Microsystem Coaching Michelle Wilde Quality Improvement In Primary Care

What is a Clinical Microsystem? The building blocks of the healthcare system. Small functional frontline units that provide most health care to most people The Place where Patients, Families and Clinical Teams meet It’s where everything happens with, for and to the patient and family.”

Dartmouth Institute Looked at the characteristics of high performing microsystem teams Formulated a curriculum to develop high performing microsystems Nelson, Batalden, Godfrey 2000 – 2007 Nelson, Batalden and Godfrey (you’ll hear these names a lot) a) looked at the characteristics of the highest performing microsystems and then formulated a ‘coach the coach’ curriculum based on the high performing microsystems, we have developed this into the MCA. They transferred Quinns findings into the Healthcare setting.

A High Performing Microsystem: Staff Staff valued Education and training Shared purpose Working together Interdependence of team Leadership Leadership is key Organisational support Empower staff Information & Technology Nelson et al found whole range of features contributed to the success, with 5 main groups of characteristics for high performing clinical microsystems: - leadership – essential to allow the work to take place – balances setting collective goals with empowering autonomy and accountability, with the wider organisational support facilitating connection and coordination between microsystems - staff – recognising the value of staff, providing appropriate training and development for their optimal contribution to the microsystem as individuals and as a multidisciplinary team - patients – primary concern is meeting all patient needs, establishing relationships with the community and other resources - performance – studying, measuring and improving care is essential – use of PDSA cycles and using data to evidence and continually improve - IM&T – information is the connector. Everyone needs to the right information at the right time to do his / her work and keep communication channels (formal and informal) open at all times Performance focused on outcomes Process improvement (PDSA) Patients Patient Focus Meeting patients needs Listening, caring Patient centred www.clinicalmicrosystem.org

Involving the front line ‘If you want to make true and lasting change, ask the people who do the work how to go about it’ Daren Anderson, MD VP/Chief Quality Officer Community Health Center, Inc. Connecticut This quote highlights the importance of “bottom up” improvement efforts and “ownership” verses “buy-in”

‘Improvement in health care is 20% technical and 80% human’ Marjorie Godfrey, MS, RN The Dartmouth Institute For Health Policy and Clinical Practice People and Behaviours This quote comes from the research Marjorie Godfrey did looking at which factors are associated with successful improvement work. She found that 80% of the factors were human factors and only 20% technical. Improvement work is really all about working with people, behaviours and building relationships.

People vs. System “80% of the problem is the system not the people” W. Edwards Deming Professor of statistics at New York University (1946–1993) Author, lecturer, and consultant Photo © 2014 The W. Edwards Deming Institute Blog Founding Director, Healthcare Improvement Leadership Development The Dartmouth Institute for Health Policy and Clinical Practice Co-Founder Institute for Healthcare Improvement Although healthcare improvement is all about working with people the problems are more than likely to be systematic issues. Microsystem improvement focuses on the system issues.

System redesign “Every system is perfectly designed to get the results it gets.” Paul B. Batalden, MD Co-Founder The Institute for Healthcare Improvement Founding Director, Center for Leadership and Improvement, The Dartmouth Institute for Health Policy and Clinical Practice Founding Director, Healthcare Improvement Leadership Development Co-Founder Institute for Healthcare Improvement This quote reflects how each system is designed perfectly to get the results it currently gets. If we want to change the results we get we need to redesign the system.

For a Microsystem to work: 1. Structure – improvement ramp 2. A coach to inspire and support 3. Leadership – without hierarchy 4. Small iterative tests of change 5. Spread and share – Improvement Capability Dartmouth have said that Microsystems should include: 1. The need for structure for doing improvement 2. Good to have coach to inspire and support you 3. Leadership without hierachy – effective meeting skills 4. Must spread and show colleagues what you are doing. Involve colleagues inside and outside the team.

Why a Microsystem? Focus on the front line – not always the case in the NHS You have to get the smaller systems right – “Reforming the NHS from within” (Chris Ham, Kings Fund) Change has to come from within It works! – MCA website has multiple examples

Improving Microsystems – The Elements Team Coaching Improvement Science Microsystem QI The three elements that combine to improve microsystems are: The microsystem – these are the small functional frontline units where patients, families and care teams meet. These are the essential building blocks of large organisations and the place where care is delivered to patients; the patient is at the heart of the clinical microsystem. The wider organisation can only function as well as the small units it is made up of. We focus our improvement efforts on these frontline units in order to deliver “bottom up” improvements. The microsystems improvement method follows structured standard quality improvement methodology. The key steps are shown in the ramp. As we continue our quality improvement work we will progress up the ramp. (Initially it is not important that the microsystem team knows and remembers all the stages of the ramp, just that the ramp exists and as a coach you are guiding them through a structured process). Team coaching – what makes the microsystem approach to quality improvement different is the team coaching model. As a coach you will be present to guide and encourage teams as they start their journey in quality improvement. Research has shown that teams achieve more in the presence of a coach.

Coaching It is not telling people what to do. It is giving them a chance to examine what they are doing in the light of their intentions. See it as a helping relationship Where the coach engages and interacts with a team- the microsystem in a helpful way so they can examine and understand their system and start to work together on improvements the team owns and has decided to work on Peter Senge, MIT and Society for Organizational Learning

Why Team Coaching? Developing a culture of continuous improvement Establishing shared ownership Building improvement capability at the front line

Why Improvement Science? Structure Focus, Clearly articulated, Consistent approach Measurement How do we know that the change is an improvement? Discipline How often do we jump to solutions without understanding the problem? Structure – Microsystems becoming consistent not only in Sheffield but across the UK. People become familiar with the approach which supports embedding on the methodology Measurement – all improvement is change but not all change is improvement. How do we know the effect of any change if we don’t measure? Discipline – collection of data helps verify (or further question) the real underlying problems

Quality Improvement - The structure SDSA ‘Standardise’ Treatment - PDSA Diagnosis - Change Ideas Assessment - 5Ps The structure of quality improvement can be compared to patient assessment – we first assess, then diagnose and then treat the microsystem. When we have made the desired improvement we then standardize the process.

Start with broad aim (Global Aim) then focus down to more specific and measureable outcomes (Specific Aim) Measurement data – what will evidence the impact of the change? Record your baseline Plan your change; implement your change, recording relevant data; focus on experimentation (ie start small!); study your results and analyse the impact of the change – either fully implement or plan a different change idea Eg . Recovery Team – Specific Aim of decreasing the number of inappropriate referrals by 50% by March. Started by just testing with the local Access Team. Took on board aforementioned balance measures which led to further improvements and PDSAs

The Microsystem Improvement Ramp 5P Assessment Theme Global Aim Change Ideas Specific Aim Measures Cause & Effect Using regular coached meetings with effective meeting skills the team will gradually work up through all stages of the ramp. Flowchart

Primary Care Coaches 3 Coaches from Primary Care in 2015 (Cohort 5) Sloan Medical Centre with 12k patients Dovercourt Group Practice with 8k patients Wide representation in Quality Improvement team (GPs, Practice Nurses, Managers, Midwife, Health Visitors, Admin Support, Receptionists, Volunteer, Patient Representatives)

Primary Care Work Streams Prescribing Admin and Process Systems Maternal and Child Health Clinic Referral System

“Sometimes when you are in the thick of things you cannot see a way out. By breaking the whole system down from the very start of the process to the end including appointments, patient contact, letters etc it mapped step by step the whole journey for the patient, Nurse, GP, Receptionist and Volunteer. We could then look at smaller chunks of the map and start to properly evaluate what we were doing, where we could improve, what we didn’t need and what we needed to include to make the clinic smoother, more pleasant, and less stressful for all involved.” P Nurse May 16

Future Microsystems Coaching 25 Funded MCA Coaching places 12 Coaches on Cohort 10 Feb 18 Cohort 11 starting in June 18 – spaces available Interested in being a coach? Email: michelle.wilde1@nhs.net

Small number of pre-paid places for Primary Care Staff 11th & 12th June 2018 Presentations by Kirsten Major, Paula Ward, Margie Godfrey & other national &internationally renowned quality improvement leaders Case studies and stories from the range of improvement work going on across Sheffield Learn about the MCA, and the Flow Coaching Academy (FCA) Interactive sessions to build quality improvement knowledge & skills Daytime and evening events to build your own improvement network £189 for 2 Days £139 for 1 Day Small number of pre-paid places for Primary Care Staff