Professor Moira Livingston Clinical Director NHS IQ Session 4: Using QI methodologies to inform commissioning and create better care

Using QI methodologies to inform commissioning and create better care Outline Why are we here The NHS Change model :a framework for change Commissioning for quality and transformation Measurement and method Key messages

Why are we here? Everyone Everywhere Every time experiences the safest and highest quality healthcare Financial challenges Quality: Safety, outcomes and experience, is the focus Rising expectations Increasing complex health needs Unacceptable variation We need to do more, for less... and better

Quality Better Old Way (Quality Assurance) Quality BetterWorse New Way (Quality Improvement) Action taken on all occurrences Reject defectives Source: Robert Lloyd, Ph.D. Requirement, Specification or Target No action taken here Worse

Quality Quality ImprovementTransformation Source: Robert Lloyd, Ph.D.

Aim Measurement Drivers (changes)

Common Shared Purpose

Mental models of change How we think about engagement

It’s all about BALANCE.

Commissioning for quality and transformation

The commissioning cycle is a familiar model of the stages of commissioning services in the public sector. It can provide a framework for planning activity and evaluating development needs.

This version of the cycle has some unique features, emphasising the particular issues in building commissioning which is community oriented, clinically led, collaborative and comprehensive.

At its heart is the NHS Change Model, helping commissioners ensure their change leadership efforts achieve maximum impact for sustained transformation.

It is tempting to start here. This imposes an incremental approach (not transformational), oriented around managing existing activity rather than improving population outcomes.

Forging effective relationships with key partners is an essential pre-requisite for developing quality sustainable plans. These provide the foundations for all other activity, ensuring a collaborative approach.

To improve population outcomes, commissioning priorities should be based on a robust understanding of the population’s health. This helps orientate activity around patients rather than services.

Most health and social care involves complex longitudinal journeys. Designing integrated pathways of care before considering individual services helps improve safety, effectiveness and value.

Specifying service contracts and shaping the provider market for the future is a key part of achieving the services the community needs. The goal is to ensure each component of a pathway contributes to the whole.

Commissioners’ responsibility does not end with agreeing contracts. Clinical commissioners are well placed to contribute to continuous improvement of services, collaborating between providers.

Transparent Measurement Data…Information…Knowledge Transparent Measurement Data… Information…knowledge Transparent Measurement Data… Information…knowledge

Average CABG Mortality Before and After the Implementation of a New Protocol Percent Mortality Time 1Time % 4.0% WOW! A “significant drop” from 5% to 4% Conclusion -The protocol was a success! A 20% drop in the average mortality!

Average CABG Mortality Before and After the Implementation of a New Protocol A Second Look at the Data Now what do you conclude about the impact of the protocol? Percent Mortality 24 Months UCL= 6.0 LCL = 2.0 CL = 4.0 Protocol implemented here

Characteristic Measurement for research Measurement for compliance Measurement for improvement Primary aim Create new knowledge Achieve a target Improve a service or outcome for patients Key question underpinning the measurement Are there better ways of caring for patients? Are there any “outliers” in terms of deviation from minimally acceptable patient outcomes? How can we improve service or outcomes for every patient? Hypothesis Fixed hypothesis to be tested in research process No hypothesis Flexible hypothesis that changes as tests conducted and learning takes place End point of measurement process Proving or disproving of hypothesis Measurement chart that shows comparative performance from which judgement is made Measurement chart that shows progress since last measure and potential for improvement Determining if change is an improvement Use of statistic tests (t-test, F-test, chi- square, p-values) No change focusSubsequent use of Run charts or SPC charts to show improvement over time Source: adapted by Helen Bevan and Moira Livingston from The Three Faces of Performance Measurement: Improvement, Accountability and Research.” Solberg, L, Mosser, G and McDonald, S Journal on Quality Improvement. March 1997, Vol.23, No. 3.

AuditQuality Improvement We collect “before and after” dataWe collect continuous data We collect a lot of data (“Just in case”) We collect just enough data Typically little testing of solutionsContinuous testing, learning as we go Implement change as a consequence of the audit The process of measuring is integral to the change process (“plan, do, study, act”) Moving beyond audit to quality improvement

Key Messages Clarity of purpose at the start Improvement takes leadership: Commitment Be curious: understand the issues Seek data to answer the questions: don’t start with the data you have Relationships: collaborate with partners Start again: continuous cycle/process