Service improvement for better, safer healthcare

1. Service improvement for better, safer healthcare

2. Most people would like to ‘do something about quality’ but don't have the time. They are too busy dealing with complaints, making good (correcting) mistakes, doing the wrong things right and doing what they do twice. paraphrased from Øvretveit 1992

3. There are 2,231 words meaning drunk … but only one word for quality

4. What is quality?

5. Quality does not necessarily mean excellence … Quality means: fit for the purpose.

6. Functional Health Status Access System Assess Diagnose Treat Clinical Outcomes Follow-up Patient with needs Total Costs Balanced measure of care The Model for Providing Care Satisfaction against need Nelson et al (1996)

7. 6 components of Quality • Access • Relevance to need • Effectiveness • Equity • Acceptability • Efficiency (Maxwell 1984) – Humanity

8. It is the system … Every system is perfectly designed to produce the outcome it achieves! paraphrased from Berwick (1996)

9. Process mapping … Select a process e.g. A Cake

10. Process mapping … Select a process Map the process

11. Map the process

12. Process mapping … Select a process Map the process Analyse the current situation

13. Analyse current situation Reworked loops bottlenecks Lots of steps delays Reworked loops

14. Select a process Map the process Analyse the current situation Identify opportunities to improve Process mapping …

16. Identify opportunities to improve With as few steps as possible Each step must add value to the process.

17. The health service has many heroes. The staff who - work harder - predict problems and compensate for short comings. Heroic thoroughness may make patients lives a little safer - but - a real improvement in the quality of care provided to patients is not created by heroes who compensate for the flawed processes. The real heroes are those who change the system to remove the flaws!

18. How do we make the necessary changes??? Use a model for improvement

19. Aims A model for improvement What are you trying toaccomplish? Three fundamental questions for improvement Langley et al (1996) – cited in NHS III (2007)

20. Aims What are you trying toaccomplish? How will you know that achange is an improvement? Three fundamental questions for improvement Measurement A model for improvement

21. Aims What are you trying toaccomplish? How will you know that achange is an improvement? Three fundamental questions for improvement Measurement What changes can you make that will result in the improvements you seek ? Ideas, hunches,etc. A model for improvement

22. Act Plan How to make change happen … Study Do Walton (1989) The PDSA Cycle • Objective • What do we want to do? • Plan to carry out the cycle (who, what, where, when) • Plan for data collection • What changes are to be made? • Next cycle? • Analyse the data • What did or didn’t work? • Summarise what was learnt • Just do it! • Carry out the plan • Document problems and unexpected observations

23. Changes that result in improvement A A A A P P P P S S S S D D D D Hunches Theories Ideas Repeated PDSA Cycles

24. What are you trying toaccomplish? Aims Three fundamental questions for improvement How will you know that achange is an improvement? Measurement What changes can you make that will result in the improvements you seek ? Ideas, hunches,other people etc. Act Plan How to make change happen Study Do Langley et al (1996) – cited in NHS III (2007)

25. A real example of process mapping in practice …

26. Burns Unit Quality Improvement Team • Team Members: Consultant Surgeon, Ward Sister, Nursing Staff, Clinical Psychologist, Physiotherapist • Aim: “to improve the quality of care to adults with major burns so that they receive the care they need”

27. Discharging from acute phase Burns Unit Quality Improvement Team Accepting referral Assessing Treating Evaluating

28. Burns Unit Quality Improvement Team Discharging from acute phase Accepting referral Assessing Treating Evaluating • Taking Clinical baseline • Informing relatives and carers • Taking swabs and photos • Evaluating wound • Evaluating Psych progress • Sharing info at case conf. • Feeding back to patient and carers • Evaluating infection status • Enquiring about the patient • Preparing for arrival • Advising on initial treatment • Organising follow-up appointment • Writing & sending discharge letter • Providing appropriate patient info • Giving SOS contact • Treating other medical conditions • Responding to Psych needs • Mobilising and moving • Managing pain • Planning for discharge

29. Some areas for improvement • Providing appropriate information to patients and carers when they need it • Receiving and accepting referrals • Criteria for agreeing surgery • Identifying patients who need psychological support

30. Burns Unit Quality Improvement Team Discharging from acute phase Accepting referral Assessing Treating Evaluating • Taking Clinical baseline • Informing relatives and carers • Taking swabs and photos • Evaluating wound • Evaluating Psych progress • Sharing info at case conf. • Feeding back to patient and carers • Evaluating infection status • Organising follow-up appointment • Writing & sending discharge letter • Providing appropriate patient info • Giving SOS contact • Enquiring about the patient • Preparing for arrival • Advising on initial treatment • Treating other medical conditions • Responding to Psych needs • Mobilising and moving • Managing pain • Planning for discharge

32. Burns Unit Quality Improvement Team A key area for improvement To improve the identification of patients who need psychological support

33. How the Burns Unit QI Team used the model for improvement …

34. What are you trying toaccomplish? How will you know that a change is an improvement? What changes can you make that will result in the improvements you seek? What are we trying to accomplish? to improve detection of psychological distress

35. What are you trying toaccomplish? How will you know that a change is an improvement? What changes can you make that will result in the improvements you seek? What are we trying to accomplish? to improve detection of psychological distress How will we know a change is an improvement? - screening results will be available in notes - appropriate referrals to psychology

36. What are you trying toaccomplish? How will you know that a change is an improvement? What changes can you make that will result in the improvements you see? What are we trying to accomplish? to improve detection of psychological distress How will we know a change is an improvement? - screening results will be available in notes - appropriate referrals to psychology What changes can we make that will lead to improvement? - introduce a screening tool for selected patients - try a pilot with 5 patients

37. What are you trying toaccomplish? How will you know that a change is an improvement? What changes can you make that will result in the improvements you see? Act Plan Study Do PDSA 1 A P S D Do:- tested screening tool

38. What are you trying toaccomplish? How will you know that a change is an improvement? What changes can you make that will result in the improvements you see? Act Plan Study Do PDSA 1 A P S D Study:- inclusion/exclusion criteria were unclear - errors in scoring Do:- tested screening tool

39. What are you trying toaccomplish? How will you know that a change is an improvement? What changes can you make that will result in the improvements you see? Act Plan Study Do PDSA 2 A P S D PDSA 1 A P Plan:- refine criteria - workshops for nurses S D Study: - inclusion/exclusion criteria were unclear - errors in scoring Do: - tested screening tool

40. What are you trying toaccomplish? How will you know that a change is an improvement? What changes can you make that will result in the improvements you see? Act Plan Study Do PDSA 2 A P S D Study: - screening was more accurate - implementation was patchy PDSA 1 A P Plan:- refine criteria - workshops for nurses S D Study: - inclusion/exclusion criteria were unclear - errors in scoring Do: - tested screening tool

41. What are you trying toaccomplish? How will you know that a change is an improvement? What changes can you make that will result in the improvements you see? Act Plan PDSA 3 Study Do A P S D PDSA 2 Plan:- build reminders into ward routines A P S D Study: - screening was more accurate - implementation was patchy PDSA 1 A P Plan: - refine criteria - workshops for nurses S D Study: - inclusion/exclusion criteria were unclear - errors in scoring Do: - tested screening tool

42. What are you trying toaccomplish? How will you know that a change is an improvement? What changes can you make that will result in the improvements you see? Act Plan PDSA 3 Study Do A P S D Study:- showed significant improvements PDSA 2 Plan:- build reminders into ward routines A P S D Study: - screening was more accurate - implementation was patchy PDSA 1 A P Plan: - refine criteria - workshops for nurses S D Study: - inclusion/exclusion criteria were unclear - errors in scoring Do: - tested screening tool

43. Burns Unit Quality Improvement Team Results after third PDSA • 91% of patients were being checked • Approximately 30% were found to need psychological support for anxiety, depression or PTSD Referrals to Clinical Psychology increased by 600%

44. Overview of Improvement • Success is defined as improving how we safely meet the needs of our patients • Focus on processes, not blaming others • Success depends on gathering and using data and information to identify changes and to learn from testing them out … … …

45. … … … Overview (cont.) • Using rapid small changes engages staff and creates continuous improvement • Success requires collaboration and innovation from team members working together • Combining professional knowledge with improvement knowledge is very powerful for providing safer and better care

46. In every work place (and home) there are 4 people named Everybody, Somebody, Anybody and Nobody. When there is a job to be done Everybody is asked to do it. Everybody is sure Somebody will do it. Anybodycould do it, but Nobody does it. Somebody will get angry about that because it is Everybody’s job to do it. However, Everybodythinks Anybody could do it and Nobody realises that Everybody won’t do it, unless Somebody does. It will end up with Everybody blaming Somebodybecause Nobody does what Anybody could do.

47. The tribal wisdom of the Dakota Indians, passed from generation to generation, states that when you discover that you are riding a dead horse the best strategy is to dismount. However modern management best practice within government and large organisations has developed other strategies, including the following: Change Riders. Say things like “this the way we always ride horses” Appoint a committee to study the horse. Arrange to visit other sites to see how they ride dead horses. Hold training sessions to improve dead horse riding ability. Compare the state of dead horses in today’s environment.

48. Re-classify the dead horse as “living, impaired”. Pass legislation declaring that “this horse is not dead” Harness several dead horses together for increased the speed. Do a cost analysis study to see if contractors can ride it cheaper. Offer the horse career counselling and the option of a transfer to a less stressful position of equivalent status. Check with IT Support to see if the whole network is down, or if it is just the horse. Promote the dead horse to a Senior Management position.

49. Bibliography Batalden PB & Stoltz PK (1993) A Framework for the Continual Improvement of Healthcare: Building and Applying Professional and Improvement Knowledge to Test Changes in Daily Work. Journal on Quality Improvement, October. 19 (10) 424-452 Berwick DM (1996)A primer on leading the improvement of systems. BMJ 312 619-622 Cox S, Wilcock P & Young J (1999) Improving the Repeat Prescribing Process in a Busy General Practice - A study using continuous quality improvement methodology, Quality in Health Care, 8 119-125 Maxwell RJ (1984) Quality assessment in health. BMJ; 288: 1470-2 Nelson G, Batalden P, Plume S, Mohr J (1996) Improving Health Care Part 2 - A Clinical Improvement Worksheet and Users’ Manual. The Joint Commission Journal on Quality Improvement. 22 (8) 531-548 NHS Institute for Innovation and Improvement (2007) The Improvement Leaders’ Guide to Process Mapping, Analysis and Redesign. NHS III Available on line at; http://www.institute.nhs.uk/improvementleadersguide Øvretveit J. (1992) Health Services Quality: An introduction to quality methods for health services. Blackwell Scientific. London Scholtes PR, Joiner BL, Streibel JL (2003) The Team Handbook – 3rd Edition. Pub: Oriel Inc.

50. Improvement knowledge & skills • Process mapping, analysis and redesign • Working with groups • Involving patients and carers • Evaluating improvement • Sustainability • Technology in improvement • Delivering improvement Improvement Leaders’ Guides General Improvement Skills Process and systems thinking • Measurement for improvement • Matching capacity and demand • Improving flow • Working in systems Personal and organisational development • Managing the human dimensions of change • Redesigning roles • Building and nurturing an improvement culture • Leading improvement www.institute.nhs.uk/improvementleadersguides