The Kent, Surrey, Sussex (KSS) heart failure collaborative aim is to improve heart failure care across the region and use the NICE clinical guideline for chronic heart failure as the basis for standards of treatment required across the region. In anticipation of the new guideline, published September 2018, the collaborative steering group arranged a meeting of primary and secondary care heart failure clinical teams, commissioners, quality managers and GPs to help understand service and pathway changes that may need to change in response to the updated NICE guideline. A World Café approach* was used at the meeting to explore challenges for the teams implementing the guideline and to identify how the collaborative may support teams to overcome these challenges through quality improvement.
“A World Café is a structured process for sharing knowledge where groups of people discuss a topic at several tables, each table has a host to facilitate the conversation, and the topic discussed at each table is changed periodically".
Aims and objectives
- Provide an opportunity for learning from others
- Help understand the breadth of the patient pathway
- Bring together the heart failure community including, clinicians, commissioners, primary care, secondary care, auditors and managers
- To allow individual providers to identify areas of good practice and what others can learn from this
- Identify key areas from the guideline that may prove challenging for local teams to implement
- Enable teams to critique their own service against the NICE guideline
- Identify common areas where services are not currently meeting the NICE guideline
- Identify and prioritise issues that matter to teams
- Help understand unwarranted variation in services across the region
- To help teams understand the quick and easy solutions they can implement to solve service problems
Reasons for implementing your project
- We have an established heart failure collaborative in KSS and a dashboard developed with the KSS Academic Health Science Network (AHSN) that reports on an agreed set of quality standards. To date the collaborative has met annually
- The focus of the collaborative event was implementation of the new NICE guideline. Invitation to the event was extended to heart failure teams in KSS and targeted invites to commissioners, GPs and a patient, who were felt to be previously underrepresented in the group but who are important stakeholders to the improvement process
How did you implement the project
The collaborative event started with a presentation of the new NICE guidance by a member of the NICE heart failure guideline committee. There was particular focus on the key changes in the new guideline and the rationale for these changes.
We had previously agreed 6 questions that the steering group felt would address some of these changes. These were likely to be areas services may find challenging thus allowing discussion around challenges and implementation.
Questions for the World Café tables were:
- The guideline states to measure NT pro-BNP in suspected heart failure – how is this built into patient pathways currently for outpatients and inpatients?
- How do we ensure timely echo and specialist assessment in suspected heart failure?
- How do we work towards the recommendations for extended first consultation within 2 weeks of diagnosis and follow up within a further 2 weeks?
- The specialist heart failure multidisciplinary team (MDT) has specific roles in the guideline – is this happening in your area and what gaps do you have?
- How do we implement 6 monthly reviews of patients with confirmed heart failure?
- What access to cardiac rehabilitation do you have?
- Instructions for World Café:
Total time for the world café was 90 minutes. Collaborative members were split into 8 groups (10 per group) and each group were given the opportunity to address all of the 6 questions (above) with 10 minutes allocated to each question. Collaborative members were pre-assigned to tables to ensure a good mix of teams and roles on each table.
Each facilitator had a designated question and moved to a different table for each round with a flip chart for note taking.
The final 30 minutes of the World Café was used to draw together the themes raised by the tables for each of the questions with a panel feedback to the entire group of the headline messages.
A more in depth review of the World Café discussion was then undertaken by the steering group to identify the quality improvement projects to take forward to address the common issues, and leads for each of these projects.
By way of evaluation participants were asked ‘What did you find most helpful from the day?’ and this has been presented as a word cloud in which the most frequently cited words appear largest (The word cloud is attached). The World Café featured prominently in this feedback from participants as being helpful.
- 6 quality improvement projects have been identified as a result of the World Café discussion and will be reported back to the collaborative members to help support local improvement. Each quality improvement project has a designated lead and will report progress to the steering group.
The projects identified are:
- Develop a collaborative recommendation for the acute and community settings, for NT pro-BNP testing. Test use of the recommendation in one or two areas and demonstrate any benefit/savings
- Develop a heart failure group education toolkit for patient education
- Undertake an audit to gain further understanding of MDT working across the area (whether happening, frequency, MDT members attending, what works well/key challenges)
- Explore the use of a polypharmacy review tool to identify patients with complex medication regimes and/ or non-adherence who may benefit from pharmacy support, for the MDT in primary care
- Undertake a focus group to understand issues around 6 monthly reviews from a primary care perspective
- Gain further understanding of cardiac rehabilitation provision and uptake across Kent, Surrey and Sussex
Key learning points
We found that the World Café was a really useful process for facilitating discussion.
Our experience of running the World Café provides the following learning points to share:
- Using the morning session for an overview of the NICE guideline was important as this ensured all attendees had had an opportunity to hear the key changes in advance of the World Café
- Good facilitation is essential
- Have clear questions but allow conversations to flow
- Organisation and planning is key
- Timekeeping needs careful management
- Mixing teams so they meet new people/professions was useful- allocating people to tables rather than a free choice in seating was beneficial
- Be clear at the outset what you are trying to achieve from the 10 minute discussion
The British Heart Foundation (BHF) has been supporting the KSS heart failure steering group to lead improvement for the collaborative. They helped the steering group identify the people needed to be part of the World Café discussion, and to set up and facilitate the World Café. The BHF also funded the collaborative meeting space for the World Café.