1. Intelligent targets Learning Session 3 Workshop 30 September 2009

2. Performance Improvement for Patients
A View from the Top ??
Minister view clear about need to improve quality of care
Consensus that more focus /pace required
Wide range of national performance improvement tools
Where are we know ?
The Dark Side ‘Annual Operating Framework’
Top down improvement
Nationally set targets

3. Perceptions and Myths
Improvement targets not owned by all
Not sensible or clinically credible
Single points of complex pathways – not representative
Perverse incentives
Limited change
Changes not sustainable
It has achieved improvement !

4. Somewhere over the rainbow ?
Self governing organisations
Quality focused improvement targets
Clinically driven and owned
Across care pathways
Patient care at the centre
To..
Improve patient experience
Involve carers and professionals
See some change in a complex system

5. View from the bottom (up)
Intelligent targets
Objectives
Complete care pathway
Critical success / ‘Wow’ factors
Outcomes measures (effectiveness, safety, experience)
Approach
4 pilots (cardiac, stroke, unscheduled care, mental health)
National Steering Group supported by 4 core groups
Driven and made up of healthcare professionals, policy leads
Facilitated by NLIAH

7. Wales stroke audits over 5 years -what is worse?
Brain scan in 24 hours – 60% to 38%
OT assessment - 62% to 50%
Home visit before discharge – 80% to 53%
-what is better?
Aspirin started – 72% to 76%
MDT goals agreed – 58% to 70%

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

9. A quote
Although clinicians setting targets is the way forward, how do we re-educate them to move away from end line inspection to on line inspection? They have grown up in organisations which review complaints, undertake audit, reflect on research….which all have their place, but amazingly with such a captured audience ‘the patient’ they fail miserably to monitor, measure and improve quality at the bedside. Can you imagine a world whereby all staff were involved in quality questioning….I would predict a stepped change in complaints!

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

11. 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

12. 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

13. Model for Improvement

14. 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
In 2002 in the mayo Clinic in the states decided to look at how good it was at delivering an acute MI bundle.

15. At the beginning an average of 56% of patients got what they should have had- that’s 44% that didn’t.
The scale on this slide is mislabelled and should read from 0 to 100%.
Improving reliability in the process from 56 to 80% required introducing level one and two changes, which had a cummulative effect.

16. Strategies –Level 1 “Intent, vigilance, hard work”
Standardized protocols
Feedback
Training
Checklists
The evidence is that threatening people does not improve reliability!

17. don’t rely on checking”
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
Mechanising the system- coverting human’s into robots
Evidence based practice as the default, not the aspiration- If the process doesn’t get something right, then investigate and do something about it.
Its important to attach the process to the way we work.

18. The improvements in relaibilty in care were reflected in improvements in Mortality rates.

19. Stroke
An example from our setting

20. Acute Phase Driver Diagram

21. All Wales Data

22. Examples from One Trust

26. All Wales - Compliance with First Hours Bundle
Within 3 hours
Screening tool
Confirmation of diagnosis by experienced clinician
Stat aspirin

27. All Wales - Compliance with First Day Bundle
Within 24 Hours
CT Scan
Admission to stroke bed
Swallow screen
Regular aspirin

34. 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!

35. Respecting measurement
Domain
Examples
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

36. 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
5 year rolling prgramme