1. Leading the Way to quality improvement
Thursday 27th October 2011
Leading the Way to quality improvement
Tim Heywood
Insert name of presentation on Master Slide

2. Messages about leadership for quality improvement have been consistent for years:
Accountability
Communication
Patient focus
Measurement and targets
Learning and education
Culture and behaviour

3. “The challenge is not to agree the principles of good leadership practice, but to implement practical interventions that will embed these principles in day-to-day organisational life.”
1000 Lives Campaign ‘How to’ Guide

4. Thinking of change as ‘social movement’4

5. 1000 Lives Plus - From compliance to commitment
States a minimum performance standard that must be achieved.
Uses hierarchy, systems and standard procedures for coordination and control.
Threat of penalties/sanctions.
Fear creates momentum for delivery.
Based on organisational accountability (if I don’t achieve this I fail to meet my performance objectives).
Commitment
States a collective goal that everyone can aspire to.
Based on shared goals, values and sense of purpose for coordination and control.
Commitment to a common purpose creates energy for delivery.
Based on relational commitment (if I don’t achieve I let the group or community down).
Helen Bevan – IFQSHC presentation, 2011

6. Leadership Driver Diagram

7. System level measures Mortality case note reviews
Understanding mortality rates
Investigating high mortality measures
Case studies

8. 6 principles for effective mortality reviews
Do the review
Reviews must be undertaken at an agreed frequency, involving relevant people in a way that is sustainable.
Do it intelligently
There should be an agreed process for selecting cases that either covers all deaths, or a properly representative sample.
Get some learning
The review process must be structured in a way that allows identification of system issues.
Share that learning
The review process should produce timely feedback to Clinicians, service leaders and Quality & Safety Committee.
Report comprehensively
Reporting should highlight learning about clinical system issues and also the review process itself.
Feed learning into strategy
There must be a process for ensuring that Health Board strategy on avoidable death and harm reflects the outcomes of the review process

9. Involving students in mortality reviews – a test of change
What are we trying to achieve:
Sustainable involvement of students in mortality and harm reviews.
How will we know when we have achieved it:
Increased student understanding of the purpose and process of reviews;
Reported positive experience of students;
No negative impact on other review team members;
What test can we make:
Identify student volunteers  to be involved in the test.
Provide information on the background and training in use of the tool.
Involve students in weekly review meetings.
Get feedback from students and other team members.

10. Demonstrating visible leadership

11. Aim of WalkRounds
To combine a top-down and bottom-up approach to safety awareness and management
To demonstrate visible senior leadership in patient safety
Gain information and act on safety problems and issues

12. WalkRounds – a history 1999 Concept developed by IHI
piloted in several US hospitals
2003 First published research on WalkRounds
2004 incorporated into the UK Safer Patient’s initiative
2007 identified as a key leadership intervention for the 1000 Lives Campaign

13. Why are WalkRounds important?
Depends on your perspective..
Patient
Benefit from decreased risk
Leaders
Directly interact
Learn unfiltered truth
Directly influence culture
Front line staff
Opportunity to discuss concerns
Opportunity to be heard and respected
Safety Experts
Gather data that lead to action
Improve how action is taken

14. Testing and implementation of WalkRounds in Wales
Acute Settings.
Community services
GP Practices
Care Homes
Virtual WalkRounds in community pharmacy practices.
.. Next test: ‘mid-organisation’ WalkRounds

15. Accountability for execution

16. The model for Execution
Achieve strategic Aims
Manage local improvement
Develop workforce
Spread & sustain
Build leadership
and accountability
Exec Team
Divisional teams
Directorate/locality teams
Service delivery teams

17. Conference Rooms Real World Approve Design Design Design Design
Implement 17

18. Conference Rooms Real World Approve (if necessary) Design Test and
Modify
Test and
Modify
Test and
Modify
Implement
Real World 18

19. Systematic review of improvement projects
Clarify purpose, expected outcome and how this links to organisational purpose and priorities.
(Driver diagrams can really help here)
Understand the importance of testing, implementing reliable processes, spreading and sustaining changes.
Be alert to words like ‘audit’; ‘pilot’ and ‘roll-out’
Always insist on basing conversations around the data.
What are we trying to do – e.g. design a new process, improve an existing product or service

20. Balancing measurement for improvement and assurance at different levels
Focus on process measures
Focus on outcomes
Board level
Frontline team level
Core system-wide assurance measures
RAMI
GTT Harm rates
Programme specific outcome measures:
Condition specific mortality rates
Incidence of specific categories of avoidable harm.
Improvement measures
Process reliability
Care bundle compliance
Uptake of evidence-based
practice
National
level
Division/ Directorate
levels

21. A scoring scale for assessing improvement programme progress
Score
Narrative 10
Reliable implementation has been achieved in all relevant areas/populations. 9
Reliable implementation has been achieved in half of all relevant areas/populations 8
Reliable implementation has been achieved outside the initial pilot area/ population. 7
A plan to spread reliable implementation is in place and spread is underway beyond the pilot area/population. 6
Reliable implementation has been achieved in the pilot area / population 5
Changes have been fully tested using multiple PDSA cycles in the pilot area and we are now in the process of implementation 4
Testing of changes is underway in the pilot area / population. Data collection has commenced and baseline information is available 3
The Local implementation and data collection strategy for the programme has been agreed. 2
A programme team has been set up 1
An organisation lead has been appointed for the programme

22. Surveying culture

23. Why survey culture?
“Understanding our shared assumptions about ‘ the way things are round here’ is an important step towards improvement. Participating in this survey will help to bring these issues to the surface so that they can be discussed in an open and positive way”.
1000 Lives Plus culture survey guidance 2010

24. Top 5% performers Bottom 5% performers
Research on the relationship between organisational culture and outcomes
A study of 11 US hospitals used risk adjusted 30 day mortality for AMI as an outcome measure and explored reasons for variation between high and low performers:
Top 5% performers
Bottom 5% performers
Curry, L et al.(2011) What distinguishes top-performing hospitals in AMI mortality rates?
Ann Intern Med. 154: American College of Physicians
Mortality rates were as much as double in poor performers compared with top performers, but differences in care processes and protocols could not account for this…
Eleven U.S. hospitals that ranked in either the top or the
bottom 5% in risk-standardized mortality rates for 2 recent years of
data from the Centers for Medicare & Medicaid Services (2005 to
2006 and 2006 to 2007), with diversity among hospitals in key
characteristics.
Participants: 158 members of hospital staff, all of whom were
involved with AMI care at the 11 hospitals.
Measurements: Site visits and in-depth interviews conducted with
hospital staff during 2009.
A 6-member multidisciplinary team performed data analysis
by using the constant comparison method, in
which essential concepts from interview data are coded and
compared over successive interviews to extract recurrent
themes across the data. Other team members reviewed coded
transcripts for the site visits they had conducted. This process
of refining codes and describing the properties of each continued
until no new concepts emerged. Targeted analyses were
performed to examine the consistency of the data within sites
and to identify distinctions in coded themes between high performing
and low-performing hospitals. 24

25. Distinguishing cultural features in high performing hospitals
Domain
Theme
Organisational values and goals.
Shared values to provide exceptional care.
Alignment of quality and financial goals.
Senior management involvement.
Adequate financial and non-financial resources.
Use of quality data in management decisions
Holding staff accountable for decisions.
Broad staff presence and expertise.
Sustained medical champions.
Empowered nurses and pharmacists.
High quality standards for all staff.
Communication and coordination among staff.
Valuing diverse roles and skills.
Recognising interdependencies.
Smooth information flow.
Problem solving and learning.
Use of adverse events as opportunities to learn.
Use of data for non-punitive learning.
Innovation and creativity in trial and error.
Learning from outside sources

26. 2008: n = 4,616
2011: n = 10,320

27. Culture survey profiles by length of service

28. How can front line staff to engage leaders..
Discuss and understand your Driver Diagram ‘story’.
Will
Request WalkRounds
Do a local culture survey
Generate stories for use ‘higher in the organisation
Build system-wide leadership for quality improvement
Engage in Learning Sets with a consistent team
Ideas
Meet regularly to brainstorm, review themes from feedback, incidents and near misses
Visit other sites and services; adapt practices from elsewhere
Be clear who is accountable for your work
Execution
Use SBAR to communicate ‘up’
Always use your data for review