Collaborative Improvement Learning Model for Improvement PDSA & Team working Breeda.Worthington@wales.nhs.uk Mob:07971794703 Insert name of presentation on Master Slide

Now we know what we don’t want! Successful Collaborative Meetings!? Successful Collaborative Spread!? Beyond the 1000 Lives Campaign

Session objectives The expected collaborative process To have heard about (and hopefully understood): The expected collaborative process The Model for Improvement the framework for change The ‘PDSA’ the tests of change Teamwork the mechanism of change Beyond the 1000 Lives Campaign

Original Meds Mgt measures For this Bundle, use the following process measures: % of patients with a diagnosis of dementia with a documented record of indication for antipsychotic % of patients with a diagnosis of dementia prescribed an antipsychotic DDD/1000 PUs for an agreed basket of antipsychotics

Dementia target 3 Measures: For this intervention, process measures to be used include: Number of people with dementia who are receiving anti- psychotic medication Proportion of people with dementia who are on anti-psychotic medication where review within 3 months Proportion of people with dementia who have been on anti-psychotic medication for >9 months % compliance with care bundle (all 4 above interventions documented)

“Houston, we have a problem …” We are here because: PRINCE Project Management Targets Performance Management alone doesn’t work. 1000 Lives Plus

Knowledge for Improvement Improvement: Learn to combine subject matter knowledge and profound knowledge in creative ways to develop effective changes for improvement. Subject Matter Knowledge Profound Knowledge Improvement

“Knowing is not enough; we must apply “Knowing is not enough; we must apply. Willing is not enough; we must do.” - Goethe 3 6

Collaboration Peers learning (& competing with?) from one another Support the methods Share the practice 1000 Lives Plus

Collaborative Improvement Model Repeated improvement cycles: planning → testing → evaluation → sharing → implementing Repeated improvement cycles: planning → testing → evaluation → sharing → implementing Repeated improvement cycles: planning → testing → evaluation → sharing → implementing Learning session 1 Learning session 2 Learning session 3 Planning Support systems 1000 lives support team Interactive learning sessions Inter-clinic communication (e.g. monthly meetings) Continuous feedback (sharing data)

Learning Sessions aimed at achieving… LS1 WILL/IDEAS Get ideas Get methods Get started LS2 WILL/IDEAS/ EXECUTION/MONITOR Get more ideas Get better at methods Get a ‘Stride’ LS3 WILL/IDEAS/ EXECUTION/SPREAD Celebrate success Get ready to sustain and spread 1000 Lives Plus

How to change the system? 1. The Aim…. 2. The Goals and Measures… 3. The ideas and evidence…. 4. The tests of change…. To be successful, any improvement effort must start by addressing the three basic questions shown here: 1. The first question is about setting an aim that is measurable, specific, and yet an aim that requires taking the status quo off the table in order to achieve it. 2. The second question requires that the team decide on how it will measure its progress in reaching the aim. For example: you don’t know whether your golf game is improving unless you keep track of the number of strokes per round. 3. The BTS gives teams a place to start - with changes that have been shown to be effective. This question is based on the assumption that all improvement requires change, but not all changes lead to improvement. The Model for Improvement (Nolan &Colleagues IHI) 1000 Lives Plus 14

Tools for improvement: Data tools: Team tools: Action tools: Run Charts  Team assessment PDSA’s  Schewart Charts  Process mapping  SBAR Frequency Plots  Learning sessions  ‘How to guides’  Pareto Charts  Team ‘meetings’ Posters MONITOR WILL/IDEAS EXECUTION Beyond the 1000 Lives Campaign

Tools to Learn from Variation in Data Run Chart Shewhart Chart Frequency Plot Scatterplot Pareto Chart IH p. 8-34

Assessment Scale 1. Forming team 2. Activity but no changes 3. Modest improvement 4. Significant progress 5. Outstanding sustainable results 1 8 9 9

“The First Law of Improvement” Every system is perfectly designed to achieve exactly the results it gets.

Process Mapping for improvement …system focus Problems in hand-off between steps Problems in execution within steps Source: Juran Institute

All improvement requires change - but not all change results in improvement! Have you undertaken any recent changes that haven’t resulted in improvement? Individual exercise 4-5 mins with an example from each table describing why you think it went wrong So change can go wrong or even make it worse – think Poll tax! That’s where PDSA’s come in…

Beyond the 1000 Lives Campaign

THAT PDSA! PLAN IMPLEMENT CRASH!!

How to change the system? 1. The Aim…. 2. The Goals and Measures… 3. The ideas and evidence…. 4. The tests of change…. To be successful, any improvement effort must start by addressing the three basic questions shown here: 1. The first question is about setting an aim that is measurable, specific, and yet an aim that requires taking the status quo off the table in order to achieve it. 2. The second question requires that the team decide on how it will measure its progress in reaching the aim. For example: you don’t know whether your golf game is improving unless you keep track of the number of strokes per round. 3. The BTS gives teams a place to start - with changes that have been shown to be effective. This question is based on the assumption that all improvement requires change, but not all changes lead to improvement. The Model for Improvement (Nolan &Colleagues IHI) 1000 Lives Plus 23

Repeated use of the PDSA Cycle Changes that result in improvement A P S D DATA D S P A Implementation of change A P S D Hunches, theories, best practices Wide-scale tests of change A P S D Once a process functions reliably 90% of the time or better, it is reasonable to pursue improvement in the next PDSA cycle Follow-up tests Sequential building of knowledge under a wide range of conditions Very small scale test (but with HUGE potential!!!) 1000 Lives Plus

Multiple PDSA Cycle Ramps Detail Design A P S D Risk/harm assess’s Alternate Therapies Review Patients Capacity/ Demand

Developing improvement with PDSA (real world) ? P D S A Improvement P D S A Improvement warning - Remember cycles link but don’t always take you to where you want to go….because change is never as simple or as easy as we hope it will be! Bright idea! P D S A

Because change involves people… Receptionists Patients AHPs Carers Pharmacists Outside Agencies Social Services Managers Doctors Volunteers Nurses

So let’s try it now… PDSA… WHAT Planning your improvement actions: SO WHAT Using the PDSA/PDCA trainer sheet…identify for yourself an objective and start to write down things you could try to achieve the objective whilst deciding what you will measure to let you know when you have achieved it! E.g. weight, fitness, golf handicap? Review NOW WHAT

Adopter Categorization: Speed of Adoption Innovators Early Adopters Early Majority Late Majority Tradition-alists 2% 13% 35% 35% 15%

Recorded medication reviews in Care Homes (in last 12 months) By some teams trying this PDSA/PDCA…

Scripts leaving the practice with ‘As directed’ instructions (as directed) By some teams trying this PDSA/PDCA…

ADAPT – for your situation IMPROVE – for the reason you started with ADOPT – something else ADAPT – for your situation IMPROVE – for the reason you started with Sherlock Holmes

And finally, there are a number of responses to the frustration of trying to change behaviour… Did you know it takes 42 muscles in your face to frown…… and only 17 to smile However - it only takes 4 muscles to extend your arm and smack someone in the mouth

If we can improve care for one person, then we can do it for ten. If we can do it for ten, then we can do it for a 100. If we can do it for a 100, we can do it for a 1000 And if we can do it for a 1000, we can do it for everyone in Wales.