1. Insert name of presentation on Master Slide Intelligent Targets: What we want and what we don’t want Friday 1 October 2010 Dr Alan Willson

2. Ministerial drive Improve patient experience Involve carers and professionals See some change in a complex system Intelligent Targets

3. What we don’t want Perversity Imposed targets Lovely targets but no change Intelligent Targets

5. Workforce Capital £ £ Intelligent Targets

6. What are we actually trying to do? Improve the reliability of care in Wales Raise the standards of care in Wales Intelligent Targets

7. The Intelligent Targets Approach Focus on process of change Use expert groups for subject knowledge Use model for change as a standard Greenhalgh criteria Intelligent Targets

8. Greenhalgh criteria It must have clear relative advantage It must have compatibility with the user’s values and ways of working Complexity must be minimised Users will adopt more readily if innovations allow trialability There must be observability, that is it must be seen to deliver benefit Reinvention is the propensity for local adaptation Intelligent Targets

9. An evidence-based model for producing clinical change The Model for Improvement Agreed process changes (care pathways and driver diagrams) Outcome and Process measures Appropriate Performance Management Support for improvement (will/ ideas/ execution) Tools: data handling, driver diagrams, collaborative learning Intelligent Targets

10. Model for Improvement

11. An example from another setting Acute MI Care in US Aspirin at discharge ACEI for LVSD Beta-blocker at arrival Beta-blocker at discharge Door to lytic Door to PCI Smoking cessation advice Composite and all-or-none scores Survival rate/index Aspirin at arrival Intelligent Targets

13. Strategies – Level 1 “Intent, vigilance, hard work” Standardized protocols Feedback Training Checklists

14. Strategies – Level 2 “Redesign the system – don’t rely on checking” Decision aids and reminders built into the system Automation Evidence as the default Scheduling Connection to habits

15. Intelligent Targets

16. What to measure and what it means DomainExamples Uptake (organisational conditions Identified management lead Identified clinical champion Intranet sign up Data submitted Teams trained Local communication strategy in place Process change (Intelligent Targets) Bundle compliance Uptake of new practice (specific to driver diagram) Outcome change (consequence of process) Reduced morbidity Reduced mortality Reduced dependency Reduced hospital stay

17. Taking this forward Stroke as a starter Four clinical areas Agree driver diagrams Design and prove spreadsheet Incorporate in Annual Operating Framework 2010/11 Support learning and implementation Build Intelligent Targets

18. Stroke An example from our setting Intelligent Targets

19. Acute Phase Driver Diagram Intelligent Targets

20. All Wales Data Intelligent Targets

22. Driver Diagrams Do Establish the expected outcome Identify the critical points within the system Set out the relevant evidence based interventions Intelligent Targets

23. Driver Diagrams Don’t Describe the whole pathway or all the necessary interventions Limit clinical or professional judgement Prevent or discourage innovation Intelligent Targets

24. Examples from one Trust

26. Intelligent Targets

29. Findings Method makes sense Measurement and reliability are new concepts Team work is encouraged across pathway Connections with management need work We are seeing change and so are patients! Intelligent Targets

30. “..we have to accelerate the adoption and full implementation of best and evidence-based practice in all settings all of the time – there can no longer be any justification for not doing this. Paul Williams letter to Chief Executives, launching 1000 Lives Plus. March 2010. 1000 Lives Plus – Reducing harm, waste and variation. “..we have to accelerate the adoption and full implementation of best and evidence- based practice in all settings all of the time – there can no longer be any justification for not doing this. Paul Williams letter to Chief Executives, launching 1000 Lives Plus, March 2010. Intelligent Targets

31. Why is this difficult? “Evidence-based therapies that prevent morbidity and death are often not translated into clinical practice. One reason for this is that research often neglects to look at how to deliver therapies to patients. Consequently, errors of omission are prevalent and cause substantial preventable harm” BMJ, Oct 2008, Vol 337 Intelligent Targets

32. 1000 Lives Plus and the Strategy for NHS Wales - “National Purpose, Local Action”. How clinically led service improvement will be driven… For national improvement priorities, Health Board’s will assemble a clinically-led team. Teams from across Wales come together for peer learning. Teams agree objectives internally and with HB management. Teams agree measures to track process. Teams collect information to track internal trends and to compare progress between teams. Team leaders share experience and help each other via site visits and learning events. Intelligent Targets

33. The 1000 Lives Plus - Drawing on the evidence of what works Pronovost et al (2008) Translating evidence into Practice – A model for large scale knowledge translation. BMJ

34. When progress is difficult, the reason is likely to relate to one or more of the following: –Failure of Will e.g. a few strong “blockers,” lack of investment in training and education, lack of back-up from more senior levels. –Failure of Ideas e.g.Not drawing on the evidence base, or not participating in Learning Sets. –Failure of Execution e.g. The leader does not have the authority (as well as the responsibility) to deploy the resources s/he needs. Cross- service links have not been clarified. Competing priorities have not been reconciled. The Model for Improvement is not being used. Obstacles and barriers Intelligent Targets