Leading the Way to quality improvement Thursday 27th October 2011 Leading the Way to quality improvement Tim Heywood Insert name of presentation on Master Slide

Messages about leadership for quality improvement have been consistent for years: Accountability Communication Patient focus Measurement and targets Learning and education Culture and behaviour

“The challenge is not to agree the principles of good leadership practice, but to implement practical interventions that will embed these principles in day-to-day organisational life.” 1000 Lives Campaign ‘How to’ Guide

Thinking of change as ‘social movement’ 4

1000 Lives Plus - From compliance to commitment States a minimum performance standard that must be achieved. Uses hierarchy, systems and standard procedures for coordination and control. Threat of penalties/sanctions. Fear creates momentum for delivery. Based on organisational accountability (if I don’t achieve this I fail to meet my performance objectives). Commitment States a collective goal that everyone can aspire to. Based on shared goals, values and sense of purpose for coordination and control. Commitment to a common purpose creates energy for delivery. Based on relational commitment (if I don’t achieve I let the group or community down). Helen Bevan – IFQSHC presentation, 2011

Leadership Driver Diagram

System level measures Mortality case note reviews Understanding mortality rates Investigating high mortality measures Case studies

6 principles for effective mortality reviews Do the review Reviews must be undertaken at an agreed frequency, involving relevant people in a way that is sustainable. Do it intelligently There should be an agreed process for selecting cases that either covers all deaths, or a properly representative sample. Get some learning The review process must be structured in a way that allows identification of system issues. Share that learning The review process should produce timely feedback to Clinicians, service leaders and Quality & Safety Committee. Report comprehensively Reporting should highlight learning about clinical system issues and also the review process itself. Feed learning into strategy There must be a process for ensuring that Health Board strategy on avoidable death and harm reflects the outcomes of the review process

Involving students in mortality reviews – a test of change What are we trying to achieve: Sustainable involvement of students in mortality and harm reviews. How will we know when we have achieved it: Increased student understanding of the purpose and process of reviews; Reported positive experience of students; No negative impact on other review team members; What test can we make: Identify student volunteers  to be involved in the test. Provide information on the background and training in use of the tool. Involve students in weekly review meetings. Get feedback from students and other team members.

Demonstrating visible leadership

Aim of WalkRounds To combine a top-down and bottom-up approach to safety awareness and management To demonstrate visible senior leadership in patient safety Gain information and act on safety problems and issues

WalkRounds – a history 1999 Concept developed by IHI 2000-2003 piloted in several US hospitals 2003 First published research on WalkRounds 2004 incorporated into the UK Safer Patient’s initiative 2007 identified as a key leadership intervention for the 1000 Lives Campaign

Why are WalkRounds important? Depends on your perspective.. Patient Benefit from decreased risk Leaders Directly interact Learn unfiltered truth Directly influence culture Front line staff Opportunity to discuss concerns Opportunity to be heard and respected Safety Experts Gather data that lead to action Improve how action is taken

Testing and implementation of WalkRounds in Wales Acute Settings. Community services GP Practices Care Homes Virtual WalkRounds in community pharmacy practices. .. Next test: ‘mid-organisation’ WalkRounds

Accountability for execution

The model for Execution Achieve strategic Aims Manage local improvement Develop workforce Spread & sustain Build leadership and accountability Exec Team Divisional teams Directorate/locality teams Service delivery teams

Conference Rooms Real World Approve Design Design Design Design Implement 17

Conference Rooms Real World Approve (if necessary) Design Test and Modify Test and Modify Test and Modify Implement Real World 18

Systematic review of improvement projects Clarify purpose, expected outcome and how this links to organisational purpose and priorities. (Driver diagrams can really help here) Understand the importance of testing, implementing reliable processes, spreading and sustaining changes. Be alert to words like ‘audit’; ‘pilot’ and ‘roll-out’ Always insist on basing conversations around the data. What are we trying to do – e.g. design a new process, improve an existing product or service

Balancing measurement for improvement and assurance at different levels Focus on process measures Focus on outcomes Board level Frontline team level Core system-wide assurance measures RAMI GTT Harm rates Programme specific outcome measures: Condition specific mortality rates Incidence of specific categories of avoidable harm. Improvement measures Process reliability Care bundle compliance Uptake of evidence-based practice National level Division/ Directorate levels

A scoring scale for assessing improvement programme progress Score Narrative 10 Reliable implementation has been achieved in all relevant areas/populations. 9 Reliable implementation has been achieved in half of all relevant areas/populations 8 Reliable implementation has been achieved outside the initial pilot area/ population. 7 A plan to spread reliable implementation is in place and spread is underway beyond the pilot area/population. 6 Reliable implementation has been achieved in the pilot area / population 5 Changes have been fully tested using multiple PDSA cycles in the pilot area and we are now in the process of implementation 4 Testing of changes is underway in the pilot area / population. Data collection has commenced and baseline information is available 3 The Local implementation and data collection strategy for the programme has been agreed. 2 A programme team has been set up 1 An organisation lead has been appointed for the programme

Surveying culture

Why survey culture? “Understanding our shared assumptions about ‘ the way things are round here’ is an important step towards improvement. Participating in this survey will help to bring these issues to the surface so that they can be discussed in an open and positive way”. 1000 Lives Plus culture survey guidance 2010

Top 5% performers Bottom 5% performers Research on the relationship between organisational culture and outcomes A study of 11 US hospitals used risk adjusted 30 day mortality for AMI as an outcome measure and explored reasons for variation between high and low performers: Top 5% performers Bottom 5% performers Curry, L et al.(2011) What distinguishes top-performing hospitals in AMI mortality rates? Ann Intern Med. 154:384-390. American College of Physicians Mortality rates were as much as double in poor performers compared with top performers, but differences in care processes and protocols could not account for this… Eleven U.S. hospitals that ranked in either the top or the bottom 5% in risk-standardized mortality rates for 2 recent years of data from the Centers for Medicare & Medicaid Services (2005 to 2006 and 2006 to 2007), with diversity among hospitals in key characteristics. Participants: 158 members of hospital staff, all of whom were involved with AMI care at the 11 hospitals. Measurements: Site visits and in-depth interviews conducted with hospital staff during 2009. A 6-member multidisciplinary team performed data analysis by using the constant comparison method, in which essential concepts from interview data are coded and compared over successive interviews to extract recurrent themes across the data. Other team members reviewed coded transcripts for the site visits they had conducted. This process of refining codes and describing the properties of each continued until no new concepts emerged. Targeted analyses were performed to examine the consistency of the data within sites and to identify distinctions in coded themes between high performing and low-performing hospitals. 24

Distinguishing cultural features in high performing hospitals Domain Theme Organisational values and goals. Shared values to provide exceptional care. Alignment of quality and financial goals. Senior management involvement. Adequate financial and non-financial resources. Use of quality data in management decisions Holding staff accountable for decisions. Broad staff presence and expertise. Sustained medical champions. Empowered nurses and pharmacists. High quality standards for all staff. Communication and coordination among staff. Valuing diverse roles and skills. Recognising interdependencies. Smooth information flow. Problem solving and learning. Use of adverse events as opportunities to learn. Use of data for non-punitive learning. Innovation and creativity in trial and error. Learning from outside sources

2008: n = 4,616 2011: n = 10,320

Culture survey profiles by length of service

How can front line staff to engage leaders.. Discuss and understand your Driver Diagram ‘story’. Will Request WalkRounds Do a local culture survey Generate stories for use ‘higher in the organisation Build system-wide leadership for quality improvement Engage in Learning Sets with a consistent team Ideas Meet regularly to brainstorm, review themes from feedback, incidents and near misses Visit other sites and services; adapt practices from elsewhere Be clear who is accountable for your work Execution Use SBAR to communicate ‘up’ Always use your data for review