GP Leadership Quality Improvement Projects

1. London School of General Practice and HENCEL, HENWL and HESL Train the Trainers:GP ST Leadership Quality Improvement Projects This is a shared resource created by Dr Douglas Hing on behalf of London School of General Practice

2. Plan • The Project • Background: Leadership, Quality and Language • Quality Improvement Project (QIP) • Process Mapping • Stakeholder Analysis • The Intervention: Plan-Do-Study-Act • Reflections and self assessment • Trainers’ role • QIP ideas

3. The Project • London School GP (LSGP) initiative • Leadership development for GPST through leading a Quality Improvement Project (QIP) • Practical experience and self-reflection • QIP is the preferred option over Audit for GPST • Trainees lead QIP, write up and complete self assessment • Trainers mentor, review self assessment and give feedback • Start Jan 2014 • Potential for presentations and publications

4. Leadership • Leadership in the health and care services is about delivering high quality services to patients by: - demonstrating personal qualities - working with others - managing services - improving services - setting direction - creating the vision, and - delivering the strategy www.LeadershipAcademy.nhs.uk

5. Why Quality Improvement Training? • The Health Foundation reported Quality Improvement (QI) training should be part of the curricula for students, as well as being available as part of ongoing professional development training • There is a move towards seeing QI as a dynamic concept underpinning service planning and provision, but as yet this has not permeated most training courses

6. While most newly qualified physicians are well prepared in the science base of medicine and in the skills that enable them to look after individual patients, few have the skills necessary to improve care and patient safety continuously - Qual Saf Health Care 2002;11(2):168-173 The need to provide patient-centred care and value for money means that health professionals require more than clinical skills alone. They also need to know how to assess, enhance and disseminate good practice - J Contin Educ Health Prof 2011;31(3):207- 214.

7. A lack of knowledge and skills is a significant barrier to improving quality in healthcare: - Students identified gaps in training. They do not feel well prepared and want additional training on Leadership and QI - Training helps reduce hierarchical barriers - Supports bottom-up decision making • QI is superseding clinical audit as a mandatory part of junior doctor training • For revalidation, doctors will have to demonstrate they regularly participate in activities that review and evaluate the quality of their work

8. Educating health professionals about how to improve quality and safety may be key to the future of healthcare - J Royal Soc Prom Health 2007;127:87-94.

9. Language If you talk to a man in a language he understands, it goes to his head. If you talk to him in his language, that goes to his heart. - Nelson Mandela

10. Political chaos is connected with the decay of language... One can probably bring about some improvement by starting at the verbal end. - George Orwell

11. What is “Quality” in healthcare? • Safe: avoiding harm to staff and patients from the care that is intended to help them • Timely: reducing waits and harmful delays for both those who receive and those who give care • Effective: care based on robust evidence to all who could benefit and not given to those not likely to benefit • Efficient: avoiding waste, of equipment, supplies, ideas, energy • Equitable: care that does not vary in quality because of personal characteristic such as gender, ethnicity, geographic location, and socio-economic status • Patient-Centered: care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions - Crossing the Quality Chasm: A New Health System for the 21st Century, The Institute of Medicine, 2001 Crossing the Quality Chasm: A New Health System for the 21st Century, The Institute of Medicine, 2001

12. Quality is everyone’s responsibility - W. Edwards Deming

13. What is Quality Improvement (QI)? • Definition varies widely, no consistent definition • It is NOT making things better by doing the same things again and simply ‘trying harder’ • A way of approaching change in healthcare that focuses on self-reflection, assessing needs and gaps, and considering how to improve in a multifaceted manner • QI Training aims to create an ethos of continuous reflection and a commitment to ongoing improvement

14. Not all changes are improvements but all improvement involves change. Changing the systems that deliver care has thus become the cornerstone of the movement that is now referred to as quality improvement - JAMA 2007; 298(9):1059-1061

15. Why QI Projects (QIP)? • Adult learners are best educated by involving them in real work that interests them. A teaching organisation can leverage learners’ power and enthusiasm to create change • Learners are a valuable untapped resource. They are not constrained by the usual way of doing things and can question systems from another perspective • In turn, when the learners feel that they are doing “real work” and facilitating important improvements in quality they are stimulated to learn more

16. (Unfortunately) the focus is sometimes on making one-off improvements rather than training how to think critically about improvement, take a whole systems approach and continuously improve healthcare processes and services - Am J Med Qual 2010;25(4):305-311

17. Quality Improvement Project (QIP) • Trainees identify an improvement and lead it • Clear Project (simple and SMART) • The Background • Process Mapping • Stakeholder Analysis • The Intervention • Conclusions • Reflections (self-assessment) 8-12 weeks to complete 1-2 cycles of a simple QIP

18. Process Mapping • 5 minutes to map out 10 steps of a pathway from beginning to end for: • Group 1: a flu jab • Group 2: a prescription to collect • Group 3: a referral to physiotherapy

19. Stakeholders • Stakeholders are individuals, groups or organisations that are affected by the activity. • Identify the stakeholders in your process map.

20. Stakeholder Analysis • Analyses the attitudes of stakeholders to the project

21. Stakeholder Analysis High Influence Low Low Interest High

22. Aim: Reducing inappropriate A+E attendances High Triage nurses Ambulance Service GPs + Receptionists Community Services CCGs Hospital Trust Out of Hours Provider Influence Patients A+E Staff Locum staff GPs in Urgent Care Centres Low Low Interest High

23. Stakeholder Analysis High Manage Closely: Key stakeholders to engage fully through communication and consultation Keep Satisfied: Review your analysis of their position regularly Influence Monitor Can ignore if time and resources are stretched Keep Informed: May be helpful to take steps to increase their influence Low Low Interest High

24. Aim: GPSTs develop leadership skills from QIP High RCGP LETBs / LSGP GP Trainers Influence Other GPs Other trainees TTT Facilitators Low Low Interest High

25. Plan-Do-Study-Act (PDSA) cycle • Test changes in real work settings • Guides the test of a change to determine if the change is an improvement • Continuous small scale tests of change to be used for improvement • May not get desired results when making changes to processes, so it is safer to test out improvements on a small scale first • Enables stakeholders the opportunity to see if proposed change will work

26. www.institute.nhs.uk

27. → Set aims: keep it simple / SMART → Establish Measures: can be qualitative → Select Changes: can borrow ideas Sequential cycles when the study reveals results which suggest a different intervention is needed:

28. Marshmallow Challenge • 5 minutes • Build the tallest free-standing structure • 20 sticks of spaghetti • 1 metre of tape • 1 metre of string • 1 marshmallow • Quality (the entire marshmallow) needs to be on top (NHS organisational structures each item costs £1m) (Quality)

29. Set Aims: build tallest free-standing structure in 5mins • Establish Measures: height from table to marshmallow • Study: measure height • Select Changes: - Ideas for change may come from the insights of those who work in the system, from change concepts or other creative thinking techniques, or by borrowing from the experience of others who have successfully improved. • Test Changes: - Test changes in the real work setting by planning it, trying it, observing the results, and acting on what is learned.

30. Marshmallow Challenge 2 • 5 minutes • Build the tallest free-standing structure • 20 sticks of spaghetti • 1 metre of tape • 1 metre of string • 1 marshmallow • Quality (the entire marshmallow) needs to be on top (NHS organisational structures each item costs £1m) (Quality)

31. Conclusions • Plan: clear aim • Do: carry out plan and collect data (measure) • Study: summarise what was learned (e.g. Marshmallow not light). Was there an improvement? • Act: select a simple change (e.g. start with quality / marshmallow) • Plan: clear aim with added learning • Do...

32. Reflection and Self assessment • Trainees to use a self assessment tool to manage their own learning and development by reflecting on areas of leadership to develop further • Option: The Leadership Framework Self assessment tool • Traffic light tick box (note red  bad) • Stimulates thought and reflection • Not all sections relevant • Personal Action Plan optional afterwards • www.leadershipacademy.nhs.uk/wp-content/uploads/2012/11/NHS • Leadership-Framework-LeadershipFrameworkSelfAssessmentTool.pdf

33. Trainers’ Role • Mentor trainee (ownership is key) • Review trainees’ self assessment • Complete Feedback Sheet

34. Option: BMJ Quality • Online platform which supports individuals and teams through improvement projects and onto publication • Provides frameworks, learning modules, tools and resources to make healthcare improvement simple • Access includes an exclusive route to publication in the BMJ Quality Improvement Reports journal • Annual subscription required • Mentors have free access • http://quality.bmj.com

35. QIP Ideas • Accessing appointments on the day • Avoiding prescribing inappropriate medicines • Inappropriate A+E attendance • Monitoring cardiovascular health of at risk patients • Patients’ medicines adherence • Patient satisfaction • Referral pathways usage • Staff satisfaction • Vaccine storage

36. To the extent that quality and safety are addressed at all, they are taught using pedagogies with a narrow focus on content transmission, didactic sessions that are spatially and temporally distant from clinical work, and quality and safety projects segregated from the provision of actual patient care... Transformation will require new pedagogies in which a) quality improvement is an integral part of all clinical encounters b) health professions students and their clinical teachers become co-learners working together to improve patient outcomes and systems of care - BMJ Qual Saf 2011;20 Suppl 1:i79-82

37. Further Information DougJHing@gmail.com Cristina.mottes@southlondon.hee.nhs.uk