Healthcare Improvement Scotland Blog

Being aware of your unborn baby’s movements can save your baby’s life – Anna Todd

Posted on February 26, 2020


I’ve had three pregnancies and I have two children. But I see myself as having three: Rosie, Alice and my son, Scott, who was unable to survive birth.

Every year we celebrate Scott’s birthday. Five years on and it’s still emotional for us all. We take a wreath in the shape of a boat to his grave and we release balloons. We celebrate who he might have become and what he might be doing now.

But in many ways, Scott does live on and not just in our hearts. Our losing Scott helped save another life: his little sister Alice, who is now three. I like to think he’s saving other lives too as I work with various organisations to help spread the word about the importance of mums-to-be paying attention to their baby’s movements in the womb.

“The loss is indescribable. So much hope and expectancy, which grew alongside our baby growing in the womb, were all taken in the blink of an eye. The sense of profound loss was horrendous.”

My first child Rosie was born in 2011. After a textbook pregnancy I found myself whisked into theatre at Wishaw General, my baby in distress. Rosie was eventually born as healthy as can be. I however needed physio, treatment for an abscess and counselling for post-natal depression – all within a year and a half after giving birth.

By 2014, the trauma of Rosie’s birth behind me, we were ready to extend our family. Again there were no issues during the pregnancy itself, but complications arose during birth, caused by what’s known as an incompetent cervix. The condition affects 1 in 100 pregnancies and means that the body can’t hold the baby anymore. Scott was delivered stillborn.

The loss is indescribable. So much hope and expectancy, which grew alongside our baby growing in the womb, were all taken in the blink of an eye. The sense of profound loss was horrendous.

The care from staff at Wishaw General Hospital after we lost Scott was extraordinary. The bereavement care available to me and my husband Stuart allowed us both to find a way to move on. Everything in the care I received was tailored to me. I was treated like a person and nothing was too much to help us come to terms with our loss.

The counselling did its work and a year later we were both amazed that we wanted to try again.  I became pregnant at the start of 2016.

After what happened to Scott, the pregnancy was naturally an anxious one. During my baby shower at 34 weeks, I was suddenly aware the baby had stopped moving. With the loss of Scott, I was acutely tuned in to how my body felt and knew something wasn’t right. Over the next 48 hours, movements were sporadic and I was in and out of hospital as the baby was monitored. It was my acute awareness of how my baby was feeling that saved her life. The hospital staff listened to me and they were receptive to my needs and concerns. After it was discovered that the baby’s blood pressure was dangerously low, an emergency Caesarean brought baby Alice into the world. At 4lb 14 ounces, Alice needed a lot of help after birth, but now she’s as healthy, amazing and troublesome as any three year old!

While the number of stillbirths has reduced in recent years, in Scotland four babies a week are stillborn. I’m delighted the Scottish Government’s Stillbirth Group have launched a new campaign to raise awareness of the three key ways expectant mums can potentially lower their risk of this happening to them. Being aware of foetal movements is one of those ways, along with sleeping on your side and stopping smoking.

“If I had one piece of advice, it would be for mothers to trust their instincts and their sense of their own body. Your baby talks to you through movement, so be prepared to listen. You could save your baby’s life.”

I’m so happy that the importance of being tuned to baby’s movements in the womb is getting the national importance that it deserves through this campaign and the work of the Scottish Patient Safety Programme’s Maternity Care Programme. Since Alice was born I’ve found myself working at times with SANDS Charity (Stillbirth and Neonatal Death Society) as a befriender to help others through the trauma of stillbirth, I’ve spoken at the Royal College of Physicians to help develop a bereavement pathway, and I’ve spoken at midwifery conferences. It all helps with the permanent sense of loss to know that others might learn and benefit, that losing Scott may be helping to save others.

If I had one piece of advice, it would be for mothers to trust their instincts and their sense of their own body. Your baby talks to you through movement, so be prepared to listen. You could save your baby’s life.

Anna Todd is a mother of three and a befriender with the SANDS Trust.

For information on work to prevent stillbirth in Scotland, visit:

SPSP Maternity Care Programme: ihub.scot

Advice on preventing stillbirth

Categories: ihub

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Safer staffing? Call the midwife! – Laura Boyce

Posted on February 13, 2020

Two years ago I was a senior charge midwife in a busy labour ward.

While labour wards can be joyful places, as parents welcome a new little one into the world, they can also be very intense, stressful places as staff try their very best to make sure birth is a positive, safe experience for both parents and child.

“When the Scottish Government published The Best Start report for maternity and neonatal services, I was excited, enthused and apprehensive.”

Maternity services in Scotland vary hugely not just in relation to geography, but also to the workforce, the location of care delivery and capacity of services. So when the Scottish Government published The Best Start report for maternity and neonatal services in 2017, I was excited and enthused but equally apprehensive.

The key recommendations of Best Start included continuity of carer, putting women and babies at the centre of care, multi-professional working and a new model of neonatal intensive care service.

While midwifery student numbers were receiving substantial investment, I was aware that the experience and expertise of the midwives I was working alongside would be lost just as these younger, less experienced staff were coming into the workplace: almost 40% of midwives were aged in the 50 and over bracket.

Therefore, Best Start was a BIG ask, and I had a LOT of questions.

How will such ambitious recommendations ever be achievable? How can we ensure the staff are confidently skilled in all areas of the pregnancy journey? How can I as a clinical leader support this in a busy, high risk obstetric unit?

When the Government announced in 2018 its intentions to enshrine safe staffing in law, I had even more questions.

What is safe staffing? What would this mean for the staff on the shop floor? How will this impact midwifery care and, wider than that, nursing care?

“The basic aim of the Bill was to provide high quality care by ensuring the right people were in the right place, with the right skills at the right time”

I became engrossed in the new Bill and its progress through parliament. The basic aim of the Bill was to provide high quality care by ensuring the right people were in the right place, with the right skills at the right time to ensure the best health and care outcomes. Throughout my work as a clinical midwife, research midwife and senior midwife, in a variety of boards I’ve come to see these factors as central to the work of not just midwives but to the wider workforce of the NHS. So when a secondment opportunity arose to work as part of the advisory team supporting NHSScotland Boards with the use of workload and workforce planning tools, I went for it.  

Initially based in the Chief Nursing Officer’s Directorate before moving to Healthcare Improvement Scotland in 2019, being a programme advisor has allowed me to look closely at the workforce planning processes not just in midwifery, but across a range of healthcare professions. It’s allowed me to explore the wide variation in tools and resources that are used in clinical service. To really understand the basic fundamentals of budgets, planning and service redesign for the best service user experience. To appreciate the positives of good governance and risk assessment.  All of these are areas I knew about as a midwife, but can I really say I understood them?

Now, in my role with Healthcare Improvement Scotland, I’m working to answer for others all the questions that I’ve had.

“Supporting boards to understand the demands of the new Safer Staffing legislation and prepare for meeting its requirements as we move towards final enactment, I have been on a rollercoaster of learning and overcoming challenges.”

Supporting boards to understand the demands of the new legislation and prepare for meeting its requirements as we move towards final enactment, I have been on a rollercoaster of learning and overcoming challenges. My role has evolved massively in a short period of time and I now find myself speaking at national events and presenting abstracts for improvement work in this field. I have forged networks and empowered so many wonderful professionals and like-minded individuals who all aspire to that safe, effective and high quality care goal.

How we will monitor and report on the compliance of the legislation is in its infancy, but it’s exciting and uplifting to be a part of something that is shaping healthcare for future generations.

Find out more about the Health and Care (Staffing) (Scotland) Act: 

Link to information on the Healthcare Improvement Scotland website.

Link to the Act on the Scottish Parliament website

Contact the mailbox: HCIS.HSP@nhs.net

Laura Boyce is a Programme Advisor with the Healthcare Staffing Programme.

Categories: Uncategorized

Tagged: Healthcare Staffing Programme, safer staffing

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Full ESTEEM ahead for those who experience psychosis – Jonathan O’Reilly

Posted on January 9, 2020

“I no longer see psychosis as a catastrophe…I’ve been able to accept my diagnosis and not let it define me or my trajectory.”

These words were spoken at the first meeting of our Early Intervention in Psychosis Improvement Network (EIPIN) by Michael who has personal experience of psychosis.

With vulnerability and openness, Michael – and Stephanie, who also had experience of psychosis – brought to life for those attending the meeting what the experience is like, the recovery journey, and the impact and importance of early intervention.

Michael’s words of acceptance and hope had particular resonance for those attending the network meeting, as this is the very outcome we are striving to achieve for everyone who experiences psychosis in Scotland.

What is psychosis?

“Treating psychosis in the early stages can reduce the amount of time a patient needs to spend in hospital, reduce relapses, and leads to more effective and long lasting outcomes.”

Psychosis is characterised by hallucinations, delusions and disturbed thinking. It can cause considerable distress and disability for people affected, and for their families or carers. It’s estimated that there are approximately 1,600 new cases of psychosis in Scotland each year. Psychotic disorders can be extremely debilitating and it’s vital that those experiencing psychosis are treated quickly and effectively. Treating psychosis in the early stages can reduce the amount of time a patient needs to spend in hospital, reduce relapses, and leads to more effective and long lasting outcomes. Research from previous work in Scotland has shown improved outcomes when using a specially-designed model (called ESTEEM), compared to a more generic model, as inpatient stays can be significantly reduced, sometimes by up to 55%.

How the network came about

In the summer of 2019, Scottish Government published the action plan, Our Vision to Improve Early Intervention in Psychosis in Scotland, affirming their commitment to action 26 of the Mental Health Strategy, to improve access to services for those experiencing psychosis.

The Early Intervention in Psychosis Improvement Network is part of Healthcare Improvement Scotland’s Mental Health Improvement Portfolio of work.

By establishing and launching the network with the first meeting, Scotland took its first step in achieving those actions and mobilising a network consisting of health and social care, education sector, third sector, individuals with lived experience and carers.

The first EIPIN meeting was hosted by Healthcare Improvement Scotland with over 100 people from across Scotland in attendance. The aim of the meeting was to raise awareness of the importance of Early Intervention in Psychosis, the current evidence base for treatment, and how that evidence is currently being applied in the ESTEEM service in Glasgow (a community mental health service for people between 16-35 years, who appear to be experiencing their first episode of psychosis). Most importantly, the network will look at the positive impact of early intervention services on people’s lives.

Partnership working to drive improvements in care

“This work will ensure people presenting for the first time with psychosis anywhere in Scotland get access to effective care and treatment, with a focus on early intervention and recovery.”

A crucial part of this programme of work has been to recruit NHS Forth Valley and NHS Highland and their associated Health and Social Care Partnerships (HSCPs) to better understand the current provision of EIP services, what’s required to improve services, consider how data can be best collected and optimised, and determine what a good service for people experiencing psychosis looks like for service providers and service users.

I’m delighted to be involved in this important work. The work will ensure people presenting for the first time with psychosis anywhere in Scotland get access to effective care and treatment, with a focus on early intervention and recovery.

The success of the network launch – and the enthusiasm of all those who have stepped forward to be involved – has put us all on a strong footing to deliver improvements and recommendations to change the future for so many people experiencing psychosis in our communities.

Jonathan O’Reilly is an Improvement Advisor within the Mental Health Portfolio of Healthcare Improvement Scotland

More information

To learn more about the EIPIN and how we are progressing the action plan visit ihub.scot or on Twitter @spsp_mh. Get involved in the conversation on social media by following the hashtag #EIPScot.

Categories: ihub, Mental Health

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Expertise and evidence will always have value – Professor Angela Timoney

Posted on January 7, 2020

“The people of this country have had enough of experts”
Michael Gove, 3 June 2016

It is a little galling after years of studying and honing your craft to be told that your expertise is not required. To be fair to Michael Gove, he claimed that he was interrupted and that he intended to qualify his statement to explain that he was speaking in regard to economists. However, I am not sure the health economists working with us in Healthcare Improvement Scotland (HIS) will think this qualification makes it better.

So I believe we have not had enough of experts. In SIGN (which is part of HIS) we rely on our multidisciplinary teams to use their expertise to critically appraise the literature and come to a considered judgement in order to inform practice. Where I have some sympathy for the quote is where we have relied on experts making statements not based on evidence who expect to be listened to simply because of their years of experience. That is precisely why we need evidence-based guidelines.

“The problem with evidence, of course, is that it is of variable quality. It may be conflicting. It may not even answer the precise question that we in Scotland consider needs to be addressed.”

The problem with evidence, of course, is that it is of variable quality. It may be conflicting. It may not even answer the precise question that we in Scotland consider needs to be addressed. This is why we need our experts, our clinicians with expertise and our patients with expertise who live with the condition to work together and apply considered judgement. Considered judgement is just one point in the process of guideline development, but one I think should not be forgotten. The phrase itself makes it clear this is a judgement, it may change if the evidence were to change or it may not apply in a particular circumstance. But unless a judgement is made then it is really difficult for practitioners and patients to act with confidence.

SIGN has a long and proud history of providing recommendations for practice in NHSScotland and for leading rigorous guideline development in the international community. For example, two members of the SIGN team recently presented our work, on asthma, on involving patients and on guidelines methodology, to an international conference in Australia.

“SIGN has a long and proud history of providing recommendations for practice in NHSScotland and for leading rigorous guideline development in the international community.”

I think our patient information booklets enable Realistic Medicine. Each guideline has a booklet for patients describing to them what is advised for their condition and enabling a meaningful conversation about their diagnosis treatment and care: “If the guideline says this, what does this mean for me..?”

I am pleased to be Chair of SIGN, I think it is a fantastic team and I want to ensure that the clinicians and patients in NHSScotland recognise this gem. Clinical practice in Scotland is not that different from the rest of the UK or our European and American colleagues but isn’t it reassuring to know that we have guidelines based on evidence which applies to the context of practice for NHSScotland?

So, Michael …  This country has not has enough of experts, it needs expert assessment of evidence to address variation, bring new evidence to the forefront and support patients, their families and practitioners in their practise.

Professor Angela Timoney is Chair of the Scottish Intercollegiate Guidelines Network (SIGN), part of Healthcare Improvement Scotland.

More information

Visit the SIGN website to read our evidence based guidelines for NHSScotland.

Categories: SIGN

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Collaboration the key to consistent hospital care for those with dementia – Matilda McCrimmon

Posted on December 17, 2019

“My Mum was admitted to the medical assessment unit. The next day she was moved to a ward…this was after I told the staff she was very distressed by being moved about.  She became so distressed she pulled her cannula out…. I spoke to the nurses in ward about not moving her again, but they said it would likely happen because of policy. Luckily she was discharged suddenly and this did not happen.”

“I would like to say how kind, caring and efficient all the staff were to my Dad when he was admitted before Christmas. He has dementia and as a result really struggles to be an inpatient and get very distressed easily.  My mother and siblings were able to stay overnight to keep him calm and secure, and all the staff we encountered, from medical to domestic, showed immense understanding and compassion.”

These two stories from the Care Opinion website show the different experiences people with dementia are having in our hospitals, and the clear need for a consistent approach across Scotland, to ensure both they and their carers can be confident that no matter where they are treated, their care is of good quality. The Dementia in Hospital Collaborative, led by Healthcare Improvement Scotland’s Focus on Dementia team and the Alzheimer Scotland Dementia Nurse Consultants, aims to provide that approach.

A national priority

Dementia was made a national priority by the Scottish Government in 2007. We have made huge strides in improving hospital care for people living with dementia and their carers in the past 12 years. Unfortunately, these are not universal. Excellent work has taken place in some areas to ensure patients living with dementia experience minimal moves during hospital stays and where moves are necessary they are planned and at appropriate times. Yet in other areas, patients continue to be moved or “boarded”, creating distress and potentially prolonging hospital stays. I’ve visited patients requiring one to one nursing due to distressed behaviour to find that they have a nurse who sits and observes them, only intervening to stop “unsafe” behaviour. In other areas I have witnessed this being transformed into a therapeutic experience for the patient, with the one to one being used to provide social interaction and meaningful activity.

“We have made huge strides in improving hospital care for people living with dementia and their carers in the past 12 years.”

Improving on leadership

With a focus on preventing, identifying and managing the symptoms of stress and distress, the Dementia in Hospital Collaborative will support improved care for people with dementia in hospital settings. Key to this is ensuring there is clear leadership in each board to drive and monitor improvement. This leadership and improvement role is provided by our group of 16 Alzheimer Scotland Dementia Nurse Consultants, of which I am one. Our roles are four fold: to provide professional leadership, develop expert practice, training and education and develop and support practice improvement. These roles are partially funded by Alzheimer Scotland and provide the opportunity to develop these aims in a nationally coordinated way.

“With a focus on preventing, identifying and managing the symptoms of stress and distress, the Dementia in Hospital Collaborative will support improved care for people with dementia in hospital settings.”

As individuals, not only do we come from diverse geographical locations, we also have quite diverse professional backgrounds. Some of us have worked in mental health and general nursing, some have come directly from clinical practice and others have had roles in practice development or education. Our day to day roles also vary depending on our board, with a combination of direct patient care and community care. Some have input in mental health settings and others only in acute settings. The bringing together of our varied settings, roles and experience allows us to have a view of the wider landscape but also to identify common themes and challenges. Dementia is a complex condition, often accompanied by frailty and chronic disease. We’re just at the start of our journey to improve things, but believe that by combining our expertise with that of the Focus on Dementia team, we can to make a real difference for people living with dementia and their carers when it comes to hospital care.

Matilda McCrimmon is Alzheimer Scotland Lead Nurse for Dementia at Golden Jubilee Hospital.

More information

Visit the ihub website for information on the work of the Dementia in Hospital Collaborative.

Categories: ihub

Tagged: focus on dementia

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Resistance is human (part 5) – Ruth Glassborow

Posted on December 2, 2019

In the last part of this blog series, Ruth Glassborow highlights some of the specific factors that need to be taken into account when working with primary care.

In part four of my blog series on resistance to change, I started to share my findings from interviewing 11 GPs and 2 Practice Managers around what helps and hinders their engagement with change initiatives.  I highlighted:

  • the importance of the individual initiating the change making personal contact with practices
  • the necessity of being able to demonstrate the benefits for patients
  • the reason why attention does need to be given to the financial case for change, and
  • that overall the benefits of the change must outweigh the costs and there is often a complex relationship between the two that can vary between practices.

This is the new bit. In addition to the above, evidence that change will lead to better outcomes was highlighted as important by a number of the GPs I interviewed. One GP went as far as saying that, for a current change initiative, he was deliberately avoiding the evidence in case it persuaded him that he needed to do something he didn’t want to do.

However, in practice, GPs consistently engage with change initiatives where there is limited evidence. Why is this?  Why does evidence matter in some situations but not others?

My interviews highlighted that GPs do not need a strong evidence base when they can intuitively see the benefits of a proposed change and the change fits within current cultural/professional norms. However when either of the reverse apply then evidence becomes a key issue.

Further, the issues around evidence and finance interface with each other. So to help change initiators to think through how well their idea is likely to be received, I’ve summarised the role of finance and evidence in making the case for change in primary care in the following flow chart:

You can find more information about the findings behind this.

A very practical example of this is our current work in Scotland to develop and roll out approaches which reduce the amount of time GPs spend reviewing documentation. Following initial prototyping work with practices, we are now running a national programme to spread the work to further practices. We’ve had enormous interest from primary care as they can intuitively see the benefits of a change which reduces the amount of time they spend on paperwork (in one of the prototyping practice by on average 5 hours a week). It is a change that fits with current professional and cultural norms (who doesn’t want to do less paperwork?) and we’ve resourced the roll out alongside providing the evidence that once implemented, the change will save GP time on an ongoing basis. When you work that scenario through the above flow chart, you end up at a green box; a change that is ready for implementation. Which explains the level of interest we’ve seen in participating in the spread programme.

Where the flow chart is perhaps more useful is when a proposed change ends up at an amber or red box, as this highlights that the change may not yet be appropriately designed for successful implementation. From a practical point of view, it also provides ideas about adaptations that may be necessary to overcome the potential resistance.

Summary

In summary, this final blog in my series on resistance to change has highlighted some of the specific factors that need to be taken into account when working with primary care. I am conscious that these findings were based on a small non-random sample. Further, in Scotland the new contractual arrangements in primary care have bought a different context that may also impact on their validity. So I share them as insights to spark some further debate on how we can effectively engage primary care in the current modernisation agenda, and hopefully, to help with thinking through how to design improvement initiatives that are likely to succeed.

I would love to hear the views of those working in primary care whether any of the above resonates with your experiences and what you think about my analysis of the role of funding and evidence.

Find out more about the role of funding and evidence in making the case for change within primary care.


Resistance to Change – Blog Series Links:

Resistance to Change – Blog 1

Resistance to Change – Blog 2

Resistance to Change – Blog 3

Resistance to Change – Blog 4


Ruth Glassborow is Director of Improvement at Healthcare Improvement Scotland.

Categories: Resistance to change blog series

Tagged: Resistance to change

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Resistance is human (part 4) – Ruth Glassborow

Posted on November 25, 2019

In part four of this blog series, Ruth Glassborow continues to explore resistance to change, turning now to explore what enables and hinders primary care engagement with change.

Back in 2011 my job included leading work across Scotland to increase the number of people being diagnosed with dementia. In parallel, I was completing a Masters in Public Administration. As primary care had a key role to play in this work, I decided to focus my dissertation on understanding more about the factors enabling and hindering primary care engagement in this national improvement initiative.

This blog shares the insights I gained from interviewing 11 GPs and 2 Practice Managers. Although the sample size was small and non-random, I picked up some useful insights which I would like to share here.  

First things first, all my interviewees highlighted the vital importance of involving primary care in the design of changes which impact on them. Whilst this may seem a statement of the blindingly obvious, in my work I still come across secondary care initiated change initiatives which impact on primary care but have not involved them in any way. And then we wonder why they resist!

Related to this, a key point raised by eight respondents was the importance of personal contact by the individual initiating the change. Why do they want personal contact? Because this recognises that primary care is not a single entity, but rather many different organisations each with their own unique histories, cultures and ways of doing things. Personal contact enables a joint exploration of why the change is considered important and how it might need to be tailored for any individual practice.

Which leads me back to another key issue highlighted in earlier blogs: the importance of change adopters being dissatisfied with the status quo and believing that there is a better way of doing things. In other words, being convinced of the case for change. My interviews identified that there are essentially three elements that make up the case for change in primary care:

  1. Agreement that there is a problem that needs addressing which requires action within primary care
  2. Agreement that the changes being proposed will deliver benefits to the individual practice
  3. Belief that the benefits justify the costs.

This immediately leads to the question: what benefits matter most to primary care? The following table highlights the type of benefit mentioned in the interviews and the number of respondents who mentioned it.


Table: Classification of benefits


I think it is important not to gloss over the first: benefits to patients. Every single interviewee highlighted this as a critical factor in deciding whether to engage in a change initiative. Indeed this aligns with my own experiences over the last three decades of working in healthcare. The vast majority of clinicians are motivated to provide high quality patient care and they will resist change which they think will have a negative impact on patient care. Personally, I take comfort from this knowledge, as I would hate to work in a system where clinicians willingly implemented changes which they thought would have a negative impact on the quality of care being provided.

The other benefit mentioned by all interviewees was whether implementing the change would increase practice income. In my experience, this can get translated into an unhelpful stereotype that GPs won’t do anything unless they are paid for it. In reality it is more complicated than that.

The finances do matter, particularly for GPs who are self-employed and running their own business. If those of us working outside primary care had to pay out of our own pockets for a locum to cover our work when we were attending a meeting, I am sure we would either not attend or ask the organisers of the meeting to pay for the locum cover. This is the day-to-day reality for many of our colleagues in primary care. Furthermore, if you ask them to make a change that increases workload to the extent that they have to pay additional hours to their staff, the financial costs of that ultimately comes out of their pockets. So no wonder they want compensating for it. I think most of us would too if we were in their shoes.

However, my interviewees highlighted that it is not just about the money – overall the benefits of the change must outweigh the costs and there is often a complex relationship between the two that can vary between practices. The water is then further muddied by the role that evidence plays in the overall cost-benefit analysis. This is something we will explore further in my next and final blog in the series.

This fourth blog in the series has highlighted insights gained from interviewing GPs and Practice Managers. The next and final blog in the series on resistance to change highlights some of the specific factors that need to be taken into account when working with primary care.


Ruth Glassborow is Director of Improvement at Healthcare Improvement Scotland.

Categories: Resistance to change blog series

Tagged: Resistance to change

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