Presentation title: 32pt Arial Regular, black Recommended maximum length: 1 line Service improvement for better, safer healthcare

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

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

What is quality?

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

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

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

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

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

Process mapping … Select a process Map the process

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

Lots of steps delays bottlenecks Reworked loops Analyse current situation

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

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

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! The health service has many heroes. The staff who - work harder - predict problems and compensate for short comings.

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

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

What are you trying to accomplish? How will you know that a change is an improvement? Aims Measurement Three fundamental questions for improvement A model for improvement

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

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

Hunches Theories Ideas Changes that result in improvement DS AP DS AP DS AP DS AP Repeated PDSA Cycles

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

A real example of process mapping in practice …

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”

Accepting referral Discharging from acute phase AssessingTreatingEvaluating Burns Unit Quality Improvement Team

Accepting referral AssessingTreatingEvaluating Discharging from acute phase -Enquiring about the patient - Preparing for arrival - Advising on initial treatment - Taking Clinical baseline - Informing relatives and carers -Taking swabs and photos -Treating other medical conditions -Responding to Psych needs - Mobilising and moving - Managing pain - Planning for discharge - 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 Burns Unit Quality Improvement Team

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

Accepting referral AssessingTreatingEvaluating Discharging from acute phase -Enquiring about the patient - Preparing for arrival - Advising on initial treatment - Taking Clinical baseline - Informing relatives and carers -Taking swabs and photos -Treating other medical conditions -Responding to Psych needs - Mobilising and moving - Managing pain - Planning for discharge - 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 Burns Unit Quality Improvement Team

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

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

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

Do: - tested screening tool D S AP PDSA 1 ActPlan StudyDo What are you trying to accomplish? How will you know that a change is an improvement? What changes can you make that will result in the improvements you see?

Study: - inclusion/exclusion criteria were unclear - errors in scoring Do: - tested screening tool D S AP PDSA 1 ActPlan StudyDo What are you trying to accomplish? How will you know that a change is an improvement? What changes can you make that will result in the improvements you see?

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

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

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

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

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% Burns Unit Quality Improvement Team

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 … … …

… … … 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

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

Change Riders. 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: 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.

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. Harness several dead horses together for increased the speed. Pass legislation declaring that “this horse is not dead” Re-classify the dead horse as “living, impaired”.

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) Berwick DM (1996) A primer on leading the improvement of systems. BMJ 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, Maxwell RJ (1984) Quality assessment in health. BMJ; 288: 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) NHS Institute for Innovation and Improvement (2007) The Improvement Leaders’ Guide to Process Mapping, Analysis and Redesign. NHS III Available on line at; 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.

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

Useful Links NHS Institute for Innovation and Improvement NHS Trent Improvement Network Institute for Health Care Improvement (USA) The Healthcare Improvement Skills Center Website for the Scholtes et al (2003) referenced above