even the margins. We don't engage very well. The people who have who are not the kind of white middle class. A lot of our guidelines, every space medicines mentioned you're on on evidence based medicine is about looking at guidance and guidelines and publish material. But if you really look into some of that stuff, the guidelines of treatment are based on research that's been done in a very select group of people and often don't involve the elderly because they have to any code morbidities don't involve the poor because they can't engage in it. Don't involve ethnic minorities or people with very English isn't the first language. There's all sorts of things where, actually, we don't appreciate the diversity of the population. We're trying to help, Um, and that makes our our change idea is weaker. Um, because it hold, um, I mentioned beginning that buddy has a problem with drugs and drug there. Um, you know, the Q. I attempt in that world, they're going to be challenging, but we need to get into that world. And by getting into that world, we need to engage with those people know, produce a middle class solution, the problems that they think that they see a ton of them. Um, so I see it. I don't know how much I really see it in myself, reflecting on my own progress in this kind of fever. See it more in and the work they were trying to do? Yeah. Wonderful. Thank you so so much. I think we will head into our first break. That s Oh, thank you. So, watch of the topical on, uh uh, probably national their talks this morning on so on. Thank you to one of our attendees sticking with this this morning. So we're gonna have ah, cooperate. Um, for the next 15 minutes or so I'm and then you guys can also head over and have a Have a look at the posters in the post hole on. So, as your viewing, you should be able to see a tab on the side, which takes it to the post. A hole where you can have a look on You can interact with them, but comments like them all that kind of stuff. I'm unhelpfully. We've got our presenters active to answer those questions for you on. We'll see you back here at 11 a.m. For our next talk, which is getting involved with medical education from Mr Barry. Thank you so much.