Introduction to Measuring Quality for Internal Service Improvement

1. Introduction to Measuring Quality for Internal Service Improvement Sebastian Yuen and Richard Wilson

2. Understand Variation

3. Measurement Questions • How old are you? • How many qualifications do you have? • How many hours a week do you work? • How safe is your department? • How does your practice compare with peers? • What do your patients think of your service? • How do you know your project is improving care?

4. Types of measures Characteristic: Judgement Research Improvement Aim: Achievement of target New knowledge Improvement of service One large test Test blinded Sequential tests Tests observable Testing strategy: No tests Obtain 100% of available, relevant data “Just enough” data, small sequential samples “Just in case” data Sample size: Hypothesis flexible, changes with learning Hypothesis: No hypothesis Fixed hypothesis Variation (Bias): Adjust measures to reduce variation Design to eliminate unwanted variation Accept consistent variation Determining if change is an improvement: Statistical tests: (t-test, F-test, chi square, p values) “Run Charts” or “Statistical Process Control” (SPC) charts No change focus Example: 4 Hour Wait Effectiveness of Drug Implementing PEWS

5. Reasons For Referral To Social Care

6. RAG Rating

7. What Does This Show?

8. “When you have two data points, it is very likely thatone will be different from the other.” W. Edwards Deming

9. Is This An Improvement?

10. Seek Usefulness Not Perfection

11. Child Protection Activity

12. Child Protection Activity • Is it relevant? • Is this good / bad / normal? • Is it improving over time? • Do we understand the variation? • What are we aiming for? • Does it inspire staff to improve?

13. Speed Of Completion Of Assessments

14. Speed Of Completion Of Assessments • Is this good / bad / normal? • Is it improving over time? • Do we understand the variation? • Is this something we are trying to improve?

15. Plot Data Over Time

16. MRSA Bacteraemia (All Sources) - HPA

17. Annotate: Tell A Story

18. MRSA Bacteraemia (All Sources) - HPA There is no problem It cannot be measured There is no data showing a problem here The data is wrong There is no evidence for handwashing / bare below the elbows My patients are sicker / different I can’t do that – I’m a surgeon! Bare below the elbows The patients come from care homes Infection control nurses The blood cultures are contaminated Antibiotic use controlled Swab all patients on arrival Zero tolerance by DH FT application depends on it Specially trained nurses do all blood cultures

20. Use Small Samples, Regularly

21. Measurement

22. “All improvement will require change, but not all change will result in an improvement” The Improvement Guide: A practical approach to enhancing organizational performance (2nd Edition 2009) Gerard J. Langley, Kevin M. Nolan, Thomas W. Nolan, Clifford L. Norman, Lloyd P. Provost

23. Developing Measures • Name of measure • Why is it important? • Who owns it? • Operational definitions: • Data collected, how often, by whom, calculation • Numerical goal (and target date to achieve it) • How to display data, how often, by whom? • Who will review results and take action?

24. Driver Diagram Lddddddddddddddddddl Ll ll

26. Use A Basket Of Measures (Dashboard)

27. Basket of Quality Measures • Process Measures • Was the WHO Safer Surgery Checklist completed? • Outcome Measures • Crash calls • Mortality • PROMs • Balancing Measures • Re-admission within 30 days of discharge Frontline staff to perform, display and improve measures

28. What Is A Care Bundle? The Improvement Guide: A practical approach to enhancing organizational performance (2nd Edition 2009) Gerard J. Langley, Kevin M. Nolan, Thomas W. Nolan, Clifford L. Norman, Lloyd P. Provost

29. What Is A Care Bundle? • Allows systematic appraisal of clinical processes • Ensures patients receive best care 100% of time • Each component must be evidence-based • The delivery of each component can be improved • Delivery of each component must be achievable • Delivery of each component must be measurable • The bundle is more than sum of its parts

30. PEWS Process Bundle

32. Central Line Bundles • Wash hands • Maximal barrier precautions on insertion • Chlorhexidine skin antisepsis • Optimal catheter site selection: avoid femoral vein for central venous access • Daily review of line necessity with prompt removal of unnecessary lines

33. Central Line Bundle: Process (Luton) Central Line Compliance Central Line Infections

34. Central Line Bundle: Outcome (Luton) Central Line Compliance Central Line Infections

35. For Rare Outcomes: Use Days Between Incidents

37. What Is A Run Chart? • A line graph that displays observed data points plotted in chronological order • X-axis: Time • Y-axis: Observation • Can add a mean, median or target • Annotate when changes made • Use as a driver for change / celebration of success

39. Example Run Chart

40. Only measure what you want to improve Use a balanced set of measures Use qualitative and quantitative data Measure over time Measure small samples regularly Integrate measurement into the daily routine Keep it simple: pen and paper can be better than Excel Need to share the data with the team - transparency Data enables conversation about problems & solutions Measurement Summary

41. Paediatric Dashboard - Walsall

42. Customer loyalty metric "How likely is it that you would recommend our company to a friend or colleague? (on a scale of 0-10)"  Promoters (9–10 rating) Passives (7–8 rating) Detractors (0–6 rating) NPS = % Promoters minus % Detractors Interpretation: -100 (everybody is a detractor) +100 (everybody is a promoter) An NPS that is positive is good An NPS of +50 is excellent Net Promoter Score

43. Paediatric Dashboard - Asthma

44. Paediatric Dashboard - Walsall

45. Staff Experience

46. Neonatal Outcomes