North Tees and Hartlepool NHS Foundation Trust Clinical Leadership Development Programme Leadership and Improvement

All working life in NHS Diagnostic Radiographer and teacher Improvement roles since 1994 BPR Leicester Royal Infirmary National Patients ‘Access Team NHS Modernisation Agency 2002 – 2005 NHS Institute for Innovation and Improvement Awarded OBE for services to NHS 2003 Visiting professor University of Derby 2008 Improvement: 17 years and still learning

 Understanding the skill of improvement  Linking strategic goals and frontline improvements

 Find two other people who you have not worked with before  Watch the slideshow  Remember as many images as possible ◦ The countdown slide is not one of the images!  No writing down or conferring!

 Any improvement is a change ◦ not every change is an improvement ◦ but we cannot improve something unless we change it Eliyahu Goldratt Goldratt E (1990) Theory of Constraints, North River Press, Massachusetts

 Any improvement is a change  any change is a perceived threat to security ◦ there will always be someone who will look at the suggested change as a threat Eliyahu Goldratt

 Any improvement is a change  any change is a perceived threat to security  any threat to security gives rise to emotional resistance ◦ you can rarely overcome emotional resistance with logic alone  Eliyahu Goldratt

“ Anyone who thinks you can overcome emotional resistance with logic was probably never married”

 Any improvement is a change  any change is a perceived threat to security  any threat to security gives rise to emotional resistance  emotional resistance can only be overcome by a stronger emotion Eliyahu Goldratt

 What to change? ◦ Pin point the core problems  What to change to? ◦ Construct (simple) practical solutions  How to cause the change? ◦ Induce the appropriate people to invent such solutions ◦ they must own the problem Eliyahu Goldratt Goldratt E (1990) Theory of Constraints, North River Press, Massachusetts

1. Set Direction: Mission, Vision and Strategy Make the status quo uncomfortable Make the future attractive 3. Build Will Plan for improvement Set aims/allocate resources Measure system performance Provide encouragement Make financial linkages Learn subject matter 5. Execute Change Use Model for Improvement for design and redesign Review and guide key initiatives Spread ideas Communicate results Sustain improved levels of performance 4. Generate Ideas Understand organisation as a system Read and scan widely, learning from other industries and disciplines Benchmark to find ideas Listen to patients Invest in research and development Manage knowledge 2. Establish the Foundation Prepare personally Choose and align the senior team Build relationships Develop future leaders Reframe operating values Build improvement capability Source: Robert Lloyd Executive Director Performance Improvement Institute for Healthcare Improvement January 16, 2007

 What tools and techniques, knowledge and skills are needed to make good sustainable improvements?  If you are familiar with ‘Lean’ ‘LIPS’ ‘Productive Ward’’, what are the underpinning tools and techniques

Knowledge of Systems Theory of knowledge Knowledge about Variation Knowledge of Psychology W Edwards Deming (1994) The New Economics

4 equally important parts of improvement Diagnostic tools e.g. Process and systems thinking Project and programme management User and public involvement Change management Discipline of improvement in health and social care (Penny 2003) PeopleProcess What How

Diagnostic tools e.g. Process and systems thinking Project and programme management User and public involvement Change management Discipline of improvement in health and social care (Penny 2003) PeopleProcess What How

First define the problem  Root Cause Analysis (5 Whys)  Process Mapping  Ishikawa (Fishbone)  Brainstorming  Pareto Analysis  etc And  User and staff stories and anecdotes

What are the problems for users, carers and staff and what are the causes of the problem? Ishikawa (Fishbone) Diagrams PPPP PeoplePlace ProceduresPolicies

Example Cause & Effect Diagram © 2004 Institute for Healthcare Improvement

Activity: What are the causes of your problem? PPPP PeoplePlace ProceduresPolicies

Macro Meso Micro ©Profound Knowledge Products, Inc All Rights Reserved

Ask yourself What are the problems that cause the bigger problem? What are you trying to achieve? (aim for each driver) How will you know a change is an improvement ? (outcome measures for each driver ) Drivers Which in turn contribute directly to the ‘bigger’ aim Aim The ‘big’ dots Ask yourself What is the big (possibly strategic) problem you are addressing? What are you trying to achieve? (aim) How will you know a change is an improvement ? (outcome measures) Ask yourself What changes can you make that will result in the improvement you seek? What are the change ideas / interventions/ solutions to test with PDSA cycles before implementing? How will you know a change is an improvement? (process measures for each intervention) Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 Interventions The ‘small’ frontline dots Contribute directly to the drivers

Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 The interventions / change ideas that contribute directly to secondary drivers Secondary Drivers: Contribute directly to primary drivers Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 ? Primary Drivers: Contribute directly to the strategic aim The strategic aim (and big problem)

Reducing harm in perioperative care Reduce surgical site infections Improve team work and communications Appropriate use of prophylactic antibodies Maintain normothermia Maintain glycaemic control in known diabetes Use recommended hair removal methods Use of the WHO Surgical safety checklist Primary DriversSecondary Drivers Ref. Patients Safety First

North Tees and Hartlepool NHS Foundation Trust Corporate strategy 2010 – 2015 Patient safety Patient satisfaction Staff satisfaction Provider of choice Quality of services Governance and mandatory services Financial stability New facilitates Care delivered closer to home ‘High level Aims and objectives’ Pages

Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 The interventions / change ideas that contribute directly to secondary drivers Secondary Drivers: Contribute directly to primary drivers Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 ? Primary Drivers: Contribute directly to the strategic aim The strategic aim (and big problem)

 The Model for Improvement breaks things down into small steps and works of the ‘little dots’ – at the frontline  These small steps should be part of the answer to the question of how to move the big dots  Align all improvement projects to strategy

What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo Understanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives Measuring processes and outcomes What have others done? What hunches do we have? What can we learn as we go along? Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organizational performance 2 nd ed, Jossey Bass Publishers, San Francisco The more specific the aim, t he more likely the improvement Repeated clarification - w ithout it aims drift Meet needs of external customers

Use Pareto Principle to identify cause(s) of problem to work on first  ‘The Rule’  ‘The Law of the Vital Few’  For many phenomena, 80% of the consequences stem from 20% of the causes  Observation that 80% of income went to 20% of the population Vilfredo Pareto, 1906

What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo Understanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives Measuring process, outcomes and balancing What have others done? What hunches do we have? What can we learn as we go along? Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organisational performance 2 nd ed, Jossey Bass Publishers, San Francisco

ctice/general/knowing_how_we_are_doing.html

Project Identification Getting a baseline Did project make a difference Will project sustain Evaluating worth of the project Mike Davidge NHS Institute for Innovation and Improvement  /productive_general_practic e/general/knowing_how_we _are_doing.html /productive_general_practic e/general/knowing_how_we _are_doing.html

7 Repeat steps Decide Aim2 Choose Measures3 Define Measures 4 Collect Data 5 Analyse & Present 6 Review Measures Mike Davidge NHS Institute for Innovation and Improvement  /productive_general_practic e/general/knowing_how_we _are_doing.html /productive_general_practic e/general/knowing_how_we _are_doing.html

AspectImprovementAccountabilityResearch Aim Improvement of careComparison, choice, reassurance, spur for change New knowledge Methods: Test Observability Tests are observableNo test; merely evaluate current performance Test blinded or controlled tests Bias Accept consistent biasMeasure and adjust to reduce bias Design to eliminate bias Sample Size “Just enough” data, small sequential samples Obtain 100% of available, relevant data “Just in case” data Flexibility of Hypothesis Hypothesis flexible, changes as learning takes place No hypothesisFixed hypothesis Testing Strategy Sequential testsNo testsOne large test Determining if a Change is an Improvement Run charts or control charts No change focusHypothesis, statistical tests (t-test, F-test, chi square), p-vlaues Confidentiality of the Data Data used only by those involved with improvement Data available for public consumption and review Research subjects’ identities protected Robert Lloyd Executive Director IHI adapted from Solberg L, Mosser G, Mcdonald S (1997) Three faces of performance measurement: Improvement, accountability and research Journal of Quality Improvement Vol. 3 No 3

34 Charts vs. Tables

Something very important! Last month This month What action is appropriate?

What does this data tell us?

Run charts Day Seconds to answer phone Seven one side Seven down (or up) DO Look for a run of seven points all above or all below the centre line or all increasing or all decreasing

Average length of pre-ward stay Stroke Ward from 01/2007 to 07/ Months Mike Davidge NHS Institute for Innovation and Improvement Patient length of pre-ward stay Stroke Ward from 01/2007 to 07/ Patients

North Tees and Hartlepool NHS Foundation Trust Corporate strategy 2010 – 2015 Strategic measures Patient safety Patient satisfaction Staff satisfaction Provider of choice Quality of services Etc etc

Ask yourself What are the problems that cause the bigger problem? What are you trying to achieve? (aim for each driver) How will you know a change is an improvement ? ( outcome measures for each driver ) Drivers Which in turn contribute directly to the ‘bigger’ aim Aim The ‘big’ dots Ask yourself What is the big (possibly strategic) problem you are addressing? What are you trying to achieve? (aim) How will you know a change is an improvement ? (outcome measures) Ask yourself What changes can you make that will result in the improvement you seek? What are the change ideas / interventions/ solutions to test with PDSA cycles before implementing? How will you know a change is an improvement? ( process measures for each intervention ) Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 Interventions The ‘small’ frontline dots Contribute directly to the drivers Activity: Process and outcome measures?

What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo Understanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives Measuring processes and outcomes Change ideas: What have others done? What hunches do we have? What can we learn as we go along? Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organisational performance 2 nd ed, Jossey Bass Publishers, San Francisco

Solution / change in organisation A Change principle Solution / change in organisation B

PDSA cycle for learning and improvement Act what changes are to be made? next cycle? Plan objective questions and predictions (why) plan to carry out the cycle (who, what, where, when) Study complete the analysis of the data compare data to predictions summarise what was learned Do carry out the plan document problems and unexpected observations begin analysis of the data

 We planned to….. ( state the basic plan)  In order to ….. (tie it back to the Aim)  What we did was….. (brief description of actions)  Looking at what happened, what we learned from this was….. ( lessons learned)  What we plan to do next is …. (state next plan) © Paul Plsek PDSAPDSA

Repeated PDSA cycles work towards the AIM PDSA Data Driven Change Change in Team Culture Hunches Theories Ideas Aim What am I trying to achieve? How will I know a change is an improvement? What changes can I make that will result in the improvement Need to start small!!

AffectionTrust DistrustRespect Extent to which I believe you care about me Extent to which I believe you are competent and capable LOW HIGH Adapted from P Scholtes (1998) The Leaders’ Handbook; McGraw Hill

 Think quietly by your self for a few minutes  Then find two others and share

What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo