Driver Diagrams – linking ideas to action Main title slide page Driver Diagrams – linking ideas to action Julie Connell – Improvement Leader Safer Care Team – Oxford Health HS FT

Members Learning about QI will: Main title slide page Members Learning about QI will: Be introduced to why we need a driver diagram Understand when to use a driver diagram Introduced to aims, primary drivers, secondary drivers and change ideas Introduced to the process of building driver diagrams Understand the benefits of a driver diagram Understand that measures can be generated from driver diagrams Where we came from In 2009 the South west SHA ran a Improvement collaborative, when they discovered how succesful the collaborative was tey decidie to trial one in Mental health. Starting in the southwest and then and following intrest from the rest of the Sout of engalnd it spread to the whole of the south of england. In 2015 it became funded by the AHSN’s in the south of england

Main title slide page Why the collaborative is here today

Who do we work for

Why do we need an aim? Who is in the faculty

AIM Aims give meaning in our lives, they create a target to achieve and inspire and motivate us to achieve it. What, how much, by when – so what? Make your aims SMART Specific Measurable Achievable Realistic Timely

How do we know the change is an improvement ?

We use measure to determine if a specific change actually leads to improvement

What changes do we make ?

Driver Diagram Template AIM PRIMARY DRIVERS CHANGE IDEAS SECONDARY DRIVERS Aim Primary driver Secondary driver Change idea Change idea Change idea Change idea Change idea Change idea Change idea Change idea

AIM STATEMENT PRIMARY DRIVERS SECONDARY DRIVERS CHANGE IDEAS/TESTS

GOOD How much by when BAD Vague UGLY Disengage staff AIM STATEMENT x We aim to improve safety by reducing needless harm By April 2017 we will reduce the number of incidents of violence and aggression on Ward 10 by 50% x Message from Director of Ops: ‘Our patient satisfaction scores are in the bottom 10% of NHS comparative database. We need to get the scores above the 50th percentile by end of Q1 2017’ x We will reduce the number of falls on Ward 11 by 75% over the next year. Our first goal is 25% over the first 3 months x According to the consultant we hired we need to evaluate our clinic follow up, we need to improve the effectiveness and reliability of home visit assessments and reduce readmissions. The board agrees so we will work on these issues this year. x Taken from: Quality Improvement in Healthcare:The Case for Change University of Bath

You have decided you want to reduce/increase your weight Describe your aim 5 mins But we need more than hope if we want to improve We have to acknowldege and understand where QI sits alongside Q assurance and Q planning We need to understand that we need a methodolgy to implement QI We know we have to understand how culture will impact on our improvement efforts We have sway with the change to sustain are aims and achievments

AIM STATEMENT PRIMARY DRIVERS SECONDARY DRIVERS CHANGE IDEAS/TESTS

Primary Drivers Referred to as primary drivers because they ‘drive’ the achievement of your main goal Directly contribute towards achieving your aim - At the heart of the matter Ask yourself: If I made an improvement in this driver what would it achieve? (Would it move you closer to your aim?) If I did all these things (all primary drivers) could anything else stop me achieving my aim? If so, you may have missed another primary driver. You are likely to have two or three primary drivers

Weight increase/reduction Add in the primary drivers

AIM STATEMENT PRIMARY DRIVERS SECONDARY DRIVERS CHANGE IDEAS/TESTS

SECONDARY DRIVERS Elements within the related primary driver Break down the primary driver into manageable components Add secondary drivers to your diagram

AIM STATEMENT PRIMARY DRIVERS SECONDARY DRIVERS CHANGE IDEAS/TESTS

Step 5. Priorities for action Once you have identified your drivers you can start to identify change ideas and tests of change You need to decide priorities for action, interventions and change ideas Where can you most influence your aim?

6. Agree measures You can then start to identify relevant, appropriate measures that fit each driver to show progress towards your overall aim It may be difficult or take time to show progress in your overall aim. These measures will help demonstrate what progress is being made and can help others stay interested and motivated in your project.

Fall Prevention Driver Diagram

PDSA does not stand for: People’s Dispensary for Sick Animals

Specifically a driver diagram: In summary: If you are feeling overwhelmed by the scale of what you want to achieve, driver diagrams can help you cut your aims down to a manageable size to enable you to identify elements to concentrate on now, and what can go on the ‘to do’ list for later The act of producing the diagram is a very important way of getting the team working together and committing to some common agreed goals and priorities Driver diagrams are a tool which assist teams in doing improvement work and help to communicate to others the aim and the rationale for selecting specific change ideas to achieve improvement Specifically a driver diagram: Assists teams in generating change ideas that lead to the root cause and will impact the aim Serves as a foundation/tool for developing measures and understanding where each is relevant Communicates to others the logic or design of the project Helps staff to understand how their work contributes to goals/aims A PDSA is undertaken on a sample, or small section of patients, or small part of the patient pathway or service. It is tested for a short period, such as a month and operates alongside current processes. Plan  Determine the improvement to be made, the improvement method and the method for evaluating the results. What do you want to be accomplished? By What method will you achieve this objective? How will you know when you have reached this objective? Do Perform the activities defined in the plan. Study Measure and compare the results with those desired and learn from them Act Take advantage of what you have learned and determine where to apply changes that will result in improvement. When a pass through these four steps does not result in the need to improve, refine the scope to which PDSA is applied until there is a plan that involves improvement.

NHS Scotland Quality Improvement Hub   http://www.qihub.scot.nhs.uk/knowledge-centre/quality-improvement-tools/driver-diagram.aspx The King’s Fund http://www.kingsfund.org.uk/projects/pfcc/driver-diagrams Institute for Healthcare Improvement – video  http://www.ihi.org/education/ihiopenschool/resources/Pages/Activities/GoldmannDriver.aspx How to conduct PDSA’s – a framework of considerations to help guide your project Plan the Trial Define the objectives State the scope of the PDSA What are you going to do? Why are you doing it? How are you doing it? When are you doing it? How long will the PDSA continue? Are there any circumstances when you would stop the trial? Who needs to be involved? Does everyone understand their role? How will you communicate with these people? How will you know if the PDSA is a success? What data collection methods are you using? Who will collect the data? How will you feedback to the team? Do ; Undertake the PDSA Carry out the trial Encourage continual feedback - you may wish to set up midpoint meetings to discuss progress Reassure staff involved Motivate staff Encourage and support staff Collect information Study the Results of the Trial Examine your findings Review and compare information from before, during and after the trial Reflect on what was learned What did it feel like? Did staff and patients notice an improvement? Was the process shorter or longer? Did you acheive your objective? If not, why not? What went well? What could be improved? Act upon the Results of the Trial Use the information that you have gained Do you need to retest? You may choose to modify your process and test again. Do you have enough information? Does the trial need to be longer? Can you implement the change immediately? Who do you need to share your findings with? Can other areas benefit from your knowledge? How will you performance manage the process in the longer term? Implement the new process! During the 'do' stage of PDSA, staff involved may need lots of support and encouragement as well as reassurance. Undertaking any degree of change involves a degree of risk and adjustment. It is common for people to say that it is not working and want to stop. Your earlier planning will have dictated any circumstances when you may wish to halt the PDSA. Encouraging staff to verbalise their fears or insecurities will allow you to reassure and support them. Provide as much positive feedback as you can. Explain that if the PDSA does not result in a measurable improvement it will not be repeated. You can learn as much from things that don't work as things that do – it is all part of the learning process. As described earlier, PDSA cycles are a good way to introduce change in a safe and planned manner. If you are intending to use PDSA, remember to start small – lots of small PDSAs allow you to identify exactly which changes work and which don't. In addition, remember that effective communication is the key to successful redesign.

Developing improvement with PDSAs Implementing new procedures & systems - sustaining change PLAN DO STUDY ACT PLAN DO STUDY ACT Accumulating information and knowledge Testing and refining ideas PLAN DO STUDY ACT PLAN DO STUDY ACT PDSAs build on each other It may take several PDSA cycles to get to an implemented improvement PLAN DO STUDY ACT PLAN DO STUDY ACT Bright idea!

Model for Improvement

Phillip Confue: Chief Executive The patient safety collaborative has been a game changer for CFT in the way patient safety is understood from the Board to the ward. Our reporting culture has improved, staff are more engaged and empowered in making positive changes and patients are getting the benefits from safer care’ Phillip Confue: Chief Executive Cornwall Partnership NHS Foundation Trust Being a part of this programme has allowed us to skill up our workforce so that using improvement methodology is becoming the way we do business. - our staff now ask how they can use improvement methodology to solve their harm problems’   Dr Helen Smith: Co Medical Director Devon Partnership NHS Trust The collaboration has raised the profile of safety improvement across the organisation and has helped us focus our attention on delivering reliable, safe processes and the spreading of best practice across the organisation and has been instrumental in encouraging collaboration with other mental health providers in delivering safe care. The method of improvement approach has driven the embedding of real change that has led to tangible improvements in the quality of care provided to people using our services.’ Billy Hatifani: Director of Risk & Safety/ Deputy DoN/ Emergency Planning Lead Fettle ward was an early adopter of the methodology. They now make no changes without testing, especially with patient feedback. Their ward was rated "outstanding" by CQC.

Reduced the number of self harm incidents and sustained this, Oxford The level of harm as a result of Absence without Leave (detained) incidents is sustained as zero on all wards, 2gether aim of reducing the number of AWOLS which has been achieved and sustained, Oxford Trust wide there has been a 23% reduction in prone restraint incidents from 2014-15 to 2015-16. Seclusion incidents have reduced by 46% from 201415-2015/16. Rapid tranquilisation incidents have reduced by 26% over the same period. An RCA is now completed for all rapid tranquilisation. The number and timeliness of the completion of RCAs has improved within adult mental health which will support prompt learning. Dorset Reduced the number of self harm incidents and sustained this, Oxford Patient Safety Walk Rounds by the Executive Team have resulted in actions to improve patient safety concerns as identified by frontline staff. 94% of actions have been closed and sustained. 2gether This programme has supported our staff to make widespread improvements including a 51% reduction in falls, 30% reduction in AWOL, 95% medication reconciliation, DPT

What your organisation agrees to do By joining the South of England Mental Health Quality and Safety Improvement Collaborative, Chief Executives are committing to:  Personally sponsor safety in their own organisation; Personally attend (as a minimum)1 learning set a year; Identifying a lead Executive in their organisation who will act as their organisation’s collaborative lead; The lead Executive attending the first day of all Learning Sets; Identify an appropriately senior Clinical Lead for safety who will attend; Learning Sets and become a member of the Clinical Faculty; Identify, via their lead Executive and program manager, workstream leads and work stream teams; Meeting the transport and accommodation costs of their staff who attended Learning Sets; Identify an internal program manager who will; Co-ordinate internal improvement initiatives with the Executive lead, Identify internal workstream leads, Support workstream leads, Attend all Learning Sets Facilitating the release of workstream leads to attend Learning Sets; Collaborate with other members of the Collaborative by sharing knowledge, skills and data (associated with work streams within the programme).  

What you will receive

Cont…….

with love and vision. Love of your patients. Love of your “Quality improvement begins with love and vision. Love of your patients. Love of your work. If you begin with technique, improvement won’t be achieved.” A. Donabedian, M.D

Thank you Heather.pritchard1@nhs.net @IQMentalHealth @HeatherpNHS Main title slide page Co-brand logo here Thank you Heather.pritchard1@nhs.net @IQMentalHealth @HeatherpNHS